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ORIGINAL ARTICLE
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Prevalence and Etiology of Thrombocytopenia in Pregnant Women in a Tertiary Care Hospital in Delhi


1 Department of Pathology, Maulana Azad Medical College, New Delhi, India
2 Lady Hardinge Medical College, New Delhi, India

Date of Submission16-May-2021
Date of Decision02-Jun-2021
Date of Acceptance03-Jun-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Sarika Singh,
Department of Pathology, Maulana Azad Medical College, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_52_21

  Abstract 


Background: Thrombocytopenia is the second most common hematologic abnormalities in pregnancy next to anemia. Its etiology is not well understood in the pregnant females. Aim: To find out the prevalence of thrombocytopenia (hospital based) in pregnant women and the various etiologic factors responsible for thrombocytopenia in pregnant Indian women. Setting and Design: This was a prospective, cross-sectional study. Materials and Methods: One thousand pregnant registered females attending the antenatal clinic were studied with detailed history, examination, hemogram on Sysmex KX-21 hematology analyzer (Transasia: Mumbai, India Diamed, Switzerland) five part differential analyzer in blood collected in ethylenediaminetetraacetic acid vials, liver and kidney function tests, and other relevant special hematologic tests depending upon the clinical diagnosis. Statistical Analysis: By using the Chi-squared test, values of P < 0.05 being considered statistically significant. Results: The prevalence of thrombocytopenia in pregnancy was 134/1000 (13.4%). Moderate thrombocytopenia was observed in 72/134 (53.7%) and severe thrombocytopenia in 14/134 (10.4%). About 125/134 (93.3%) of the thrombocytopenic patients were in the third trimester. Majority of them belonged to 21 to 25 years of age and had B+ blood group. Most common etiology was gestational thrombocytopenia (GT) in 46/134 (34.3%). Anemia was found in 27/134 (20.1%) patients. Conclusion: In Indian thrombocytopenic female, most common cause is GT but lesser than western world. The prevalence of associated anemia is higher in this part of world.

Keywords: Anemia, pregnancy, pregnancy third trimester, thrombocytopenia



How to cite this URL:
Singh S, Balhara K, Oberoi M. Prevalence and Etiology of Thrombocytopenia in Pregnant Women in a Tertiary Care Hospital in Delhi. MAMC J Med Sci [Epub ahead of print] [cited 2021 Dec 3]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=326951




  Introduction Top


Thrombocytopenia is defined as the platelet count of less than 150,000/µl.[1] Pregnancy causes varied alterations in hematopoietic systems. Thrombocytopenia is second only to anemia as the most common hematologic abnormality in pregnancy.[2] It occurs commonly during pregnancy and accounts for around 7–8% of the all the pregnancies.[3] The causes are accelerated platelet consumption or decreased production and are classified as mild (platelet count of ≥100,000 to <150,000/µl), moderate (≥50,000 to <100,000/µl), and severe (<50,000/µl).[4] The various causes of thrombocytopenia are summarized in [Table 1].
Table 1 The pregnancy-specific and nonpregnancy-specific causes of thrombocytopenia

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Gestational thrombocytopenia (GT) is the most common cause accounting for about 75% of cases of thrombocytopenia during pregnancy.[5],[6] Immune thrombocytopenic purpura (ITP) constitutes approximately 5%,[7],[8] pre-eclampsia (PE) 21%, and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome about 9% of eclampsia and pre-eclampsia cases.[9],[10]

There is no risk of severe hemorrhage in GT but PE, HELLP syndrome, ITP, and other rare causes such as thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, disseminated intravascular coagulopathy (DIC), von Willebrand disease IIB (vWD IIB) may result in various obstetrical complications and cause maternal mortality from ruptured subcapsular hematomas, hemorrhage, and stroke. The fetal complications associated are perinatal deaths, fetal growth retardation, and neonatal thrombocytopenia.

The baseline low platelet counts and decreasing trend with increasing gestational age predispose Indian women to the risk of thrombocytopenia.

Thrombocytopenia is often underdiagnosed and mismanaged condition in Indian women, hence the present study helps to find out various etiologic factors of thrombocytopenia during pregnancy and to review management strategies for the best fetomaternal outcome. Awareness of the causes facilitates proper diagnosis and management of thrombocytopenia in the pregnant state.


  Materials and Methods Top


The present study was carried out in a tertiary care hospital of Delhi from June 1, 2014 to July 31, 2014. It was a cross-sectional study, comprising of total 1000 pregnant women registered in the hospital during that period. The institutional Ethical Clearance Committee approved the study. A Proforma was made and the written informed consent was taken from all women recruited. They were screened for thrombocytopenia through automated blood count analyzer, Sysmex KX-21 hematology analyzer (Transasia: Mumbai, India Diamed, Switzerland) with the routine hematologic investigation. The relevant history (obstetrical history, patient’s history, family history, complaints of petechiae, bruising, nausea/vomiting, drug usage [such as NSAIDS, heparin, carbamazepine, diazepam, isoniazid, rifampin, antibiotics such as sulfa drugs, cephalosporins, etc.], viral infection, neurologic deficits, fever, bleeding from any site, blood transfusion) was taken.

