Immune Thrombocytopenia in Pregnancy
A 23-year-old woman with known immune thrombocytopenic purpura delivered vaginally at 39 weeks and is now bleeding heavily from the genital tract. The uterus is well contracted and no lacerations are seen. Platelet count is 18 × 10⁹/L, haemoglobin 105 g/L, with normal prothrombin time and fibrinogen. Which of the following is the most appropriate management?
- A.Platelet concentrate transfusionCorrect
- B.Fresh frozen plasma transfusion
- C.Cryoprecipitate transfusion
- D.Packed red blood cell transfusion
Explanation
Immune thrombocytopenic purpura is an autoimmune disorder in which antiplatelet antibodies drive peripheral destruction of platelets in the spleen, producing isolated thrombocytopenia with normal coagulation studies. When such a patient bleeds actively after delivery, the deficient component is platelets, so platelet concentrate transfusion is the immediate life-saving treatment, ideally with intravenous immunoglobulin and corticosteroids to prolong platelet survival, since transfused platelets are also destroyed rapidly. A count of 18 × 10⁹/L with active haemorrhage is well below the threshold of 50 × 10⁹/L usually required for surgical or obstetric haemostasis. Standard postpartum haemorrhage measures continue in parallel, including uterotonics, tranexamic acid, and exclusion of trauma and retained tissue, which have already been checked here. Fresh frozen plasma replaces clotting factors and is indicated in disseminated intravascular coagulation or massive transfusion, not in isolated thrombocytopenia with normal prothrombin time. Cryoprecipitate is given for hypofibrinogenaemia, which is excluded by the normal fibrinogen. Packed red cells correct anaemia and oxygen carriage but do nothing to stop platelet-related bleeding.
Why each option
- A.
- Correct. Active bleeding with a platelet count of 18 × 10⁹/L requires platelet transfusion, supported by immunoglobulin and steroids.
- B.
- Fresh frozen plasma replaces coagulation factors and is unnecessary when prothrombin time and fibrinogen are normal.
- C.
- Cryoprecipitate is indicated for low fibrinogen, typically in disseminated intravascular coagulation, which is not present.
- D.
- Red cells treat anaemia and are given for haemodynamic support, but do not correct the underlying thrombocytopenia.
Reference: ASH 2019 Guidelines for Immune Thrombocytopenia; UpToDate 2025, Thrombocytopenia in pregnancy
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