How I treat thrombocytopenia in pregnancy

An Introduction to the Complete Blood Count for Clinical Chemists: Platelets

BACKGROUND

The most ordered laboratory test worldwide is the complete blood count (CBC).

CONTENT

In this primer, an introduction to platelet testing in the context of the CBC is provided with a discussion of the laboratory evaluation of platelet abnormalities including thrombocytopenia and thrombocytosis.

SUMMARY

As clinical chemists continue to be tasked to direct laboratories outside of the traditional clinical chemistry sections such as hematology, expertise must be developed. This primer is dedicated to that effort.

The risk profiles of pregnancy-related cerebral venous thrombosis: a retrospective study in a comprehensive hospital

OBJECTIVES

To investigate the risk factors and underlying causes of pregnancy-related cerebral venous thrombosis (PCVT).

METHODS

A retrospective cohort of 16 patients diagnosed with CVT during pregnancy and postpartum (within six weeks after delivery) in a comprehensive hospital in China between 2009 and 2022 were carefully reviewed, focusing on demographic, clinical, and etiological characteristics, especially underlying causes. We matched 16 PCVT patients with 64 pregnant and puerperal women without PCVT to explore risk factors and clinical susceptibility to PCVT.

RESULTS

PCVT occurred commonly during the first trimester (43.75%) and the puerperium (37.5%). The frequency of anemia, thrombocytosis and thrombocytopenia during pregnancy, dehydration, and pre-pregnancy anemia was significantly higher in women with PCVT than in those without PCVT (P < 0.05). Among the 16 patients, five were diagnosed with antiphospholipid syndrome and one was diagnosed with systemic lupus erythematosus. Three patients had distinct protein S deficiency and one had protein C deficiency. Whole Exome Sequencing (WES) was performed for five patients and revealed likely pathogenic mutations associated with CVT, including heterozygous PROC c.1218G > A (p. Met406Ile), heterozygous PROS1 c.301C > T (p. Arg101Cys), composite heterozygous mutation in the F8 gene (c.144-1259C > T; c.6724G > A (p. Val2242Met)) and homozygous MTHFR c.677C > T (p. Ala222Val).

CONCLUSIONS

The occurrence of anemia, thrombocytopenia and thrombocytosis during pregnancy, dehydration and pre-pregnancy anemia suggested a greater susceptibility to PCVT. For confirmed PCVT patients, autoimmune diseases, hereditary thrombophilia, and hematological disorders were common causes. Screening for potential etiologies should be paid more attention, as it has implications for treatment and long-term management.

Mendelian randomization reveals association of gut microbiota with Henoch-Schönlein purpura and immune thrombocytopenia

Gut microbiota have been linked to immune thrombocytopenia (ITP) and Henoch-Schönlein purpura (HSP) in recent studies, but a cause-and-effect relationship is unclear. We used Mendelian randomization (MR) to assess causal relationships between gut microbiota and HSP/ITP using summary statistics from the GWAS dataset of the international MiBioGen and FinnGen consortium. The IVW method was used as the main evaluation indicator. MR analysis of 196 intestinal flora and HSP/ITP/sTP phenotypes showed that 12 flora were potentially causally associated with ITP, 6 with HSP, and 9 with sTP. The genes predicted that genus Coprococcus3 (p = 0.0264, OR = 2.05, 95% CI 1.09-3.88)and genus Gordonibacter (p = 0.0073, OR = 1.38; 95% CI 1.09-1.75) were linked to a higher likelihood of developing ITP. Additionally, family Actinomycetaceae (p = 0.02, OR = 0.51, 95% CI 0.28-0.90) and order Actinomycetales (p = 0.0199, OR = 0.50, 95% CI 0.28-0.90) linked to reduced HSP risk. Genus Ruminococcaceae UCG013 (p = 0.0426, OR = 0.44, 95% CI 0.20-0.97) negatively correlated with sTP risk. Our MR analyses offer evidence of a possible cause-and-effect connection between certain gut microbiota species and the likelihood of HSP/ITP.

Evaluating circulating soluble markers of endothelial dysfunction and risk factors associated with PE: A multicentre longitudinal case control study in northern Ghana

Serpin E1/PAI-1, N-terminal pro-brain natriuretic peptide (NTpro-BNP) and neuropilin-1 are markers which have been associated with endothelial dysfunction. However, data on the levels of these markers in PE is limited. The limited data on the pathophysiology of PE in relation to these markers necessitated the study. This was a multicentre case-control study conducted at the Obstetrics and Gynaecology Department of the Tamale Teaching Hospital, the Bawku Presbyterian Hospital and the Bolgatanga Regional Hospital. Out of 520 consenting pregnant women, 127 pregnant women met the inclusion criteria (53 with PE and 74 controls) and were included in this study. Venous, placental, cord and peripheral blood were collected for biomarker assay, haematological parameters and placental parasite determination. Placental tissue sections were obtained for placental malaria and histopathological lesions associated with hypoperfusion. Maternal heart rate and foetal umbilical artery Doppler impedance indices; resistance index (RI) and systolic diastolic (SD) ratio were determined to confirm utero-placental hypoperfusion. Significantly higher proportions of foeto-maternal complications; eclampsia, low birth weight (LBW), neonatal intensive care unit admissions (NICU), intrauterine growth restriction (IUGR), caesarian deliveries and early gestational age at delivery were associated with PE. Women with PE had lower concentrations of platelet (p = 0.02) whereas red cell distribution width (RDW) was markedly elevated (p = 0.01). NTPro-BNP concentration was markedly elevated (p = 0.01) in women with PE whereas neuropilin-1 concentration was lower (p = 0.03) compared to the non-PE group. Maternal heart rate was elevated in women with PE and Doppler resistance indices (RI and SD) were significantly elevated in foetuses of PE women than foetuses of the controls. Placental mal-perfusion lesions were higher in women with PE compared to the non-PE group. Women with PE had increased risk of adverse foeto-maternal complications, significantly associated with placental mal-perfusion lesions, had reduced platelet concentration and elevated RDW-CV levels. NTPro-BNP, RI and SD are elevated in women with PE whereas neuropilin-1 concentration is reduced. Significant changes in these pathological variables in PE women is indicative of significant derangement in endothelial function culminating in adverse maternal and perinatal outcomes of pregnancy.

