Hematologic Complications of Pregnancy

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Pregnancy induces a number of physiologic changes that affect the hematologic indices, either directly or indirectly. Recognizing and treating hematologic disorders that occur during pregnancy is difficult owing to the paucity of evidence available to guide consultants. This review discusses specifically the diagnosis and management of benign hematologic disorders occurring during pregnancy. Anemia secondary to iron deficiency is the most frequent hematologic complication and is easily treated with oral iron formulations; however, care must be taken not to miss other causes of anemia, such as sickle cell disease. Thrombocytopenia is also a common reason for consulting the hematologist, and distinguishing gestational thrombocytopenia from immune thrombocytopenia (ITP), preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), or thrombotic thrombocytopenic purpura (TTP) is essential since the treatment differs widely. Occasionally the management of mother and infant involves the expeditious recognition of neonatal alloimmune thrombocytopenia (NAIT), a condition that is responsible for severe life-threatening bleeding of the newborn. Additionally, inherited and acquired bleeding disorders affect pregnant women disproportionately and often require careful monitoring of coagulation parameters to prevent bleeding in the puerperium. Finally, venous thromboembolism (VTE) during pregnancy is still largely responsible for mortality during pregnancy, and the diagnosis, treatment options and guidelines for prevention of VTE during pregnancy are explored.

Section snippets

Iron Deficiency

The most frequent hematologic complication during pregnancy is anemia. A number of normal physiologic processes occur during pregnancy leading to the term “physiologic anemia of pregnancy.” The plasma volume increases (40%–50%) relative to red blood cell mass (20%–30%) and accounts for the fall in hemoglobin concentration.1 However, if the hemoglobin falls below 11 g/dL, an evaluation for iron deficiency anemia (IDA) should be initiated since iron deficiency is responsible for the majority of

Differential Diagnosis of Thrombocytopenia in Pregnancy

Similar to the finding of anemia in pregnancy, thrombocytopenia is also common, occurring in approximately 8%–10% of pregnancies,21 and usually secondary to physiologic changes during gestation, namely, an increase in blood volume, platelet activation, and increased platelet clearance. Gestational thrombocytopenia accounts for the majority of thrombocytopenias during pregnancy (Table 1) and most cases are mild (100–150,000/μL) and not associated with any adverse events for either the mother or

Bleeding Disorders

Bleeding complications in pregnant women can occur as the result of an inherited or acquired coagulopathy. Acquired bleeding disorders during pregnancy usually arise acutely during massive postpartum hemorrhage when uterotonics or sutures have failed. Over the subsequent 1–4 months following delivery, acquired hemophilia can develop secondary to an antibody against a coagulation factor.

Manifestations of a previously unrecognized bleeding disorder are more likely to manifest in women during

Venous Thromboembolism

The rapid recognition and treatment of venous thromboembolism (VTE) during pregnancy is essential since VTE is a major cause of maternal mortality. The risk of thrombosis increases as pregnancy progresses and subsequently peaks during the puerperium. The elements of Virchow’s triad (hypercoagulability, stasis, endothelial damage) underlie the pathogenesis of VTE in pregnancy. First, the hypercoagulable state is created by an increase in coagulation factors, acquired resistance to activated

Conclusions

Many hematologic problems develop in pregnancy or can be triggered by the pregnant state. Normal physiologic changes during pregnancy can alter hematologic indices during pregnancy and make recognition of pathologic states difficult. Pregnancy can exacerbate underlying hematologic disorders, as well as predispose to life-threatening hematologic emergencies. These conditions are a significant source of morbidity and mortality during pregnancy that has implications for both the mother and the

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    Financial disclosure: The author declares that she has no conflicts of interest or competing financial or personal relationships that could inappropriately influence the content of this article.

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