Thrombocytopenia in pregnancy: differential diagnosis, pathogenesis, and management

Maternal thrombocytopenia is not predictive of neonatal thrombocytopenia: a single-center Irish study

Background

Maternal thrombocytopenia during pregnancy is common. However, the relationship between maternal and neonatal thrombocytopenia is poorly understood.

Objectives

We aimed to determine whether an association exists between platelet counts of neonates born to mothers with moderate-to-severe thrombocytopenia (<100 × 109/L) and neonatal platelet counts.

Methods

We identified records from 557 patients with moderate-to-severe thrombocytopenia (maternal platelet count <100 × 109/L) and the 338 associated newborn charts from 2018 to 2022 in a single large maternity center. Pregnant people with a platelet count of <100 × 109/L prior to delivery during present gestation were included. Any thrombocytopenia that occurred outside of pregnancy or in the postpartum period was excluded. A logistic regression was then generated to examine the association between maternal thrombocytopenia and neonatal thrombocytopenia. A receiver operating characteristic (ROC) curve was generated to assess accuracy of (i) lowest maternal platelet count and (ii) trimester of thrombocytopenia onset in predicting neonatal thrombocytopenia.

Results

A total of 550 full blood count assessments were taken in neonates of pregnant people with thrombocytopenia. Sixteen neonates with clinically significant thrombocytopenia (platelet count <100 × 109/L) were identified. A binomial logistic regression was fitted that demonstrated limited association between lowest maternal platelet count and trimester of onset of maternal thrombocytopenia and the development of neonatal thrombocytopenia. An ROC curve was generated to determine the accuracy of maternal platelet count at identifying neonatal thrombocytopenia. The coordinates of the best platelet count threshold for this dataset were then derived from the ROC curve and determined that a threshold of 77.5 × 109/L maternal platelets offered the best accuracy.

Conclusion

Neonatal full blood count assessment based on maternal platelet counts of <100 × 109/L has a poor diagnostic yield with no statistically significant association in this cohort on logistic regression analysis. A lower threshold of 77.5 × 109/L may be of higher clinical utility and improve laboratory and clinical workflow.

Risk of thrombocytopenia in neonates of thrombocytopenic mothers

OBJECTIVE

Maternal thrombocytopenia during pregnancy may occur due to several possible etiologies, with potential neonatal impact. The aim of the present study was to investigate whether there is a correlation between maternal and neonatal platelet count among women with thrombocytopenia during pregnancy.

METHODS

A cross-sectional retrospective study (2012-2019) was conducted at a tertiary medical center. Complete blood count was routinely measured in all patients on admission to the delivery ward. Thrombocytopenia was defined as a platelet count below 150 K/μL. Clinical and outcome parameters of thrombocytopenic mothers and their newborns were collected from the electronic files and analyzed by severity of maternal thrombocytopenia.

RESULTS

Of 45 385 women with a documented platelet count at admission, 2841 (6.24%) had thrombocytopenia: 2623 (5.7%) mild (100-149 K/μL), 207 (0.45%) moderate (50-99 K/μL), and 11 (0.02%) severe (<50 K/μL). Eight newborns had thrombocytopenia; corresponding rates by severity of maternal thrombocytopenia were 0.11%, 1.43%, and 18.18% (P = 0.04). None of the thrombocytopenic neonates had an intraventricular hemorrhage or other bleeding complications. The correlation between maternal and neonatal platelet counts was weak (Pearson r = 0.038; P = 0.046).

CONCLUSION

We suggest that although the chances of neonatal thrombocytopenia are higher with worsening maternal thrombocytopenia, actual occurrence is rare, and the correlation is poor. Therefore, maternal thrombocytopenia cannot be regarded as a significant risk factor for neonatal thrombocytopenia. Neonatal platelet count should be obtained when maternal thrombocytopenia is autoimmune or less than 100 K/μL.

Genetic basis of pregnancy-associated decreased platelet counts and gestational thrombocytopenia

ABSTRACT

Platelet count reduction occurs throughout pregnancy, with 5% to 12% of pregnant women being diagnosed with gestational thrombocytopenia (GT), characterized by a more marked decrease in platelet count during pregnancy. However, the underlying biological mechanism behind these phenomena remains unclear. Here, we used sequencing data from noninvasive prenatal testing of 100 186 Chinese pregnant individuals and conducted, to our knowledge, the hitherto largest-scale genome-wide association studies on platelet counts during 5 periods of pregnancy (the first, second, and third trimesters, delivery, and the postpartum period) as well as 2 GT statuses (GT platelet count < 150 × 109/L and severe GT platelet count < 100 × 109/L). Our analysis revealed 138 genome-wide significant loci, explaining 10.4% to 12.1% of the observed variation. Interestingly, we identified previously unknown changes in genetic effects on platelet counts during pregnancy for variants present in PEAR1 and CBL, with PEAR1 variants specifically associated with a faster decline in platelet counts. Furthermore, we found that variants present in PEAR1 and TUBB1 increased susceptibility to GT and severe GT. Our study provides insight into the genetic basis of platelet counts and GT in pregnancy, highlighting the critical role of PEAR1 in decreasing platelet counts during pregnancy and the occurrence of GT. Those with pregnancies carrying specific variants associated with declining platelet counts may experience a more pronounced decrease, thereby elevating the risk of GT. These findings lay the groundwork for further investigation into the biological mechanisms and causal implications of GT.

Maternal Coagulation Disorders and Postpartum Hemorrhage

Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.

Thrombocytopenia in Pregnancy: Identification and Management at a Reference Center in Pakistan

Objective: The study aimed to evaluate the causes of thrombocytopenia in pregnancy and its management along with the outcome in the COVID-19 era.

Methods: Recruitment for this prospective, cross-sectional observational study of thrombocytopenia in pregnancy (platelet counts <100x10⁹/L) was done from January 2017 to August 2020 at the National Institute of Blood Diseases (NIBD) after taking the patients’ informed consent. Complete clinical and lab profile of patients was also collected.

