39 wks preg, Prednisone for delivery, advice?

Hi all - I used to post here a little bit on the old board. Just coming for some advice & reassurance...

Backstory - dx'd with ITP when I was 10 - 19 years ago, on the heels of mono. Totally asymptomatic. Have never been treated, really (counts usually between 20 - 60K), minus one time to get some dental work done (Couldn't seem to sustain a count above 50K at that point - 3 yrs ago) - treated with WinRho - very limited success. Managed to get a 50 count long enough to get some root canals done - had no trouble (Last year, I took a bit of a calculated risk, and ended up getting more dental work done, without treatment, with zero problems with massive amounts of freezing - not my most responsible moment, but I've never had bleeding issues, so took the chance).

Since becoming pregnant - I recognised that I would be high-risk. I have a super wonderful high-risk OB/GYN plus a "Medical Disorders in Preg" (internal medicine) Dr. who is also very competent. I discovered early on as I was transferring my records from offices out of province, that my lab work came back indicating that my platelets were "very large". I vaguely remember this from when I was a kid. When I got my new OB - I requested we do manual counts, as I had done some research and found that the machine count can sometimes miscount oddly-shaped platelets. Suddenly, from the 37K I was sitting at previously, I had 60 - 65K!! I was pretty amazed as they seemed to be very stable and we all decided not to treat until pre-delivery (and even then we wouldn't) provided they stayed comfortably above 50K.

Last week after my CBC (count of 50K), I got a call from the Dr. that they wanted me to come in for treatment. I had decided early on that I was pretty opposed to being on Prednisone as I have had a family history of people really suffering mentally on it - plus they wanted to do a mg/kg and my preg weight is about 100kg.... I had an argument with the internal med Dr. about it, but my OB agreed to back me up, so we decided if treatment was necessary, we would use IVIG as a first course. I went into to hospital to get first round of IVIG. They came to do a CBC, I requested a manual count - the head of the phlebotomy refused to do it, and where my count had been 50K upon admission, it was now 29K. I figured, either way, no sense in arguing since more treatment would likely increase the odds of raising my counts. Sadly, not the case.

I went to the Dr. yesterday for my 39 wk check up - platelets at 44K (manual count). Got a machine count CBC yesterday, and I'm down to 25K. I keep making motions to insist on getting a manual count, but realistically, when I go to deliver - they will refuse, so I've resigned myself that it will just be better to compare similar numbers/methods - everyone is more comfortable with seeing the numbers go up and down in small increments, which is more likely the case if we don't switch between manual and machine counts.

She put me on Pred as follows (no argument here, I just want to be safe for delivery and have a healthy baby) - yesterday 50mg, today 60mg, tmrw 70mg, Sun. 70mg. (She did not think, with the time frame we are working with, that it would be responsible to put me on 100mg...I heaved a sigh of relief) She may want to induce me on Sunday depending on my counts and what my body seems to be doing.

I'm wondering if anyone else has had a similar dose of Pred (after other failed treatments) and what kind of results (if any) you experienced in the extreme short term? Did they have to taper you from such a short but high dosage? What are platelet transfusions all about? Is there any chance the IVIG may just be taking it's sweet time to work (had treatment on 18th & 19th Dec)?

I know realistically, I will have no epidural (which is why I'm not excited about induction), and if I need a C-section it will be under general anaesthetic, likely requiring a platelet transfusion...I'm just trying to wrap my head around what I can look forward to...

I consider myself very lucky to have had ITP this long and be so clueless about treatment. I read other folks' stories on here, and my heart goes out to them. I have very limited experience with the roller coaster of treatment, and for that I'm grateful. Thank you in advance for any advice you can offer & good luck with your own counts.

Stik:

If a person is responsive to Prednisone, counts can rise dramatically in a few days on a high dose. You might just get lucky there. No, it would not have to be tapered, but I would suggest going down more slowly after 20 mg's so your counts don't crash.

IVIG usually works within a few days, so if it didn't raise counts after 5 or 6 days, it probably won't. It's pretty temporary anyway.

Platelet transfusions generally only help during active bleeding episodes or during delivery. I wouldn't use it as a treatment.

Just an FYI - I was induced with my second child (water broke 3 weeks early) and did not have an epidural or any other medication. Au naturale. I wouldn't say it was the easiest 24 hours of my life, but I did it. She was the hardest labor I had of the three, but looking back, I wouldn't have wanted it any other way.

Sandi -

Thank you so much for your reply - it's nice to get a little insider info - you were a big help to me before, on the old board too

I keep reminding myself that, as far as it goes, labour will be an unpleasant day (or two), but the supreme challenge will be the next 40+ years of parenting...heh heh heh! It's easy to get hung up on the short term!

Again, I'm very lucky to have the support I do from my family, doctors, doula, etc. and luckier still that I have fabulous resources at my fingertips - like this forum! What a wonderful thing it is to be able to inform yourself before consenting to medical treatment, or to at least have a vague idea of what may be in store....

