Volume 04 Issue 09-2024
13
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
04
ISSUE
08
P
AGES
:
13-19
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The article shows the results of 12 pregnant women with a complication of idiopathic thrombocytopenic purpura in
the form of hemorrhagic syndrome. Their clinic, diagnosis, conservative and surgical treatment. Traditional and
inhalation injection of glucocorticoid hormones, as well as intravenous injection of immunoglobulin in 75% of patients
had positive effect and remission was obtained on days 3-4. If the conservative treatment was ineffective, surgeries
were performed splenectomy (SE), and uterine bleeding stopped on 2-3 days and platelets increased to 210 thousand.
During pregnancy, patients with idiopathic thrombocytopenic purpura (ITP), complicated by hemorrhagic syndrome,
conservative and surgical treatment in 100% of cases performed a positive effect.
KEYWORDS
Immune thrombocytopenia, pregnancy, delivery.
INTRODUCTION
Target
. Idiopathic thrombocytopenic purpura (ITP) is a
disease that usually develops as a result of an immune
conflict directed to antigens of either platelets or
megakaryocytes, which is characterized by a decrease
in the number of platelets, in the absence of other
abnormalities in the count of blood cells, and
Research Article
COURSE AND DIAGNOSIS OF IDIOPATHIC THROMBOCYTOPENIC
PURPURA IN PREGNANT WOMEN
Submission Date:
Aug 30, 2024,
Accepted Date:
Sep 04, 2024,
Published Date:
Sep 09, 2024
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume04Issue09-03
Nosirova Feruza Normuhammad qizi
Gynecologist of private clinic “Samo tibbiyot” LLC
, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 04 Issue 09-2024
14
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
04
ISSUE
08
P
AGES
:
13-19
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
hemorrhagic syndrome [1,5 ,6,8,9]. Today, you can
meet many women with various autoimmune diseases
associated with blood clotting, which a woman may
not be aware of. Especially, the clinical manifestation
occurs during pregnancy.
Since a large load is placed on the woman's div, a
new blood circulation is added, called fetoplacetic,
which includes the mother-child-placenta. One of the
most common autoimmune blood diseases is ITP,
which, with a decrease in the number of platelets in the
blood, is often accompanied by a hemorrhagic
syndrome. According to the literature, the prevalence
of ITP among adults and children ranges from 7 to 13
per 10,000 people [1,5,6,8,9]. According to the data of
3. S. Barkagan [3], per 100,000 populations there are
7.5 females and 4.5 males. V. A. Klimansky [12] believes
that among patients with ITP, women predominate in
a ratio of 3.9:1, and in reproductive age this ratio
increases to 8:1.
The predominant lesion of women may be due to the
fairly frequent development of endocrine disorders at
puberty. ITP most often (in 40% of cases) is the cause
of hemorrhagic syndrome in both hematological and
obstetric practice [15,16,17,19]. The majority (80-90%)
of pregnant women have a chronic form of ITH1, 10%
have an acute form. According to the period of the
disease, exacerbation (crisis), clinical compensation
(no manifestations of hemorrhagic syndrome with
persistent
thrombocytopenia)
and
clinical
hematological
remission
are
distinguished.
Thrombocytopenia syndrome is registered in 10% of
pregnant women, and about 1/3 of them require
additional therapy. With ITP, pregnancy cannot be
terminated without obstetric indications only because
of thrombocytopenia and hemorrhagic syndrome.
Pregnancy planning is one of the most important
conditions for its successful course. The onset of
pregnancy should occur in a state of clinical
compensation of patients, i.e. in the absence of
hemorrhagic syndrome and the number of platelets
above
the
critical
level
(30-50.0
x
109/l)
[15,16,17,19,20,21]. Triggers of ITP can be infections
(often viral) - 59%, pregnancy - 20%, stress - 15%, surgical
procedures - 4%, physical activity - 1% and vaccinations
in 1% of cases [1,5,6,8, 9,10,11,13].
