Thursday, August 29, 2013

Low platelets and postpartum hemorrhage

Time for some crowdsourcing!  A reader just emailed me with a request for information about low platelets and the risk of PPH. Here's her situation:

Hi Rixa,

I'm a long time blog follower and have loved following all of your births. I had a homebirth two years ago - I switched to a homebirth at 40 weeks after I was risked out of a birthing center for the baby being 'too high, too big, and too much fluid.' I ended up with a wonderful positive homebirth experience (although I did push for 4 hours!!) Your blog was especially comforting while I was anxiously awaiting my son (he arrived at 42w3d).

I'm 38 weeks with #2 and everything has been great. But I just found out my platelets are low - they were 109 at 28 weeks, 90 at 37 weeks, and 83 yesterday. My CNM's have referred me to an OB, who is recommending I do a hospital birth. She has also referred me to a hematologist - who I just met with in the spirit of gathering as much info as possible. The OB was actually quite pleasant to speak with - she understands my desire for homebirth and seems very supportive of natural hospital birth. I'm just not sure at what point I should actually be thinking about a hospital birth. I have read many conflicting articles, blog posts, etc. on the subject in the past few days.

PPH is the worry - but the frustrating part is that nobody (OB or hematologist) can tell me what the actual percentages are for PPH with a low platelet vaginal unmedicated birth. The hematologist said there is no risk to the baby at birth, so the main concern is me. He wanted to prescribe steroids to increase my platelets which he says also has no risks to the baby (I disagree). The CNM's did say they felt the treatment for PPH would be the same at home as in hospital - but they are not comfortable going against the OB and hematologist recommendation for steroids/hospital birth. I have another midwife I can use (CPM), but I just want to make sure I'm being smart about the decisions.

If you wouldn't mind posting some of the questions, that would be wonderful. I would love to find out if anyone has had personal experience, and what the outcomes were.

Thank you!
I'm super busy with the start of the semester. If anyone can provide information, or has dealt with low platelets personally or professionally, please help her out!

29 comments:

  1. In the event of a life-threatening PPH, you want to be in a hospital. An acquaintance of mine died of a severe PPH because she thought she could have her homebirth, far away from hospital support, with a low RBC. She bled out before anything could be done. She had six other children.

    My stepmother, who did NOT have a low RBC, birthed in a center and had to transfer to the hospital after the birth. They made it in time, but she was in the hospital for a fair bit and (may?) have had a transfusion. She was completely healthy, had excellent nutrition and exercise habit and no risk factors.

    If you choose to have a homebirth, please listen to your hematologist, take the steroids, and let the midwife give you a managed third stage.

    PPH is one of the leading causes of maternal mortality worldwide. I wouldn't mess with it.

    ReplyDelete
  2. Reasons to be in hospital:
    --if you need a second (or first, honestly) large-bore IV established quickly.
    --rapid access to blood transfusion
    --airway protection (if you have to be intubated)
    --rapid access to drugs beyond Pitocin (prostaglandins, cyotec, Methylergonovine, etc)

    Basically, at home you can only manage stage 0 of PPH (active management + fundal massage). There are 4 stages, and one can spiral into the other without warning. Here is a sample hospital protocol: http://mail.ny.acog.org/website/optimizing_hemorrhage/sample_hemorrhage_policy.pdf

    ReplyDelete
  3. I don't have any experience with low platelets, but I do with PPH. It is quite possible I would have died at home, but not necessarily. I will say this, PPH is scary. I have spent a lot of time researching and learning all I can about it to help overcome the trauma of my last two experiences. I have learned that you can lose so much blood as to also lose your ability to clot. That would be the biggest concern to me if my platelets were starting out low to begin with.
    I barely escaped a transfusion last time, despite losing nearly 2 liters of blood, because my blood count was surprisingly normal for being full term. Surprising, because I was anemic a few weeks before. If I hadn't started off with a blood count of 13, I would have been in much worse shape. I would definitely recommend doing what you can to get your blood as normal as possible before birth.
    If you would like to read my personal experiences you can check out my blog http://choresofopportunity.blogspot.com/

    ReplyDelete
  4. As much as I would like to say "have your homebirth" I have that fear of knowing about PPH in the back of my mind. I truly believe that the majority of births can go off without a hitch and that in hospitals we over-manage the whole process. But there are some things you don't want to mess with and the potential to bleed out is one of them.