Effect of delivery mode on postnatal platelet count dynamics in neonates born to mothers with immune thrombocytopenia

We aimed to determine the effect of delivery mode on postnatal platelet count dynamics in neonates born to mothers with immune thrombocytopenia (ITP). This single-center, retrospective study included 41 mothers with ITP and their 65 infants born by vaginal delivery (VD, n = 30) and cesarean section (CS, n = 35) between January 1997 and March 2022. The median difference in platelet counts from day 0 to day 2 (ΔPlt [D 0-2]) was significantly lower in the VD group (- 39 × 10⁹/L, interquartile range [IQR]: - 47 to - 24 × 10⁹/L) than the CS group (15 × 10⁹/L, IQR: - 6.5 to 33 × 10⁹/L) (p < 0.001). The median ΔPlt (D 0-5) was significantly lower in the VD group (- 55 × 10⁹/L, IQR: - 85 to - 31 × 10⁹/L) than the CS group (33 × 10⁹/L, IQR: 1-69 × 10⁹/L) (p < 0.001). Multivariate analysis also showed a significant association of delivery mode with ΔPlt (D 0-2) and ΔPlt (D 0-5) (both p < 0.001). VD neonates with platelet counts ≥ 100 × 10⁹/L at birth were significantly more likely than CS neonates to develop thrombocytopenia < 100 × 10⁹/L at nadir (1/26 vs. 6/25) (p = 0.0496). Our findings indicate that mode of delivery is a useful predictor of postnatal platelet count dynamics in neonates born to mothers with ITP.

Primary autoimmune thrombocytopenia in pregnancy: maternal and neonatal outcomes

Aim: To evaluate clinical characteristics, maternal and neonatal outcomes among pregnant women with primary autoimmune thrombocytopenia (ITP). Materials and methods: All pregnant women with ITP who had undergone antenatal follow-up and delivery at the Department of Obstetrics and Gynecology at a referral center, between 2011 and 2021, were retrospectively investigated. Patients were evaluated in three groups according to antenatal treatment modality. Results: 42 pregnant women with ITP were included in the study. A total of 29 (%69) pregnant womenhad been diagnosed with ITP before pregnancy and 13(%31) were diagnosed during pregnancy. 17 (%41) pregnant women did not receive any antenatal treatment, and 25 (%59) pregnant women receieved treatment. Postpartum haemorrhage (%50) was reported more frequently in the steroids+IVIG group. A total of 42 pregnancies, 43 babies (one twin pregnancy, 41 singletons) were liveborn. Three neonates (%7) had thrombocytopenia and one of them had intracranial haemorrhage. Conclusions: In pregnancies complicated with ITP, the platelet count is moderately or severely low, which can have adverse maternal and neonatal outcomes. Postpartum haemorrhage is a significant cause of maternal morbidity in cases with ITP. Therefore, pregnant women with ITP should be delivered in facilities that can adequately manage postpartum haemorrhage.

HELLP syndrome, intracerebral hemorrhage, and hemophagocytic syndrome after cesarean section in a pregnant patient with severe preeclampsia: a case report

BACKGROUND

Pregnancy-related intracranial hemorrhage (ICH) is a rare but potentially life-threatening event with complex and varied cause, such as HELLP syndrome and hemophagocytic syndrome.

CASE PRESENTATION

A 33-year-old patient underwent a cesarean section with a preliminary diagnosis of "severe preeclampsia and class3 HELLP syndrome ". The patient had poor response to language before surgery, and the catheter drainage fluid was hematuria. Later, the surgeon reported severe bleeding in the operation. Following thromboelastography (TEG) result and postoperative laboratory tests confirmed class1 HELLP syndrome and ICH occurred on the second day after the surgery, and hemophagocytic syndrome was diagnosed during subsequent treatments.

CONCLUSION

For patients with HELLP syndrome, we should pay attention to their coagulation condition. The coagulation tests and platelet counts should be repeated if their clinical presentation changed. Those with neurological alarm signs should receive CT or MRI scan. If a pregnant woman had prolonged hemocytopenia and thrombocytopenia, not only the HELLP but also the hemophagocytic syndrome should be considered.

Thrombocytopenia in pregnancy

Hematologists are often consulted for thrombocytopenia in pregnancy, especially when there is a concern for a non-pregnancy-specific etiology or an insufficient platelet count for the hemostatic challenges of delivery. The severity of thrombocytopenia and trimester of onset can help guide the differential diagnosis. Hematologists need to be aware of the typical signs of preeclampsia with severe features and other hypertensive disorders of pregnancy to help distinguish these conditions, which typically resolve with delivery, from other thrombotic microangiopathies (TMAs) (eg, thrombotic thrombocytopenic purpura or complement-mediated TMA). Patients with chronic thrombocytopenic conditions, such as immune thrombocytopenia, should receive counseling on the safety and efficacy of various medications during pregnancy. The management of pregnant patients with chronic immune thrombocytopenia who are refractory to first-line treatments is an area that warrants further research. This review uses a case-based approach to discuss recent updates in diagnosing and managing thrombocytopenia in pregnancy.

Gaucher disease carrier with gestational thrombocytopenia and anemia: a case report

Background

Gaucher disease is an autosomal recessive inborn error of metabolism that causes disorders of blood, bone, and central nervous system as well as hepatosplenomegaly. We present the case of a carrier of Gaucher disease with gestational thrombocytopenia and anemia that required blood transfusion therapy.

Case presentation

A 24-year-old Nepalese primipara was diagnosed with idiopathic thrombocytopenia at 12 weeks of gestation. Her platelet count had reduced to 30,000/µL at 21 weeks of gestation, and the hemoglobin content reduced to 7.6 g/dL at 27 weeks of gestation. As she did not respond to any medication, blood transfusion was performed. A female infant weighing 2677 g was delivered vaginally at 39 weeks of gestation. On the 78th day of puerperium, the platelet count of the mother recovered to 101,000/µL, and the hemoglobin content recovered to 12.5 g/dL. The infant had convulsions, respiratory depression, wheezing, systemic purpura, and exfoliation of the epidermis at birth. The infant was diagnosed with Gaucher disease at 37 days of age and passed away at 82 days of age. Subsequently, the parents were diagnosed as carriers of Gaucher disease.

Conclusion

As carriers of this disease do not usually show symptoms, it is imperative to provide information regarding disease management for future pregnancies.