The combination of autoimmune thrombocytopenia
and pregnancy leads to an increase in the number of
obstetric complications, of which the most severe is
premature detachment of a normally located placenta,
bleeding in the postpartum period, observed in 15-20%
of women with ITP [15-21].
Purpose of the study
. Development of tactics for the
treatment of pregnant women with ITP hemorrhagic
syndrome. The following tasks were set: To
substantiate the tactics of treatment for bleeding in
pregnant women with ITP; To substantiate indications
for emergency splenectomy in pregnant women.
Volume 04 Issue 09-2024
15
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
04
ISSUE
08
P
AGES
:
13-19
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
METHODS
We studied 69 adult female hematological patients
diagnosed with ITP, aged 19-35 years, who were in the
Department of Surgical Hematology of the Research
Institute of Hematology and Blood Transfusion, and in
the maternity wards of other clinics. Of these, \2 (\1.4%
") were pregnant women: with an acute form 5 (41.7%),
a chronic form 7 (58.3%). In the first trimester of
pregnancy there were 5 (41.7%) patient’s women. In the
second trimester 4 (33.3%) sick women. In the third
trimester there were 3 (25.0%) sick women. 2 women
with an acute form, and 5 with a chronic form had skin
hemorrhagic signs, and in the blood test platelets up to
30 thousand. 5 (41.7%) pregnant women with ITP at
various times were admitted with uterine bleeding. In
the blood test, platelets were from one to 20 thousand:
of them with an acute form in 3 (60.0%) pregnant
women, the only symptom was uterine bleeding, and
the rest had skin ecchymosis, petechiae and other
hemorrhagic manifestations. One of them was
admitted with a complication - cerebral hemorrhage. In
2 (40.0%) pregnant women with a chronic form, skin
ecchymosis and uterine bleeding were noted, blood
tests showed platelets from one to 20 thousand. At
admission, all patients had pallor of the skin and
mucous membranes, anemia of varying degrees in the
general blood test. In 7 (58.3%) pregnant women:
posthemorrhagic anemia in 3 (42.9%) mild, 3 (42.9%)
moderate and 1 (14.2%) severe. In all cases,
thrombocytopenia ranged from one to 20.0 *109/l -
30.0 *109/l. In coagulograms - hypocoagulation,
bleeding time, thrombin time are prolonged, plasma
tolerance to heparin is reduced, blood clot retraction is
reduced. To clarify the diagnosis in pregnant women
with an acute form, blood was taken for a myelogram
under anesthesia. In the myelogram, the number of
megakaryocytes is normal or increased. In biochemical
analyzes without any significant changes. In all cases,
the lymph nodes were not palpated, there was no
hepatosplenomegaly. According to the ultrasound
data, in all patients the fetus developed according to
the gestational age, signs of intrauterine suffering of
the fetus were detected in the form of hypoxia in 6
pregnant women. The duration of the disease with the
chronic form of ITP ranged from 8 months to 5 years,
and during this period, patients received treatment
from 1 to 5 or more times.
All patients received conservative treatment:
restorative agents, hemostatic and vasoconstrictive
drugs,
glucocorticosteroid
(GCS)
hormones
-
prednisolone
or
dexamethasone
in
tablets,
intravenously or inhaled injections, including pulse
therapy and immunoglobulin, simultaneously with the
treatment of comorbidities. During examination, 2
pregnant women had moderate diabetes mellitus, 3
had hypertension, and 2 had a history of chronic
duodenal ulcer. Patients with diabetes mellitus and
hypertension
received
conservative
treatment,
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OCLC
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1121105677
Publisher:
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Servi
including intravenous immunoglobulin (IVIG) at a dose
of 2 grams per 1 kg of div weight (course dose),
distributed over 2-5 consecutive days (daily dose,
depending on the number of days, was administered
from 0 ,4 (with 5-day administration) up to 1 g/kg of
div weight). Pregnant women 23-24 and 37-38 weeks
with chronic duodenal ulcer received dexamethasone
in the form of inhalation for 5 days. The remaining
patients received conservative treatment from the
very beginning, including glucocorticoid therapy.
