Dr. Sarp Aksel returns to Healthful Woman to discuss thrombocytopenia, or low platelet count, in pregnancy. He explains how this condition is diagnosed, complications and concerns, and how doctors manage thrombocytopenia.
“Thrombocytopenia (the fancy word for low platelets) in pregnancy” – with Dr. Sarp Aksel
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Dr. Fox: Welcome to today’s episode of “Healthful Woman” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Sarp, Dr. Aksel, welcome back to the podcast. How goes it?
Dr. Aksel: It goes. Good to be back.
Dr. Fox: Fantastic. We’re recording in the middle to end of May. And it’s pretty much right after all of the masking restrictions have started to lift both in the CDC and now New York and other places. How’s that going so far?
Dr. Aksel: It’s such a shocker to see your nose and mouth. It’s very exciting. Glad it hasn’t changed over the last year or so.
Dr. Fox: Yeah. Not much as far as I can tell. In health care settings, they’re still mandated. So we’re wearing them around the office but out on the street, we’re seeing people’s faces again, in people’s homes and some places of business. I went to Starbucks this morning and I saw for the first time masking is optional, which was brand new…
Dr. Aksel: Amazing.
Dr. Fox: … just came out this morning obviously.
Dr. Aksel: A lot less smiling faces. I thought people smiled more, honestly.
Dr. Fox: It’s interesting because with the stores, at least, you know, we’re in Manhattan and Manhattan was pretty big on masking. Maybe more so than some other places. And I think what’s happening is some stores are finding that there’s a subset of customers who are really happy about the fact that they can take off their masks and come in. And there’s a certain subset that are very unhappy about the fact that others can take off their mask and come in. And it’s probably going to take some time for this to sort of settle out, the dust settles, so to speak on this.
Dr. Aksel: What a shocker that things are polarizing in this country at this point.
Dr. Fox: I’m not sure if that specifically falls along…
Dr. Aksel: Masks.
Dr. Fox: …party lines. Because in New York City, I think everyone falls very similarly on one side of a line politically.
Dr. Aksel: I think we’re so excited about any kind of drama of masks. You know, we never would have thought about it before. Two years ago, who would have thought that masks would have in any way, shape, or form been polarizing?
Dr. Fox: Yeah. I definitely think that anyone who bought stock in masks 1.5 years ago definitely rode that wave and did well but unpredictable. Wonderful. Well, we’re going to segue into something totally separate from COVID and that is thrombocytopenia, which is a long, long word, which means low platelet count. It’s one of those great situations where we get to come up with a fancy word to make us sound smarter than we truly are.
Dr. Aksel: And terrified patients in the meantime.
Dr. Fox: Thrombocytopenia, am I going to live? Oh my God, that sounds horrible. So let’s start from the beginning. So thrombocytopenia means a low platelet count. We’re talking about this specifically in pregnancy, although it is something in a non-pregnant state potentially, but we’re going to talk about pregnancy. What exactly are platelets? Why do we care about them?
Dr. Aksel: Everyone’s blood has various different components in it. Some parts of the blood carry oxygen. Other parts have, you know, clotting factors, and that’s kind of where the platelets come in. They help us clot our blood, whether it’s a knee scrape or a hemorrhage after a delivery. So they’re kind of pretty important in making sure that we don’t bleed out no matter what the cause.
Dr. Fox: When people think of their, you know, blood, a lot of them think on the sort of the realm of anemia, like what is my blood count? And that’s really just the red blood cells. So the red blood cells are the most famous of what’s in our blood and that’s what makes it red. And it’s also what carries the oxygen and so people think about that a lot. And there’s obviously water, which gives it volume, but there’s all these other things floating around that you really only know about it if you don’t have them.
Like platelets, which help people clot. You know, either prevent them from bleeding or if they are bleeding, helps them stop. Things that help fight infection are white blood cells, a lot of stuff in there. So the platelet count is something that we focus on in pregnancy because women are going to come up to deliver where they’re going to be a situation where they’re bleeding. And obviously, we would be concerned if they’re low enough that they would bleed before then, but we just know that something’s happening.