Results: A total of 150 pregnant women with thrombocytopenia were enrolled, with the mean age being 27.3±4.64 years. Mean platelet counts at baseline were 48.0±24. Main clinical manifestations at baseline included: anemia 65.9%, bruises 23.25%, and edema 9.3%. Causes of thrombocytopenia were gestational thrombocytopenia (GT) 72 (48%), acute fatty liver five (3.3%), pre-eclampsia in 11 (7.3%), and eclampsia seven (4.6%). Causes not specific to pregnancy included 30 (20%) cases of ITP, hepatitis C, and nutritional deficiency was reported in nine (6%) patients each. 72/150 received supportive care treatment to manage thrombocytopenia and were closely monitored and given supplements. Twenty (66.6%) ITP patients received treatment with steroids, with complete response in 70% of them seen. Overall, 38 (25.3%) women with bleeding symptoms and platelet count <50x10⁹/L received platelet transfusions.

Conclusion: The study shows that pre-eclampsia and eclampsia are serious conditions with a high risk for complications, while GT is a benign and the most common cause of thrombocytopenia in pregnancy which requires no active treatment. The other causes such as ITP and infections require individualized management.

Prediction of postpartum hemorrhage in pregnant women with immune thrombocytopenia: Development and validation of the MONITOR model in a nationwide multicenter study

Globally, postpartum hemorrhage (PPH) is the leading cause of maternal death. Women with immune thrombocytopenia (ITP) are at increased risk of developing PPH. Early identification of PPH helps to prevent adverse outcomes, but is underused because clinicians do not have a tool to predict PPH for women with ITP. We therefore conducted a nationwide multicenter retrospective study to develop and validate a prediction model of PPH in patients with ITP. We included 432 pregnant women (677 pregnancies) with primary ITP from 18 academic tertiary centers in China from January 2008 to August 2018. A total of 157 (23.2%) pregnancies experienced PPH. The derivation cohort included 450 pregnancies. For the validation cohort, we included 117 pregnancies in the temporal validation cohort and 110 pregnancies in the geographical validation cohort. We assessed 25 clinical parameters as candidate predictors and used multivariable logistic regression to develop our prediction model. The final model included seven variables and was named MONITOR (maternal complication, WHO bleeding score, antepartum platelet transfusion, placental abnormalities, platelet count, previous uterine surgery, and primiparity). We established an easy-to-use risk heatmap and risk score of PPH based on the seven risk factors. We externally validated this model using both a temporal validation cohort and a geographical validation cohort. The MONITOR model had an AUC of 0.868 (95% CI 0.828-0.909) in internal validation, 0.869 (95% CI 0.802-0.937) in the temporal validation, and 0.811 (95% CI 0.713-0.908) in the geographical validation. Calibration plots demonstrated good agreement between MONITOR-predicted probability and actual observation in both internal validation and external validation. Therefore, we developed and validated a very accurate prediction model for PPH. We hope that the model will contribute to more precise clinical care, decreased adverse outcomes, and better health care resource allocation.

Prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary and quaternary centre in KwaZulu-Natal

Background

Thrombocytopenia is a common haematological disorder, characterised by platelet counts below 150 × 10⁹/L. The aetiology of thrombocytopenia is multifactorial; notably, in a misdiagnosis this condition may be due to pre-analytical laboratory artefacts. Knowledge about the common aetiology of thrombocytopenia will assist clinicians in decision-making and interpretation of laboratory tests and this may lead to prompt, adequate patient management and cost-saving measures.

Objective

This study determined the prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary or quaternary laboratory in Durban, KwaZulu-Natal, South Africa.

Methods

We conducted a retrospective study at the Inkosi Albert Luthuli Central Hospital haematology laboratory between October 2015 and April 2016. A total of 2076 full blood count results with a platelet count of less than 100 × 10⁹/L were retrieved from the Inkosi Albert Luthuli Academic Hospital database. Laboratory data were extracted and matched with clinical data and used to identify the potential aetiology of thrombocytopenia.

Results

The prevalence of thrombocytopenia was 14.9% within the selected study period. The haematology or oncology wards and clinic accounted for 55.2% of thrombocytopenia cases, whereas the adult and paediatric intensive care units accounted for 29.3%. Notably, 15.5% of thrombocytopenia cases were reported in non-haematology wards and clinics. The most common cause of thrombocytopenia was chemotherapy which accounted for 38.5% of all causes.

Conclusion

In our tertiary and quaternary setting, thrombocytopenia in adults was most common in patients admitted to haematology and oncology wards. Moreover, chemotherapy-induced thrombocytopenia accounted for more than a third of all these cases.

5 Years' Experience of a Tertiary Center with Thrombocytopenic Pregnancies: Gestational Thrombocytopenia, Idiopathic Thrombocytopenic Purpura and Hypertensive Disorders of Pregnancy

Aim To evaluate thrombocytopenic pregnancies including gestational thrombocytopenia (GT), idiopathic thrombocytopenic purpura (ITP), and hypertensive disorders of pregnancy (HDP).

Materials and Methods We evaluated the pregnancy outcomes and laboratory findings of 385 patients diagnosed with GT, ITP, or HDP whose thrombocyte levels were < 150 000/µL.

Results GT, ITP, and HDP were the final diagnoses in 315 (81.8%), 35 (9.1%), and 35 (9.1%) cases, respectively. Patients diagnosed during the 1st trimester and diagnosed with ITP had significantly lower minimal platelet counts during the antenatal period and prior to delivery (p < 0.001; p < 0.001; p < 0.001; p < 0.001). Transfusion of any kind of blood product was given in 9.9% (n = 38) of all cases. Twelve patients had methylprednisolone and/or intravenous immunoglobulin treatments during the antenatal period. All patients who had undergone medical treatment were also found to have ITP. Four out of 385 patients underwent hysterectomy post partum due to refractory hemorrhage. Analysis of newborn platelet levels showed no statistical differences between any of the groups. Despite the lack of statistical significance, the rate of thrombocytopenia in newborns was 50% in patients with severe thrombocytopenia, while rates were 25.6 and 18.1% in patients with moderate and mild thrombocytopenia, respectively.