    If you have an OB who is supportive of natural hospital birth and you feel like you will be heard then I would go with a hospital birth and a good birth plan. Research the doc to make sure she isn't just saying things to appease you. Ask doulas, midwives and others in your area what they think.

    Stay home as long as possible and get a saline block instead of an IV if things are going well.

    ReplyDelete
  5. Whether or not things seem to be going well has nothing to do with whether or not you develop PPH, though...if you know your platelets are low, why not have the large-bore IV started and ready to go? Doesn't hurt any more than the hep lock.

    (so, my husband is an ER doc, and the procedure they have to go through to get an IV started on someone who has had severe blood loss is NOT something I ever want to experience. EVER EVER EVER. OMG, NO. NONONO. They drill into your bone marrow. If you're in the hospital already, things probably won't get to this point, but ack).

    ReplyDelete
  6. I loved my three homebirths, but I would not mess around with this one. I had a relatively small and easily controlled PPH with one of my hospital-born kids (EBL < 1L); the recovery was still far tougher than any of the other four births. And honestly, I would have reservations about the judgment of a CPM who would attend a homebirth with such a clear risk factor.

    ReplyDelete
  7. Thanks for all the replies (I'm the reader that posted the question), but I feel I need to clarify.
    The risks of PPH are not known to be higher with low platelets - for a vaginal birth with no other risk factors. The concern is that IF I were to have a PPH it MIGHT be an issue that my platelets are low (although they also do not seem to have any data on this).
    So my questions are really:
    1. has anyone been through this and what course of action did you take?
    2. What was recommended by your OB/Hematologist in terms of 'safe' numbers (meaning at what point did they recommend treatment such as steroids?)
    3. Has anyone taken steroids during late pregnancy, and what experience did you have with them? I'm nervous about the possibility of glucose levels rising, as well as complications in birth with steroid use.
    Thank you!

    ReplyDelete
  8. The closest thing to direct experience I have for you is my own mother, who had anemia, then a PPH following a C-section (placenta previa, breech baby). She had to have a transfusion. On the steroids--my friend had to have them for her baby's lung function. Kid is fine.

    Look, honestly, I would trust my hematologist, the midwife who risked me out, my OB, and other people with massive amounts of medical training more than I would trust a group of people on the Internet. Aside from which, *even if* we're going off subjective experience and anecdotes, we've all only got our own experience and that of our families and friends to draw on. The specialists you have seen deal with hundreds of pregnant women a year. Trust them.

    And I have to second the reservations about a CPM who would be willing to attend a birth where CNMs will not. At least where I live, a CPM has nowhere near the training of a CNM, let alone that of the other specialists you have seen.

    ReplyDelete
  9. Here are my thoughts as a previous labor and delivery RN and non-practicing CNM:
    Low platelets puts you're way behind the 8 ball should you have a PPH. Low platelets don't increase the risk of PPH happening, though. But if you have other risk factors for PPH (like big baby, polyhydramnios, long second stage) I'd be very concerned. As a CNM I would not want to manage your care in the hospital by myself given this risk. I would make sure my MD on call was in house during second stage and ready to help should you have a PPH. BUT there are many MDs who would want to care for you during your labor and birth without a CNM, which is extremely reasonable given your clinical situation and risk factors. The MD you consulted seems like a good choice as she is supportive of your wishes while being in the hospital.

    Homebirth is not at all safe in this situation, and I bet that totally sucks to hear. And hopefully what will happen is an uneventful labor, birth, and postpartum recovery in the hospital, which will make all the preparation seem pointless. But should you need quick life saving care, the hospital is the place to be.

    As a nurse I've cared for women with low platelets, and depending on how low they were (I think 75k or less) we gave IV steroids during labor. During their prenatal care when I was working as a midwife, we consulted OB and hematology and followed labs closely. There were no untoward events that I can recall.

