International Journal of Contemporary Pediatrics

Meena SL et al. Int J Contemp Pediatr. 2019 May;6(3):1344-1348

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20192041
Original Research Article

Clinical profile and outcome of neonatal thrombocytopenia in a tertiary

care hospital
Sumarth Lal Meena, Kanwar Singh*, Sanjiv Jain, Anil Jain, B. S. Karnawat

Department of Pediatrics, JLN Medical College and Hospital, Ajmer, Rajasthan, India

Received: 13 March 2019

Accepted: 08 April 2019

*Correspondence:
Dr. Kanwar Singh,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Thrombocytopenia (platelet count <1,50,000/µL) is one of the most common haematological problems
in neonatal intensive care units. In contrast, only 2% of the normal neonates are thrombocytopenic at birth with severe
thrombocytopenia (platelet count <50,000/µL) occurring in less than 3/1000 term infants. Multiple disease processes
can cause thrombocytopenia in neonates. The important causes of thrombocytopenia in neonates are sepsis, birth
asphyxia, prematurity, intra-uterine growth retardation, hyperbilirubinemia, respiratory distress syndrome, meconium
aspiration syndrome and low birth weight. Apart from platelet count, bleeding manifestations depend on underlying
ailments. The aims and objective were to study the clinical profile, etiology and outcome of neonatal
thrombocytopenia in a tertiary care hospital.
Methods: Prospective study involving 100 neonates with or developed neonatal thrombocytopenia in NICU.
Results: In present study, 100 new-borns with thrombocytopenia 46% were mild, 35% were moderate and 19% were
severe thrombocytopenia. 51 (51%) had early onset neonatal thrombocytopenia and 49 (49%) babies had late onset
neonatal thrombocytopenia. Anaemia was the dominant maternal predisposing risk factor. Sepsis was the most
common cause of neonatal thrombocytopenia. Most common symptom was apnoea. Sepsis, RDS and NEC had
significantly contributed to mortality. Most common cause of death was sepsis followed by RDS and NEC.
Conclusions: Neonatal thrombocytopenia is a treatable and reversible condition. Hence, it is important to identify
neonates at risk and initiate transfusion therapy to prevent severe bleeding and potentially significant morbidity.
Anaemia and PROM were the commonest maternal risk factors. Therefore, author recommended that babies born to
mothers with these risk factors should be closely monitored for thrombocytopenia.

Keywords: Bleeding, Maternal anaemia, Neonatal thrombocytopenia, Sepsis

INTRODUCTION weight neonates (ELBW <1000 gms birth weight) or

preterm babies (GA <36 weeks) or sick neonates in
Thrombocytopenia (platelet count <1,50,000/µL) is one NICUs.1 In contrast, only 2% of the normal neonates are
of the most common haematological problems in thrombocytopenic at birth with severe thrombocytopenia
Neonatal intensive care units (NICUs).1 The overall (platelet count <50,000/µL) occurring in less than 3/1000
prevalence of thrombocytopenia in neonatal ranges from term infants.2
1 to 5% and is reported to be much higher in neonates
admitted to neonatal intensive care units, ranging from 18 Multiple disease processes can cause thrombocytopenia
to 35%.1 It is more common among extremely low birth in neonates and these can be classified as early onset (<72

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 Meena SL et al. Int J Contemp Pediatr. 2019 May;6(3):1344-1348

