Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document any presenting complaints related to thrombocytopenia (unlikely) or the reason for the prenatal visit.
History of Present Illness:
Gravidity, parity, and estimated date of confinement (EDC).
Onset and duration of any bleeding symptoms (e.g., petechiae, epistaxis, menorrhagia).
History of previous pregnancy complications (e.g., preeclampsia, gestational thrombocytopenia).
Review of systems focusing on potential causes of thrombocytopenia (e.g., viral illness, medication use, autoimmune diseases).
Past Medical History:
Underlying medical conditions that may contribute to thrombocytopenia (e.g., autoimmune disorders, liver disease, chronic ITP).
History of previous thrombocytopenia (outside of pregnancy).
Surgical history (including splenectomy).
Medication history (focusing on medications that can cause thrombocytopenia).
Family History:
Family history of thrombocytopenia or autoimmune diseases.
Social History:
Tobacco, alcohol, or illicit drug use (can affect platelet function).
Physical Exam:
Vital signs (assess for fever or signs of infection).
General examination (look for signs of bleeding, petechiae, or hepatosplenomegaly).
Laboratory Tests:
Complete blood count (CBC) with confirmation of thrombocytopenia (platelet count less than 150,000/mcL).
Peripheral blood smear (to assess platelet morphology and rule out other blood cell abnormalities).
Depending on suspected cause, additional tests may be ordered:
Coagulation studies (PT, PTT) – may be normal in isolated thrombocytopenia.
Hepatitis serologies (A, B, C)
Antinuclear antibody (ANA) and other autoimmune workup (if suspicion of autoimmune thrombocytopenia)
Assessment:
Gestational age at diagnosis of thrombocytopenia.
Severity of thrombocytopenia (mild, moderate, or severe).
Presence of bleeding symptoms.
Suspected cause of thrombocytopenia (gestational thrombocytopenia, preeclampsia, autoimmune ITP, other).
Fetal risks associated with maternal thrombocytopenia (depending on severity and cause).
Plan:
Monitoring:
Frequent monitoring of platelet count (depending on severity).
Non-stress test (NST) or biophysical profile (BPP) to assess fetal well-being.
Consider serial ultrasounds to assess for signs of fetal-maternal bleeding (placental abruption).
Management:
Treatment of underlying cause if identified (e.g., stopping offending medications, treating infections).
Consider intravenous immune globulin (IVIG) or corticosteroids for severe thrombocytopenia or autoimmune ITP, in consultation with a high-risk pregnancy specialist.
If preeclampsia is suspected, management will follow established guidelines for preeclampsia.
Delivery Plan:
Depending on the severity of thrombocytopenia, fetal well-being, and gestational age, consider:
Early delivery if severe thrombocytopenia poses a significant bleeding risk to the mother or fetus.
Vaginal delivery may be preferred with a platelet count above a certain threshold (individualized decision based on risks and benefits).
If cesarean delivery is planned, platelet transfusion may be considered to achieve a minimum platelet count before surgery.
Consultation: Consider referral to a high-risk pregnancy specialist and/or hematologist for co-management depending on the complexity of the case.
Patient Education:
Educate the patient about thrombocytopenia in pregnancy, potential risks, monitoring plan, and treatment options.
Discuss the importance of avoiding activities that could increase bleeding risk.
Encourage open communication and reporting of any new symptoms.
Follow-up:
Schedule frequent prenatal visits to monitor platelet count and fetal well-being.
The frequency of follow-up will depend on the severity of thrombocytopenia and the delivery plan.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. Management of thrombocytopenia in pregnancy should be individualized and involve consultation with a high-risk pregnancy specialist and other relevant specialists as needed