Evaluation of Outcome of Pregnancy Complicated with Thrombocytopaenia- A Prospective Observational Study
Correspondence Address :
Dr. Rao Bahadur Badugu,
House No. 8-471/E, 8th Cross Road, Kuppurao Colony, Devunimanyam, Mangalagiri, Andhra Pradesh, India.
E-mail: drraobahadur@yahoo.com
Introduction: Thrombocytopaenia occurs in 7-12% of pregnancies at the time of delivery. Knowledge, regarding the causes and effects of thrombocytopaenia on mother and newborn, facilitates proper diagnosis and management of thrombocytopaenia in pregnant women for better maternal and foetal outcomes.
Aim: To determine the incidence, causes and outcome of pregnancy with thrombocytopaenia.
Materials and Methods: A prospective observational study was conducted among women attending Outpatient Department for an antenatal checkup at NRI Medical College and General Hospital, Chinnakakani, Guntur, Andhra Pradesh, India, from October 2017 to October 2019. A total of 44 antenatal women with platelet count less than 1,50,000/cumm were included in the study. They were followed-up throughout the antenatal period until delivery to record any complications that developed due to low platelet counts in the mother and neonate. A neonatal platelet count was done on day one of life. Data was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) version 22.0, all qualitative variables were expressed in terms of proportion.
Results: A total of 500 cases were studied of which 50 cases had thrombocytopaenia with an incidence of 10%. Out of 50 cases, six were lost for follow-up and the remaining 44 cases were included in the study. Out of 44 patients, 23 (52.27%) had mild thrombocytopaenia, 12 (27.27%) had moderate and 9 (20.46%) had severe thrombocytopaenia at the time of diagnosis. Common causes seen were Gestational Thrombocytopaenia (GT) 17 (38.6%), Preeclampsia (PE) 8 (18.18%), Gestational hypertension 4 (9.09%). A total of 5 (11.36%) required intensive care unit care, 3 (6.81%) had multiorgan dysfunction syndrome (MODS), 2 (4.54%) underwent hysterectomy, 2 (4.54%) had postpartum haemorrhage (PPH), 2 (4.54%) had secondary suturing done for wound infection, 1 patient (2.27%) underwent laparotomy (for rectus sheath haematoma), and mortality was seen in two cases. A total of 14 cases (31.8%) required blood and blood product transfusions. Eight neonates were admitted to the neonatal intensive care unit. There was no case of neonatal thrombocytopaenia.
Conclusion: Thrombocytopaenia is a significant problem in pregnancy; hence, the routine antenatal platelet count should be done for a timely diagnosis of thrombocytopenia.
Gestational thrombocytopaenia, Haemorrhage, Hypertension
Thrombocytopaenia is defined as a platelet count of less than 1,50,000/cumm. It occurs in 7-12% of pregnancies at the time of delivery (1),(2). There is a physiological fall in the platelet count in normal pregnancy. These changes could be because of the dilutional effect, low platelet production, or may be because of increased platelet turnover in pregnancy (2).
The most common clinical manifestations of thrombocytopaenia are petechiae, ecchymosis, epistaxis, gum bleeding, and abnormal uterine bleeding. Surgical bleeding associated with thrombocytopaenia is uncommon unless platelet counts are less than 50,000/cumm, and spontaneous bleeding is rare unless the platelet count is below 10,000/cumm. However, pregnant women with a platelet count of less than 1,00,000/cumm should undergo further clinical and laboratory assessment (3).
Knowledge regarding the causes and effects of thrombocytopaenia on mother and newborn facilitates proper diagnosis and management of thrombocytopaenia in pregnant women for better maternal and foetal outcomes. Thrombocytopaenia in pregnancy can result in bleeding during pregnancy, preterm delivery, Intrauterine Growth Restriction (IUGR), Postpartum Haemorrhage (PPH), abortions, abruption, Intrauterine Death (IUD), excessive bleeding complication during caesarean delivery, neonatal thrombocytopaenia (4),(5).
Platelet count is not routinely done during the antenatal period, hence, the effect of thrombocytopaenia during pregnancy is not well studied in India. The present study was done with the aim to know the incidence, aetiology and outcome of pregnancy with thrombocytopaenia.
A prospective observational study was conducted among women attending Outpatient Department for an antenatal checkup at NRI Medical College and General Hospital, Chinnakakani, Guntur, Andhra Pradesh, India, from October 2017 to October 2019. Ethical approval was taken for the study (NRIAS/IEC/431/2018). Informed consent was obtained from the participants.
A total of 50 out of 500 pregnant women included in the study were diagnosed with thrombocytopaenia with a platelet count <1,50,000/cumm at the first visit to the hospital. Out of 50 cases, six cases were lost for follow-up, and the remaining 44 cases were included in the study.
Inclusion criteria: Antenatal women with platelet count less than 1,50,000/cumm.
Exclusion criteria: Prior diagnosed cases of Idiopathic Thrombocytopenic Purpura (ITP), patients on steroids and Non Steroidal Anti-Inflammatory Drugs (NSAIDs) therapy, patients who underwent splenectomy, Human Immunodeficiency Virus (HIV) positive, and on drugs causing thrombocytopaenia.
