Thrombocytopenia in Pregnancy Nearing Term: A Clinical Analysis

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.

Dengue and HELLP: Beware of the Masquerade

HELLP is a syndrome characterized by hemolysis, elevated liver enzymes, and low platelets. It is a rare complication of pregnancy and is usually associated with pre-eclampsia. However, 10–20% cases of HELLP can present without hypertension. Dengue fever is an arboviral-borne tropical illness that is characterized with fever, thrombocytopenia, and bleeding manifestations. We present a case of a primigravida with HELLP syndrome masquerading in the background of dengue fever. Unique features to this case report include delayed presentation of HELLP syndrome with normotension which can have overlapping features with dengue fever, especially in term pregnancy. This case highlights the need of strict vigilance in cases of dengue fever with pregnancy.

Hematobiochemical variability and predictors of new-onset and persistent postpartum preeclampsia

Preeclampsia (PE) can occur antepartum or postpartum. When it develops de novo after childbirth, it is termed new-onset postpartum PE (NOPPE). Often, antepartum PE disappears after childbirth; however, in some women it persists after childbirth. This form of PE is termed persistent PE (PPE). Thus, there are two forms of postpartum PE: NOPPE and PPE. The pathogenesis and pathophysiology of these diseases have not been fully characterized, and whether NOPPE and PPE are different or similar pathological conditions remains unexplored. Thus, we aimed to compare the haematological and biochemical characteristics of NOPPE and PPE, predict the occurrence of new-onset PE and identify lifestyles that predispose women to postpartum PE. A total of 130 women comprising 65 normotensive postpartum women, 33 NOPPE and 32 PPE women were recruited for this hospital-based case-control study. The socio-demographic and lifestyle characteristics of the participants were obtained through well-structured questionnaires. Haematological and biochemical indices were measured using automated analysers and ELISA. The prevalence of postpartum PE was 11.9%. Dyslipidaemia (p =  < 0.0001), hypomagnesaemia (p =  < 0.001), elevated serum levels of ALT, AST (p =  < 0.0001), sVCAM-1 (p =  < 0.0001) and sFlt-1 (p =  < 0.0001) were more prevalent and severe in the PPE than in the NOPPE. Sedentary lifestyle was common among both groups of hypertensive women. Elevated ALT and AST were significant predictors of NOPPE. These findings indicate that preeclampsia exists after childbirth in a high percentage of women. NOPPE and PPE are different pathological conditions that require different clinical management. Combined glucose, lipid and liver assessment could be useful in predicting postpartum PE.

Intraoperative Post Partum Hemorrhage in a Patient with Dengue Fever

A 33 year old obstetric patient with mild fever of undiagnosed etiology underwent emergency caesarean section under general anesthesia. She had platelet count of 98,000 per microliter and increased APTT of 37.8 s at the time of surgery. After uneventful anesthetic induction and delivery of fetus, slow and oozing type of bleeding led to massive hemorrhage. Patient remained vitally stable throughout perioperative phase and was extubated. Next day, patient's dengue IgM antibody was reported positive. Neonate was well and his dengue test was negative. Pregnant women are at high risk of developing severe complications of dengue fever with unclear mechanisms related to impaired coagulation. Regional anesthesia may not have safe outcome due to dengue infection.

Immune Regulation, Maternal Infection, Vaccination, and Pregnancy Outcome

About 12.5% of all maternal deaths in the United States are due to infectious causes. This proportion, although stable during the past three decades, represents an increase in infectious causes of mortality, as the overall mortality rate in U.S. pregnant women had increased steadily during that same period. During healthy pregnancies, a delicate immunological balance-in which a mother's immune system tolerates the semi-allogeneic fetus yet maintains immune competency against infectious agents-is achieved and maintained. This immunological paradigm, however, results in increased susceptibility to infectious diseases during pregnancy, particularly in later stages and during the early postpartum period. The inflammatory process induced by these infectious insults, as well as some noninfectious insults, occurring during pregnancy can disrupt this carefully achieved balance and, in turn, lead to a state of rampant inflammation, immune activation, and dysregulation with deleterious health outcomes for the mother and fetus. Elucidating mechanisms contributing to the disruption of this immunologic homeostasis, and its disruption by infectious pathogens, might offer opportunities for interventions to reduce maternal and fetal morbidity and mortality.

Thrombocytopaenia in pregnancy: the importance of differential diagnosis during the COVID-19 pandemic

Since the beginning of the COVID-19 pandemic, an optimal management of vulnerable patients, such as pregnant women, has been regarded as a challenge for healthcare professionals. Although thrombocytopaenia is considered a minor criterion for admission within an intensive care unit, a low platelet count has been observed in COVID-19 patients, including a pregnant woman, who developed severe pulmonary complications. Furthermore, thrombocytopaenia has been proposed as a potential biomarker in order to identify cases at high-risk complications. Nevertheless, thrombocytopaenia is a relatively frequent condition observed in pregnancy. In this context, a differential diagnosis is essential for the correct management of COVID-19 pregnant women.