    Good luck!

    ReplyDelete
  10. "And honestly, I would have reservations about the judgment of a CPM who would attend a homebirth with such a clear risk factor."

    ^ This. The risks of a hospital birth are present but they pale in comparison to the risk in your case of an uncontrollable PPH at home with someone who can do little except call an ambulance. It sounds like you have found a supportive OB, so the potential benefits of hospital birth far outweigh the costs.

    Also, as a general commentary I'm a little put off by the idea of "crowdsourcing" advice on something like this. The best course of action is always to seek multiple professional medical opinions (with CNMs or MDs) rather than relying on lay people for medical advice over the Internet. In this case the risks are pretty clear so the professional and lay advice are likely to coincide, but in fuzzier cases how do you evaluate which responses are based on reliable evidence?

    If you find a consensus among enough trustworthy medical professionals it will be based on the best scientific evidence available and probably personal experience of several cases similar to yours, while at best the CPM or another lay person can lean on the few cases they've seen or something they've heard/read. There's a lot more room for error and they can never be held responsible if harm results from their advice. This could be a life-or-death situation, why would you ask a non-expert?

    ReplyDelete
  11. Thank you again for all of the comments. I do understand what you are saying - but the problem is that the experts seem to be across the board in recommendations. Today I spoke with another OB who said she would not recommend the steroids unless I was closer to the 50,000 range for platelets. So there is a huge variance of information and when I asked about specific studies and numbers the hematologist said none exist. So it's basically an issue of risk of steroid use (which there are risks involved), versus a potential risk of PPH. I don't want to base my information off just crowdsourcing, but do feel it helps to gather as much information as possible in this situation. Knowing that this blog has many professional followers (CNM's, CPM's, etc) I thought I would reach out. I should have also clarified that the CPM said she would be comfortable doing my homebirth IF my platelets stayed in the 80 range like they are now (and she would continue to test them).

    ReplyDelete
  12. Good luck, mama, and keep us updated, please.

    I get what you're saying here - that this knowledge/factor doesn't increase the risk of PPH, but if you do have PPH then it's serious/worse. I also get your frustration - that the medical professionals are saying different things, and that there aren't studies or numbers to look to.

    ReplyDelete
  13. Is there an option of laboring at home with the CPM and then going in to the hospital as close to the birth as possible? That's what I did with my son after experiencing a shoulder dystocia with my daughter. But I live in NZ where the midwives can provide care at home and in the hospital.

    Also, to challenge your thinking just a little bit, on what basis does your CPM feel comfortable attending you at home with a platelet count 80? If there's no research, shouldn't she be held to the same standards as the other HCPs you're interacting with?

    ReplyDelete
  14. My thoughts as an ob---no great data to support the steroids but not harmful. If given for several days antenatally you may need a larger stress dose of steroids during delivery to prevent adrenal problems. I've seen life-threatening hemorrhages occur with seemingly uncomplicated vaginal deliveries without risk factors and done an emergency C-section for cord prolapse on a mom w/ HELLP and platelets of 37k without any bleeding problems. Obstetrics is unpredictable--bad things happen when we least expect it and I'm frequently preparing for the worst but hoping and encountering the best. Also, anesthesiologists are unlikely to do regional anesthesia (epidural or spinal) with platelets that low so you can be assured that a hospital birth would still be unmedicated.

    ReplyDelete
  15. I'm a midwife in Canada. I have had women in my care with platelets in your range. We would not do a home birth because, as previous people have said, there are potential problems with a PPH *if* it happens - not that you are guaranteed to have one.

    You may not be eligible for an epidural (even if you wanted one) if they are not over 100 when you go into labour.

    I have never seen or heard of anyone getting steroids to increase platelet count (despite OB consults in some cases). I don't think it's something we do in my area of the world.

    One other thing to consider - have you had blood work done at the hospital or just a community lab? We have been finding that women who have low platelets when blood work done at the community lab, have levels that are just fine when repeated at the hospital lab. Any chance you could get a requisition and get it checked there if it hasn't been already?