If someone’s coming up to surgery, for example, the surgeon’s going to know what the platelet count is to make sure it’s not low. And so the same way with pregnancy, everyone’s coming up to a delivery one way or another. And we need to know that what the platelet count is to make sure that she’s going to be able to get through that safely and not bleed too much.
Dr. Aksel: Absolutely.
Dr. Fox: And so how often do we find platelets that are low and what do we even consider low numbers-wise?
Dr. Aksel: So when we usually talk about them, we talk about them in the thousands. So, you know, you might hear your doctor say you have a platelet count of 175 or 150, that doesn’t necessarily mean that you only have 175 platelets in your body. It means you have thousands per a certain amount of volume. And so when we talk about platelets, normally it can be anywhere from, you know, 150 to 450, can be normal outside of pregnancy. We’ve sort of set an arbitrary, you know, definition of less than 150 as being abnormal in pregnancy.
Dr. Fox: Yeah. And again, some of the confusion that people have is the fact that we use a shorthand. Like when we say 150, that’s short for 150,000. Like if you look at the report, it’ll say 150,000, we just call it 150 to be shorter. Everyone knows what we’re talking about. If someone actually had 150, it’d be a big deal. And so I think most women end up having around 300,000 give or take. And when it starts dropping below 150, that’s when we start talking about it and it ends up being about 1 in 20 women will have this, maybe 5% of pregnancies have a platelet count under 150,000.
And most of them are fine. Nothing’s going to happen to them, nothing is going to happen to their baby, everything is gonna go fine with their delivery. They’re just sort of on watch, so to speak. So about 5% of the people we put on watch with low platelets, and we try at the same time to notify them and not scare the hell out of them. And that’s a fine line. You want people to know what’s going on but not scare them. And so we try to tell them, “Okay, like, we’re on notice, we’re watching this but we think most likely everything’s going to be okay.” And some people find that very terrifying but hopefully, not because, again, it doesn’t tend to be a very difficult problem for women from a health perspective.
Dr. Aksel: You’re totally right on that fine line that we tow between being informative and transparent about lab work, but also sort of not scaring people. You know, last week I had a patient with a platelet count of 148 and, you know, she was terrified. She was like, “What’s going to happen. Am I going to bleed to death? Am I bleeding right now? Do I not know that I’m bleeding right now?” You know, so I think delivering that news oftentimes, you know, takes a little bit of finesse.
Dr. Fox: And one of the interesting things about the way healthcare is nowadays is sometimes that decision is even out of our hands, how to do it because with portals and the lab giving patients access to their own results, which is a good thing, people should have access to their own healthcare information. You know, they’re going to get a result that says 148,000 it’s in red. It says, you know, warning, warning, danger, danger, all over.
Dr. Aksel: Exclamation marks.
Dr. Fox: Yeah. There’s exclamation points and it’s flagged, “Talk to your doctor.” And people are like, “Oh my God, this is horrible.” And we’re like, “No, no, no, it’s okay.” And sometimes even normal results get flagged because values that pregnant women have that are normal might be considered abnormal for the references the lab uses. They’re not currently fine-tuned enough to say, “Okay, you’re a 34-year-old pregnant woman. This value is normal for you.” They just have a reference range, which is from some book that’s usually from some 40-year-old man. That’s sort of the typical.
And that happens a lot as well. But for platelets, in particular, it’ll frequently scare people more than necessary just by looking at the lab report. So, you know, warning to everyone out there, when you look at your lab reports, before having that onset of terror, make sure to speak to your doctor to see if it’s okay. Because usually, it is because if it was a problem they usually would have called you about it already.
Now, in terms of the 5% of women who do have platelets that we consider low, there’s a lot of reasons why they can be low. And it’s important for us to try to figure out the reason because there’s different implications based on the reasons. Meaning one of the reasons, for example, is that the platelets aren’t even low. It’s just when the machine that looks at the blood and spits out the result, reads it, it reads it wrong. And so why would that happen? In pregnancy, sometimes the platelets get sticky and they clump together.