Clinical examination was performed to find out any signs of thrombocytopenia such as petechiae, ecchymosis, nose, and gum bleeding.

Investigations performed: complete blood count [hemoglobin, white blood cell count, differential leucocyte count (DLC), red blood cell count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red blood cell distribution width (RDW), and platelet count], kidney function tests, liver function tests (LFTs), hepatitis B surface antigen (HBsAg), human immunodeficiency virus (HIV), and venereal disease research laboratory (VDRL). Coagulation tests [prothrombin time (PT), activated partial thromboplastin time (APTT), fibrin degradation product (FDP), D-dimer, and fibrinogen] in those with signs or symptoms of DIC and other confirmatory tests if any (depending on clinical condition) such as the peripheral smear, lupus anticoagulant (LAC)/antiphospholipid antibodies antiphospholipid antibody syndrome (APLA), thyroid profile, etc., were performed.

Statistical analysis

Chi-squared test was used to find the association between different parameters using the SPSS 24 software (SPSS Inc, Chicago, IL, USA). P-value <0.05 was considered statistically significant.


  Results Top


A total of 1000 pregnant women were studied. The age ranged from 21 to 40 years. The most common age group was 21 to 25 years (47.8%), followed by 26 to 30 years (27.6%). Most of the patients (93.3%) were of the third trimester. Out of the total 1000 pregnant women, 134 were found to be thrombocytopenic giving a prevalence of 13.4%. Forty-eight out of these 134 patients (35.8%) were found to have mild thrombocytopenia, 72 (53.7%) had moderate, and 14 (10.4%) had severe thrombocytopenia. One hundred and nineteen patients out of 134 (88.8%) were Hindus and 15 (11.2%) were Muslims. Forty-five (33.6%) were primigravida and 89 (66.4%) were multigravida out of total 134 cases [Table 2].
Table 2 The etiology of thrombocytopenia and its distribution according to various trimester, age groups, and severity of thrombocytopenia

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Most common etiology found was GT 46/134 (34.3%), followed by pregnancy induced hypertension (PIH) 17/134 (12.7%), dimorphic anemia 16/134 (11.9%), deranged LFT 8/134 (6%), and viral infections [HepB, HIV, TORCH- (T)oxoplasmosis, (O)ther Agents, (R) ubella, (C)ytomegalovirus, and (H)erpes Simplex)] 7/134 (5.2%) [Table 2].

A statistically significant association was found between the etiology and the trimester (P = 0.000), thrombocytopenia (P = 0.000), and age group (P = 0.017) [Table 2]. Majority of the thrombocytopenic patients were of age group 21 to 25 years with GT as the predominant cause.

An association of the blood group and etiology was also observed with the significant P-value of 0.011 [Table 3]. About 27 out of 134 (20.1%) patients were A+, 54/134 (40.3%) patients were B+, and 16/134 (11.9%) patients were AB+. Majority of thrombocytopenic patients were B+ with GT as the predominant cause.
Table 3 The etiology of thrombocytopenia and its association with blood group of the thrombocytopenic pregnant females

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Anemia was the significant finding in our setup, found in 27/134 (20.1%) patients. Out of total 134 patients, 16 (59.3%) had dimorphic anemia, 4 (3%) had macrocytic anemia, 2 (1.5%) had PIH with macrocytic anemia and hypothyroidism with macrocytic anemia each, and 1 (0.7%) had PE with dimorphic anemia.


  Discussion Top


The pathophysiology of thrombocytopenia in the pregnancy is still not understood well. There is a lacuna in the existing knowledge on this topic, especially in the Indian subcontinent. Through this study, we aim to find the prevalence of thrombocytopenia in pregnancy and the various etiologic factors responsible for it in Indian women and compare it with the world literature.

The prevalence of thrombocytopenia varies in the different population-based surveillance studies. Burrows and Kelton[11] found thrombocytopenia in 6%, Sainio et al.[10] in 7.3% cases. Boehlen et al.[12] and Kam et al.[5] reported a higher prevalence rate of 11.5% and 10% respectively. Dwivedi et al.[13] found the prevalence of 8.17% with 4.08% having severe thrombocytopenia in their study. Karim and Sacher[14] reported that severe thrombocytopenia is rare and occurs in less than 0.1% of pregnancies. In the present study, the prevalence of thrombocytopenia was 13.4%, higher than the other studies.