    ReplyDelete
  16. I've got really low iron and low platelets. i take raw iron 3x day as well as floradex. I've been taking Yellow Dock to help with platelets and you can also do vit K tincture. i'm at 32 weeks and my numbers are going up, slowly but steadily. we are also planning to do pitocin shot immediately after birth to help prevent hemorrhaging. i also have a history of retained placenta (with my first, but no issues with my second...).

    ReplyDelete
  17. I just had baby #4, and was risked out of homebirth for this very issue. My numbers dropped to 72. I can't tell you about risk of PPH after a vaginal birth, I ended up with an emergency section for placental abruption.
    I can tell you that after my section, I lost a liter of blood. My platelets dropped further to 50 (obvious reasons) and the steroid shot they gave me upped my levels back into the 70's by the next day.

    I wouldn't screw around with low platelets and a home birth. As much as I wanted a home birth (and ended up with the complete opposite of anything I wanted), there are definitely times to risk out. A wise midwife would follow that plan.

    ReplyDelete
  18. I had falling platelets during my last pregnancy. My hospital based CNMs consulted with their OB and told me I would need to be tested during labor and would possibly risked out for an epidural, and they'd want to know what my platelets were like if I needed a section, but otherwise not to worry.

    I never found out what would happen because I had a precipitous birth at home. Cord prolapse, retained placenta, PPH. I ended up fine, but anemic. My baby died - the cold comfort is it had nothing to do with my platelets.

    I still would have to agree with the above posters. Knowing when to risk out is a blessing.

    ReplyDelete
  19. Just a quick update - I got retested at the hospital lab as suggested here and by another midwife - and my platelets came back at 101 (considered safe zone). So I will get retested at the hospital next week to see if they stay stable and go from there (fingers crossed) Thanks for all of the input and suggestions.

    ReplyDelete
    Replies
    1. I am sooo glad u went to GET RE-TESTED!!

      Seriously. I believe much if our society and culture just takes everything to b the truth at The first glance. .

      IF I was in your position...hmmm I would DEFINITELY take stock in the super-momma Feminine energy.....and also add blackstrap molasses and lentils and vit.C to days.

      I would also wear earplugs. To the naysayers...geez I just sooo believe the female body is meant and will try as hard as ever to regulate and accomplish the impossible!

      Keep up the grwat work and being resource ful!!

      Delete
  20. I had idiopathic thrombocytopenia purpura (ITP) or low platelets with all 3 of my pregnancies. I had a C-section, hospital VBAC & then a home birth. My midwife used the nutritional approaches to bring my platelets up. Luckily, I've never had to take prednisone. Please see my blog post (the middle part): http://reflectingtheheart.blogspot.com/2011/10/pregnancy-update-33-weeks.html I would also highly recommend following the Weston A. Price foundation diet recommendations for pregnant women: http://www.westonaprice.org/childrens-health/diet-for-pregnant-and-nursing-mothers It advises raw whole milk, grass fed meats, liberal amounts of fat from healthy sources, bone broths & pastured eggs. I truly believe it would have helped my condition.
    I had easy & fast home birth. No bleeding problems. My homebirth midwife did a uterine massage after birth & gave me IM shot of oxytocin. Most homebirth midwives carry oxytocin injection, IV starter kit & IV fluids with them.
    If you are doing everything you can & your platelets are still testing low, ask your lab to do a MANUAL instead of machine platelet count. My platelets tended to clump together so every time we did a machine count, they came back low.

    ReplyDelete
  21. This comment has been removed by the author.

    ReplyDelete
  22. Also, low platelets & iron deficiency anemia are 2 different conditions. Iron supplements will NOT treat low platelets.

    ReplyDelete
  23. You know, I did my share of "risky" food things while pregnant, but advising women to drink raw milk because of imaginary health benefits for their platelet counts? Really?

    I just glanced at the diet's website, and they recommend feeding raw milk, raw meat and home-made formula to infants. Sure, let's just go ahead and throw food safety out the window because it makes us feel natural...or something.