And so when the machine looks at them, normally the way it differentiates between a red blood cell, a white blood cell, and a platelet is the size. A white blood cell is very big, a red blood cell is like medium to small. And a platelet is tiny, like a dot on the screen. But if let’s say 5,000 platelets sort of congregate together, it’ll look like a big blob. And it’ll count those 1000 platelets instead as 1 white blood cell.
And so sometimes you get back a result where the platelets are low and all that has to happen is someone, not us, we’re not really properly trained to do this, plucky hematologist or someone in the lab looks under a microscope and says, “No, no, no, no. They’re clumped. The number is normal. The count is normal. They’re going to work fine. You don’t even have low platelets. It’s just a consequence of having it done by a machine rather than being done by a human.” And in those situations, like, literally, there’s no problem. Like the perfectly fine.
Dr. Aksel: Yeah. That definitely happens.
Dr. Fox: Yeah. And the only thing that needs to be done is sort of logistically, we have to verify that with someone close to delivery that in fact, even though the machine says their count is low, that in fact, it’s normal. So that’s one cause of low platelets, again, which they don’t even have low platelets. The next most common cause is something that we call gestational thrombocytopenia, which is like a fancy term upon a fancy term, which basically means nothing. It means you’re pregnant and your platelets are low. And it means we don’t really know why.
It’s what we call a diagnosis of exclusion. There’s a thought that something about pregnancy makes someone’s platelets go down. We don’t really know why, they’re not ill. There doesn’t seem to be any risk. You know, they don’t bleed more. It’s just for whatever reason, their count is lower. And what counts of platelets do women typically have if that’s the diagnosis we land on?
Dr. Aksel: Usually, you know, we’re looking at counts between 100 and 150,000 and sometimes it’ll dip a little bit below 100 but there are other conditions that you might want to make sure, you know, a patient doesn’t have, but predominantly they’re hovering between 100 and 150.
Dr. Fox: I mean, one of the ways we excluded is that they’re not crazy low. Like someone has a platelet count that’s, you know, under 50, we’re not going to call it gestational thrombocytopenia. We’re going to think there’s something more, you know, sinister going on. But when they sort of never get below 100 or below 90 or 80, and they’re sort of in that range, it’s frequently what it is because we don’t find any other cause. And again, those women, even though the platelets dropped during pregnancy, it does not tend to have any actual consequences healthwise for her or the baby or the delivery or anything like that. And so that’s good.
The other causes are the more rare ones. There’s something called, here’s a nice one, idiopathic thrombocytopenic purpura, which we call, because that’s a mouthful, we call ITP for short. You may have heard the term ITP but that’s what it stands for. It is quite a situation to say to someone you have idiopathic thrombocytopenic purpura. I mean, literally, they’re like getting their affairs in order. The concept of that is that there’s an autoimmune condition in the mother, meaning she develops a condition where her body incorrectly recognizes her own platelets as foreign and says, “I’m gonna attack these, and I’m gonna kill them.”
And that happens sometimes with conditions like lupus, it could happen rheumatoid arthritis or thyroid conditions where the body incorrectly identifies something that’s supposed to be there as something that’s not supposed to be there and starts attacking it. And based on what they’re attacking, knows what the symptoms are. There is one for platelets. It’s hard to know for sure because there isn’t a good antibody test for this. It’s not like you can draw blood and say, oh, you have this versus you don’t.
It’s not a diagnosis of exclusion per se, but it’s sort of one of these situations where if the platelets are dropping low enough that it’s hard to call it gestational thrombocytopenia anymore, we sort of flip and say, it’s probably this ITP. And some people believe they’re actually the same condition, just a different degree. Some people believe gestational thrombocytopenia is like a temporary, mild form of ITP, where women develop few antibodies when they’re pregnant. Some people believe they’re totally separate.
We don’t really know but the real practical distinction is the number. If the is high enough, it’s probably gestational. And, in particular, if her numbers are high when she’s not pregnant, it’s probably gestational. Whereas if they’re very low or if they’re sort of borderline low when she’s not pregnant, then it’s probably some form of this ITP, which is autoimmune. The other ones are like medical problems or she has preeclampsia, which is, you know, acute condition that happens in pregnancies, drop your platelets. Or she developed some crazy medical condition which could happen.