Pre- and postpregnancy platelet counts: evaluating accuracy of gestational thrombocytopenia and immune thrombocytopenia purpura diagnoses

BACKGROUND

Given the overlapping clinical indicators and lack of diagnostic testing, misdiagnosis of immune thrombocytopenic purpura and gestational thrombocytopenia in pregnancy may be common. Current recommendations suggest utilizing platelet nadir during pregnancy to guide diagnosis.

OBJECTIVE

This study aimed to assess the accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses using pre- and postpregnancy platelet counts.

STUDY DESIGN

This was a retrospective cohort study of patients diagnosed with gestational thrombocytopenia and immune thrombocytopenic purpura from January 2017 to December 2019. Platelet counts were extracted from charts and evaluated at several time periods, namely prepregnancy (within 5 years), during pregnancy, and postpartum (>6 weeks to 5 years). A diagnosis of gestational thrombocytopenia was considered inaccurate if platelet counts were <150,000/µL pre- or postpregnancy with no other apparent causes or if the platelet nadir dropped below 100,000/µL during pregnancy. A diagnosis of immune thrombocytopenic purpura was deemed inaccurate if pre- or postpregnancy platelet counts were >150,000/µL. The primary outcome was accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses in patients. Secondary outcomes included mean platelet counts during pregnancy and difference in mean platelet counts for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia. Outcomes were summarized with descriptive statistics and compared using Student t tests.

RESULTS

A total of 116 patients met the inclusion criteria of which 111 (96%) and 5 (4%) had gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses, respectively. Platelet counts outside of pregnancy were available for 91 (82%) of the patients, and 66 (57%) had prepregnancy platelet counts available. Of the 91 patients, the diagnosis was considered accurate in 61 (67%) and 5 (100%) patients with gestational thrombocytopenia and immune thrombocytopenic purpura, respectively. Conversely, 30 of 35 (86%) patients with immune thrombocytopenic purpura were found to be inaccurately diagnosed with gestational thrombocytopenia after application of platelet thresholds. Among these 30 patients, 10 had a prepregnancy platelet count <150,000/µL, 12 had a postpartum platelet count <150,000/µL, 3 had a platelet count nadir <100,000/µL during pregnancy, and 7 met more than 1 criterion. Pre- and postpregnancy platelet counts and platelet count nadir differed significantly for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia (P<.001).

CONCLUSION

When pre- and postpregnancy platelet counts were checked, one-third of cases of gestational thrombocytopenia met the criteria for immune thrombocytopenic purpura and were thus incorrectly diagnosed during pregnancy. Prepregnancy platelet counts, available for most patients, should be considered when diagnosing gestational thrombocytopenia vs immune thrombocytopenic purpura.

Risk factors for severe neonatal thrombocytopenia in cases of maternal immune thrombocytopenia

AIM

Maternal immune thrombocytopenia (ITP) may induce neonatal thrombocytopenia (nTP), which carries a risk of neonatal haemorrhagic complications. Some risk factors for nTP have reached consensus such as maternal splenectomy and previous severe nTP, while others such as maternal platelet count have not.

METHODS

We conducted a retrospective cohort study in a university hospital, including 145 neonates of mothers with ITP. We assessed the risk of severe nTP and bleeding complications.

RESULTS

Severe nTP in the first 24 h after birth was more common in case of maternal splenectomy (OR = 4.4) and a previous severe nTP (OR = 46.9). Severe nTP at nadir (lowest platelet count during the initial postnatal days) was more frequent in cases of a previous neonate with severe nTP (OR = 42), maternal treatment during pregnancy (OR = 2.4) and a low maternal platelet count during pregnancy or at delivery. These risk factors were not significantly associated with an increased risk of neonatal haemorrhagic complications.

CONCLUSION

In our population, we confirm the risk of severe nTP in case of maternal splenectomy or previous nTP. By monitoring the platelet count to its nadir, we identified three additional risk factors: maternal treatment during pregnancy and low maternal platelet count during pregnancy or low maternal platelet count at delivery.

Prednisone plus IVIg compared with prednisone or IVIg for immune thrombocytopenia in pregnancy: a national retrospective cohort study

Background:

The responses of intravenous immunoglobulin (IVIg) or corticosteroids as the initial treatment on pregnancy with ITP were unsatisfactory. This study aimed to assess the safety and effectiveness of prednisone plus IVIg versus prednisone or IVIg in pregnant patients with immune thrombocytopenia (ITP).

Methods:

Between 1 January 2010 and 31 December 2020, 970 pregnancies diagnosed with ITP at 19 collaborative centers in China were reviewed in this observational study. A total of 513 pregnancies (52.89%) received no intervention. Concerning the remaining pregnancies, 151 (33.04%) pregnancies received an initial treatment of prednisone plus IVIg, 105 (22.98%) pregnancies received IVIg alone, and 172 (37.64%) pregnancies only received prednisone.

Results:

Regarding the maternal response to the initial treatment, no differences were found among the three treatment groups (41.1% for prednisone plus IVIg, 33.1% for prednisone, and 38.1% for IVIg). However, a significant difference was observed in the time to response between the prednisone plus IVIg group (4.39 ± 2.54 days) and prednisone group (7.29 ± 5.01 days; p  < 0.001), and between the IVIg group (6.71 ± 4.85 days) and prednisone group (p < 0.001). The median prednisone duration in the monotherapy group was 27 days (range, 8–195 days), whereas that in the combination group was 14 days (range, 6–85 days). No significant differences were found among these three treatment groups in neonatal outcomes, particularly concerning the neonatal platelet counts. The time to response in the combination treatment group was shorter than prednisone monotherapy. The duration of prednisone application in combination group was shorter than prednisone monotherapy. The combined therapy showed a lower predelivery platelet transfusion rate than IVIg alone.

Conclusion:

These findings suggest that prednisone plus IVIg may represent a potential combination therapy for pregnant patients with ITP.

Bleeding complications associated with pregnancy with primary immune thrombocytopenia: a meta-analysis

Introduction  Immune thrombocytopenia (ITP) during pregnancy has received little attention from researchers. Reliable information about the outcome of mothers and newborns is required to properly counsel women who are pregnant or planning to become pregnant. Our primary outcomes were the frequency and severity of maternal and neonatal bleeding events in the setting of ITP in pregnancy. Mode of delivery, neonatal thrombocytopenia, and maternal/infant mortality were secondary outcomes.

