Coagulopathy in Pregnancy Differentiating ITP, DIC, and HELLP Syndrome.pdf

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1. Coagulopathy in Pregnancy: Differentiating
ITP, DIC, and HELLP Syndrome
Dr. dr. Wulan Fadinie, M.Ked (An), Sp.An-TI, Subsp. An.O.(K).
Divisi Anestesi Obstetrik, Departemen/Program Studi Anestesiologi &
Terapi Intensif, Fakultas Kedokteran, Universitas Sumatera Utara.

3. Physiological Hematologic Changes in Pregnancy
Blood and plasma volume
Plasma volume increases by 40–50%.
Red cell mass increases by 20–30% → results in physiological anemia of pregnancy (hemodilution).
Leukocytes
Mild leukocytosis (10,000–15,000/µL), rising further during labor (>20,000/µL).
Platelets
Slight decrease (gestational thrombocytopenia), but usually remains functional and
within safe range.
Coagulation factors
Increased Factor VII, VIII, X, XII and fibrinogen (often >400 mg/dL).
Increased von Willebrand factor.
→ Overall state of physiological hypercoagulability.
Fibrinolytic system
Reduced plasminogen activity and increased PAI-1/PAI-2.
→ Decreased fibrinolysis.

4. Pathophysiology Leading to Coagulopathy in Pregnancy
Baseline hypercoagulability
Normal adaptation can become pathological when triggered by infection, placental ischemia, or
endothelial injury.
Endothelial dysfunction
In preeclampsia/HELLP → endothelial activation → release of procoagulants → platelet
consumption → microangiopathic hemolysis.
Consumptive coagulopathy
In placental abruption or DIC: massive activation of coagulation pathways → consumption of
fibrinogen, platelets, and factors → diffuse bleeding.
Autoimmune destruction
In ITP: antiplatelet antibodies cause platelet destruction → thrombocytopenia without coagulation
factor abnormalities.
Hyperfibrinolysis (in some cases)
Excessive fibrinolysis (e.g., in obstetric DIC) → fibrinogen depletion, increased D-dimer.

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Factor VIIFactor VIIIFactor XFibrinogen
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Increased levels of
plasminogen activator
inhibitors
Reduced plasminogen
activity
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Neamţu, Simona-Daniela, et al. "The procoagulant status. Hypercoagulability as a risk factor of primary and secondary infertility."Romanian Journal of Morphology and Embryology62.3 (2022): 829.
Jaafari, Abdullah Siddiq Ahmed, et al. "Hypercoagubility: An Updated Overview for Healthcare Providers."Journal of Ecohumanism3.8 (2024): 13299-13313.

6. Prevents excessive bleeding during
childbirth
Protects mother and foetus from
haemorrhagic complications
Increased risk of venous
thromboembolism
Importance of thrombosis prophylaxis in
high-risk pregnancies
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Neamţu, Simona-Daniela, et al. "The procoagulant status. Hypercoagulability as a risk factor of primary and secondary infertility."Romanian Journal of Morphology and Embryology62.3 (2022): 829.
Jaafari, Abdullah Siddiq Ahmed, et al. "Hypercoagubility: An Updated Overview for Healthcare Providers."Journal of Ecohumanism3.8 (2024): 13299-13313.
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Bussel, James B., Ming Hou, and Douglas B. Cines. "Management of primary immune thrombocytopenia in pregnancy."New England Journal of Medicine389.6 (2023): 540-548.
Sokol, Lubomir, and Ling Zhang, eds.Non-Neoplastic Hematologic Disorders: A Quick Review of Modern Diagnostic and Therapeutic Approaches. Springer Nature, 2024.
Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.
Blood coagulation disorders occurring during pregnancy, increasing the risk
of bleeding or thrombosis.
Importance of Differentiating ITP, DIC, and HELLP:
ITP à Autoimmune disorder characterized by primary thrombocytopenia.
DIC à Systemic activation of coagulation leading to microvascular thrombosis and bleeding.
HELLP à Complication involving hemolysis, elevated liver enzymes, and low platelet count.

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An autoimmune disorder characterized by a low platelet count (thrombocytopenia) without
other identifiable causes.
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Autoantibodies target platelets, marking them for destruction by splenic macrophages,
leading to reduced platelet counts and increased bleeding risk.
Beltrami-Moreira, Marina, Amy Sharma, and James B. Bussel. "Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management."Expert Review of Hematology17.9 (2024): 595-607.