But ultimately, I would say, you know, in our experience, the two most common and the ones that we’re almost always going back and forth on trying to figure what is this, either gestational thrombocytopenia or ITP. Is that what you found in your own practice thus far?
Dr. Aksel: It is. And a lot of the questions that I typically spend time in the office answering when platelet counts come up is really, you know, “There was nothing wrong with me before, where is this coming from? Is it gonna get better?” And usually, it’s very reassuring. You know, it’s a simple explanation that this is probably pregnancy-related and that it will resolve. It’ll go back to normal if you never had abnormal values before outside of pregnancy, chances are that once you’re done with the pregnancy, your levels are going to normalize again.
Dr. Fox: In terms of trying to differentiate whether it’s gestational thrombocytopenia or whether it’s ITP, it usually does not matter. There’s not much of a significance between the two. There are some things we need to know we’ll talk about but basically, the most important issue is what is the actual number? What is the platelet number? Meaning if someone’s platelet count is 90, it doesn’t really make a difference to us what the diagnosis is. It’s just that they’re 90, whereas the same thing if they’re 60, it doesn’t matter that much between those two, what the diagnosis is other than the number.
And the reasons we care about the number is number one is the number high enough that you won’t have an issue with bleeding. It’s like her own medical health, which is on our minds but rarely an issue because they rarely drop low enough for that to be a concern. They’d have to drop below 50 for a C-section and below 20 for a vaginal delivery. They can get really low before it affects the mother and a risk of bleeding. But what ends up happening practically, and this is what, you know, 9 out of 10 or 99 out of 100 women who we were talking about low platelets. The conversation is, “Can I get an epidural?”
By I, I mean the woman in labor, not me the doctor. That would be interesting if were the one in labor. So it’s really an issue, can she get an epidural? Why is it an issue getting an epidural if your platelets are low, potentially?
Dr. Aksel: So when you’re getting an epidural, it’s a very small space that a trained anesthesiologist is placing a very small needle but there can be some bleeding. And as we discuss, platelets are very instrumental in making sure that you don’t continue bleeding, that you’re able to clot if something goes wrong. So making sure that even if there is a little bit of bleeding in this very small space, making sure that it stops is important. Making sure it doesn’t accumulate and you end up with something called a hematoma could be very important because, in that small space, you have your spinal cord. And I’ve been told by neurologists, spinal cords are important and they should be left alone.
Dr. Fox: They should be left alone. It’s a tough area because number one, it’s a very small space that they’re working in and trying to get into. And number two, it can’t be seen by them. They’re doing it by feel, by touch. Meaning if you’re working on someone’s arm and you’re putting the stitches, you can see if they’re bleeding or not. You just look at it, either they’re bleeding or not bleeding. Whereas if you’re trying to work inside the body without opening the body, you have to just go by touch and by feel.
And so the anesthesiologist would not know if there’s bleeding internally that’s not stopping near the level of the spine unless the patient had symptoms from that. And the symptoms once that happens is really dangerous, like severe pain, or she can’t move her legs as well. I mean, when you start affecting the nerve and compressing the nerves, and sometimes you need emergency surgery like spine surgery to relieve that. So the anesthesiologists are justifiably and correctly very cautious about putting an epidural or a spinal if you’re having a C-section, any needle inside someone’s spine, near their spinal cord or into their spinal cord when there’s any concern that they may not have proper clotting, and they may be at increased risk for bleeding.
So, there is no specific number cutoff for platelets above which it’s safe and below that which it’s not safe. It’s all the lower it gets, the higher the risk, and different anesthesiologists feel differently about this and different women feel differently about this. And it ends up being a conversation about whether it’s an option to get an epidural in labor or a spinal for a C-section based on the platelet count. And so that number is important.