Material and Methods  We comprehensively reviewed the prospective studies that enrolled ≥20 pregnant women with primary ITP. Two reviewers, blinded to each other, searched Medline and Embase up to February 2021. Meta-analyses of the maternal and newborn outcomes were performed. Weighted proportions were estimated by a random-effects model.

Results  From an initial screening of 163 articles, 15 were included, encompassing 1,043 pregnancies. The weighted event rate for bleeding during pregnancy was 0.181 (95% confidence interval [CI], 0.048–0.494). Most of these were nonsevere cases. The weighted event rates were 0.053 (95% CI, 0.020–0.134) for severe postpartum hemorrhage, 0.014 (95% CI, 0.008–0.025) for intracerebral hemorrhage, and 0.122 (0.095–0.157) for severe thrombocytopenia events in neonates (platelet count <50,000/μL). There were no reliable predictors of severe neonatal thrombocytopenia. The incidence of neonatal mortality was 1.06%. There were no maternal deaths.

Conclusion  Primary ITP in pregnant women is rarely associated with poor outcomes.

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.

Gestational Thrombocytopenia: A Review on Recent Updates

Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.

Assessment of post-partum haemorrhage risk among women with moderate thrombocytopenia

It is unknown whether moderate thrombocytopenia represents a risk factor for post‐partum haemorrhage (PPH). We assessed PPH risk among women with a platelet count of between 100 and 50 × 10⁹/l and stratified the risk for O/non‐O blood group. We included consecutive women undergoing vaginal delivery or caesarean section with moderate thrombocytopenia. Women with >150 × 10⁹/l platelets at delivery were selected as controls and matched for age, type of birth and ethnicity. Odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated as risk estimates. A total of 94 thrombocytopenic women and 94 controls were included in the study. The rate of PPH was significantly higher in thrombocytopenic women than in controls (37% vs. 10%, p < 0.001); there was a higher risk of PPH in the thrombocytopenic group when compared to the control group (adjusted OR 4.7, 95% CI 2.1–10.8, p < 0.01) and this association was stronger in blood group O carriers (adjusted OR 11.0, 95% CI 2.4–49.6, p < 0.01). In conclusion, our study shows that a moderate thrombocytopenia is a risk factor for PPH, especially in blood group O carriers.

How to evaluate and treat the spectrum of TMA syndromes in pregnancy

Thrombotic microangiopathy (TMA) is the broad definition for thrombocytopenia, microangiopathic hemolytic anemia, and end-organ damage. Two important categories are thrombotic thrombocytopenic purpura (TTP) and complement-mediated hemolytic-uremic syndrome (CM-HUS). Pregnancy and the immediate postpartum period are associated with TMAs specific to pregnancy in rare situations. These include pregnancy-induced hypertension, preeclampsia, and hemolysis, elevated liver enzymes, and low platelets. TTP and CM-HUS may present in pregnancy. However, the diagnosis may not be immediately obvious as they share characteristics of pregnancy-related TMAs. Within this review, we discuss investigations, differential diagnosis of TMAs in pregnancy, and management. The importance is a risk of maternal mortality but also poor fetal outcomes in relation to TTP and CM-HUS. Treatment of these disorders at presentation in pregnancy is discussed to achieve remission and prolong fetal viability if possible. In subsequent pregnancies, a treatment pathway is presented that has been associated with successful maternal and fetal outcomes. Critical to this is a multidisciplinary approach involving obstetricians, the fetal medicine unit, and neonatologists.

Correlation of platelet parameters with adverse maternal and neonatal outcomes in severe preeclampsia: A case-control study

BACKGROUND

Pre-eclampsia (PET) is a potentially devastating multi-systemic disorder resulting in the generation of oxidative stress. Platelet activation causes vasoconstriction and release of inflammatory cytokines, resulting in an intensified inflammatory response, endothelial damage, and coagulopathy which culminate in adverse pregnancy outcomes.

AIM

To compare the platelet parameters between preeclamptic and normotensive pregnant women and their relationship to adverse outcomes in women with pre-eclampsia.

MATERIALS AND METHODS

This was a case-control study of platelet indices of 60 pre-eclamptic and 60 normotensive pregnant women recruited at 28 weeks and followed till delivery. A blood sample was collected at entry into the study and just before delivery. The sample was analyzed within 1 h of collection using the Mythic 18 hematological auto-analyzer. Data were analyzed using IBM-SPSS version 22. A P-value of <0.05 was considered statistically significant.

RESULTS

The mean platelet count, Platelet distribution width (PDW), plateletcrit were statistically significantly different between normotensive and severe preeclamptic participants (p= <0.001). Statistically significant differences were not present in any of the platelet parameters between mild and severe PET. The odds of developing eclampsia was low at higher mean platelet count and plateletcrit levels above 161.36 ± 73.74 × 109/L [p = 0.02, AOR = 0.27, 95% CI (0.08-0.88)] and 0.13 ± 0.05% [p = 0.001, AOR = 0.22, 95% CI (0.08-0.58)] respectively. Eclampsia was strongly associated with P-LCR (platelet-large cell ratio) above 23.15 ± 4.92% [p = 0.004, AOR = 11.00, 95%CI (1.48-89.02)]. Abruptio placentae had low odds at lower levels of mean plateletcrit. Pre-term birth was significantly lower at mean plateletcrit levels above 0.14 ± 0.05%; admission into neonatal intensive care unit was strongly associated with a mean PLC ratio above 22.73 ± 5.91%.

CONCLUSION

This study demonstrated significant differences in platelet count, plateletcrit, platelet distribution width, and P-LCR between pre-eclamptic and normotensive women. Increase in P-LCR is a risk factor for eclampsia although the effect size is low.

Management of refractory immune thrombocytopaenia in pregnancy

A 25-year-old woman with a history of immune thrombocytopaenia (ITP) in childhood was referred to haematology clinic for review with a platelet count of 50 μ/L at 9 weeks gestation, gravida 2, para 0. She developed progressive severe thrombocytopaenia as the pregnancy progressed, with associated bleeding complications. The thrombocytopaenia was refractory to standard therapies. This led to a need for a planned delivery, which was performed via caesarean section under general anaesthetic with platelet transfusion support, Intravenous Immune Globulin (IVIG), high-dose corticosteroid and the thrombopoietin (TPO) mimetic romiplostim. Both the mother and the neonate survived; however, the neonate required treatment for severe prolonged neonatal thrombocytopaenia. The patient subsequently re-presented 15 months later with recurrent ITP complicating another pregnancy, refractory to rituximab but responsive to romiplostim. She had a successful elective caesarean section under epidural anaesthesia, but the neonate once again suffered severe thrombocytopaenia, which was responsive to IVIG.