Study Procedure
Platelet count estimation was done for all cases at the first visit and repeated in the third trimester. Platelet counts were repeated before and after delivery. Neonatal platelet count was done on day one of life. They were followed-up throughout the antenatal period until delivery to record any complications that developed due to low platelet counts. Platelet count was estimated by automated haematology analyser Symex XN 1000 by flow cytometry and manual method by peripheral smear. Based on platelet value, cases were divided as mild thrombocytopaenia (1,00,000-1,50,000/cumm), moderate thrombocytopaenia (50,000-99,000/cumm) and severe thrombocytopaenia (<50,000/cumm) (6).
Statistical Analysis
The data was analysed in Statistical Package for Social Sciences (SPSS) version 22.0. All the quantitative variables like age, platelet count, were expressed in terms of descriptive values like mean. All the qualitative variables were expressed in terms of proportion.
The incidence of maternal thrombocytopaenia was 10% i.e, (50/500). The mean age noted was 23.56±3.5 years. (Table/Fig 1) shows the socio-demographic data. Out of 44 patients, 52.27% (n=23) had mild thrombocytopaenia, 27.27% (n=12) had moderate and 20.45% (n=9) had severe thrombocytopaenia at the time of diagnosis.
Gestational Thrombocytopaenia (GT) accounts for 38.63% (n=17), gestational hypertension was seen in four patients (9.09%) (Table/Fig 2).
A total of 13.63% (n=6) delivered between 28-32 weeks of gestation, 6.81% (n=3) delivered between 32-36+6 week period of gestation, and 65.90% (29 patients) delivered after 37 completed weeks of gestation, and 13.63% (n=6) had abortion.
A total of 47.72% (21 patients) had vaginal delivery, 38.63% (17 patients) delivered by Lower Segment Caesarean Section (LSCS). LSCS was done for preeclampsia and antepartum haemorrhage (n=2), eclampsia+HELLP (n=2), severe preeclampsia (n=3), CPD (n=1), previous LSCS (n=4), foetal distress (n=2), failed induction (n=3). In 31.81% (14 patients) blood and blood product transfusions was required, of which 4.54% (n=2) required only platelets, 11.36% (n=5) required only packed red cells, 6.81% (n=3) required packed red cells and platelets, 6.81% (n=3) required packed red cells along with platelets and Fresh Frozen Plasma (FFP), 2.27% (n=1) required packed cells along with FFP’s and albumin. There was no need for transfusion in 68.18% (30 patients).
Two maternal deaths were seen (one patient died due to sepsis and MODS, and one due to acute fulminant hepatic failure). Out of 37 live births, 29 neonates were healthy, and eight neonates were admitted in NICU because of IUGR. There was no incidence of neonatal thrombocytopaenia (Table/Fig 3). The birth weight of two neonates was less than 1 kg, one neonate had birth weight of 1.2 kg, 12 neonates weighted between 1.6-2.5 kg, 22 neonates weighted between 2.6-4.0 kg. Twenty nine neonates had APGAR score at 5 minutes more than 7, and eight neonates had APGAR score at 5 minutes less than 7.
In the present study, the incidence of maternal thrombocytopaenia was 10%, which is comparable to the studies by Chauhan V et al., (7) (8.40%), and Singh N et al., (8) (8.80%). A higher incidence was observed by Ajibola SO et al., (9) (13.50%) and Onisai M et al., (10)(11.11%). In the present study, mean age was 23.56±3.5 years. Suri V et al., (11) Jaleel A et al., (12), Borna S et al., (13), Turgut A et al., (14) showed the mean age was 27, 28.43, 28, and 27.6±5.7 years, respectively. The present study, showed mean gravidity was 2.15±0.99. Chauhan V et al., (7), Dwivedi P et al., (15) showed mean gravidity of 1.75, and 2.15±0.99, respectively. In the present study, 45.45% (20 cases) were primigravida, 52.27% (23 cases) were second and third gravida, and 2.27% (one case) was fourth gravida patient. Brohi ZP et al., (16) study showed 40.8% were primigravida. In Katke RD and Gohil DP study 35% cases were primigravida, 32% cases were gravida 2 and 33% cases were gravida 3 to 5 (17). The present study showed mean gestational age at diagnosis was 32+1±8.7 weeks. In Parnas M et al., 74.4% were between 37-40 weeks of gestation (18). In Dwivedi P et al., the mean gestational age was 38 weeks (15).
The present study showed mild thrombocytopaenia in 52.27% (23 patients). Mild thrombocytopaenia was noted in 54% cases by Borna S et al., which is comparable to the present study (13). In Chauhan V et al., 63.2% women had mild thrombocytopaenia, which was higher as compared to the present study (7). In the present study, moderate thrombocytopaenia was seen in 27.27% cases and severe thrombocytopaenia in 20.46% cases. In Katke RD and Gohil DP 70.9% of patients had moderate thrombocytopaenia and 29.1% of patients had severe thrombocytopaenia (17). In Chauhan V et al., (7), Borna S et al., (13) showed 35.4%, 30%, respectively with moderate thrombocytopaenia and 1.5%, 16%, respectively with severe thrombocytopaenia. Singh N et al., (8) showed 7.4% of patients had severe thrombocytopaenia (8). In present study, mean gestational age at delivery was 34.44±8.5 weeks. Bouzari Z et al., (19), Chauhan V et al., (7), Lin YH et al., (20) showed mean gestational age at delivery of 35.83±3.61 weeks, 38.6±1.34 weeks, 39 weeks, respectively.