Hopefully, next time I show up on here, it will be to brag about my brand new daughter!!

Thanks again for your help. I feel worlds better. xo

Good luck to you! I hope all goes well.

** I came to post an update on the outcome of my pregnancy, and was upset to discover that the username affiliated with my original post is no longer mine (Stikrawk) and furthermore, I was not able to login anymore. I re-registered with Stikrawk (thus allowing me to post now) but I find it a little confusing and upsetting that this post is now listed under a user name that I have no affilation with...Can someone enlighten me as to what has happened??**

So, I took the Pred, and it did very little (although it's hard to tell, as counts always fall during the 3rd trimester, so I'm told). I think I started with a count of 24 or 29K? I worked my way up to the 100mg/day, and then started to taper. At my 40 week appointment, as I had not started to go into labour, we decided that induction was looking necessary (as my platelets still appeared to be falling). The induction was scheduled for the following Saturday.

They did a CBC when I got there, and I was sitting at 24K (machine count, would have likely been doubled if they had agreed to do a manual count as I have giant platelets) which made everyone nervous, partially because I couldn't have an epidural (which terrifies the nurses, I suspect, as they are maybe not super fond of listening to the noises of a "natural" labour...heh heh!), and partially because everyone was afraid I would just start to spontaneously bleed if they looked at me wrong. I repeated a bazillion times "asymptomatic for 19 years" again and again to all the scared nurses.

The induction began with cervidil - they didn't want to use the foley catheter stretcher thing because of the risk of bleeding. Fast forward 11 hours through pitocin-induced, incredibly intense contractions (some series of contractions lasting 6-8 minutes with no breathing time in between,a bit of a weird "anomalous" heartrate drop in the baby from time to time that concerned my nurse, no pain meds (by my choice as I was afraid I would forget how to breathe),an amnio infusion to help with the baby's heartrate (won't go into details but suffice to say, it was mildly unpleasant, but helped her rate even out) and almost no progress (I dilated to 3 cm from 1cm, in 11 hours). I asked if I could discuss the possibility of c-section with the Dr. The beautiful, angelic nurse agreed that this was a good idea before it became an emergency - as it looked like it would eventually because the labour had been going on for so long (and by definition I wasn't even "in labour yet" as I hadn't reached 4cm...ach!). I talked it over with the attending, he called in anesthesia for a consult - we discussed the risks of general anesthetic, they ordered me up some platelets and blood just in case. The anesthetist did not seem very worried about bleeding - I explained my history with ITP and my giant platelets and he made a comment to the effect of if I'd had a surgical history that illustrated my lack of bleeding (had never had surgery before this) he would have been comfortable placing an epidural, even with my very low (machine) platelet count.

Anyways - it was all very leisurely and relaxed - from the decision time to being rolled down the hall was about 45 minutes, during which time they turned off the labour augmenting drugs, and I got to hang out with my partner and the rad nurse - we had a great chat, laughed a lot and I felt totally okay with my decision. When I got to the OR, everyone introduced themselves to me (and I to them "Hi my name is Stik and I'll be having a baby tonight!"). I woke up in 40 minutes. My partner had the baby in his hands 3 minutes after she was born. Her apgars were 9 and 9. I didn't bleed more than expected and I didn't need ANY BLOOD PRODUCTS!!! I was so shocked to hear this!! And happy!!

They tested my platelets (and hers) the next morning and they were 61K (I suspect that was a manual count, but still1!). Hers were also 61K, and they kept us a few extra days to monitor - they were in the 65K range for about a week - the last count we got done they were at 123K - wahoo!!

The worst part of the surgery, other than the sore throat from the general anesthetic, was the lack of mobility for the first few days, and now, still not being able to lift anything heavier than the baby for the next few weeks....Not so bad for major surgery and childbirth all wrapped into one!

All things considered, it was a perfect birth. I owe a lot to the brilliant medical staff at my hospital. I was very nervous about the whole experience, but feel super happy about the way everything turned out. I tapered off the Predisone and finished on 23-January. My last platelet count (manual) was 86K, which is higher than they have been in years and years, so maybe the predisone did do a little good - who knows?! We'll see at my next CBC....

Healthy baby, healthy mom = fabulous conclusion to a long story!!

I don't have an answer for you. There was a major update done a few weeks ago and things seemed to go haywire for a bit then. Jeff, the PDSA web guy, would know more than I do. His e-mail address is at the top of the main Forum page.

I have had one or two other complaints of the same sort. I'm sorry for the inconvenience it may have caused.

Congratulations on the baby I'm glad all went fairly smoothly! I had a labor like that with my second child. Water broke two weeks early and I had to be induced. I had Pitocin and had contractions like that - one on top of the other. I also refused pain meds because I'm a weenie and the thought of an epidural scared me. It was a 24 hour labor, but I did eventually deliver. I didn't have the complication of ITP then though!

Congratulations! What did you name her?

Her name is Amelia!

Pretty name and pretty baby!