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The incidence of ITP during pregnancy is approximately 1–2 cases per 1,000 pregnancies.
•History of autoimmune diseases.
•Certain viral infections.
•Use of specific medications.
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Du, Ping, et al. "A Systematic Review of the Epidemiology and Disease Burden of Congenital and Immune-Mediated Thrombotic Thrombocytopenic Purpura."Journal of Blood Medicine(2024): 363-386.
Beltrami-Moreira, Marina, Amy Sharma, and James B. Bussel. "Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management."Expert Review of Hematology17.9 (2024): 595-607.

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Thrombocytopenia
(platelet count <100,000/µL).
Petechiae and ecchymosis.
Mucosal bleeding
(e.g., gums, nose).
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Patients with ITP often present with
symptoms such as petechiae,
ecchymosis, and mucosal bleeding
due to low platelet counts.
Malutan, Andrei Mihai, et al. "Autoimmune Thrombocytopenia in Pregnancy: Insights from an Uncommon Case Presentation and Mini-Review."Journal of Clinical Medicine14.3 (2025): 872.

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ITP is a diagnosis of exclusion, based on patient history and isolated
thrombocytopenia.
•Complete blood count (CBC) showing low platelet count.
•Peripheral blood smear.
•Tests for antiplatelet antibodies.
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Beltrami-Moreira, Marina, Amy Sharma, and James B. Bussel. "Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management."Expert Review of Hematology17.9 (2024): 595-607.
Fogerty, Annemarie E. "ITP in pregnancy: diagnostics and therapeutics in 2024."Hematology2024.1 (2024): 685-691.

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Postpartum
hemorrhage.
Neonatal
thrombocytopenia.
Complications of ITP during pregnancy include
an increased risk of postpartum bleeding and
potential neonatal thrombocytopenia due to
transplacental passage of autoantibodies.
Beltrami-Moreira, Marina, Amy Sharma, and James B. Bussel. "Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management."Expert Review of Hematology17.9 (2024): 595-607.

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Corticosteroids (e.g., prednisone).
Intravenous immunoglobulin (IVIG).
Splenectomy
(rarely performed during pregnancy).
Management of ITP in pregnancy
includes corticosteroids or IVIG.
Splenectomy à rarely performed and
considered when other therapies fail.
Malutan, Andrei Mihai, et al. "Autoimmune Thrombocytopenia in Pregnancy: Insights from an Uncommon Case Presentation and Mini-Review."Journal of Clinical Medicine14.3 (2025): 872.
Waghmare, Bhavana V., and Shubhada Jajoo. "Navigating Primary Immune Thrombocytopenia During Pregnancy: Management Strategies and Considerations: A Comprehensive Review."Cureus16.8 (2024).

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•Can be safely performed if platelet count
≥70,000/µL and there are no other coagulation
abnormalities.
•Some evidence supports safety even when
platelets are slightly lower (<75,000/µL), but
risk-benefit must be weighed carefully.
•Epidural catheter placement and removal should
be timed with stable platelet counts
•Considered when platelet count is <70,000/µL,
in the presence of coagulopathy, or when urgent
delivery does not allow time for optimization.
•Increased risks include difficult airway
management and bleeding during intubation.
•Preparation with blood products and platelet
transfusion should be ensured.
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are A, Pavord S, Knight M, Alfirevic Z, Roberts D, Robinson S, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG. 2018;125(5):604–12.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168–86.
Sun D, Shehata N, Ye XY, Arnold DM. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy: a retrospective cohort study. BJOG. 2016;123(8):1225–33.
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•Mode of delivery should be determined by obstetric
indication, not solely by ITP status.
•Vaginal delivery is safe if platelet count >50,000/µL.
•Cesarean section is reserved for obstetric reasons, not
prophylactically for ITP.
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are A, Pavord S, Knight M, Alfirevic Z, Roberts D, Robinson S, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG. 2018;125(5):604–12.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168–86.
Sun D, Shehata N, Ye XY, Arnold DM. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy: a retrospective cohort study. BJOG. 2016;123(8):1225–33.
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Intraoperative Considerations
•Ensure immediate availability of
platelet transfusion and blood
products for severe
thrombocytopenia or postpartum
hemorrhage.
•Use atraumatic techniques for
airway and vascular access; avoid
intramuscular injections.
•Employ multimodal analgesia but
avoid NSAIDs due to platelet
dysfunction.
•Be cautious with invasive
monitoring if platelet counts are
low.
Postpartum Management
•Women with ITP remain at risk of
postpartum hemorrhage (PPH);
reported incidence ranges from
1.9% to 22%.
•Active management of the third
stage of labor(uterotonics, uterine
massage, close observation) is
essential.
•Massive transfusion protocols
should be readily available.
Neonatal Considerations
•Neonates of ITP mothers are at risk
of neonatal thrombocytopenia and
bleeding complications.
•NICU monitoring may be required
even if maternal platelet counts are
stable.
Pavord S, Knight M, Alfirevic Z, Roberts D, Robinson S, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG. 2018;125(5):604–12.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168–86.
Sun D, Shehata N, Ye XY, Arnold DM. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy: a retrospective cohort study. BJOG. 2016;123(8):1225–33.

