Mild thrombocytopenia prior to elective cesarean section is an independent risk factor for blood transfusion

Abstract

Purpose

Thrombocytopenia is the second most common hematological disorder in pregnancy and complicates approximately 10% of all pregnancies. The data regarding the association of mild thrombocytopenia in women undergoing cesarean section and risk of bleeding or bleeding-related complications are scarce. Thus, the aim of the current study was to assess the association of mild thrombocytopenia with hemorrhage-related morbidities, among patients undergoing elective cesarean section.

Methods

We performed a retrospective cohort study, in a single tertiary university-affiliated medical center, between 1 January 2012 and 31 May 2019. Medical charts of women who underwent elective cesarean section at term (37+0/7–41 + 6/7 weeks of gestations) were retrieved and analyzed. We compared women with mild thrombocytopenia (platelet count of 100–149 × 103/μL) to women with normal platelet count (150–450 × 103/μL). The primary outcome was the need for red blood cell transfusion during the index admission. A secondary outcome was severe bleeding not requiring blood transfusion defined as postpartum hemoglobin decline of  ≥ 3 g/dL as compared to the prepartum levels.

Results

During the study period, 1577 women were included in the final analysis, of them 396 (25.11%) had mild thrombocytopenia prior to delivery. As compared to the control group, women with mild thrombocytopenia had higher rates of blood transfusion (3.79 vs. 1.52%, p = 0.01), and had a significant decline in hemoglobin levels.

In a multivariable logistic regression model, mild thrombocytopenia was independently associated with blood transfusion with adjusted OR of 2.34 (95% CI 1.10–4.96, p = 0.03).

Conclusion

Preoperative mild thrombocytopenia is associated with an increased risk of blood loss and blood transfusion in women undergoing elective CS. More studies are required to assess those observations in context of urgent cesarean sections and whether any preventive measures can reduce the risk for bleeding.

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References

  1. 1.

    Reese JA, Peck JD, Deschamps DR et al (2018) Platelet counts during pregnancy. N Engl J Med 379(1):32–43. https://doi.org/10.1056/NEJMoa1802897

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Cines DB, Levine LD (2017) Thrombocytopenia in pregnancy. Blood 130(21):2271–2277. https://doi.org/10.1182/blood-2017-05-781971

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Palta A, Dhiman P (2016) Thrombocytopenia in pregnancy. J Obstet Gynaecol (Lahore) 36(2):146–152. https://doi.org/10.3109/01443615.2015.1041893

    CAS  Article  Google Scholar 

  4. 4.

    Nagrebetsky A, Al-Samkari H, Davis NM, Kuter DJ, Wiener-Kronish JP (2019) Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 122(1):19–31. https://doi.org/10.1016/j.bja.2018.09.010

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Xu X, Zhang Y, Yu X, Huang Y (2019) Preoperative moderate thrombocytopenia is not associated with increased blood loss for low-risk cesarean section: a retrospective cohort study. BMC Pregnancy Childbirth 19(1):1–9. https://doi.org/10.1186/s12884-019-2417-1

    Article  Google Scholar 

  6. 6.

    Dotters-Katz SK, Smid MC, Carlson LM, Manuck TA (2017) How low is too low: peripartum hemorrhage risk among women with thrombocytopenia. Am J Perinatol 216(1):S378–S379. https://doi.org/10.1016/j.ajog.2016.11.378

    Article  Google Scholar 

  7. 7.

    Govindappagari S, Moyle K, Burwick RM (2020) Mild thrombocytopenia and postpartum hemorrhage in nulliparous women with term, singleton. Vertex Deliv Obstet Gynecol 135(6):1338–1344. https://doi.org/10.1097/AOG.0000000000003861

    CAS  Article  Google Scholar 

  8. 8.

    Berg CJ, Margaret AH, Samuel MA, Elizabeth AB, Haywood LB, Marvin LH, Avick GM, Kenneth J, Moise WMC Jr (2020) Maternal mortality in the United States: updates on trends, causes, and solutions. NeoReviews 20(10):e561–e574

    Google Scholar 

  9. 9.

