Midwives are experts in the care of normal pregnancy/birth, but are also professionally accountable for detecting deviations and initiating immediate referral to an appropriate expert (Nursing and Midwifery Council (NMC), 2012). Although the scope of midwifery practice does not include medical diagnosis, as front-line carers, midwives are well placed to make appropriate assessments regarding the health of pregnant women (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Further, it is essential that midwives build a relationship of trust with women and work in partnership, sharing information and consulting regarding their care (NMC, 2015). Care should be tailor-made, offering choices and a service that delivers personalised and safe care for all women and their babies (National Maternity Review, 2016). Midwives are also required to work across professional boundaries (Kirkup, 2015), especially where complex conditions require the involvement of doctors, such as immune thrombocytopaenia (ITP) in pregnancy. Multidisciplinary working is also key to ensure that women receive the correct treatment, particularly when a pregnancy deviates from the norm and becomes high risk owing to an altered health condition.
As an autonomous practitioner, the midwife is viewed as a specialist whose expertise and knowledge base are considered fundamental components in ensuring that women have a safe and life-enhancing experience of childbirth (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). It is recommended that each woman should have a named midwife who cares for her throughout her pregnancy. This model of continuity of care can limit the risk to women and babies, preventing incidents and serious adverse outcomes (National Institute for Health and Care Excellence (NICE), 2008). Such integrated models of care are crucial in minimising the potential morbidity associated with ITP (Gernsheimer et al, 2013).
Midwives should be familiar with the change in terminology from ‘idio pathic thrombocytopaenia’ to immune thrombo cytopaenia (McCrae, 2011). This complex condition arises as a consequence of altered immunity; antibodies alter glycoproteins on the surface of platelets, impairing platelet production by rapid destruction of platelets by the spleen (Stasi, 2011). This results in a diminished number of circulating platelets, which, if severe, increases the risk of haemorrhage (Semple et al, 2010; Kühne et al, 2011). In pregnancy, the normal range of platelets is 150–400 × 109/L, which is less than non-pregnant values (Lefkou and Hunt, 2015). The international working group on ITP (Rodeghiero et al, 2009) provided a cut-off for ITP as a platelet count of < 100 × 109/L in the absence of other causes for thrombocytopaenia. Midwives are referred to a recent paper with more detailed discussion on platelet physiology in pregnancy with varying types of thrombocytopaenia (Boothman, 2016); however, the focus of this paper is on ITP. Unlike other autoimmune diseases, ITP is not exacerbated by pregnancy (Parnas et al, 2006; Sukenik-Halevy and Fejgin, 2008); indeed, it is reported that maternal/perinatal outcomes for women with ITP are mostly positive (Suri et al, 2006). Nonetheless, midwives must be aware that although rare (< 1: 1000 pregnancies) possible complications of maternal/fetal haemorrhage may arise (Terrell et al, 2010; Kistanguri and McCrae, 2013). The clinical presentation of ITP may be obscured by signs of normal pregnancy; for example, progesterone-induced bleeding from the gums. However, nosebleeds, bruising and continued bleeding from acu punc ture sites should always be viewed as abnormal and midwives should advise women to report these (Cines et al, 2009; British Committee for Standards in Haematology, 2012). Risk of intracranial bleeding is very rare (< 1: 1 000) and some of the presenting features may mimic pre-eclampsia (e.g. alterations in the visual field and headache) (Fogarty et al, 2012). Other signs and symptoms include: hypertension, bradycardia, nausea and vomiting; all of which are possible signs of raised intracranial pressure (Roytowski and Figaji, 2013). Presentation of these symptoms requires immediate referral to a doctor for a full neurological assessment (NMC, 2012).
Key aspects of care for women with immune thrombocytopaenia
Antenatal
Booking history and case note review
Although a full history is always important as part of a risk assessment, midwives should note that neither age, gender nor ethnicity confer protection against ITP (Fogarty and Segal, 2007). Ibuprofen should be avoided in pregnancy (NHS Choices, 2016); however, women should be reminded that this drug, along with aspirin, is contraindicated with ITP due to the effect on platelets (Myers, 2012). A dental hygiene assessment should be sought for gingivitis. The pattern of care should be tailored specifically for women with ITP; this must be obstetrician-led in conjunction with midwifery care and specialist haematologist input. Antepartum assessments should take place monthly in the first two trimesters, every 2 weeks after 28 weeks, and weekly from 36 weeks up to birth (Provan et al, 2010). Women with ITP may already be members of a national support organisation, but if not, the midwife should direct them to such groups (Box 1).
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ITP Support Association
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ITP Foundation
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ITP–immune thrombocytopaenia
An assessment by the anaesthetist should be undertaken in the antenatal period to review platelet function prior to labour and birth; a plan of care should be documented in the case notes.
Serum testing
ITP may present early in the first trimester; however, in the absence of bleeding and a platelet count under 30 × 109/L in the second trimester, women only require ongoing assessment. In the third trimester, as labour and birth approach, higher platelet counts (> 50 × 109/L) are required (Kappler et al, 2014). Where counts do not fluctuate, they should ideally be assessed monthly and at least once per trimester (Nicolescu et al, 2013). Midwives should ensure all blood results are suitably recorded and retained and that a doctor has indicated all results have been reviewed.