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DIC occurs in approximately 1% of hospitalized patients.
•Obstetric complications such as abruptio placentae,
amniotic fluid embolism, and sepsis.
•Other conditions include severe infections, major trauma,
malignancies, and severe transfusion reactions.
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DIC à is commonly associated
with severe underlying
conditions, particularly in
obstetric and septic scenarios.
Adelborg, Kasper, Julie B. Larsen, and Anne-Mette Hvas. "Disseminated intravascular coagulation: epidemiology, biomarkers, and management."British journal of
haematology192.5 (2021): 803-818.
Erez, Offer. "Disseminated intravascular coagulation in pregnancy: new insights."Thrombosis Update6 (2022): 100083.

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Diffuse bleeding from
various sites,
including mucosal
surfaces and surgical
wounds.
Signs of thrombosis,
such as digital
ischemia.
Hypotension and
shock.
Patients with DIC may present with a combination of bleeding and
thrombotic complications, reflecting the underlying coagulopathy.
Erez, Offer, et al. "DIC in pregnancy–pathophysiology, clinical characteristics, diagnostic scores, and treatments."Journal of blood medicine(2022): 21-44.

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Erez, Offer. "Disseminated intravascular coagulation in pregnancy: new insights."Thrombosis Update6 (2022): 100083.
Thrombocytopenia
(low platelet count).
Prolonged prothrombin time (PT)
and activated partial
thromboplastin time (aPTT).
Elevated D-dimer levels.Decreased fibrinogen levels.

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Multiorgan failure due to
microvascular thrombosis.
Increased mortality, with death rates
ranging from 20% to 50%, depending
on the underlying cause and severity.
The severity of DIC can lead to
significant morbidity and
mortality, underscoring the
importance of prompt
recognition and management.
Erez, Offer. "Disseminated intravascular coagulation in pregnancy: new insights."Thrombosis Update6 (2022): 100083.

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Address the
underlying cause,
such as prompt
delivery in cases
of placental
abruption.
Supportive care,
including
transfusions of
platelets, fresh
frozen plasma
(FFP), and
cryoprecipitate to
manage bleeding.
Heparin therapy
may be
considered in
cases dominated
by thrombosis,
though its use is
controversial.
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Okoye, Helen C., et al. "Diagnosis and treatment of obstetrics disseminated intravascular coagulation in resource limited settings."African health sciences22.1 (2022): 183-90.

