Chen Zhe, Liang Mei-ying, Wang Jian-liu
Department of Obstetrics, Peking University People's Hospital, Beijing, China.
Zhonghua Fu Chan Ke Za Zhi. 2011 Nov;46(11):834-9.
To investigate the etiology and clinical characteristics of pregnancy-emerged thrombocytopenia.
A retrospective analysis was conducted on clinical data of 159 pregnancies with thrombocytopenia, who were admitted to Peking University People's Hospital from January 2000 to January 2010. All the patients recruited in this study had no history of blood or immune system disease before pregnancy, and thrombocytopenia was the predominate clinical manifestation during pregnancy, with platelet counts less than 100 × 10(9)/L at least twice during pregnancy. The thrombocytopenia should not be induced by drugs, viral infections, preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP). All cases were followed up. The general condition, the onset time of thrombocytopenia, platelet changes, accompany symptoms, maternal and perinatal outcomes as well as follow-up conditions were compared based on the etiology.
(1) ETIOLOGY: among the 159 cases, 101 (63.5%) were diagnosed gestational thrombocytopenia (GT); 43 (27.0%) were idiopathic thrombocytopenic purpura (ITP); 9 (5.7%) were blood system diseases, including 4 cases of megaloblastic anemia (MA), 2 cases of aplastic anaemia (AA), and 3 cases of myelodysplastic syndrome (MDS). Six cases (3.8%) were diagnosed immune system diseases, including 3 cases of systemic lupus erythematosus (SLE), 2 cases of antiphospholipid syndrome (APS), and 1 case of Evans syndrome. (2) Maternal and perinatal outcomes:pregnancy induced hypertension was diagnosed in 21 cases (13.2%), abnormal glucose metabolism in 13 cases (8.2%), anemia in 44 cases (27.7%) and preterm delivery in 18 cases (11.3%). Twenty-nine cases (18.2%) were treated with corticosteroids or gamma globulin during pregnancy. The average gestational week was 38 weeks. Fifty-five cases (34.6%) underwent vaginal delivery, 104 cases (65.4%) received cesarean section. Postpartum hemorrhage was observed in 34 cases (21.4%), and puerperal infection happened in 2 cases (1.3%). No maternal death was found. In a total of 160 fetuses (including twins), there were 157 live births. Three cases of fetal death and 2 cases of early neonatal deaths were observed. Fetal growth restriction was observed in 4 cases, and neonatal thrombocytopenia was seen in 6 cases. No intracranial hemorrhage was detected. (3) The onset time of thrombocytopenia: among the 159 cases, 29 cases (18.2%), 67 cases (42.1%), 63 cases (43.6%) of thrombocytopenia were detected in the first, second and third trimester, respectively. There was a significant difference of the onset time of thrombocytopenia between GT and ITP groups (P < 0.05). Patients with GT tended to have a later onset of thrombocytopenia, which mainly happened in the second and third trimester, while patients with ITP tended to happen in the first and second trimester. (4) The degree of thrombocytopenia: the cases with the minimum platelets level of (51 - 100) × 10(9)/L, (31 - 50) × 10(9)/L, (10 - 30) × 10(9)/L, < 10 × 10(9)/L during pregnancy were 75 (47.2%), 39 (24.5%), 31 (19.5%), 14 (8.8%) respectively. There was a significant difference between GT and ITP groups in the lowest platelets level (P < 0.01). (5) Thrombocytopenia accompany with anemia: among the 159 cases, there were 44 cases (27.7%) accompanied with anemia. The proportion was 9.9% (10/101) in GT group, 58.1% (25/43) in ITP group, with significant difference (P < 0.01). Anemia was also found in 5 cases in blood system disease group (5/9), and 1 case in immune system disease group (Evans syndrome, 1/6). Pancytopenia was observed in 2 cases with ITP (4.7%, 2/43) and 3 cases with blood system disease (AA: 1 cases, MA: 2 cases, 3/9). (6) The recovery of the platelets counts postpartum: the postpartum follow-up periods were 7 months to 10 years. Patients recovered within 1 week, 6 weeks, 6 months postpartum were 66 cases (41.5%), 43 cases (27.0%), 17 cases (10.7%) respectively. The platelets counts did not recover within 6 months postpartum in 33 cases (45.7%).
