2. Thrombocytopenia
DEFINITION: Neonatal thrombocytopenia is defined as platelet count less than
150,000/mm3
Normal platelet count: 150,000 to 450,000 plt’s per microliter of blood
CLASSIFICATION: 3 TYPES (Depending upon the manifestations, clinical features
and the exact plt count)
MILD: 1.5 to 1 lac
MODERATE: 50,000 to 99,000
SEVERE: <50,000
P/C at birth increase with advancing gestational age.
3. Incidence:-
Thrombocytopenia is the most common hematologic abnormality among sick
newborn infants(when admitted to neonatal intensive care unit NICU,incidence
is as high as 35%)
Its incidence reaches 70% among neonates born with weight <1000 gm.
4. Approach to Thrombocytopenia
Two Types:
Early onset Thrombocytopenia: <72 hours of life
Late onset thrombocytopenia: >72 hours of life
5.
6. TAR Syndrome-Thrombocytopenia with absent radius
e.g: Baby admitted in NICU,has got some active nasal bleed ,persistent thrombocytopenia P/C 56,000 , sepsis-> negative workup
,doesnot had any kind of etiology sepsis,DIC ,any congenital chromosomal abnormalities but still has got this persistent thrombocytopenia
as matter of neonatal screening you had advice the xray of the baby , you do the xray of the hand of the child and you see this kind of xray
, so what could you suspect as the cause in this case? Ans: TAR –absent radius + thrombocytopenia without any underlying sepsis.
Thrombocytopenia with radial abnormality and normal thumb is TAR syndrome.
P/c is usually <50,000 and WBC is increased, mimicks congenital leukemia.
7. ATRUS SYNDROME-Amegakaryocytic Thrombocytopenia with
radioulnar synostosis
e.g: A baby is admitted in NICU and has got persistent thrombocytopenia and also there is no any
underlying cause, you do all the sepsis screening,all the fungal screening,rule out all the congenital
abnormality and everything ,but you still don’t find out anything and accidently you do this xray,and you
you find this kind of xray,so what could be the cause? Thrombocytopenia with inability to rotate forearm
s/o congenital amegakaryocytic thrombocytopenia with proximal radioulnar synostosis.
8.
9.
10. Diagnosis
Maternal history
-History of thrombocytopenia
-Bleeding before or during pregnancy
-A previous splenectomy
-Drug use
-Infection
Infant
-Baby may be healthy or may appear sick.
-Petechiae or large bruises
-Hepatospleenomegaly
-Jaundiced
-Hemangioma
11. Laboratory studies
Maternal platelets count (platelet typing if the maternal
count is normal)
Baby: CBC,platelets count,Prothrombin Time
(PT),Activated Partial Thromboplastin time (APTT)
13. Management
Platelet transfusion
-Indications:
1. Bleeding
2. Platelets count <20,000/mm3
-Donor should not be mother ( use a random donor),except for the infant with
allo-immune thrombocytopenia.In this case, the maternal platelets after
appropriate testing may be used.
- 10-20ml/kg of plt’s transfusion raises the plt count by 50,000 to
1000,000/ml,unless there is peripheral destruction of the platelets
- Never give plt’s through an arterial or umblical line because thrombosis may
occur.
Whole blood transfusion
In an emergency,whole blood may be used for exchange transfusion
14.
15. Due to passive transfer of antibodies from mother to fetus.NAIT
Neonatal alloimmune
thrombocytopenia
Antibody produced in the mother against
Human platelet antigen(HPA) present in the
fetus and absent in the mother.The antigen
is inherited by the fetus from the father.
The anti HPA antibody produced in mother
crosses the placenta and reaches fetal
circulation causing platelet destruction
-Early onset Severe thrombocytopenia +
healthy appearing neonate = NAIT
-Majority of patients are asymptomatic
-NAIT is self resolving condition
Autoimmune
thrombocytopenia
Varios auto-immune syndromes( e.g
SLE) may cause autoimmune
thrombocytopenia.