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•Establish standard and invasive monitoring: ECG,
pulse oximetry, NIBP/arterial line.
•Secure large-bore IV access (≥16G).
•Arrange for blood products (PRBCs, FFP,
platelets, cryoprecipitate) and perform early
cross-matching.
•Anticipate hemorrhagic shock → initiate
resuscitation with warmed crystalloids.
•General anesthesia is preferred in emergency settings with
hemodynamic instability.
•Use rapid sequence induction (RSI) with agents that maintain
hemodynamics
•Maintain anesthesia with volatile agents and non-
depolarizing muscle relaxants.
•Regional anesthesia is contraindicated until coagulation
parameters are corrected and hemodynamic s are stabilized.
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are A, Pavord S, Knight M, Alfirevic Z, Roberts D, Robinson S, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG. 2018;125(5):604–12.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168–86.
Sun D, Shehata N, Ye XY, Arnold DM. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy: a retrospective cohort study. BJOG. 2016;123(8):1225–33.
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•Surgical control of bleeding: uterine evacuation, oxytocin infusion for uterine contraction.
•Massive transfusion protocol as indicated:
•PRBCs for blood loss and Hb correction.
•FFP for prolonged PT/APTT.
•Platelets if <75,000/µL with active bleeding.
•Cryoprecipitate if fibrinogen <100–150 mg/dL.
•Use TEG guidance for targeted transfusion therapy (faster than PT/APTT).
•Correct hypocalcemia due to citrate load with IV calcium.
•Apply fluid warmers to prevent hypothermia.
•Monitor electrolytes, especially potassium, to prevent arrhythmias from transfusion-related hemolysis
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Butwick AJ, Goodnough LT. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anaesthesiol. 2015 Jun;28(3):275-84. doi: 10.1097/ACO.0000000000000180. PMID: 25812005; PMCID: PMC4567035.
Puthenveettil N, Yoosaf SS, Raja S, Nair S. Anaesthetic management of disseminated intravascular coagulation associated with abruptio placentae and intrauterine death. Indian J Anaesth. 2022 Nov;66(11):809-810. doi: 10.4103/ija.ija_719_22. Epub 2022 Nov 18. PMID: 36590183; PMCID:
PMC9795501.
Thachil J, Toh CH. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev. 2009;23(4):167-76. doi:10.1016/j.blre.2009.04.002
Intraoperative

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•Intensive monitoring in PACU/ICU.
•Serial labs: Hb, platelets, fibrinogen, PT/APTT, electrolytes, and repeat TEG.
•Manage hypertension with agents such as labetalol infusion.
•Watch for complications: persistent bleeding, postpartum hemorrhage, or multi-organ failure
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Postoperative Care
Puthenveettil N, Yoosaf SS, Raja S, Nair S. Anaesthetic management of disseminated intravascular coagulation associated with abruptio placentae and intrauterine death. Indian J
Anaesth. 2022 Nov;66(11):809-810. doi: 10.4103/ija.ija_719_22. Epub 2022 Nov 18. PMID: 36590183; PMCID: PMC9795501.

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HELLP syndrome is a severe variant
of preeclampsia characterized by:
•Hemolysis (H)
•Elevated Liver enzymes (EL)
•Low Platelet count (LP)
•Endothelial dysfunction leads to
systemic inflammation and
activation of the coagulation
cascade.
•Microangiopathic hemolytic
anemia results from red blood cell
fragmentation.
•Hepatocellular injury causes
elevated liver enzymes.
•Consumption of platelets leads to
thrombocytopenia.
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Petca, Aida, et al. "HELLP syndrome—holistic insight into pathophysiology."Medicina58.2 (2022): 326.

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•Occurs in approximately 0.5–0.9% of all
pregnancies.
•Affects about 10–20% of women with severe
preeclampsia or eclampsia.
•Most cases develop before delivery, typically
between 27 and 37 weeks of gestation.
•Multiparity (having given birth more than once).
•History of preeclampsia or HELLP syndrome.
•Advanced maternal age.
•Obesity and metabolic disorders.
•Antiphospholipid syndrome.
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Abdullahi, Fadumo Mohamed, et al. "HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a
cross-sectional study."BMC Pregnancy and Childbirth24.1 (2024): 626.
Huang, Hui, et al. "Clinical classification, pregnancy outcomes and risk factors analysis of severe preeclampsia complicated with HELLP syndrome."Frontiers in surgery9 (2022): 859180.

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01
04
02
05
03
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Right upper quadrant
or epigastric pain.
Nausea and
vomiting.
Headache and visual
disturbances.
Hypertension.Proteinuria.Edema.
Huang, Hui, et al. "Clinical classification, pregnancy outcomes and risk factors analysis of severe preeclampsia complicated with HELLP syndrome."Frontiers in surgery9 (2022):
859180.

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•Hemolysis: Elevated lactate
dehydrogenase (LDH >600 IU/L).
•Elevated liver enzymes: Aspartate
aminotransferase (AST) or alanine
aminotransferase (ALT) >70 IU/L.
•Low platelet count: <100,000/µL.
•Complete blood count to assess
anemia and thrombocytopenia.
•Peripheral blood smear showing
schistocytes.
•Coagulation profile to evaluate for DIC
•Renal function tests.
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Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.

