Purushottam Rathi

Associate Professor, Department of Pediatrics, SBH Government Medical College, Chakkarbardi, Dhule, INDIA.

Email: drpprathi@gmail.com

Table 1: Distribution according to gestational age and birth weight

In present study prematurity (45 %) was most common cause noted for neonatal thrombocytopenia, followed by sepsis (24 %) and respiratory distress (14 %). Depending on the grade of thrombocytopenia neonates with mild thrombocytopenia (1-<1.5 lacs/μl) were 30%, while Moderate thrombocytopenia (50,000-<1 lacs/μl) were 25% and severe thrombocytopenia (<50,000/μl) were 45%.

Table 2: Distribution of neonates depending on the grade of thrombocytopenia

Depending on the time of onset of thrombocytopenia, neonates were labelled as early onset (within 72 hours) and late onset (after 72 hours). Early onset (within 72 hours) were 56% and late onset (after 72 hours) were 44%. Prematurity, sepsis, respiratory distress and intra uterine growth retardation were common causes for both early onset and late onset thrombocytopenia.

Table 3: Distribution of neonates depending on the time of onset

Anaemia (Hb < 7 gm%) (16%), Hypertensive diseases of pregnancy (14%), Eclampsia (4%), Prolonged rupture of membranes (> 18 hours) (3%) and Oligohydramnios (2%) were common maternal high-risk factors associated with neonatal thrombocytopenia.

Table 4: Distribution of neonates according to their maternal risk factors.

In present study 53 (26%) neonatal deaths were noted in neonates with thrombocytopenia. Sepsis (60%), prematurity (13%), birth asphyxia (11%) and respiratory distress (8%) were common causes of death neonates with thrombocytopenia. Sepsis along with thrombocytopenia noted with poor outcome in present study.

Table 5: Neonatal etiology with outcome.

DISCUSSION

Neonatal thrombocytopenia is a common clinical problem and is a prognostic marker of many disease conditions in neonates. Platelets appear in fetal circulation as early as 5 weeks of gestation. It reaches an adult value of 150 000 to 450 000/ μL by the second trimester and remains constant throughout life. Despite the general acceptance of neonatal platelet counts of <50X10⁹/L as an indicator for special clinical attention, the correlation between the severity of thrombocytopenia and risk of bleeding remains unclear.⁴ In our study the prevalence of thrombocytopenia is 27.2% which is less than in study done by Gupta et al. (70.5%).² The leading causes of neonatal thrombocytopenia include prematurity, sepsis, respiratory distress syndrome, birth asphyxia, meconium aspiration syndrome, and hyperbilirubinemia, among which sepsis and prematurity contribute to a significant number of severe thrombocytopenia. In present study prematurity (45 %) was most common cause noted for neonatal thrombocytopenia, followed by sepsis (24 %) and respiratory distress (14 %). Among preterm born infants admitted to the NICU, lower gestational age, SGA birth weight, hypoxia at birth, and age greater than 72 hours are major factors that increase the risk for the development of severe thrombocytopenia, which is also associated with NEC and culture proven sepsis, especially that caused by Candida infection.^7,8 Neonatal sepsis (24 %) was found to be second common cause in the present study. Gupta et al.² and Khalessi et al.⁶ found sepsis to be the most common cause of neonatal thrombocytopenia with a proportion of 42% and 24.1% respectively. Septicemia leads to thrombocytopenia because of both decreased production and increased consumption of platelets, thereby resulting usually in severe thrombocytopenia.² The cause of sepsis is mainly infections which could be bacterial, viral or fungal. The pathogenesis for thrombocytopenia in sepsis is endothelial damage which accelerates platelet consumption, impaired platelet production and their sequestration in the enlarged spleen.⁹ It is estimated that up to 20% of neonates develop sepsis and approximately 1% die of sepsis related causes². Sepsis related mortality is largely preventable with rational antimicrobial therapy and aggressive supportive care. Respiratory distress and birth asphyxia accounted for 18% cases in present study. Perinatal asphyxia is reported to be widely associated with neonatal thrombocytopenia. Sharma and Thapar demonstrated that perinatal asphyxia was significantly associated with thrombocytopenia.¹⁰ New-borns with respiratory distress and birth asphyxia also develop thrombocytopenia because of hypoxic injury caused to neonatal megakaryocytes.¹¹ In present study neonatal thrombocytopenia cases with early onset (within 72 hours) were 56% and late onset (after 72 hours) were 44%. While another study demonstrated, that neonatal thrombocytopenia was 43.4% in early onset group and 56.5% in late onset group, majority of the severity of the thrombocytopenic infants presented only after 72 hours of life and the most common etiology was the late onset of sepsis.¹² In present study, sepsis was significantly associated with late onset thrombocytopenia and prematurity, birth asphyxia was significantly associated with early onset neonatal thrombocytopenia. In Sonam S et al. study, both sepsis and birth asphyxia were associated with late onset neonatal thrombocytopenia.¹ Depending on the grade of thrombocytopenia neonates with mild thrombocytopenia were 30%, while moderate thrombocytopenia were 25% and severe thrombocytopenia were 45%. Sonam et al..¹ had shown severe thrombocytopenia to be found in 65.6% of infants in their study. The proportion of severe thrombocytopenia in present study are less than above study, because of a higher contribution of prematurity and septicemia in admission cases, more cases with severe thrombocytopenia in above study. The predisposing factors associated with neonatal thrombocytopenia were maternal PIH, maternal drug intake, septicemia, necrotizing enterocolitis, and perinatal asphyxia. In present study 26% neonatal deaths were noted in neonates with thrombocytopenia. Sepsis (60%), prematurity (13%), birth asphyxia (11%) and respiratory distress (8%) were common causes neonatal mortality. Sepsis along with thrombocytopenia noted with poor outcome in present study. Thrombocytopenia has been reported as an independent risk factor for sepsis related death among neonates.¹³ Increased platelets destruction, an impaired platelet production or a combination may be the underlying mechanism of thrombocytopenia. ¹⁴

CONCLUSION

Prematurity, sepsis and perinatal asphyxia are common causes of neonatal thrombocytopenia and associated mortality. All these are preventable conditions. Early identification and management is must to reduce mortality and morbidity. Severe thrombocytopenia, sepsis, prematurity were found to be an independent risk factor for poor outcome in NICU admitted neonates.

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