Conclusion Thrombocytopenic pregnancies must be carefully evaluated with regard to the severity of thrombocytopenia, gestational period at initial diagnosis, and etiology. In particular, patients with ITP must be evaluated carefully as these patients are more likely to require transfusions and have platelet counts < 50 × 10 ³ /µl.

Anaemia and thrombocytopenia among pregnant women attending Aminu Kano Teaching Hospital, Kano State, North Western Nigeria

BACKGROUND

Pregnancy induces a number of physiologic changes either directly or indirectly that affect the haematologic parameters. The most frequent haematologic complication associated with pregnancy is anaemia and thrombocytopenia.

OBJECTIVES

The aim of this case-control study was to investigate the prevalence of anaemia and thrombocytopenia among one hundred and twenty consecutively-recruited pregnant subjects and sixty age-matched non-pregnant controls.

METHOD

Socio-demographic and clinical data were obtained using a questionnaire. Three milliliters of blood were obtained from both the pregnant subjects and non-pregnant controls and distributed into EDTA and used for full blood count was determined using the fully automated Mythic 18 3-part differential haematology analyzer.

RESULT

The socio-demographic distribution among the subjects showed that the age group 25-29 years had the higher number of participants 41 (34.2%) followed by 30-34 years 39 (32.5%). Distribution based on socio-demography indicated that majority of the subjects were of Hausa ethnic group 47 (78.3), had no formal or Islamic education 53 (44.2%) and predominantly housewives 74 (61.7%). Distribution based on obstetric variables indicated that majority of the subjects were multiparous 86 (71.7%), had no problem in their previous pregnancies 99 (82.5%) and are not having problem in this current pregnancy 109 (90.8%). The HBG and HCT were significantly lower among the pregnant subjects compared to controls (p= 0.05 and 0.0308) respectively. The prevalence of anaemia and thrombocytopenia among the pregnant subjects was 75% and 6.7% respectively. The prevalence of anaemia (80%) and thrombocytopenia (8.0%) was higher among pregnant women in the second trimester compared to those in the first and third trimesters.

CONCLUSION

The values obtained from this research showed an increase in prevalence of anaemia and thrombocytopenia among pregnant women compared to the non-pregnant controls. It is vital to routinely monitor the indices of anaemia and thrombocytopenia among pregnant women to reduce the incidence of these diseases and of their complications.

Thrombocytopenia in Pregnancy: Mechanisms and Management

Thrombocytopenia is a common hematologic issue encountered by obstetricians and hematologists, detected in about 10% of all pregnancies. In the vast majority of cases, the thrombocytopenia will be attributed to gestational thrombocytopenia (GT), where the thrombocytopenia is mild, does not necessitate active management, and does not introduce maternal or fetal bleeding risk. Although GT is common, the specific mechanism responsible for it is not known with certainty, and therefore, differentiating it from other causes of thrombocytopenia can be challenging. Previously proposed explanations for GT suggest that a decrease in platelet count is universal in pregnancy, and women diagnosed with GT are simply those with a baseline platelet count on the lower end of normal range. This concept is challenged in this review, and a possible mechanism for GT is proposed. Additionally, a framework for approaching the diagnosis and management of thrombocytopenia in pregnancy is presented.

Prevalence of thrombocytopenia among pregnant women attending antenatal care service at Gondar University Teaching Hospital in 2014, northwest Ethiopia

Introduction

Thrombocytopenia is a common hematologic abnormality during pregnancy. Pregnant women with thrombocytopenia have a higher risk of bleeding excessively during or after childbirth, particularly if they need to have a cesarean section or other surgical intervention during pregnancy, labor or in the puerperium. The main aim of this study was to determine the prevalence of thrombocytopenia among pregnant women attending antenatal care service at Gondar University Hospital, northwest Ethiopia.

Materials and methods

A cross-sectional study was used to assess the prevalence of thrombocytopenia among pregnant women attending antenatal care service at Gondar University Hospital from January to April 2015. A total of 217 pregnant women were included in the study and a structured pretested questionnaire was used to obtain sociodemographic information, nutritional factors, obstetrics and gynecological factors, history and clinical condition. Blood samples were collected for platelet count and other platelet parameters, which were determined by using SysmexKX 21 automation. The data were entered to Epi info version 6 software and analyzed using SPSS version 20 software. Bivariable and multivariable statistical analyses were used to evaluate the effect of independent variable over the dependent variable. A p-value of <0.05 was considered as statistically significant.

Result

A total of 217 women receiving antenatal care service at Gondar University Hospital participated in the study. Thrombocytopenia among 19 pregnant women showed a prevalence of 8.8%. The mean ± standard deviation platelet count was 238.85×10⁹/L (±74.57). Thrombocytopenia was significantly associated with patients who lived rurally (crude odds ratio =4.3, 95% confidence interval 1.48–12.76).

Conclusion

The prevalence of thrombocytopenia was 8.8% predominantly with mild type of thrombocytopenia. Thrombocytopenia was higher among pregnant women who lived rurally. Therefore, health care providers should screen routinely for thrombocytopenia to avoid excessive bleeding during pregnancy, especially in women who live rurally.