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•Disseminated intravascular
coagulation (DIC).
•Placental abruption.
•Acute kidney injury.
•Pulmonary edema.
•Liver hematoma or rupture.
•Stroke.
•Intrauterine growth restriction
(IUGR).
•Preterm birth.
•Perinatal mortality.
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Petca, Aida, et al. "HELLP syndrome—holistic insight into pathophysiology."Medicina58.2 (2022): 326.

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Maternal Stabilization:
•Antihypertensive
therapy to control
blood pressure.
•Magnesium sulfate for
seizure prophylaxis.
•Corticosteroids to
enhance fetal lung
maturity if gestational
age is less than 34
weeks.
Delivery:
•Indicated promptly if
gestational age is ≥34
weeks or if there is
maternal or fetal
deterioration.
•Mode of delivery
(vaginal vs. cesarean)
depends on obstetric
indications and
maternal-fetal status.
Postpartum Care:
•Close monitoring of
maternal vital signs
and laboratory
parameters.
•Management of any
ongoing
complications.
•Counseling regarding
the risk of recurrence
in future pregnancies.
Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.

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•Generally contraindicated if platelet count
<75,000–100,000/µL or if there is coagulopathy,
due to increased risk of spinal/epidural
hematoma.
•May be considered if platelets are stable and
>75,000/µL without additional coagulation
abnormalities, after multidisciplinary discussion.
•Indicated for severe thrombocytopenia (<50,000/µL),
coagulopathy, or emergency cesarean delivery.
•Rapid sequence induction is preferred due to
aspiration risk. Difficult airway should be anticipated
(airway edema, laryngeal swelling).
•Agents: thiopental/propofol, with rocuronium. Avoid
drugs with significant hepatic metabolism if severe
liver dysfunction exists.
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Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.
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•Maintain stable hemodynamics, avoiding wide fluctuations in blood pressure.
•Treat hypertension
•Oxytocin infusion for uterine contraction; avoid methylergometrine and carboprost
in severe hypertension or pulmonary compromise.
•Correct coagulopathy aggressively with FFP, cryoprecipitate, or platelets guided by
labs or viscoelastic testing (TEG/ROTEM).
•Prevent hypothermia and acidosis, as both worsen coagulopathy.
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Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.
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•Post-op HELLP = high-risk critical care.
•Hemodynamic stabilization (ICU/PACU observation)
•Control of hypertension & seizures (Continue as needed)
•Correction of coagulopathy (Transfusion)
•Vigilant monitoring for renal/liver complications (strict UOP charting)
•Multidisciplinary follow-up for future pregnancies:
•Risk of recurrence (5–25%) in future pregnancy.
•Long-term risk: chronic hypertension, CKD, cardiovascular disease.
•Preconception counseling and multidisciplinary care for next pregnancy.
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Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.
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Parameter ITPDICHELLP
EtiologyAutoimmuneCoagulation activationSevere preeclampsia
Platelet Count↓ (isolated)↓ (with increased D-
dimer)
↓ (with elevated liver
enzymes)
FibrinogenNormal↓ Normal or ↓
PT/APTTNormalProlongedNormal
Clinical SignsPetechiae, ecchymosisDiffuse bleeding, shockEpigastric pain,
hypertension
Pishko, Allyson M., and Ariela L. Marshall. "Thrombocytopenia in pregnancy."Hematology2022.1 (2022): 303-311.
Erez, Offer, et al. "DIC in pregnancy–pathophysiology, clinical characteristics, diagnostic scores, and treatments."Journal of blood medicine(2022): 21-44.
Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.

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Immune Thrombocytopenic
Purpura (ITP)
•Isolated thrombocytopenia
without coagulation
abnormalities.
•Absence of hemolysis or
significant elevation in liver
enzymes.
Disseminated Intravascular
Coagulation (DIC):
•Thrombocytopenia
accompanied by prolonged
Prothrombin Time (PT) and
Activated Partial
Thromboplastin Time (APTT).
•Elevated D-dimer levels
indicating fibrin degradation.
•Decreased fibrinogen levels due
to consumption.
HELLP Syndrome:
•Combination of hemolysis,
elevated liver enzymes,
and low platelet count.
•Often associated with
preeclampsia or
eclampsia.
Pishko, Allyson M., and Ariela L. Marshall. "Thrombocytopenia in pregnancy."Hematology2022.1 (2022): 303-311.
Erez, Offer, et al. "DIC in pregnancy–pathophysiology, clinical characteristics, diagnostic scores, and treatments."Journal of blood medicine(2022): 21-44.
Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.