    And just for the record, I adore raw milk, raw milk cheese, steak tartare, etc---but I didn't feed them to my newborn, ffs.



    ReplyDelete
    Replies
    1. Actually, raw milk is safer than pasteurized milk: http://www.realmilk.com/safety/is-raw-milk-safe-for-babies/ They are completely different foods & are processed by the body differently. Weston A. Price foundations doesn't advocate feeding raw meat to infants, only raw liver to babies over 6 months of age since it's a great source of much needed & easily absorbed iron. Raw liver is a bit of a stretch for me, but my family has been consuming raw milk for the past 2 years without any problems. Here is an informative article about benefits of raw milk & some people decide the benefits outweigh the risks: http://chriskresser.com/raw-milk-reality-benefits-of-raw-milk

      Delete
  24. I can't comment on any of the medical advice, but I had an experience where I had planned a home birth and ended up going to the hospital (a simpler reason that our attending midwife was out of town when my very short labor came). I don't know what the hospital protocol is where you live, but I delivered in Germany, and here you can have an outpatient birth if you chose. This means that if everything is good with mother and baby, you can go home a few hours after birth and recover there. The exams and followup care happen at home (my midwife did the followup at home for the first 2 weeks). The baby's first exam (not including the one directly after birth) was done by our regular pediatrician rather than in the hospital. Though the birth was in the hospital, the recovery was at home and comfortable. So, if you decide the the hospital is the best place to deliver, if all goes well, perhaps a home recovery is still an option.

    I wish you and your family well and hope that you find peace of mind as you move into this big transition! Trust in you intuition and also in the medical research out there to support you.

    ReplyDelete
  25. I had low platelets in my third pregnancy. We were initially going to be having a home birth, but when my levels dropped below 100, our midwife was unable to do it (hospital funded home birth program). I was offered the steroid injections, to stabilise my platelets, and my MW also suggested i see a naturopath. I opted to not have the steroid injections, and saw a naturopath. After several weeks of drinking a disgusting concoction before every meal, and taking supplements, we saw my platelets go from the mid 70's to the mid 80's. As they were still not coming up high enough, fast enough, we had our care transferred to a higher risk hospital unit (the MW doing our care was able to come with us, she was such a blessing). When the time came, we made it to the hospital (just!) and had a very straight forward, drug free, labour and delivery. Upon our arrival at the hospital, i had an IV line inserted, in case of PPH, and blood taken to test platelet levels during labout. I had a managed third stage labour, and minimal blood loss. We went home 6 hours after the birth of our third son. It turns out, when i had the bloods done in labour, that the platelets were right on 100.

    I have since had my platelets checked again, twice. The first time i had them checked (6 weeks post partum), they were 120, and 6 months post partum they were at 149. Slowly creeping back up.

    For us, we were where we needed to be for our birth to be safe. We had a totally supportive, beautiful MW, and were comfortable with our decision. Good luck with the rest of your pregnancy, i hope you have as easy a birth as me xo

    ReplyDelete
  26. I wanted to let you know that I had a healthy baby boy last week at home. I ended up taking the steroids, and luckily only had to take them for a very short time. My platelets were well in normal range with the steroids and that gave me complete confidence to have the homebirth (and made the midwives confident as well). The only downside was then having to taper off the steroids while attending to a newborn - they made me a bit jittery and anxious, but I still think it was worth it to have the homebirth that I wanted.

    ReplyDelete
  27. Kate,

    I was just wondering if you ever found any reliable sources to answer your questions. I am in this boat (fourth pregnancy) and I'm sicknof being treated like I'm broken only to go on to have an uneventful birth without hemmorage and a platelet count in the 50's. I'm frustrated with the myriad of "opinions" from various professionals; none of which can site any reliable source. I so long for a peaceful homebirth where I can focus on birthing my sweet baby but because of the lack of research, no midwife will take me. The only hospital in the area is practically prehistoric in practice and I feel I'm in a corner. Please let me know if you ever found any answers! I sure would appreciate it!

    ReplyDelete

Related Posts Plugin for WordPress, Blogger...