Thrombocytopenia in pregnancy with different diagnoses: Differential clinical features, treatments, and outcomes

To investigate the clinical features and perinatal treatment of thrombocytopenia induced by different causes during pregnancy.Clinical data from 195 pregnant women with thrombocytopenia attending 2 tertiary hospitals from January 2014 to October 2016 were retrospectively studied. The obtained data were analyzed with SPSS 19.0 software.There were 117 (60.0%), 55 (28.2%), and 23 cases (11.8%) of pregnancy-associated thrombocytopenia (PAT), idiopathic thrombocytopenia (ITP), and hypertensive disorder in pregnancy (PIH), respectively. The percentage of nulliparous women, gestational age at delivery, date of diagnosis of thrombocytopenia, and delivery mode significantly differed between the patients in these 3 groups (P < .05). Patients with PIH had a higher percentage of premature delivery and of lower birth weight infants than patients in the other 2 groups. The 3 groups had similar incidences of postpartum hemorrhage, rates of stillbirth, and neonatal Apgar scores at 5 minutes. PAT and PIH patients had different platelet counts after delivery compared with at diagnosis, whereas the platelet counts of the ITP patients were similar at diagnosis and after delivery. ITP patients in the nontreatment group and the treatment group had significantly different platelet counts (P < .05), and in the treatment group, the maternal platelet count did not differ for treatment with intravenous immunoglobulin (IVIg) versus corticosteroids.The causes of thrombocytopenia in pregnancy are diverse, and the clinical features vary widely. Timely analysis is needed to determine the primary cause of thrombocytopenia, and appropriate therapy should then be selected to effectively improve the prognosis of pregnancies.

High-Dose Methylprednisolone to Prevent Platelet Decline in Preeclampsia: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether early administration of high-dose methylprednisolone limits the fall of platelets in preeclampsia.

METHODS

A randomized trial of 180 mg methylprednisolone or placebo administered in divided doses over 36 hours was conducted in women admitted for preeclampsia and platelet counts below 150×10/L in four French academic centers. Patients were not included when platelet counts were below 50×10/L or when immediate delivery was required. The primary study outcome was the proportion of patients with platelet counts above 100×10/L 36 hours after the first dose of study medication. The total sample size needed to detect a 23% difference in the rate of this outcome between groups with a one-tailed α of 0.05 and 90% power was 94 patients.

RESULTS

Thirty-six patients were randomly assigned to receive methylprednisolone and 34 placebo between October 2007 and May 2011. Platelet counts above 100×10/L at 36 hours after the first dose of study medication were recorded in 30 (83%) in the active group and 29 (85%) in the placebo group (relative risk 0.98, 95% confidence interval 0.80-1.20; P=.82). The only adverse potentially study-related event was hyperglycemia in one woman allocated to methylprednisolone.

CONCLUSION

In women with preeclampsia and platelet counts under 150×10/L, methylprednisolone was not effective in maintaining platelet counts above 100×10/L.

CLINICAL TRIAL REGISTRATION

EU Clinical Trials Register, http://clinicaltrialsregister.eu, EudraCT 2006-004881-15-FR.

Moderate to Severe Thrombocytopenia During Pregnancy: A Single Institutional Experience

Most of thrombocytopenic pregnant women present mild decrease of platelet counts and have favorable outcome. However, small portion of these cases can show moderate to severe thrombocytopenia and may increase the risk of bleeding during delivery. We investigated the prevalence, causes, and outcomes of pregnancies complicated by moderate to severe thrombocytopenia. We reviewed medical records of pregnant women who were diagnosed with moderate to severe thrombocytopenia (<100 × 10⁹/L) during their pregnancies. A total of 4822 deliveries were performed and 26 patients (0.54%) with moderate to severe thrombocytopenia were identified. The most common cause of moderate to severe thrombocytopenia was immune thrombocytopenia (ITP) (42.3%), followed by gestational thrombocytopenia (GT) (34.6%). Compared to GT, ITP showed lower platelet counts at presentation (52.4 × 10⁹/L vs. 80.5 × 10⁹/L, P = 0.041). Patients with GT could conduct successful delivery without specific management, and patients with ITP showed favorable delivery outcomes with adequate treatment. In conclusion, the incidence of moderate to severe thrombocytopenia during pregnancy was very low and most common causes were ITP and GT. Patients with moderate to severe thrombocytopenia could have favorable delivery outcomes with adequate treatment.

Thrombocytopenia as a thrombotic risk factor in patients with antiphospholipid antibodies without disease criteria

INTRODUCTION

The antiphospholipid syndrome (APS) is an acquired immune disorder defined by the presence of thrombosis (arterial and/or venous) and/or pregnancy morbidity along with the presence of positive antiphospholipid antibodies (aPL). There is a clear relationship between aPL and some events not included in the clinical criteria, including haematologic.

OBJECTIVES

a) to study the probability of developing clinical APS in patients with positive aPL and thrombopenia; b) to identify potential risk factors for thrombosis, and c) to study the association between thrombocytopenia and aPL.

METHODS

A retrospective study of 138 patients with positive aPL without fulfilling clinical criteria for APS. Thrombocytopenia was defined as a platelet count≤100,000/μl. Patients with other causes of thrombocytopenia were excluded.

RESULTS

Seventeen of the 138 (12%) patients in the study had thrombocytopenia. The mean platelet count was 60,000/μl. The risk of developing thrombocytopenia was higher in smokers (OR 2.8; P=.044), in those with lupus anticoagulant (OR 13.5; P<.001) and those with higher burden of aPL (OR 50.8; P<.001). After a mean follow-up of 146±60.3 months, 5 patients with thrombocytopenia (29.4%) developed thrombosis.

CONCLUSIONS

In our series, the incidence of thrombocytopenia is 12%. aPL-positive patients who develop thrombocytopenia have a potential risk of developing thrombosis. Tobacco could be a risk factor for thrombocytopenia. Autoantibodies load is a risk factor for the development of thrombocytopenia.

Safety of splenectomy during pregnancy

OBJECTIVE

The aim of our study is to evaluate the risk of morbidity and mortality of splenectomy in pregnant women compared with non-pregnant women.

MATERIALS AND METHODS

We conducted a retrospective population-based matched cohort study using the Health Care Cost and Utilization Project, Nationwide Inpatient Sample database from 2003 to 2011. Pregnant women with splenectomy were age-matched to non-pregnant women with splenectomy. We compared risks of morbidity and mortality between pregnant and non-pregnant women using conditional logistic regression analysis.