Conservative treatment had no effect in two patients,
uterine bleeding continued, and these patients
underwent emergency splenectomy. A patient with
intracranial hemorrhage developed bruises in the oral
mucosa and hemorrhages in the sclera, and an
emergency splenectomy was also performed.
Splenectomy in patients with ITP with severe
hemorrhagic diathesis is most often complicated by
bleeding during and after surgery.
These patients underwent splenectomy by the
modified method proposed by us, in which the
bleeding associated with the operation technique was
minimal. In the postoperative period on the 2nd day,
the signs of hemorrhagic diathesis were stopped.
Example 1:
Patient N., aged 28, was admitted to the
maternity ward with a pregnancy of 37-38 weeks and
diagnosed with chronic ITP, hemorrhagic syndrome -
petechiae, ecchymosis, gingival and uterine bleeding.
In the analyzes, thrombocytopenia 12.0*109/l,
hypocoagulation. Conservative treatment for 3 days
(loading dose of corticosteroids) had no effect,
hemorrhagic syndrome persisted. In order to prevent
possible bleeding, the patient was taken for a
caesarean section after appropriate preparation. The
operation was performed by two teams: the first stage
was a caesarean section by a team of obstetricians and
gynecologists. After a caesarean section, a
splenectomy was performed using the method we
proposed, postoperative bleeding was about 30 ml,
the operation was uneventful. On the 1st day after
splenectomy, clinical remission occurred, platelets
rose to 120 thousand with a final stop of hemorrhagic
signs.
Example 2:
Patient K., 32 years old, was admitted to the
maternity ward with a pregnancy of 36-37 weeks and
diagnosed with an acute form of ITP, severe
hemorrhagic syndrome - petechiae, ecchymosis,
gingival bleeding, bruising of the oral cavity,
hemorrhage in the sclera, uterine bleeding and
intracranial hemorrhage. Moderate anemia. The
patient received conservative treatment and pulse
therapy with methylprednisolone 1 g per day
intravenously for 1-2 hours on 3 days, which was not
effective. The patient had hemorrhagic and
neurological syndromes preserved. PS - 98-100 beats
per
minute.
AP
100/65.
Hemoglobin-87
g/l.
Hypocoagulation. The rest of the analyzes are
unremarkable. The patient was taken for surgery after
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P
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OCLC
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Publisher:
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Servi
consulting a therapist, neurologist, anesthesiologist
and appropriate training. The operation was
performed by two teams: the first stage was a
caesarean section by a team of obstetricians and
gynecologists. After a caesarean section, a
splenectomy was performed using the method we
proposed, postoperative bleeding was about 50 ml.
The operation went without complications.
The postoperative period proceeded in the intensive
care unit, without complications. On the 1st day after
the operation, the patient's platelets rose to 38,000
with bleeding stopping. In addition to the ongoing
treatment, the administration
of intravenous
immunoglobulin at a dose of 2 grams per 1 kg of div
weight was prescribed to suppress the formation of
antibodies to platelets, and a clinical hematological
effect was obtained. On the 3rd day of the operation,
the patient's platelets rose to 210 thousand with the
final stop of hemorrhagic signs.
RESULTS
Out of 12 pregnant women with ITP, 5 with an acute
form:
after
conservative
treatment
with
corticosteroids, three pregnant women received a
clinical and clinical-hematological effect, platelets
increased from 120 to 218 thousand on days 3-4. In two
patients with uterine bleeding, conservative treatment
did not give any effect; after hysterectomy,
splenectomy was performed and a clinical effect was
obtained at 36-37 and 37-38 weeks of pregnancy.