    Reale SC, Easter SR, Xu X, Bateman BT, Farber MK (2019) Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 130:e119–e122. https://doi.org/10.1213/ANE.0000000000004424

    Article  Google Scholar 

  10. 10.

    Borders AE (2019) Quantitative blood loss in obstetric hemorrhage. ACOG 134(794):150–156

    Google Scholar 

  11. 11.

    Kawakita T, Mokhtari N, Huang JC, Landy HJ (2019) Evaluation of risk-assessment tools for severe postpartum hemorrhage in women undergoing cesarean delivery. Obstet Gynecol 134(6):1308–1316. https://doi.org/10.1097/AOG.0000000000003574

    Article  PubMed  Google Scholar 

  12. 12.

    Carlson LM, Dotters-Katz SK, Smid MC, Manuck TA (2017) How low is too low? postpartum hemorrhage risk among women with thrombocytopenia. Am J Perinatol 34(11):1135–1141. https://doi.org/10.1055/s-0037-1604194

    Article  PubMed  Google Scholar 

  13. 13.

    Kramer MS, Berg C, Abenhaim H et al (2020) Postpartum hemorrhage. Am J Obstet Gynecol 209(5):449.e1-449.e7. https://doi.org/10.1016/j.ajog.2013.07.007

    Article  Google Scholar 

  14. 14.

    Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E (2006) Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstet Gynecol Scand 85:1448–1452. https://doi.org/10.1080/00016340600985032

    Article  PubMed  Google Scholar 

  15. 15.

    Verbrugge SE, Huisman A (2020) Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med 35(1):183–196. https://doi.org/10.1016/j.cll.2014.10.008

    Article  Google Scholar 

  16. 16.

    Umazume T, Yamada T, Morikawa M et al (2016) Platelet reactivity in twin pregnancies. Thromb Res 138:43–48. https://doi.org/10.1016/j.thromres.2015.12.019

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Tsunoda T, Ohkuchi A, Izumi A et al (2002) Antithrombin III activity and platelet count are more likely to decrease in twin pregnancies than in singleton pregnancies. Acta Obstet Gynecol Scand 81(9):840–845. https://doi.org/10.1034/j.1600-0412.2002.810907.x

    Article  PubMed  Google Scholar 

  18. 18.

    Al-Kouatly HB, Chasen ST, Kalish RB, Chervenak FA (2003) Causes of thrombocytopenia in triplet gestations. Am J Obstet Gynecol 189(1):177–180. https://doi.org/10.1067/mob.2003.360

    Article  PubMed  Google Scholar 

  19. 19.

    Myers B (2012) Diagnosis and management of maternal thrombocytopenia in pregnancy. Br J Haematol 158:3–15. https://doi.org/10.1111/j.1365-2141.2012.09135.x

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    ACOG Practice Bulletin No. 207 (2019) Thrombocytopenia in pregnancy. Obstet Gynecol 133(3):e181–e193. https://doi.org/10.1097/AOG.0000000000003100

  21. 21.

    Butwick AJ, Ramachandran B, Hegde P, Riley ET, El-Sayed YY, Nelson LM (2017) Risk factors for severe postpartum hemorrhage after cesarean delivery: case–control studies. Anesth Analg 125(2):523–532. https://doi.org/10.1213/ANE.0000000000001962

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Funding

The study was not funded.

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Authors

Contributions

We hereby declare that the following authors have contribute to the manuscript. EA: conceptualization, data collection, Author—primary. DE: statistics and formal analysis. LR: data collection and validation. ML: up-to-date literature collection. YY: supervision, review, and editing. LH: supervision, review, and editing.

Corresponding author

Correspondence to Emmanuel Attali.

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The authors declared that they have no conflict of interest.

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This study was approved by the Institutional Review Board (IRB) which waived the requirement of informed consent (Approval 0284–08).

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Attali, E., Epstein, D., Reicher, L. et al. Mild thrombocytopenia prior to elective cesarean section is an independent risk factor for blood transfusion. Arch Gynecol Obstet (2021). https://doi.org/10.1007/s00404-021-05988-x

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Keywords

  • Thrombocytopenia
  • Postpartum hemorrhage
  • Blood transfusion
  • Cesarean section