RESULTS

The non-pregnant group had an excess of white patients and a greater proportion of Medicaid and private insurance users. There was a tendency for greater frequency of laparotomies in pregnant patients. Risk of VTE, portal vein thrombosis, renal failure and sepsis were comparable between the groups. Risk for transfusion was higher amongst pregnant women (OR 2.2, 95% CI (1.7-2.8)), as was the risk for a longer hospital stay (OR 1.7, 95% CI (1.4-2.1)).

CONCLUSION

Caution should be taken when performing splenectomy during pregnancy as risk for complications and mortality may be increased. Additional measures should be undertaken to have blood units on reserve for this population.

Evaluation of bone marrow with particular consideration of the megakaryocyte lineage and coagulation profile in the pregnant fallow deer (Dama dama)

The aim of the study was to evaluate the megakaryocyte lineage of bone marrow and coagulation parameters in fallow deer during the last month of pregnancy. The animals were managed in the barn-feeding system. Twenty female fallow deer, aged 2-3 years, divided into 2 groups were used in the study. Group 1 comprised the females in the last month of pregnancy, and the non-pregnant females were used as the control. All the animals were clinically healthy. Coagulation parameters were measured in all the deer: thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT), and plasma concentrations of fibrinogen, D-dimer, and antithrombin III. A quantitative assessment of bone marrow was carried out for the erythroblastic, myeloid, lymphoid, monocyte-macrophage, and megakaryopoietic cell lines. A detailed analysis of megakaryocyte lineage was performed after whole blood and platelet count. There were no significant differences in the erythroblast, granulocyte, monocyte-macrophage and lymphoid systems between the animal groups. Thrombocyte count in the pregnant deer was lower than that found in the control group. Bone marrow smears revealed a slightly decreased megakaryocyte count, while the megakaryoblast and promegakaryocyte counts were unchanged. The analysis of coagulation parameters showed increased levels of fibrinogen, thrombin time, prothrombin time and activated partial thromboplastin time in the pregnant animals. The study suggested a hyperactivation of the coagulation system with a slight reduction in the megakaryocyte count in bone marrow, and a reduction in platelet count in peripheral blood at the end of pregnancy.

Disseminated Intravascular Coagulation Syndromes in Obstetrics

Disseminated intravascular coagulation (DIC) is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, DIC is a common contributor to maternal morbidity and mortality and is associated with up to 25% of maternal deaths. The etiopathogenesis of DIC is complex and currently thought to be initiated by tissue factor or thromboplastin, which is released from trophoblastic or fetal tissue, or maternal decidua or endothelium. Tissue factor activates the coagulation sequence to cause fibrin clotting and its dissolution by the fibrinolysin system. The result of this process can range from mild, clinically insignificant laboratory derangements to marked coagulopathy with bleeding at sites of minimal trauma. Although clinical recognition varies by disease severity, several organizations have attempted to standardize the diagnosis through development of scoring systems. Several important--albeit not necessarily common--obstetric disorders associated with DIC include placental abruption, amniotic fluid embolism, sepsis syndrome, and acute fatty liver of pregnancy. More common disorders include severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and massive obstetric hemorrhage. Importantly, many of these disorders either cause or are associated with substantive obstetric hemorrhage. Treatment of DIC is centered on two principles. The first is identification and treatment of the underlying disorder. Because many women with consumptive coagulopathy also have massive hemorrhage, the second tenet of treatment is that obstetric complications such as uterine atony or lacerations must be controlled simultaneously with prompt blood and component replacement for a salutary outcome.

The significance and management of thrombocytopenia in antiphospholipid syndrome

The association between antiphospholipid antibodies (aPL) and clinical problems goes beyond what is stated in the antiphospholipid syndrome (APS) classification criteria, namely thrombosis and pregnancy morbidity, and thrombocytopenia is the most common non-criteria hematologic manifestation of aPL with a frequency ranging from 20 to 50 %. Thrombocytopenia is rarely severe, and hemorrhage is far less common than thrombosis. However, when anticoagulation is considered, it may constitute a clinical problem with increased bleeding risk. Furthermore, thrombocytopenia represents a risk factor for thrombosis in aPL-positive patients. Therefore, it is important to understand the pathogenesis and the clinical associations of thrombocytopenia to build the right medical approach in aPL-positive patients. In this paper, we review the literature on aPL/APS-associated thrombocytopenia and briefly discuss the other conditions that can result in thrombocytopenia as they have commonalities with APS and their recognition is important to establish the most appropriate treatment strategy.

The Differential Diagnosis of Thrombocytopenia in Pregnancy

BACKGROUND

Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge.

METHODS

In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed.

RESULTS

Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease.

CONCLUSION

The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.

Platelet parameters in healthy and pathological pregnancy

Changes in platelet count (PLT) are very important during pregnancy. Many platelet disorders occur during pregnancy and a reduction in PLT is the most common hemostasis abnormality identified, and this has important implications for mother and foetus. Many of these disorders share clinical and laboratory features, making accurate diagnosis difficult. The aim of this study was to establish reference intervals of platelet parameters for some of the more important pathologies associated to pregnancy (pre-eclampsia, gestational diabetes, autoimmune disorders, viral infections) using the automated hematology analyzer Sysmex XE-2100 and to evaluate the difference between healthy and pathological pregnancy. We enrolled in our study 100 pregnant women in the third trimester of pregnancy. The parameters analyzed included PLT, platelet distribution width, and mean platelet volume (MPV). We found statistically significant difference in PLT in pre-eclampsia, autoimmune disorders, and viral infections. Our results demonstrated also a statistically significant difference in MPV in pre-eclampsia and gestational diabetes. Our results allow the clinicians to detect hematologic change by simple complete blood count useful for the management of the pathological pregnancies. In conclusion, the overall picture of platelet disorders is extremely variegated, leading to numerous diagnostic and therapeutic problems whose solutions require close collaboration between clinicians and laboratory specialists.

Gestational thrombocytopaenia among pregnant women in Lagos, Nigeria

Background:

Thrombocytopaenia is a common haematologic abnormality during pregnancy. Pregnant women with thrombocytopenia have a higher risk of bleeding excessively during or after childbirth, particularly if they need to have a caesarean section or other surgical intervention during pregnancy, labour or in the puperium. The aim of this study was to determine the prevalence of gestational thrombocytopaenia among pregnant women reporting for antenatal care at tertiary health care centres in Lagos.