GT is the leading cause of pregnancy-emerged thrombocytopenia followed by ITP. There are significant differences between GT and ITP in the onset time of thrombocytopenia, the lowest platelets level, the proportion of anemia accompanied and the postpartum recovery. Other etiologies including immune and blood system diseases are rare. The relevant examinations should be taken for etiology and differential diagnosis.
探讨妊娠合并血小板减少症的病因及临床特点。
对2000年1月至2010年1月北京大学人民医院收治的159例妊娠合并血小板减少症患者的临床资料进行回顾性分析。本研究纳入的所有患者妊娠前无血液或免疫系统疾病史，妊娠期间以血小板减少为主要临床表现，妊娠期间血小板计数至少两次低于100×10⁹/L。血小板减少不应由药物、病毒感染、子痫前期或溶血、肝酶升高及血小板减少综合征（HELLP）引起。所有病例均进行随访。根据病因比较患者的一般情况、血小板减少的发病时间、血小板变化、伴随症状、孕产妇及围产儿结局以及随访情况。
（1）病因：159例患者中，101例（63.5%）诊断为妊娠期血小板减少症（GT）；43例（27.0%）为特发性血小板减少性紫癜（ITP）；9例（5.7%）为血液系统疾病，其中巨幼细胞贫血（MA）4例、再生障碍性贫血（AA）2例、骨髓增生异常综合征（MDS）3例。6例（3.8%）诊断为免疫系统疾病，其中系统性红斑狼疮（SLE）3例、抗磷脂综合征（APS）2例、伊文氏综合征（Evans syndrome）1例。（2）孕产妇及围产儿结局：诊断为妊娠高血压21例（13.2%），糖代谢异常13例（8.2%），贫血44例（27.7%），早产18例（11.3%）。29例（18.2%）患者在妊娠期间接受了糖皮质激素或丙种球蛋白治疗。平均孕周为38周。55例（34.6%）经阴道分娩，104例（65.4%）行剖宫产。34例（21.4%）发生产后出血，2例（1.3%）发生产褥感染。未发现孕产妇死亡。160例胎儿（包括双胞胎）中，157例存活。观察到3例胎儿死亡和2例早期新生儿死亡。4例出现胎儿生长受限，6例新生儿血小板减少。未检测到颅内出血。（3）血小板减少的发病时间：159例患者中，血小板减少分别在孕早期、孕中期、孕晚期检测到的有29例（18.2%）、67例（42.1%）、63例（43.6%）。GT组和ITP组血小板减少的发病时间有显著差异（P<0.05）。GT患者血小板减少发病较晚，主要发生在孕中期和孕晚期，而ITP患者倾向于发生在孕早期和孕中期。（4）血小板减少程度：妊娠期间血小板最低水平为（51 - 100）×10⁹/L、（31 - 50）×10⁹/L、（10 - 30）×10⁹/L、<10×10⁹/L的病例分别为75例（47.2%）、39例（24.5%）、31例（19.5%）、14例（8.8%）。GT组和ITP组最低血小板水平有显著差异（P<0.01）。（5）血小板减少合并贫血：159例患者中，44例（27.7%）合并贫血。GT组贫血比例为9.9%（10/101），ITP组为58.1%（25/43），差异有统计学意义（P<0.01）。血液系统疾病组5例（5/9）、免疫系统疾病组1例（伊文氏综合征，1/6）也发现贫血。ITP患者中有2例（4.7%，2/43）、血液系统疾病患者中有3例（AA：1例，MA：2例，3/9）出现全血细胞减少。（6）产后血小板计数恢复情况：产后随访时间为7个月至10年。产后1周内恢复、6周内恢复、6个月内恢复的患者分别为66例（41.5%）、43例（27.0%）、17例（10.7%）。33例（45.7%）患者产后6个月内血小板计数未恢复。
GT是妊娠合并血小板减少症的主要原因，其次是ITP。GT和ITP在血小板减少的发病时间、最低血小板水平、合并贫血比例及产后恢复方面存在显著差异。包括免疫和血液系统疾病在内的其他病因较为罕见。应进行相关检查以明确病因并进行鉴别诊断。