Dr. Aksel: And thankfully, you know, you said a lot of really scary stuff but thankfully, it’s very rare that we end up having patients who have a relatively normal platelet count end up being at high risk for those very severe and very serious complications from epidural placement.
Dr. Fox: Yeah. I mean, the risks of those are, you know, in the 1 in 10,000, 1 in 100,000, like that type of number that’s very close to zero but never zero. And part of the reason is that the anesthesiologists don’t select sick people or people at increased risk to place the epidural. They place in every single person 100%, then yeah, they’d have more complications but they’re able to know, “You’re an increased risk of bleeding, you’re an increased risk of bleeding, we’re not going to do it.” And so what happens is practically, you know, again, it depends where you are regionally in your own hospital.
In our hospital, if the number’s above 100,000, pretty much every anesthesiologist is comfortable putting in an epidural spinal. Again, if we think it’s either gestational or ITP. If there’s like a medical condition, that’s a separate issue related to that condition. Above 90,000, that’s probably the same, even above 80,000, that’s probably the same. And I would say above 70, the majority are probably okay with it. Maybe some aren’t. Under 70 is where it starts getting difficult to find anesthesiologists who are comfortable with it.
And there are some that might under unique circumstances based on specifically your history what’s going on, but that’s when it really starts getting difficult to sort of know that an epidural spinal is an option for you. Once it gets below 80 or below 70. Now, let’s say you have a patient who she doesn’t want an epidural. She’s like, “You know, great. I’m not looking for an epidural. I was planning on delivering naturally. I don’t want one. I don’t need one. Why would I care if my platelets are 60,000?” How would you respond to that?
Dr. Aksel: I know that at the end of this journey, you’re going to deliver and when you deliver, you’re going to bleed. And so making sure that that bleed is as controlled as possible and that your body’s natural instincts and system is in place to stop the bleeding are going to kick in is really important for me managing your labor and managing your delivery at the time that the baby comes out, whether that’s vaginal or by cesarean. If your platelets are that low, I might consider giving you extra platelets.
If they’re under 50 or under 40,000, I might want to have additional blood available that’s of your blood type. So there’s a lot of preparation that might need to go into managing labor and delivery in someone whose platelets are very low even if epidural isn’t something that they’re considering.
Dr. Fox: Yeah, I agree. And what else to tell women is we don’t know what’s going to happen moving forward. We can’t obviously predict… We can predict but we can’t tell what’s going to happen in the future. And so if I have someone who says, “I’m not going to get an epidural.” I’ll say, “Great. If you don’t get an epidural, then it doesn’t really matter if your platelets are 60, assuming they stay there, they should be high enough that you won’t bleed and you should have a safe delivery with those platelets. Okay.”
But what happens if in labor you change your mind and you’re in a lot of pain and now you want an epidural? Not an option for you. There are other options for pain management and they exist and they have whatever efficacy to some degree, not as good as an epidural typically, but that option would be off the table. And if she says, “Well, I’m 100% sure I don’t want an epidural.” I’ll say, “Fine. What if you ultimately need a cesarean?” If that happens and there’s reasons why it happens, typically, for a cesarean for a woman who does not have an epidural, they’ll place a spinal, which is the same concept. Which is the safest way to have anesthesia for a cesarean.
It’s the way where you can remain awake during the cesarean and is the lowest risk of things like aspiration, where you get, you know, contents into your lungs and that’s done with a needle in your back the same way. And so that will be on the table for you as an option. And now if you need a cesarean you have to be put to sleep, which is doable and usually safe but high-risk. It’s definitely not a good experience to be intubated. And you’re not awake when the baby’s born. When you wake up, you have more pain because when they do the spinal, they inject morphine into your spine.
And so there’s a lot of things that on our end, as the obstetricians, we think about. You know, like what if A, what if B, what if C, what if D, that even if someone’s, you know, planned birth of E, you know, if what they want and what they hope to have doesn’t have an epidural in it, we know that there’s always these other options that may come up. And so we think about those as well. And it’s one reason why we might want someone’s platelets to be in that zone where they could get an epidural, even if they don’t plan on one, even if they strongly don’t plan on one.