Materials and Methods:

Platelet count was analyzed in 274 consecutive pregnant women who gave informed consent and 70 non-pregnant female staff of the hospitals. Platelet count was performed on each sample using the Sysmex KN-21N automated haematology analyzer. The study design was cross-sectional, proportions were analyzed for statistical significance with the chi-square, and Odds ratio was also calculated. Thrombocytopaenia is classically defined as a platelet count of less than 150 × 10⁹/L.34 Counts from 100 to 150 × 10⁹/L are considered mildly depressed, 50 to 100 × 10⁹/L are moderately depressed and less than 50 × 10⁹/L are severely depressed.

Results:

Thirty-four (13.5%) pregnant women were thrombocytopaenic compared with three (4.3%) non-pregnant women. This was statistically significant; P = 0.03; Odds ratio: 3.5 (95% CI 1.03-11.82). Out of the 37 pregnant women who were thrombocytopaenic, most of them (78%) had mild thrombocytopenia, only 6% had severe thrombocytopaenia.

Conclusion:

The prevalence of gestational thrombocytopaenia in this study was 13.5%. Although majority of the pregnant women had mild thrombocytopaenia, healthcare providers should screen all pregnant women routinely for thrombocytopaenia to avoid excessive bleeding during or after childbirth.

Anaesthesia for Caesarean Section of Pregnant Women with Idiopathic Thrombocytopenic Purpura

Women with idiopathic thrombocytopenic purpura (ITP) may become pregnant, or the disease may occur for the first time during pregnancy. Thrombocytopenia is usually noticed in the first months of pregnancy and the platelet count is often quite low. In this case report, we described the anaesthetic method for caesarean section in a pregnant woman at 38 weeks of gestation with refractory ITP.

Some hemostatic parameters in women with obstetric hemorrhage in Sokoto, Nigeria

Obstetric hemorrhage is the leading cause of maternal mortality and morbidity worldwide. This study was carried out to investigate the effect of obstetric hemorrhage on the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet count (PLC). Women with obstetric hemorrhage were divided into two categories, women with antepartum hemorrhage (APH) and those with postpartum hemorrhage (PPH). Pregnant women without hemorrhage were included as controls. Eighty-six pregnant women aged 18–45 years (mean age 36.25 ± 10.50 years) were presented to the Obstetrics and Gynaecology Department of Maryam Abacha Women and Children Hospital in Sokoto Metropolis, Sokoto State, Nigeria with history of obstetric hemorrhage. Forty-three age-matched nonhemorrhaging parturient women were included as controls. The determination of PT and APTT was done by manual methods using commercially prepared Diagen reagent kits, whereas PLC was done by manual methods using a hemocytometer. The results of PT and APTT were significantly higher among women with APH (20.7 ± 4.226 seconds and 46.04 ± 8.689 seconds, respectively) and among women with PPH (23.17 ± 2.708 seconds and 53.78 ± 4.089 seconds, respectively) compared to normal pregnant women (15.85 ± 0.8930 seconds and 36.225 ± 5.010 seconds, respectively) (P = 0.0001). Similarly, the PLC was significantly higher among normal pregnant women compared to those with APH and PPH (291.425 ± 75.980 × 10⁹ compared to 154.83 ± 47.019 × 10⁹ and 136.43 ± 43.894 × 10⁹, respectively) (P = 0.0001). The PT and APTT of women who presented with PPH were significantly higher compared to those who presented with APH (23.17 ± 2.708 seconds and 53.78 ± 4.089 seconds versus 20.7 ± 4.226 seconds and 46.04 ± 8.689 seconds, respectively) (P = 0.02 and P = 0.04, respectively). The PLC was significantly higher among women who presented with APH compared to those who presented with PPH (P = 0.01). The PT and APTT values were higher in the third trimester among women with APH (24.38 ± 2.33 seconds and 52.25 ± 6.71 seconds, respectively), PPH (24.75 ± 2.63 seconds and 58.25 ± 2.53 seconds, respectively), and control women (16.00 ± 0.82 seconds and 34.42 ± 5.59 seconds, respectively) compared to those in first and second trimester. The PLC was significantly lower in the third trimester among APH, PPH, and normal pregnant women (131 ± 23.02 × 10⁹, 99 ± 21.46 × 10⁹, and 192.86 ± 25.44 × 10⁹, respectively). PT and APTT values correlated positively and significantly with trimester (r = 0.52 and 0.65, respectively; P = 0.01). The PLC of women with APH, PPH, and normal control women correlated negatively with trimester (r = −0.36, −0.54, and −0.28, respectively; P = 0.05). Obstetrics hemorrhage compounded the hemostatic status of pregnant women in Sokoto, Nigeria. There is need for the provision of rapid diagnosis of coagulopathy to guide the provision of best therapeutic management options.

Hematological profile of normal pregnant women in Lagos, Nigeria

Background

Hematological profile is considered one of the factors affecting pregnancy and its outcome. Anemia is the most common hematological problem in pregnancy, followed by thrombocytopenia. Leukocytosis is almost always associated with pregnancy. The study reported here was designed to evaluate the overall mean values of seven major hematological parameters and their mean values at different trimesters of pregnancy.

Subjects and methods

This examination was a cross-sectional study of 274 pregnant women who registered to attend the Lagos University Teaching Hospital or Lagos State University Teaching Hospital antenatal clinics between their first and third trimester. Blood (4.5 mL) was collected from each participant into a tube containing the anticoagulant ethylenediaminetetraacetic acid (EDTA). A full blood count was performed on each sample and the results were analyzed.