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Early detection of conditions such
as ITP, DIC, and HELLP syndrome
à crucial to prevent serious
complications.
Immediate management of
the mother's condition,
including appropriate
supportive therapy and
medications.
Continuous assessment of
fetal well-being to detect
signs of distress or other
complications.
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Clinical and laboratory evaluation to
identify the specific condition.Administration of blood transfusions,
fresh frozen plasma, or medications as
clinically indicated.
Managing the triggering factor or
underlying condition causing the
disorder.
Continuous monitoring of fetal status
to determine the optimal timing and
method of delivery.
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Corticosteroid
therapy or
intravenous
immunoglobulin
may be used to
increase platelet
counts.
Management of the
underlying cause and
provision of
supportive therapy
such as blood
component
transfusions.
•Consideration of corticosteroid
use to improve liver function
and platelet counts.
•Timing of delivery based on
gestational age and the
condition of both mother and
foetus.
Pishko, Allyson M., and Ariela L. Marshall. "Thrombocytopenia in pregnancy."Hematology2022.1 (2022): 303-311.
Erez, Offer, et al. "DIC in pregnancy–pathophysiology, clinical characteristics, diagnostic scores, and treatments."Journal of blood medicine(2022): 21-44.
Giannubilo, Stefano Raffaele, et al. "HELLP syndrome and differential diagnosis with other thrombotic microangiopathies in pregnancy."Diagnostics14.4 (2024): 352.

39. Comparison Table: ITP vs DIC vs HELLP
FeatureITPDICHELLP
PathophysiologyAutoimmune destruction of plateletsConsumptive coagulopathy due to
massive activation of clotting cascade
Endothelial dysfunction → hemolysis,
liver injury, platelet consumption
Key Labs
Isolated thrombocytopenia, normal
PT/aPTT, normal fibrinogen, no
hemolysis
↓ Platelets, ↑ PT/aPTT, ↓ Fibrinogen, ↑
D-dimer
↓ Platelets, ↑ AST/ALT, ↑ LDH, evidence
of hemolysis (schistocytes)
Clinical CluesPetechiae, mucosal bleeding, history of
autoimmune disease
Diffuse bleeding + thrombosis, obstetric
complications (abruption, AFE, sepsis)
RUQ/epigastric pain, HTN, proteinuria,
preeclampsia background
Maternal RisksPostpartum hemorrhageMassive hemorrhage, multiorgan failure,
deathLiver rupture, renal failure, stroke, DIC
Fetal RisksNeonatal thrombocytopeniaStillbirth, prematurity, hypoxiaIUGR, preterm birth, perinatal mortality
Anesthesia ConsiderationRegional safe if platelets ≥70k, otherwise
GA
Regional contraindicated until
correction; GA with hemodynamic
preparation
Regional possible if platelets >75k;
GA preferred if severe
thrombocytopenia/coagulopathy
Main ManagementSteroids, IVIG; delivery based on
obstetric indication
Treat underlying cause, blood products,
supportive care
Stabilize mother, control BP, MgSO₄,
corticosteroids (if <34wks), prompt
delivery

40. 1.Pregnancy is a hypercoagulable state → protective against hemorrhage but increases thrombotic risk.
2.ITP, DIC, and HELLP syndrome are distinct causes of thrombocytopenia in pregnancy, each with unique
pathophysiology and management.
•ITP: isolated autoimmune platelet destruction.
•DIC: consumptive coagulopathy triggered by obstetric emergencies.
•HELLP: endothelial dysfunction with hemolysis, liver injury, and thrombocytopenia.
3.Accurate and rapid differentiation is crucial → guides safe anesthesia, transfusion strategy, and delivery
planning.
4.Management must be individualized à stabilize the mother, correct coagulopathy, and determine timing/mode
of delivery based on maternal–foetal condition.
5.Multidisciplinary teamwork (obstetrician, anaesthesiologist, haematologist and neonatologist) à essential to
improve maternal and neonatal outcomes.

41. The art of obstetric anesthesia
is balancing risk and safety for
both mother and child
there is no greater
responsibility