Impact of anemia and thrombocytopenia on postpartum hemorrhage risk among women with term singleton pregnancy

Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management

INTRODUCTION

Immune thrombocytopenia (ITP) affecting pregnancy is a diagnostic and often a therapeutic challenge.

AREAS COVERED

We review the current diagnostic criteria for ITP in pregnancy and the potential utility of laboratory tests. We discuss the impact of ITP on pregnancy outcomes and the effects of pregnancy on patients living with chronic ITP.  We describe the criteria for intervention, the evidence supporting first-line treatment approaches and the therapeutic decisions and challenges in cases refractory to steroids and IVIG. We review the evidence supporting the potential use of thrombopoietin receptor agonists for refractory thrombocytopenia. Finally, we describe the diagnostic, prognostic, and treatment approaches to neonatal ITP and considerations regarding breastfeeding. We searched the terms 'immune thrombocytopenia' and 'pregnancy' on PubMed to identify the relevant literature published before 31 December 2023, including within cited references.

EXPERT OPINION

Decreased platelet production may play a role in pregnancy-related ITP exacerbation. Putative mechanisms include placental hormones, such as inhibin. Although IVIG and prednisone usually suffice to achieve hemostasis for delivery, second-line agents are sometimes required to allow for neuraxial anesthesia. There is growing evidence supporting the use of romiplostim during pregnancy; however, its risk of venous thromboembolism warrants further evaluation.

Effect of decreased platelets on postoperative recurrence of chronic subdural hematoma

Introduction

Chronic subdural hematoma (CSDH) is commonly treated using simple burr hole surgery. However, postoperative recurrence occurs at a relatively high rate of 10-20%. A decrease in platelet count (PC) may be associated with recurrence via a hemostasis disorder; however, this association has not been well-studied. Therefore, this study aimed to investigate the association between PC and postoperative CSDH recurrence.

Methods

We retrospectively reviewed the data for CSDHs in 488 cerebral hemispheres of 431 patients who underwent burr hole surgery at our institution between January 2013 and December 2022. The association between preoperative PC and postoperative CSDH recurrence was investigated. We used the first quartile of PC, PC < 170 × 103/μL to define a threshold for decreased PC.

Results

In total, 459 cerebral hemispheres with CSDHs in 405 patients were followed up postoperatively for at least 3 months or until CSDH disappeared. CSDH recurred in 39 (8.5%) cerebral hemispheres. The recurrence rate was gradually increased in parallel with a decreasing PC. Among 109 CSDHs with a decreased PC (<170 × 103/μL), 15 (13.8%) recurred, whereas only 24 (6.9%) of 350 CSDHs without a decreased PC recurred (p = 0.03). In univariable logistic analysis, eosinophil-rich blood (≥100/μL eosinophils in peripheral blood) and a decreased PC were significant risk factors. Multivariable analysis showed that eosinophil-rich blood (adjusted odds ratio, 2.51; 95% confidence interval, 1.26-4.99; p = 0.009) and a decreased PC (adjusted odds ratio, 2.15; 95% confidence interval, 1.07-4.35; p = 0.03) were independent risk factors for recurrence.

Conclusion

Our study showed that a decrease in PC was associated with postoperative CSDH recurrence. Patients with CSDH and a decreased PC require careful postoperative follow-up.

Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique

BACKGROUND

Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region.

OBJECTIVES

Analyze MM, PPH, and associated risk factors.

METHODS

We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding.

RESULTS

Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both.

CONCLUSIONS

PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.