Hematologic Findings in Pregnancy: A Guide for the Internist

Abstract

Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.

Physiological Changes and Interactions Between Microbiome and the Host During Pregnancy

“…This is known as gestational thrombocytopenia, which occurs as a result of the hemodilution present in pregnancy accompanied with increased platelet activation and clearance. Pregnancy is also associated with an increase in the levels of coagulation factors due to the increase in estrogen levels during this time, resulting in a prothrombotic state, especially in the third trimester ( Patel and Balanchivadze, 2021 ). Table 1 and Figure 1 summarize the physiological changes associated with pregnancy.…”

A Rare Case of HELLP Syndrome with Hematomas of Spleen and Liver, Eclampsia, Severe Hypertension and Prolonged Coagulopathy—A Case Report

“…Gestational thrombocytopenia (GT) is a mild condition and is the most common form of thrombocytopenia in pregnant women (affects 70-80% of cases), which may reduce our vigilance. Differentiation of thrombocytopenia in pregnancy (and limitations in this regard) has been extensively described in the literature [39][40][41][42][43][44]. In GT, platelet count is rarely below 100 G/L; other possible etiologies should be urgently excluded if this level is below 50 G/L; and if thrombocytopenia persists for more than one to two months to delivery, the differential diagnosis should be extended [39,44].…”

“…Differentiation of thrombocytopenia in pregnancy (and limitations in this regard) has been extensively described in the literature [39][40][41][42][43][44]. In GT, platelet count is rarely below 100 G/L; other possible etiologies should be urgently excluded if this level is below 50 G/L; and if thrombocytopenia persists for more than one to two months to delivery, the differential diagnosis should be extended [39,44]. Low platelet count concerns TTP, HELLP, and a-HUS, but severe thrombocytopenia (especially <30 G/L) is associated primarily with TTP [18].…”

“…In a-HUS, initial management includes immediate plasma exchange (PE) (pending the results of the target diagnostics); steroids can also be used, and renal replacement therapy may be needed, and Eculizumab halts the complement cascade. Treatments for TTP include plasmapheresis (e.g., cryosupernatant plasma-based) and platelet transfusion [39]. Gestational thrombocytopenia does not respond to corticosteroids, and two mechanisms of this thrombocytopenia are taken into account: hemodilution and accelerated platelet clearance [39,44].…”

“…Treatments for TTP include plasmapheresis (e.g., cryosupernatant plasma-based) and platelet transfusion [39]. Gestational thrombocytopenia does not respond to corticosteroids, and two mechanisms of this thrombocytopenia are taken into account: hemodilution and accelerated platelet clearance [39,44].…”