Gestational thrombocytopenia

The GT is by far the most common cause of thrombocytopenia in pregnancy. It is a diagnosis of exclusion, usually diagnosed in third trimester and has following characteristics: the degree of thrombocytopenia is mild to moderate with platelet count greater than 70,000/µl, patients are asymptomatic with no history of bleeding, there is no preconception history of thrombocytopenia, an early gestation or preconception platelet count is normal, and the platelet count returns to normal within 2 to 12 weeks postpartum.[15] Severe thrombocytopenia is usually not observed in GT, and in such cases, other diagnosis must be strongly considered.

Burrows and Kelton[11] and Federici et al.[16] found GT in 74% of thrombocytopenic women. He concluded that GT is the most frequent type of thrombocytopenia and poses no apparent risks for either the mother or infant during delivery. McCrae[17] also found GT as the most common cause of thrombocytopenia in pregnant women, in 75% of all cases. Singh et al.[2] reported GT in 64.1% cases, whereas Parnas et al.[18] observed GT in 53% cases only. Studies from both developed and developing nations report GT as the causative factor in more than 53% cases; however, in the present study, GT was observed in 34.3% cases only, a finding which can be explained by the difference in population under study and nutritional deficiencies in the form of anemia prevailing in our setup which brings down the frequency of GT.

Immune thrombocytopenic purpura

It is an autoimmune disorder accounting for 1/1000 to 1/10,000 pregnancies.[19] In ITP, patients produce IgG antiplatelet antibodies to their own platelet membrane glycoproteins. Increased platelet destruction occurs in the reticuloendothelial system, mainly the spleen. The rate of platelet loss is greater than production, and hence thrombocytopenia ensues.[20],[21] Maternal ITP immunoglobulins of IgG type can also cross placenta causing thrombocytopenia in neonates.

Like GT, diagnosis of ITP is also one of exclusion, and differentiating the two is challenging due to lack of specific symptoms and diagnostic tests. Cases with moderate to severe thrombocytopenia and low platelet count prior to pregnancy usually favors ITP.[22]

Boehlen et al.[12] reported the incidence of ITP as 0.058%, McCrae[17] reported 0.1%, and Burrows and Kelton[23] reported 0.2% in pregnant women. Parnas et al.[18] observed 10% incidence due to ITP, whereas Singh et al.[2] reported it in 5.26% cases. In the present study, ITP was observed in 0.7% cases only.

Hypertensive disorders

Sainio et al. reported thrombocytopenia in 5% to 21% of all hypertensive cases.[10] In our study hypertensive disorders including PIH, PE, eclampsia, and HELLP and in association with anemia were found in 30/134 (22.3%) patients which are in concordance with the world literature. It might be related to abnormal vascular tone with resultant accelerated platelet destruction, platelet activation, and coagulation defects.[24]

Degree of thrombocytopenia

Karim and Sacher[14] cited that severe thrombocytopenia occurs rarely, accounting for less than 0.1% of pregnancies. In our study, 10.4% of women had severe thrombocytopenia which is comparatively high. Mainly infective disorders (malaria, typhoid) were found associated with severe thrombocytopenia. The majority had moderate thrombocytopenia (53.7%) and 35.8% had mild thrombocytopenia. These results are not in conjunction with what has been stated by Boehlen et al.[12] and Burrows and Kelton.[23]

Anemia

The most significant finding was of anemia (macrocytic type, dimorphic type, and in combination with other etiologies such as PIH, PE, and hypothyroidism) accounting for 27 (20.1%) of the total cases of thrombocytopenia which has not been found as a cause of thrombocytopenia in the world literature.[18],[23] Other causes such as deranged liver enzymes (6%), viral causes including hepatitis B, HIV, toxoplasma, rubella (5.2%), antepartum hemorrhage (APH) (4%), hypothyroidism (3.7%), and APLA (0.7%) were also found in present study.

The frequency of thrombocytopenia was found to be increasing with the progression of gestation. One hundred and twenty-five (93.3%) of the thrombocytopenic patients were in third trimester. Majority of them belonged to 21 to 25 years of age and majority had B+ blood group. No relation with ethnicity was found.


  Conclusion Top


The magnitude of thrombocytopenia in pregnancy is greater in Indian women. Various causes are GT, anemia (macrocytic and dimorphic type), hypertensive disorders (PIH, PE, eclampsia, HELLP syndrome), deranged liver enzymes, hypothyroidism, infections (viral and bacterial), ITP, APLA, APH, or a combination of these in order of their frequency.

Majority of the thrombocytopenic patients were 21 to 25 years of age, belonged to third trimester (93.3%) and had B+ blood group. No correlation was found with any ethnicity or community.

As Indian women have baseline low platelet counts which further reduces with advancing gestational age, platelet count estimation should be carried out at the first antenatal visit and repeated in subsequent trimesters for timely diagnosis and for the favorable fetomaternal outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3]



 

 
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