Treatment
This is only required where there is evidence of bleeding or the platelet count is below 20 000. The main treatment options include the following:
Intrapartum
Owing to the risk of haemorrhage after birth, women with ITP should be advised to give birth in a fully equipped maternity unit with easy access to blood transfusion. Lower platelet levels will have an impact on the availability of epidural (> 80 × 109/L is required for epidural) and on the management of third-stage blood loss (van Veen et al, 2010). The mode of delivery is determined by maternal condition, and elective caesarean section does not improve outcomes (Provan et al, 2010). However, before surgery or anticipated operative vaginal delivery, platelet count should be taken and should be higher than 50 000 to minimise the risk of bleeding (Gernsheimer, 2012). Midwives should ensure the anaesthetist is informed of the woman's admission to the labour ward, recent platelet results accessed and a wide-bore cannula sited. All of these measures are precautionary in the event of excess bleeding in the third stage of labour. The risk of bleeding may persist in the immediate postpartum, thus close monitoring of blood loss by the midwife is required. All loss and clinical observations must be clearly documented (NMC, 2015).
Postpartum
The risk of fetal ITP is high due to antiplatelet IVIG antibodies, which may enter fetal circulation via the placenta and cause fetal thrombo-cytopaenia; this may not be evident until 2–5 days postpartum. Consistent observation and assessment of the neonate is required because, in 5–10% of cases, the thrombocytopaenia is severe (Kistanguri and McCrae, 2013) and may require admission to a neonatal unit. Neonates should be carefully monitored for signs of neurological deficit, which may indicate intracerebral bleeding; however, this risk is very low (Stavrou and McCrae, 2009). Women should be educated about the signs and symptoms and informed on how to request urgent assistance.
Conclusions
Most women with ITP have good outcomes in pregnancy with only a few requiring first-line treatment. However, close monitoring of maternal and fetal wellbeing are required to detect complications. Midwives should ensure women are given adequate antepartum appointments with one-to-one care being the ideal; there should be an opportunity to provide contact details of support groups. Clear information on the signs and symptoms of a falling platelet count with clarification on when to seek medical or midwifery advice should be provided. Midwives may help to minimise complications by advising women to avoid certain medications. Elective operative delivery does not provide better maternal or fetal outcomes over vaginal birth, but options for analgesia may be limited. Midwives must ensure all women with ITP who are in labour have been assessed by the medical team and that intravenous access is maintained in the event of severe bleeding. Diligent management of the third stage of labour is even more crucial for women with ITP and close observation for postpartum bleeding should ensue. Finally, the midwife must be aware that a small proportion of neonates may present with signs and symptoms of bleeding and this may take several days to manifest.
Revalidation claim: Continuing professional development/40 hours
This section provides an example of how this article might be used as material for reflection for use as part of a midwife's revalidation with the Nursing and Midwifery Council (NMC). Evidence for revalidation should be linked to the NMC Code and should demonstrate the impact that the learning has had on your practice.
| Nursing and Midwifery Council Code | Description | Focus of revalidation claim √ |
|---|---|---|
| Prioritise people | Act in the best interest of people (service users) at all times | √ |
| Practise effectively | Use best available evidence to assess client need and deliver treatment/care/advise on care | √ |
| Preserve safety | Work within your skills and knowledge (competence) and use your skills and knowledge to keep people (clients) safe | √ |
| Promote professionalism and trust | Act in line with the standards of practice and behaviour to uphold the reputation of the nursing and midwifery professions |
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London
| Questions to consider | Example answers |
|---|---|
| What did you think about on reading this clinical practice article? | This article was useful for increasing my awareness of contemporary issues around immune thrombocytopaenia (ITP). This complication of pregnancy poses risks for labour and birth. The article summarised key priorities of care, providing reference sources to promote evidence-based practice |
| Why do you think the content made you feel like this? | The content of the article reassured me that my current level of understanding is contemporaneous and allowed me to access further reading |
| What did you learn as a consequence of reading the article? | The article gave a general overview of ITP with areas of good practice recommended by national bodies. In particular, it allowed to me reflect on the possible dangers of a low platelet count in pregnancy e.g. postpartum haemorrhage. This reminded me of my professional accountability in respect of the Nursing and Midwifery Council (NMC, 2012) Midwives rules and standards and Rule 5: Scope of Practice. It also made me reflect on the role of the midwife in demonstrating compassionate care by communicating with women, offering reassurance and acting as an advocate (NMC, 2015). |
Nursing and Midwifery Council (2012) Midwives rules and standards. NMC, London
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London
| Questions to consider | Example answers |
|---|---|
| What have you done to complete the learning? | I read two further articles: |
| What is the effect of your learning? | This article included the British Committee for Standards in Haematology guidelines on management of ITP. This reminded me that signs/symptoms should be treated seriously. Midwives must act within their rules and ensure immediate referral |
| What will you do differently as a result of reading the article? | I will use the article with student midwives to discuss the outcomes for ITP pregnancies, careful history taking and rapid referral. In discussing the evidence, I will refer to: Parnas M, Sheiner E, Shoham-Vardi I et al (2006) Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol 128(1–2): 163–8 |