Consensus guidelines for the management of adult immune thrombocytopenia in Australia and New Zealand

Introduction

The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura (ITP) underlines the need for contemporary guidelines relevant to the local treatment context. ITP is diagnosed by exclusions, with a hallmark laboratory finding of isolated thrombocytopenia.

Main recommendations

Bleeding, family and medication histories and a review of historical investigations are required to gauge the bleeding risk and possible hereditary syndromes. Beyond the platelet count, the decision to treat is affected by individual bleeding risk, disease stage, side effects of treatment, concomitant medications, and patient preference. Treatment is aimed at achieving a platelet count > 20 × 10⁹/L, and avoidance of severe bleeding. Steroids are the standard first line treatment, with either 6‐week courses of tapering prednisone or repeated courses of high dose dexamethasone providing equivalent efficacy. Intravenous immunoglobulin can be used periprocedurally or as first line therapy in combination with steroids.

Changes in management as a result of this statement

There is no consensus on choice of second line treatments. Options with the most robust evidence include splenectomy, rituximab and thrombopoietin receptor agonists. Other therapies include azathioprine, mycophenolate mofetil, dapsone and vinca alkaloids. Given that up to one‐third of patients achieve a satisfactory haemostatic response, splenectomy should be delayed for at least 12 months if possible. In life‐threatening bleeding, we recommend platelet transfusions to achieve haemostasis, along with intravenous immunoglobulin and high dose steroids.

Eltrombopag treatment for severe immune thrombocytopenia during pregnancy: a case report

Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia (platelet count <100 × 109/l) in the absence of other causes or disorders associated. The incidence of ITP in pregnancy is one to two cases per 1000 gestations. ITP could be diagnosed before or during pregnancy; sometimes a relapse of a previously diagnosed ITP can occur. Intravenous immune globulins (IVIg) and corticosteroids are the standard frontline therapy because of their well known safety profile either for the mother or for the neonate. Treatments for refractory patients are limited by potential fetal risk. We report the case of a patient with ITP along pregnancy, refractory to corticosteroids and IVIg, successfully treated with, the thrombopoietin receptor agonist (TPO-RA) eltrombopag. Patient received this compound for almost the whole pregnancy and in particular for the whole first trimester, without any complication for the mother and the neonate. Although transient administration of TPO-RAs in pregnancy seems to be well tolerated, their use during the whole gestation is still controversial; this is the reason of the description of this case, which did not show any complications, and thus it could add useful information on this field.

ANALYSIS OF THE PLATELET HEMOSTASIS AMONG PREGNANT WOMEN WITH IMMUNE THROMBOCYTOPENIA

Relevance: Thrombocytopenia is a common hematological problem that accompanies pregnancy. From 5% to 12% of pregnancies are complicated by thrombocytopenia. Gestational thrombocytopenia is the leading cause of complications (70-85%). Immune thrombocytopenia (ITP) is the most frequent reason among pre-pregnancy causes of thrombocytopenia and is responsible for 1-4% of all thrombocytopenia cases during pregnancy. Investigation of the functional potential of the thrombocyte link of hemostasis in conditions of a reduced number of thrombocytes is relevant. The purpose of the study was to analyze the platelet link of hemostasis in pregnant women with ITP of varying severity by the method of light aggregometry. Materials and Methods: Eighty-eight women with gestational and 28 with immune thrombocytopenia were undergoing treatment and delivery at the Institute of Pediatrics, Obstetrics and Gynecology of NAMS of Ukraine (Kyiv, Ukraine) from September 2018 to February 2021. The platelet link of hemostasis was studied in a group of women with immune thrombocytopenia; six (21.4%) of them had severe thrombocytopenia. Results: In mild and moderate immune thrombocytopenia, we noted a decrease in spontaneous and induced platelet aggregation; in severe immune thrombocytopenia, there was no spontaneous and a decreased induced platelet aggregation. This indicated a reduced potential of platelets to perform their direct function – the formation of a thrombus. Conclusion: Immune thrombocytopenia accounts for most pre-pregnancy conditions causing thrombocytopenia in pregnant women. Light aggregometry is a relevant and indicative way to analyze the aggregative ability of platelets. A multidisciplinary team consisting of an obstetrician-gynecologist, hematologist, anesthesiologist, and neonatologist should be involved in the management of such cases to provide effective obstetric care for this category of pregnant women. Risks for the mother and the fetus/newborn should be assessed throughout the pregnancy, considering clinical and laboratory aspects. Delivery of pregnant women with severe thrombocytopenia should be managed at institutions providing the highest level of obstetric and gynecological care.

Bleeding and antithrombotic therapy during pregnancy in women with poor aPL-related obstetric outcomes: A survey of 1075 cases from EUROAPS registry∗

BACKGROUND

The combination of low-dose aspirin (LDA) and low-molecular-weight heparin (LMWH) until the end of gestation are the currently the accepted standard of care for the treatment of antiphospholipid-related obstetric disorders. In refractory cases, hydroxychloroquine (HCQ) can be added to this standard of care.

OBJECTIVE

To evaluate the haemostatic safety of LDA and LMWH (medium to high prophylactic doses) during pregnancy and the puerperium in women with both full-blown obstetric antiphospholipid syndrome (OAPS) (Sydney criteria) and noncriteria - incomplete - OAPS.

STUDY DESIGN

Retrospective/prospective multicentre observational study. Obstetric background, laboratory categories, delivery mode, antithrombotic regimens and bleeding complications were compared.

SETTING

A total of 30 tertiary European hospitals.

PATIENTS

Mainly, Caucasian/Arian pregnant women were included. Other ethnicities were minimally present. Women were controlled throughout pregnancy and puerperium.

MAIN OUTCOME MEASURES

The primary end-point was to evaluate the number of major and minor haemorrhagic complications in this cohort of women. Neuraxial anaesthetic bleeding complications were particularly assessed. Secondly, we aimed to compare local/general bleeding events between groups.