Results

Overall, the values obtained were (mean ± standard deviation [SD]): hematocrit level, 30.16% ± 5.55%; hemoglobin concentration, 10.94 ± 1.86 g/dL; white blood cells, 7.81 ± 2.34 × 10⁹; platelets, 228.29 ± 65.6 × 10⁹; cell volume 78.30 ± 5.70 fL, corpuscular hemoglobin, 28.57 ± 2.48 pg; and corpuscular hemoglobin concentration, 36.45 ± 1.10 g/dL. When grouped by trimester, the mean ± SD value of packed cell volume at first trimester was 32.07% ± 6.80%; of second trimester, 29.76% ± 5.21%; and of third, 33.04% ± 3.88%. The mean ± SD hemoglobin concentration values were 11.59 ± 2.35 g/dL, 10.81 ± 1.72 g/dL, and 10.38 ± 1.27 g/dL for women in their first, second, and third trimester, respectively. Mean ± SD white blood cell concentration for first, second, and third trimesters were 7.31 ± 2.38 × 10⁹, 7.88 ± 2.33 × 10⁹, and 8.37 ± 2.15 × 10⁹, respectively, while the mean ± SD platelet values for first, second, and third trimesters were 231.50 ± 79.10 × 10⁹, 227.57 ± 63 × 10⁹, and 200.82 ± 94.42 × 10⁹, respectively. A statistically significant relationship was found to exist between packed cell volume and white blood cell count with increase in gestational age (P = 0.010 and 0.001, respectively). However, there was no statistically significant association between platelet count and increase in gestational age (P = 0.296).

Conclusion

These findings reinforce the need for supplementation and provide additional information on hematological reference values in pregnancy in Nigeria.

Thrombocytopenia in pregnant women with Plasmodium falciparum malaria in an area of unstable malaria transmission in eastern Sudan

BACKGROUND

Blood platelet levels are being evaluated as predictive and prognostic indicators of the severity of malaria infections in humans. However, there are few studies on platelets and Plasmodium falciparum malaria during pregnancy.

METHODS

A case-control study was conducted at Gadarif Hospital in Eastern Sudan, an area characterized by unstable malaria transmission. The aim of the study was to investigate thrombocytopenia in pregnant women with P. falciparum malaria (cases) and healthy pregnant women (controls).

RESULTS

The median (interquartile) platelet counts were significantly lower in patients with malaria (N = 60) than in the controls (N = 60), 61, 000 (43,000-85,000) vs. 249,000 (204,000-300,000)/μL, respectively, p < 0.001. However, there was no significant difference in the platelet counts in patients with severe P. falciparum malaria (N = 12) compared with those patients with uncomplicated P. falciparum malaria (N = 48), 68, 000 (33,000-88,000)/μL vs. 61, 000 (45,000-85,000)/μL, respectively, p = 0.8. While none of the control group had thrombocytopenia (platelet count <75, 000/μL), it was found that 6/12 (50%) and 27/48 (56.2%) (p <0.001) of the patients with severe malaria and uncomplicated malaria had thrombocytopenia, respectively. Pregnant women with P. falciparum malaria, compared with the pregnant healthy control group, were at higher risk (OR = 10.1, 95% CI = 4.1-25.18; p < 0.001) of thrombocytopenia. Two patients experienced bleeding, and there was one maternal death due to cerebral malaria where the patient's platelet count was only 28,000/μL.

CONCLUSION

P. falciparum malaria is associated with thrombocytopenia in pregnant women in this setting. More research is needed.

Changes of platelets’ function in preeclampsia

Increased aggregation of platelets during preeclampsia was shown in several studies, yet several others reported no change. The aim of our study was to investigate platelet aggregation in a group of patients suffering from preeclampsia. In a cross-sectional study blood samples were taken from 89 hospitalized patients in the third trimester of pregnancy: 38 were suffering from mild to moderate preeclampsia and 51 patients were without preeclampsia. From the blood samples platelet aggregation, secretion of adenine nucleotides from platelets, concentration of energy-rich adenine compounds and levels of cyclic adenosine-mono-phosphate and cyclic guanosine mono-phosphate in platelets were measured. In the patients with preeclampsia, the adenosine diphosphate threshold for biphasic aggregation [odds ratio (OR):.75; 95% Confidence Interval (CI): 0.55–1.02; p<0.05], total adenine nucleotides concentration in the metabolic pool of platelets (OR:0.99; CI: 0.62–1.57; p<0.01) and cyclic adenosine-mono-phosphate (OR:0.81; CI: 0.57, 1.14; p<0.05) and cyclic guanosine mono-phosphate (OR:.78; CI: 0.55–1.09; p<0.05) levels in platelets were decreased in comparison with the control group, while adenylate energy charge in the metabolic pool of platelets (OR: >100.00; CI: 0.00->100.00; p<0.05) and secretion of adenosine triphosphate (OR:.13; CI: 0.00–14.26; p<0.05) and adenosine diphosphate (OR:.77; CI: 0.08–36.79; p<0.05) were increased. The results of our study show increased activation and aggregation of platelets in pregnant females with preeclampsia.

Managing pregnancy with HIV, HELLP syndrome and low platelets

Management of pregnancies with human immunodeficiency virus, haemolytic anaemia, elevated liver enzymes, low platelets (HELLP) syndrome, and low platelets presents complexities in investigations and treatments, because these conditions and their treatment affect the mother and baby. Low platelets in severe pre-eclampsia, eclampsia and HELLP syndrome are relatively common, and should be detected early once the diagnosis of pre-eclampsia, HELLP syndrome, or both, are made. The mainstay of treatment is lowering of high blood pressure with rapid-acting antihypertensive agents, prevention of convulsions or further seizures with MgSO(4), use of steroids for fetal lung maturity if necessary, followed by delivery of the baby. The use of high-dose steroids for the rapid recovery of maternal platelet counts is controversial, and should not be used routinely in women with HELLP syndrome. The use of platelet transfusion in women with severe pre-eclampsia, eclampsia and HELLP syndrome is a temporising measure, and should only be justified if the clinical circumstances warrant their use (e.g. before caesarean section when the woman has a low platelet count with evidence of bruising or bleeding from venepuncture sites). Low platelets may be an isolated finding in asymptomatic pregnant women and warrant the offer of a human immunodeficiency virus test, as it may be the first sign of this infection. Isolated low platelets may also indicate gestational thrombocytopaenia or idiothrombocytopaenic purpura. Gestational thrombocytopaenia is a benign condition and a diagnosis of exclusion. All clinicians should be aware that low platelets warrant further investigations because of the above-mentioned issues.