Dr. Aksel: Absolutely.
Dr. Fox: And then in terms of what could we do if the platelets are, let’s say dropping below 70, what are the options in terms of treatment?
Dr. Aksel: So if this is something that we’re following routinely in the outpatient setting, in addition to getting regular levels, we might refer a patient to hematology. So we might consult the specialists in blood disorders. They might consider giving additional medications to help kind of build-up and raise your platelet counts in hopes that when delivery comes, you have a robust number. So that no matter what happens, we’re prepared and we’re safe.
Dr. Fox: What’s interesting is the treatments that are used to try to improve the platelets are ones that affect the immune system like steroids, or sometimes something called intravenous immunoglobulin or IVIG. And those, since they’re affecting the immune system really would only work if the problem is immune like ITP. But again, usually, you wouldn’t even need the treatments unless the numbers are low enough that we think it’s ITP. So they usually come hand in hand, meaning if someone has a platelet count of 90,000, we don’t feel like they need treatment because they’re still in an okay zone.
One thing we sometimes consider is if we see a trajectory of them heading downwards, we might say, “You know, just so we don’t get into that space, maybe we should consider an induction of labor. Let’s say 39 or 40 weeks to do it while your platelet count is still normal.” Again, that’s a conversation. There’s upsides, there’s downsides but it’s something we might consider either in conjunction with treatment or before instituting any treatments. And one of the interesting things is if we believe it’s ITP, that is the one that actually also has a small risk, under 10%, but a risk of the baby being born with low platelets.
Meaning if the mother has gestational thrombocytopenia, the baby’s platelet count will be fine. If she has ITP, there is a percentage of those babies where the antibodies that are doing it to the mother, get to the baby and attack his or her platelets and they could be born with low platelets. There isn’t much we do differently about that. And the baby’s platelets are checked routinely after delivery but it might be a reason why, you know, we wouldn’t do certain procedures like forceps or whatever if we think that there’s a risk of the baby’s platelet count being low and not being able to clot their own blood so well.
But it does not mean they need a cesarean, it’s just something that we make note of and obviously let the pediatricians know as well. So what do you do practically, let’s say you have a situation where you’re checking someone’s blood count routinely. They’re around 28 weeks and the platelet count comes back at let’s say 110,000.
Dr. Aksel: I would tell them that it’s a number. It’s a number that’s under 150 but it’s over 100 and I’d probably want to recheck it. You know, there’s not much to do right now other than watch and wait and repeat and see if that level is going to stay stable, or if it’s gonna start going down.
Dr. Fox: Yeah. And I think the majority of the time that plan’s in place, the number does stay above whatever number we deem is necessary. And it just means a couple of extra blood draws and then they go have a delivery with, without an epidural. Everything’s fine. The time when it starts dropping to the point either at or below a number that we’re concerned about for an epidural, that’s when we consider treatments, you know, with steroids, sometimes seeing a hematologist, maybe meeting with the OB anesthesiologist to find out what their threshold is, potentially inducing labor and whatnot.
And if it really drops, you know, below 50 or something, then we’re talking about treatment and potentially giving platelets to someone when they’re delivering, which is again, very unusual under these circumstances. And I think that the takeaway message is this comes up a lot in pregnancy. We think about it a lot but most of the time it’s completely benign, nothing to worry about. Everything’s going to be fine and periodically treatment needs to be there or some intervention but very rarely does it ultimately end up that someone can’t get an epidural or needs platelets or will be put to sleep for a cesarean or they’ll bleed too much or something like that. That’s very, very unusual, particularly if you’re on top of it. We’re on top of it as doctors.
Dr. Aksel: Yeah. I mean, the majority of the time, it ends up being a non-issue.
Dr. Fox: Sarp, thanks for coming on to talk about the platelets.
Dr. Aksel: I love it. I love the platelets.
Dr. Fox: The thrombocytes.
Dr. Aksel: The thrombocytes.
Dr. Fox: As medical says. Wonderful. All right. We’ll see you all. Have a great day. Thanks, Sarp.
Dr. Aksel: Take care.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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