RESULTS

We studied 1650 women, of whom 1000 fulfilled the Sydney criteria of the OAPS and 650 did not (noncriteria OAPS). Data on antithrombotic-related complications were available in 1075 cases (65.15%). Overall, 53 (4.93%) women had bleeding complications, with 34 being considered minor (3.16%) and 19 major (1.76%). Neither obstetric complications nor laboratory categories were bleeding-related. Assisted vaginal delivery and caesarean section were related to local haemorrhage. Heparin doses and platelet count were not associated with major bleeding.

CONCLUSIONS

LDA and medium to high prophylactic LMWH during pregnancy in women with full-blown OAPS/noncriteria OAPS are safe. A slight increase in bleeding risk was noted in instrumental deliveries. No women who underwent spinal or epidural anaesthesia suffered bleeding complications. No haemorrhage was observed in cases where HCQ was added to standard therapy.

Coronavirus disease 2019 (COVID-19) in a pregnant women with treatment resistance thrombocytopenic purpura with and suspicion to HELLP syndrome: a case report

BACKGROUND

Coronavirus disease 2019 (COVID-19) still is a global emergency. According to the studies, pregnant women are of the at risk populations and any underlying disease(s) might even worsen their condition. The aim of this study is reporting a complex case of immune thrombocytopenic purpura (ITP) during pregnancy who has been diagnosed with COVID-19 as well as suspicion of HELLP syndrome.

CASE PRESENTATION

A 24-year-old woman with a platelet count of 6000/mL and resistance to conventional therapies was referred. A day after starting 0.5 g/day of methylprednisolone for her, fever and a decrease in SpO2 presented. According to the paraclinical investigations, COVID-19 was diagnosed and the conventional COVID-19 treatments started for her (the methylprednisolone pulse stopped). Due to the increased liver enzymes and low platelet count, with suspicion of HELLP syndrome, cesarean section surgery was performed which resulted in a healthy neonate. Then, the methylprednisolone pulse was restarted for and she developed an increase in the platelet count.

CONCLUSION

It is not clear how COVID-19 and pregnancy affected the patient's condition and the underlying disease; however, it seems the delivery and/or restarting the methylprednisolone pulses caused improvement in her condition.

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice

Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.

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.

Use of thrombopoietin receptor agonists for immune thrombocytopenia in pregnancy: results from a multicenter study

Management of immune thrombocytopenia (ITP) during pregnancy can be challenging because treatment choices are limited. Thrombopoietin receptor agonists (Tpo-RAs), which likely cross the placenta, are not recommended during pregnancy. To better assess the safety and efficacy of off-label use of Tpo-RAs during pregnancy, a multicenter observational and retrospective study was conducted. Results from 15 pregnant women with ITP (pregnancies, n = 17; neonates, n = 18) treated with either eltrombopag (n = 8) or romiplostim (n = 7) during pregnancy, including 2 patients with secondary ITP, were analyzed. Median time of Tpo-RA exposure during pregnancy was 4.4 weeks (range, 1-39 weeks); the indication for starting Tpo-RAs was preparation for delivery in 10 (58%) of 17 pregnancies, whereas 4 had chronic refractory symptomatic ITP and 3 were receiving eltrombopag when pregnancy started. Regarding safety, neither thromboembolic events among mothers nor Tpo-RA-related fetal or neonatal complications were observed, except for 1 case of neonatal thrombocytosis. Response to Tpo-RAs was achieved in 77% of cases, mostly in combination with concomitant ITP therapy (70% of responders). On the basis of these preliminary findings, temporary off-label use of Tpo-RAs for severe and/or refractory ITP during pregnancy seems safe for both mother and neonate and is likely to be helpful, especially before delivery.

Labor induction in pregnancy complicated by myelodysplastic syndrome: A case report

Pregnancy may aggravate myelodysplastic syndrome. Cross-matched platelets can be used in cases of refractory thrombocytopenia. Vaginal delivery can be attempted if the platelet count is at least 20 × 109/L.

Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review

The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.

Mild thrombocytopenia indicating maternal organ damage in pre-eclampsia: a cross-sectional study

Background

Currently, there is a disagreement between guidelines regarding platelet count cut-off values as a sign of maternal organ damage in pre-eclampsia; the American College of Obstetricians and Gynecologists guidelines state a cut-off value of < 100 × 10⁹/L; however, the International Society for the Study of Hypertension in Pregnancy guidelines specify a cut-off of < 150 × 10⁹/L. We evaluated the effect of mild thrombocytopenia: platelet count < 150 × 10⁹/L and ≥ 100 × 10⁹/L on clinical features of pre-eclampsia to examine whether mild thrombocytopenia reflects maternal organ damage in pre-eclampsia.

Methods

A total of 264 women were enrolled in this study. Participants were divided into three groups based on platelet count levels at delivery: normal, ≥ 150 × 10⁹/L; mild thrombocytopenia, < 150 × 10⁹/L and ≥ 100 × 10⁹/L; and severe thrombocytopenia, < 100 × 10⁹/L. Risk of severe hypertension, utero-placental dysfunction, maternal organ damage, preterm delivery, and neonatal intensive care unit admission were analyzed based on platelet count levels. Estimated relative risk was calculated with a Poisson regression analysis with a robust error.

Results

Platelet counts indicated normal levels in 189 patients, mild thrombocytopenia in 51 patients, and severe thrombocytopenia in 24 patients. The estimated relative risks of severe thrombocytopenia were 4.46 [95 % confidence interval, 2.59–7.68] for maternal organ damage except for thrombocytopenia, 1.61 [1.06–2.45] for preterm delivery < 34 gestational weeks, and 1.35 [1.06–1.73] for neonatal intensive care unit admission. On the other hand, the estimated relative risks of mild thrombocytopenia were 0.97 [0.41–2.26] for maternal organ damage except for thrombocytopenia, 0.91 [0.62–1.35] for preterm delivery < 34 gestational weeks, and 0.97 [0.76–1.24] for neonatal intensive care unit admission.

Conclusions

Mild thrombocytopenia was not associated with severe features of pre-eclampsia and would not be suitable as a sign of maternal organ damage.

HOW Collaborative position paper on the management of thrombocytopenia in pregnancy

Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.

Cesarean Section Complications Followed by Bladder Cystotomy and Gross Hematuria Due to Unknown Dense Scar Tissue

Adhesions formed from previous Cesarean section (C-section) are a significant risk factor for bladder injury. We present a case of a 43-year-old pregnant woman who underwent a C-section and experienced severe complications due to adhesions and incisional dehiscence from a previous Cesarean delivery 11 years earlier. Several surgical and non-surgical interventions as radiologic tests, cystotomy, blood transfusion, cystogram, and others were necessary to resolve the issues followed by the Cesarean delivery. It is important for clinicians caring for women undergoing both primary and subsequent Cesarean sections to consider and mitigate risk factors for adhesion development.