Physiologic and pathologic changes of platelets in pregnancy

Platelets are key players in haemostasis and thrombus formation. Defects affecting platelets during pregnancy can lead to heterogeneous complications, such as thrombosis, first trimester miscarriage and postpartum haemorrhage. The incidence of complications is increased in women who have heritable platelet function disorders. Modifications of platelet count or platelet functions during normal pregnancy and preeclampsia will be summarized and the management of pregnant women with heritable platelet function disorders will be discussed.

Immune thrombocytopenia in pregnancy

Management of immune thrombocytopenia in pregnancy can be a complex and challenging task and may be complicated by fetal-neonatal thrombocytopenia. Although fetal intracranial hemorrhage is a rare complication of immune thrombocytopenia in pregnancy, invasive studies designed to determine the fetal platelet count before delivery are associated with greater risk than that of fetal intracranial hemorrhage and are discouraged. Moreover, the risk of neonatal bleeding complications does not correlate with the mode of delivery, and cesarean section should be reserved only for obstetric indications.

Therapeutic approaches to secondary immune thrombocytopenic purpura

Secondary thrombocytopenia is similar to primary or idiopathic thrombocytopenia (ITP) in that it is characterized by reduced platelet production or increased platelet destruction resulting in platelet levels<60,000/microL. Thrombocytopenia can occur from secondary causes associated with chronic disorders or with disturbed immune function due to chronic infections, lymphoproliferative and myeloproliferative disorders, pregnancy, or autoimmune disorders. Diagnosis of secondary ITP in some cases is complex, and the thrombocytopenia can often be resolved by treating the underlying disorder to the extent this is possible. In most cases, treatment is focused on reducing platelet destruction, but, in some cases, treatment may also be directed at stimulating platelet production. The most problematic cases of thrombocytopenia may be seen in pregnant women. This review will address various agents and their utility in treating ITP from secondary causes; in addition, thrombocytopenia in pregnancy, ITP in immunodeficiency conditions, and drug-induced thrombocytopenia will be discussed. Unlike primary ITP, treatment often must be tailored to the specific circumstance underlying the secondary ITP, even if the condition itself is incurable.

Thrombocytopaenia in pregnant women with malaria on the Thai-Burmese border

BACKGROUND

Haematological changes associated with malaria in pregnancy are not well documented, and have focused predominantly on anaemia. Examined here is thrombocytopaenia in pregnant women infected with Plasmodium falciparum or Plasmodium vivax in a low transmission area on the north-western border of Thailand.

METHODS

In this observational study we reviewed the platelet counts from routine complete blood count (CBC) in a cohort of healthy and malaria infected Karen pregnant women attending weekly antenatal clinics. A platelet count of 75,000/microL was the threshold at 2 standard deviations below the mean for healthy pregnant women used to indicate thrombocytopenia. Differences in platelet counts in non-pregnant and pregnant women were compared after matching for age, symptoms, malaria species and parasitaemia.

RESULTS

In total 974 pregnant women had 1,558 CBC measurements between February 2004 and September 2006. The median platelet counts (/microL) were significantly lower in patients with an episode of falciparum 134,000 [11,000-690,000] (N = 694) or vivax malaria 184,000 [23,000-891,000] (N = 523) compared to healthy pregnant women 256,000 [64,000-781,000] (N = 255), P < 0.05 for both comparisons. Plasmodium falciparum and P. vivax caused a 34% (95% CI 24-47) and 22% (95% CI 8-36) reduction in platelet count, respectively. Pregnant compared to non pregnant women were at higher risk OR = 2.27 (95%CI 1.16-4.4) P = 0.017, for thrombocytopaenia. Platelets counts were higher in first compared with subsequent malaria infections within the same pregnancy. Malaria associated thrombocytopaenia had a median [range] time for recovery of 7 234567891011121314 days which did not differ by antimalarial treatment (P = 0.86), or species (P = 0.63) and was not associated with active bleeding.

CONCLUSION

Pregnant women become more thrombocytopenic than non-pregnant women with acute uncomplicated malaria. Uncomplicated malaria associated thrombocytopaenia is seldom severe. Prompt antimalarial treatment resulted in normalization of platelet counts within a week.

Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia

Regional anesthesia for pain at delivery in the presence of maternal thrombocytopenia is a clinical dilemma. We reviewed 10,369 obstetric cases (12 months) from our tertiary center. Generally, hemodilution of pregnancy does not result in thrombocyte counts of <150,000/mm(3) at delivery. A total of 166 births (1.6%) were recorded in women with thrombocytes <150,000/mm(3) at delivery. Parturients with >150,000/mm(3) at week 36 were separated post hoc (n=35; 21%) and the remaining parturients were divided as having <100,000/mm(3) (n=30; 18%) or 101,000-150,000/mm(3) (n=101; 60.5%). Epidural or spinal anesthesia was administered to 30% women with <100,000/mm(3) whereas 56% women with >101,000/mm(3) received these options (P=0.003). A total of 13.9% of parturients with trimester-long thrombocytopenia required blood products; 10/23 (43.5%) parturients undergoing cesarean section also required blood products (P=0.000). Four of six babies with Apgar scores of <or=7 at 1-min were born to women with platelets <100,000/mm(3) (P=0.009). There were no statistically significant differences in mean birth weights. Women with thrombocytes <150,000/mm(3) at birth but within the normal range at week 36 were more likely multiparas (P=0.001). We conclude that a difference in maternal and neonatal outcomes exists between mothers who were thrombocytopenic only at delivery compared to those with trimester-long thrombocytopenia, with the latter mothers and babies having more adverse events.