Platelets increased from 50,000 to 120,000 on days 2-3
and the bleeding stopped.
A patient with an acute form of cerebral hemorrhage
after splenectomy with 38 thousand platelets received
intravenous immunoglobulin, on the 3rd day the
platelets rose to 210 thousand and a clinical and
hematological effect was obtained, with a final stop of
hemorrhagic
signs,
and
additionally
received
treatment from a neuropathologist. Of the 7 pregnant
women with chronic ITP, two with uterine bleeding:
one pregnant woman at 23-24 weeks after
conservative treatment including corticosteroids,
platelets rose to 180 thousand and a clinical and
hematological effect was obtained. In another
pregnant woman with a period of 37-38 weeks, after
conservative treatment, uterine bleeding continued
and after a cesarean section a splenectomy was
performed, platelets rose to 120 thousand on days 2-3
and a clinical effect was obtained with a final stop of
hemorrhagic signs.
Three pregnant women with a chronic form received
IVIG and a clinical and clinical-hematological effect was
obtained. In two pregnant women who received GCS
hormones in the form of inhalation for 5 days, platelets
rose from 160 to 180.0 thousand on days 3-4. During
pregnancy, any form of pathology accompanied by
thrombocytopenia may develop. Given the lack of a
single confirmatory test for ITP, at the stage of
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diagnosing newly diagnosed thrombocytopenia in
pregnant women, it is important first of all to exclude
life-threatening complications that require urgent
therapeutic or surgical measures. Pregnancy in
patients with ITP is not contraindicated, but should
proceed in a state of clinical compensation of ITP
(absence of hemorrhagic syndrome and platelet count
of at least 50.0 * 109/l), achieved at previous stages of
therapy. With ITP, pregnancy cannot be terminated
without obstetric indications only because of
thrombocytopenia and hemorrhagic syndrome. All
women with ITP should be under joint supervision of a
hematologist and gynecologist, and before delivery -
by an obstetrician and anesthetist.
In the process of observation, the obstetric status
comes to the fore, then the state of the pregnant
woman - hemorrhagic syndrome, platelet count. The
frequency of dynamic observation of a pregnant
woman with thrombocytopenia is determined by the
clinical condition of the patient and increases with the
duration of pregnancy. With ITP in the I and II
trimesters of pregnancy, the frequency of observation
by a gynecologist and monitoring of blood parameters
is 1 time per month, after 28 weeks - 1 time in 2 weeks,
and after 36 weeks. pregnancy weekly. In the case of
pregnancy in women with ITP in remission or clinical
compensation, only dynamic monitoring should be
carried out. Women with severe, resistant ITP need
treatment before pregnancy and planning for its onset
during remission or clinical and hematological
compensation.
CONCLUSION
Thus: patients with ITP with profuse uterine bleeding
with the ineffectiveness of conservative therapy for 3-
4 days are indicated for emergency splenectomy, as
well as patients with ITP with intracranial hemorrhage
with severe hemorrhagic syndrome. Postponing the
operation, the disease leads to death. During
pregnancy, splenectomy can be performed at any time,
however, it is preferable to perform it in the first
trimester of pregnancy or after childbirth, since the
operation is accompanied by a high rate of preterm
birth and fetal death.
Early delivery by caesarean section is indicated with an
increase in symptoms of hemorrhagic diathesis,
anemia and a deterioration in the general condition of
the pregnant woman, and splenectomy should also be
performed at the same time. This is the prevention of
maternal mortality and disability of women. Pregnancy
complicated by the presence of ITP in the mother is
always a challenge for the obstetrician-gynecologist,
therefore, in the early stages of pregnancy, such a
patient should be examined in a medical institution of
the highest level of accreditation. Strict adherence to
the algorithm of clinical and laboratory diagnostics,
effective consultation of specialists contributes to the
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achievement of a positive outcome of pregnancy and
the birth of children without perinatal complications.
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