Maternal and Fetal Outcomes of Pregnancy in Patients with Immune Thrombocytopenia

Introduction

Immune thrombocytopenia (ITP) complicates 1-2 cases/10,000 pregnancies in India. Management of these patients is a challenge as it is associated with potential risks of maternal bleeding episodes and neonatal alloimmune thrombocytopenia (NAITP).

Objective

To study the maternal and fetal/neonatal outcome of pregnancy in Indian patients with ITP and identify the risk factors for NAITP.

Materials and Methods

In this retrospective study, all ITP patients with pregnancy who were diagnosed and treated at our center over 8 years (August 2010- August 2018) were evaluated for their hematological, obstetrical, and fetal outcomes.

Results

Twenty-nine pregnancies in 27 ITP patients were studied. The mean interval between the diagnosis of ITP and each pregnancy was 29 ± 14.9 months. The mean baseline platelet count was 0.18 ± 0.05 X 10⁹/L. Twenty-seven (93.1%) cases were treated with oral prednisolone. Twenty deliveries (69.0%) were vaginal and 9 (31.0%) deliveries were by cesarean section. There were no major bleeding episodes during pregnancy or delivery.The mean neonatal platelet count was 1.23 ± 0.58 × 10⁹/L at birth. NAITP was seen in 3 (3.5%) neonates. No bleeds or intracranial hemorrhages were observed. Only maternal platelet count < 50 X 10⁹/L at delivery showed a statistical correlation with NAITP (p = 0.022). There was no positive correlation between NAITP and the duration of maternal ITP, the timing of ITP onset, or type of treatment.

Conclusion

Successful outcome of pregnancies in ITP patients is possible, and the risk of maternal bleeding and NAITP is low.

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.

Multidrug Therapy for Refractory Immune Thrombocytopenia in Pregnancy

BACKGROUND

Severe immune thrombocytopenia complicating pregnancy may require treatment beyond first-line medications (intravenous immunoglobulins or corticosteroids), but there is a paucity of literature on the use of such second-line agents in pregnancy.

CASE

The patient is a 29-year-old woman with early-onset severe immune thrombocytopenia at 13 weeks of gestation. Maternal platelet counts reached a nadir of less than 5×10/L. The thrombocytopenia persisted despite first-line medications. Romiplostim, rituximab, and azathioprine were added to the therapeutic regimen. Platelet counts eventually stabilized at greater than 150×10/L before delivery. After delivery at term, the neonate had transient B-cell suppression, which was presumed to be secondary to rituximab, but was otherwise doing well and meeting all milestones at 7 months of age.

CONCLUSION

The addition of second-line agents was associated with sustained elevation in maternal platelet counts and may have obviated the need for splenectomy.

Romiplostim for management of refractory immune thrombocytopenic purpura in the immediate postpartum period

We present a case of a pregnant woman with chronic immune thrombocytopenic purpura and chronic hypertension who developed pre-eclampsia with severe features warranting delivery. Her overall clinical picture and liver enzymes improved in the immediate postpartum period, however, aggressively progressing thrombocytopenia posed a diagnostic dilemma to the interdisciplinary care team. After failing to respond to first-line therapies including high-dose corticosteroids and intravenous immunoglobulin, she was successfully managed with a trial of the thrombopoietin receptor agonist, Romiplostim.

Multiple metal exposure and platelet counts during pregnancy: A repeated measure study

BACKGROUND

Evidence from animal and in vitro studies suggest that some metals interfere with normal platelet counts (PLT). However, limited human studies have investigated the association of metals and PLT, a marker of hematologic and hemostatic, particularly in susceptible populations such as pregnant women.

OBJECTIVES

Our purpose was to investigate the associations of repeated measures of 13 urinary metals with PLT during pregnancy.

METHODS

The present study involved 3911 pregnant women participating in a prospective cohort study in Wuhan, China, from 2013 to 2016. We measured 13 metals in urine and PLT in blood samples collected in the first, second, and third trimester (median = 13, 24, and 35 weeks of gestation, respectively). Mixed linear models and general linear models were applied to analyze the associations between multiple metals and PLT during pregnancy. The odds ratio (OR) for gestational thrombocytopenia was examined using generalized estimating equations.

RESULTS

After adjusting for other metals and covariates, the repeated measure analyses showed that decreased levels of PLT were associated with a 10-fold increase in urinary concentration of cadmium (Cd) [percent difference (%Δ) = -5.02, 95%CI = -9.53, -0.29], manganese (Mn) [percent difference (%Δ) = -4.63, 95%CI = -7.50, -1.67], and arsenic (As) [percent difference (%Δ) = -4.56, 95%CI = -8.11, -0.86]. Cross-sectional analyses by trimesters revealed that Cd was inversely associated with PLT through the three trimesters. In addition, Cd was associated with an increased OR of 1.80 (95%CI: 1.26, 2.56), 1.65 (95%CI: 1.05, 2.59), 1.54 (95%CI: 1.02, 2.33) for gestational thrombocytopenia in the first, second, and third trimester, respectively.

CONCLUSIONS

Our study suggested an association of Cd, Mn, and As with decreased PLT during pregnancy. Particularly, Cd may increase the risk of gestational thrombocytopenia.

Thrombocytopenia in pregnancy: Diagnosis and approach to management

Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.

When age is truly only a number: late diagnosis of von Willebrand disease type 2B in a 61-year-old woman

: von Willebrand disease (VWD) type 2B is a rare bleeding disorder, presenting with moderate-to-severe lifelong bleeding. We present the case of a 61-year-old woman who was misdiagnosed as immune thrombocytopenic purpura during her three pregnancies resulting in a delayed diagnosis of VWD type 2B. This genetically confirmed diagnosis resulted in testing and the establishment of the diagnosis in her otherwise asymptomatic adult son as well. VWD may not be diagnosed till beyond mid adulthood in women with thrombocytopenia previously attributed to pregnancy and should be considered as a differential in female patients developing thrombocytopenia less than 100 × 10/μl with an increased bleeding assessment tool score.