Mother is suffering from ITP or has low
platelet count during pregnancy or in
the past
Antibody is against the antigen on
mother’s own platelets(autoantibody)
as well as on baby’s platelete.
Antibodies cross the placenta and
cause destruction of fetal platelets.
16. NAIT
Any neonate with severe thrombocytopenia at birth or shortly after if in absence of other
risk factors( no underlying trauma, no underlying sepsis, no underlying vit k deficiency )
must be suspected.
Severe neonatal thrombocytopenia who straight away presented with 1CH is s/o NAIT.(plt
count <50,000)- baby present with life threatning bleed.
If suspected-send blood samples of mother and father for confirmation,especially HPA 1,3 &
5.Further for HPA 9 & 15 (Asians HPA-4).(ultimate goal is to detect HPA-antigen)
If positive then mother’s plasma will have antibody directed against the antigens.
If parents blood cannot be evaluated neonatal serum can be screened for antibodies.
Cranial USG must be done if NAIT suspected.(risk of NAIT-ICH)
NAIT it resolves in two weeks.
17.
18. Clinical findings
Neonatal alloimmune
thrombocytopenia
-The infant appears healthy but has
petechiae,brusing,bleeding,and a
low platelet count.
-Mother has a normal plt count.
-There may be a history of
previously affected pregnancy.
-Intracranial hemorrhage is the
most serious complication
occurring in 10-20 % pf cases.
Auto immune
thrombocytopenia
-Infant usually has mild to
moderate thrombocytopenia(
20,000-50,000) and is usually
healthy
-There are petechiae or bruises.
-There may be increased bruising
at the injection site or bleeding at
circumincision.
-Mother usually has
thrombocytopenia or a history of
ITP
19. Management of NAIT
Suspected NAIT in an unknown pregnancy.1st line therapy is random donor
transfusion
Platelet Count Guidelines
<30,000 Transfuse All
30,000-49000 Transfuse If-
-Born weight <1500gm
and <equal to 7days
old.
-Unstable
20. Management of NAIT
If there is any underlying cause which is also leading to thrombocytopenia , it can further
decrease the plt’s count going towards NAIT :-
-NEC
30,000-50,000 -Coagulopathy Present
-Previous major haemorrhage
-Prior to surgical procedure
-72 hours post op(baby has met some kind of
neurosurgical procedure or any kind of surgical intervention)
-These are all the high risk groups in which we have to give the plt’s cover despite of the plt
count.
50,000-1 lac Transfuse If-
-Active bleeding
-NAIT with I/C bleed
-Before/after
-neurosurgical procedure
21. If NAIT is suspected strongly IvIg @ 1g/kg/day upto 2 days may be infused to
increased patient’s own platelets.IvIg may be infused when P/C between 30 and
50000 to prevent drops.
NAIT fails to responds to random donor platelets and IvIg then antigen negative
HPA-IbIb
& 5a5a donor must be used.
Maternal platelets can be used after concentration to decreased the amount of
antiplatelet antibodies.
Inj MPS @ 1mg/kg BD x 3-5 days can be used.
22.
23. Auto immune thrombocytopenia
Management
Neonate with early onset thrombocytopenia with maternal history of
ITP/autoimmune disease.
All neonate with maternal history of autoimmune disease must have screening of
P/c shortly after birth.
If mild thrombocytopenia- repeat 2 to 3 days later because it reaches nadir
between 2nd and 5th days after birth.
If P/C <30,000-IvIg @1gm/kg is 1st line t/t.
Random donor platelets given if active bleeding present Cranial USG in all cases
with P/C <50,000 to rule out ICH.It takes weeks/months to resolve.
24. Prognosis
About 20% of all infants with neonatal alloimmune
thrombocytopenia have intracranial hemorrhages.
Cranial ultrasound study is indicated after delivery since
intracranial hemorrhages are sometimes clinically silent.