Present study showed Gestational Thrombocytopaenia (GT) (38.63%) as most common cause of thrombocytopaenia followed by PE (18.18%) (Table/Fig 4) shows a comparison of various causes in present study with different studies done by different authors (4),(5),(7),(17),(18),(21),(22),(23).
In the present study, the mean gestation age at delivery was 34.44±8.5 weeks and 23.68% had preterm delivery and 44.73% had LSCS. (Table/Fig 5) shows comparison of gestation age at delivery and mode of delivery between different studies and present study (5),(7),(17),(18),(22). According to a study by Anita H et al., 60% of cases delivered at term, those delivered before term were mostly due to abruption or for obstetric indications like severe preeclampsia, antepartum eclampsia, abruption or medical causes (5). In the present study, 44.73% (17 cases) delivered by LSCS, done for obstetrical indications like foetal distress (n=2), failed induction (n=3), previous Lower Segment Caesarean Section (LSCS) (n=4), cephalopelvic disproportion (n=1), severe preeclampsia (n=3), eclampsia+HELLP (n=2), preeclampsia and antepartum haemorrhage (n=2), but not due to thrombocytopaenia alone.
In the present study, out of 44 patients, 31.8% (n=14) required blood and blood product transfusions. In a study by Usha S et al., 66.8% required blood or blood product transfusion (22). Platelet transfusions were required in 43.1% of cases (n=69). In a study by Parnas M et al., 19.6% required transfusions and 3.21% required only platelet transfusion, which is comparable to the present study (18).
In Katke RD and Gohil DP study, one case required LSCS with obstetric hysterectomy, and one case required LSCS followed by internal iliac artery ligation and obstetric hysterectomy (17). These results are similar to the present study where two cases required hysterectomy. In the present study, PPH was seen in 4.54% (n=2). In Usha S et al., and Singh N et al., study PPH was seen in 12.4% (n=8) and 9.89%, respectively (8),(22).
In the present study, maternal mortality was seen in two cases (4.54%) cases. In a study by Katke RD and Gohil DP mortality was seen in 7.76% (n=8) due to causes like acute respiratory distress syndrome, haemothorax with liver failure, intracranial bleed, cardiorespiratory arrest, hypotension, pulmonary embolism, kidney failure, multiorgan failure, stroke (17). Birth weight <2.4 kg in the present study was seen in 40.5% neonates, which was less than study data reported by Usha S et al., (22) ( 67.1%) and more than Onisai M et al., study (24.48%) (10). In the present study, out of 37 live births, 21.62% (n=8) have APGAR score of less than 7 at 5 minutes, and in Chauhan V et al., study 6.15% of neonates had APGAR score of less than 7 at 5 minutes (7).
In the present study, IUGR was seen in 5.26% (n=2), out of which one foetus had IUD, and the other was admitted in NICU. According to Parnas M et al., (18) study, IUGR was seen in 8.5% and was associated with preeclampsia, HELLP syndrome, and DIC, which was similar to the present study. In the present study, IUD was seen in one case due to severe IUGR because of severe maternal preeclampsia. According to the study conducted by Parnas M et al., 6.5% of cases had still births (18). According to a study by Katke RD and Gohil DP 14.1% (14 patients) had a still birth (17). Neonatal thrombocytopaenia was not seen in the present study. In Chauhan V et al., neonatal thrombocytopaenia was seen in 3.1% (7). According to a study done by Anita H et al., one case had neonatal thrombocytopaenia (5). None of the babies had bleeding complications. According to Singh N et al., one neonate born to mother with ITP had neonatal thrombocytopaenia on day one, platelet count returned to normal on day 8. Bleeding manifestations were not seen in any of the neonates (8).
Mild thrombocytopaenia does not have much effect on the obstetrical management but severe thrombocytopaenia can have adverse outcome especially in life threatening conditions like HELLP syndrome which poses a great challenge to the treating obstetrician. Platelet count monitoring should be routinely done at antenatal visits for timely diagnosis of thrombocytopaenia and to achieve favourable foetal and maternal outcome in all types of thrombocytopaenia. Neonatal platelet count should be done in all cases where maternal thrombocytopaenia is diagnosed.
Limitation(s)
The sample size being very small is the limitation of this study.
Thrombocytopaenia is a significant problem in pregnant women. Maternal platelet count monitoring should be done as a routine antenatal investigation for timely diagnosis of thrombocytopaenia, which will help in administering accurate management and thereby, preventing maternal and neonatal morbidity and mortality.
DOI: 10.7860/JCDR/2022/60581.17228
Date of Submission: Oct 05, 2022
Date of Peer Review: Oct 28, 2022
Date of Acceptance: Nov 23, 2022
Date of Publishing: Dec 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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