Severe thrombocytopenia in pregnancy: a case series from west China

Thrombocytopenia is the second most common hematological disease during pregnancy and is mainly caused by gestational thrombocytopenia, immune thrombocytopenia, or preeclampsia/HELLP syndrome. This study aims to investigate the causes and pregnancy outcomes of thrombocytopenia in pregnancies with platelet counts below 50 × 10⁹/L. We retrospectively analyzed the pregnancies diagnosed with severe thrombocytopenia at a tertiary care center in western China between January 2009 and December 2017. All enrolled pregnancies were divided into three groups according to the lowest platelet counts: group A (30-50 × 10⁹/L), group B (10-30 × 10⁹/L), and group C (< 10 × 10⁹/L). Maternal and fetal outcomes were observed and compared among these three platelet levels. A total of 533 consecutive pregnancies were included. A relatively large proportion (37.3%, 199/533) of them showed a history of thrombocytopenia before pregnancy or during a previous pregnancy. Most of the women (70.2%, 374/533) received corticosteroids, intravenous immunoglobulin, or platelet transfusion treatments. The incidence of preterm birth < 37 weeks (26.3%, 15/57), cesarean section (93%, 53/57), and neonatal intensive care unit (NICU) admission (31.6%, 18/57) occurred significantly more often in group C than in groups A and B. Neonatal platelet counts were detected in 28.2% of the infants (155/549), and neonatal thrombocytopenia was found in 40.6% of the infants (63/155). Intracranial hemorrhage occurred in 0.9% of the neonates (5/549) throughout the study period, with neonatal nadir platelet counts between 20 × 10⁹/L and 245 × 10⁹/L. One perinatal death occurred in group C. Pregnancies with the lowest platelet counts below 10 × 10⁹/L are more often complicated by preterm birth, cesarean section, and NICU admission compared with those lowest platelet counts 30-50 × 10⁹/L and 10-30 × 10⁹/L. Neonatal intracranial hemorrhage was uncommon in pregnancies with severe thrombocytopenia. Active management should be performed to avoid possible preterm birth and neonatal NICU admission in pregnancies with the lowest platelet counts below 10 × 10⁹/L.

Pregnancy of patients with idiopathic thrombocytopenic purpura: maternal and neonatal outcomes

Objective:

Thrombocytopenia occurs in 7% of pregnant women. Along with other causes, idiopathic thrombocytopenic purpura (ITP), which is an autoimmune disease with autoantibodies causing platelet destruction, must be considered in the differential diagnosis. Antiplatelet antibodies can cross the placenta and cause thrombocytopenia in the newborn. The aim of our study was to assess the management of ITP in pregnancy, and to investigate neonatal outcomes.

Material and Methods:

This retrospective study was conducted in a tertiary center including 89 pregnant patients with ITP followed between October 2011 and January 2018. Patients were evaluated in two groups according to diagnoses of ITP and chronic ITP. Age, obstetric history, ITP diagnosis, and follow-up period, presence of splenectomy, platelet count during pregnancy and after birth, treatment during pregnancy, route of delivery, weight and platelet count of newborn, sign of hemorrhage, and fetal congenital anomaly were assessed

Results:

Considering the ITP and chronic ITP groups, no significant difference was seen with respect to parity, timing of delivery, preoperative and postoperative platelet counts, and hemoglobin values. Route of delivery, birth weight, APGAR scores, newborn platelet count, and congenital anomaly rates were also similar. The timing of treatment was different because patients whose diagnoses were established during pregnancy were mostly treated for preparation of delivery. Treatment modalities were similar.

Conclusion:

Probability of severe thrombocytopenia at delivery is higher in patients with ITP who are diagnosed during pregnancy when compared with patients who received prepregnancy diagnoses. ITP is an important disease for both the mother and newborn. Patients should be followed closely in cooperation with the hematology department.

Preoperative moderate thrombocytopenia is not associated with increased blood loss for low-risk cesarean section: a retrospective cohort study

BACKGROUND

The occurrence of thrombocytopenia is as high as 7-12% in pregnancy, yet minimum platelet count safe for cesarean section remains unknown.

METHODS

In this retrospective noninferior cohort study, we consecutively included patients undergoing cesarean section for a period of 6 years in a tertiary hospital and excluded patients at very high risk for excessive hemorrhage. The included patients with preoperative platelet count of 50-100 × 10⁹/L were defined as the thrombocytopenic group. The control group were eligible patients with preoperative platelet count>150 × 10⁹/L, matched to the thrombocytopenic group by age and operation timing in a 1:2 ratio. Mixed effect model was used to analyze the effect of thrombocytopenia based on a noninferiority assumption. The predefined noninferiority delta of bleeding was 50 mL.

RESULTS

There was no significant difference of the calculated blood loss between the thrombocytopenic and the control group (mean difference = 8.94, 95% CI - 28.34 mL to 46.09 mL). No statistical difference was observed in the requirement for blood transfusion, visually estimated blood loss, or the incidence of adverse events between groups. Although there were more patients admitted to intensive care unit (odds ratio = 12, 95% CI 2.69-53.62, p = 0.001) in the thrombocytopenic group, most of them required critical care for reasons other than hemorrhage. The thrombocytopenic group had longer length of hospital stay (mean difference = 0.40 days, 95% CI 0.09-0.71, p = 0.011), but the difference was considered as clinically insignificant.

CONCLUSIONS

Preoperative moderate thrombocytopenia is not associated with increased blood loss, blood transfusion, or occurrence of adverse events in patients undergoing cesarean section in absence of additional bleeding risk.

Acquired amegakaryocytic thrombocytopenia as a rare cause of thrombocytopenia during pregnancy

A rare case of acquired amegakaryocytic thrombocytopenia (AATP) in a 35-year-old woman who presented with anaemia and thrombocytopenia at 22 weeks gestation. The first diagnostic impression was of an evolving aplastic anaemia; however, the patient was simultaneously diagnosed with severe vitamin B₁₂ deficiency in the setting of vegetarianism. Once the cyanocobalamin deficiency was corrected, a repeat bone marrow biopsy revealed an isolated depletion of megakaryocytes, which suggested the diagnosis of AATP. Supportive care was provided for her anaemia and thrombocytopenia and she delivered a healthy baby girl with a normal platelet count. The patient was subsequently started on romiplostim with steady improvement in her platelet counts. This rare AATP case presentation highlights the importance of a well-structured diagnostic approach to thrombocytopenia during pregnancy and supports the successful use of thrombopoietin agonists for the management of AATP.