hours) and late onset (>72 hours) neonatal (total WBC count, absolute neutrophil count, IT ratio,
thrombocytopenia.3 The important causes of micro ESR by done using micro pipette and CRP done by
thrombocytopenia in neonates are sepsis, birth asphyxia, latex turbidimetry). Low platelet counts were cross
prematurity, intra-uterine growth retardation, verified by peripheral smear study.
hyperbilirubinemia, respiratory distress syndrome,
meconium aspiration syndrome and low birth weight. Platelet counts were repeated every 24 hours in babies
Apart from platelet count, bleeding manifestations with severe thrombocytopenia and every 48 hours in
depend on underlying ailments.4 those with moderate thrombocytopenia. PT and APTT
were obtained by automated CL analyzer. Other
Platelets are small anucleate fragments that are formed investigations such as urine culture, chest X-ray,
from the cytoplasm of megakaryocytes and have a neurosonogram and CT brain were performed whenever
characterisitic discoid shape.5 Megakaryopoiesis includes the need arises.
the production of megakaryocytes from stem cells, while
thrombopoiesis is the production of platelets from The data was recorded in the case proforma and
megakaryocytes. Platelet production begins to the yolk tabulated. Statistical analysis was done using chi square
sac and, like the remainder of hematopoiesis shifts to the test, one-way ANOVA test, students t-test. Software used
fetal liver and then to the marrow at the time of for analysis was SPSS 17.0 version, Graph pad prism 6
gestation.6 version and EPI-INFO 6 version. ‘P’ value below 0.05
was considered significant.
Considerable number of studies have shown that the
average fetal platelet count is above 150,000/µL by RESULTS
second trimester of pregnancy and remain constant then
represents thrombocytopenia just as in older children and The study was conducted on 100 newborns with
adults. Neonatal thrombocytopenia classifies into mild thrombocytopenia admitted in the NICU and subjects
(>1,00,000/µl and <1.50,000/µl), moderate (>50,000/µl) were divided into 3 groups based on their platelet counts.
and severe (<50,000 µl).1,2 46 (46%) patients had mild thrombocytopenia, 35 (35%)
babies had moderate and 19 (19%) babies had severe
The paucity of studies from India and the increasing thrombocytopenia (Table 1).
prevalence of this condition in the NICU, instigated us to
determine the etiology, clinical profile and immediate Table 1: Distribution of babies in to 3 groups
outcome of the neonates with thrombocytopenia admitted according to severity.
in JLN Medical College and Hospital, Ajmer, Rajasthan,
India. Groups Severity N=100 %
Group 1 Mild (1-<1.5 lacs/µl) 46 46%
METHODS Group 2 Moderate (50,000-<1 lacs/µl) 35 35%
Group 3 Severe (<50,000/µl) 19 19%
Prospective study involving 100 neonates with or
developed neonatal thrombocytopenia randomly selected Male and female’s ratio was 1.7 to 1.0. Low birth weight
in the Neonatal intensive care unit (NICU), Department (<2.5 kg) constituted 66 (66%) of total babies with
of Pediatrics, JLN Hospital and NICU of Government neonatal thrombocytopenia.
Mahila Hospital attached to JLN Medical College,
Ajmer, Rajasthan, India from May 2017 to April 2018. According to gestation, 27 (27%) preterm were
Ethical clearance was obtained before starting study. appropriate for gestational age and 36 (36%) preterm
were small for gestational age. 35 (35%) full term were
A detailed history inclusive of maternal obstetric history, appropriate for gestational age and 2 (2%) full term were
birth history, perinatal events with a focus on history small for gestational age. Thrombocytopenia in pre term
suggestive of bleeding and its type in the newborn was was statistically significant (P value <0.05).
obtained as per the proforma.
The most common maternal risk factor was anaemia
Information regarding a number of conditions that have which was present in 48 (48%) babies followed by
been associated with neonatal thrombocytopenia was PROM 30 (30%), PIH 19 (19%), oligohydramnios 2 (2%)
prospectively recorded e.g., history of PIH, gestational babies and eclampsia in 2 (2%) babies. Out of these risk
diabetes mellitus, premature rupture of membranes, factors, association of anaemia with severe neonatal
anaemia and SLE. Any consumption of drugs by the thrombocytopenia was statistically significant (P value
mother that can predispose to neonatal thrombocytopenia <0.05) (Table 2).
was also documented. Gestational age of all neonates was
determined based on the New Ballard’s scoring system About 51 (51%) babies had early onset neonatal
till 14 days of life. All the neonates underwent blood thrombocytopenia and 49 (49%) babies had late onset
investigations, CBC by automated haematology analyzer, neonatal thrombocytopenia. Early onset neonatal
peripheral blood smear study, blood culture, sepsis screen

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 Meena SL et al. Int J Contemp Pediatr. 2019 May;6(3):1344-1348

thrombocytopenia was more common, and it was thrombocytopenia, it was statically significant (P value
associated with mild to moderate neonatal 0.00001).

Table 2: Distribution of patients in three group according to their maternal risk factors.

Group
Maternal factors Total X2 value P value
Group 1 Group 2 Group 3
Yes 9 9 1 19 3.3644 0.1859
PIH
No 37 26 18 81
Yes 0 2 0 2
Eclampsia
No 46 33 19 98
Yes 11 10 9 30 3.574 0.1673
PROM
No 35 25 10 70
Yes 26 11 11 48 5.9944 < 0.05
Anaemia
No 20 24 8 52
Yes 1 1 0 2
Oligohydroamnios
No 45 34 19 98

Sepsis was the commonest cause of neonatal Sepsis was associated with severe neonatal
thrombocytopenia and was found in 53 (53%) babies. thrombocytopenia and it was statistically significant (P
RDS in 15 (15%), Birth asphyxia was present in 11 value 0.0001). Out of 53 babies with sepsis, 36 (67.92%)
(11%) babies, MAS in 10 (10%) babies, neonatal babies had late onset thrombocytopenia and it was
hyperbilirubinemia in 6 (6%) babies and NEC in 5 (5%). statically significant (P value 0.00003) (Table 3).

Table 3: Distribution of patients in three group according to their etiology (neonatal factors).

Group
Etiology Total X2 value P value
Group 1 Group 2 Group 3
Yes 14 24 15 53 17.94 0.0001
Sepsis
No 32 11 4 47
Yes 7 3 1 11 1.6853 0.4305
Birth Asphyxia
No 39 32 18 89
Yes 13 2 0 15
RDS
No 33 33 19 85
Neonatal Yes 4 1 1 6 1.223 0.5422
hyperbilirubinemia No 42 34 18 94
Yes 7 3 0 10
MAS
No 49 32 19 90
Yes 1 2 2 5 2.03 0.361
NEC
No 45 33 17 95

The most common symptom of thrombocytopenia was bleeding. Peteciae/purpura is statistically significant (P
apnoea in 28 (28%) followed by lethargy in 24 (24%), value 0.000735).
feeding difficulty in 23 (23%) and convulsions in 20
(20%) babies. All the above symptoms were PT INR, appt was done in 36 and it was abnormal in 17
predominantly present in moderate and severe neonatal (47.22%) babies. This was statically significant (P value
thrombocytopenia. 0.05).

In this study, 22 (22%) presented with peteciae/purpura, Blood transfusion was given in 5 (5%), platelet
17% with GI bleeding and 2% babies with pulmonary transfusion in 13 (13%) and FFP in 27 (27%) babies.

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 Meena SL et al. Int J Contemp Pediatr. 2019 May;6(3):1344-1348

The mortality was significantly high in severe neonatal thrombocytopenia was statistically significant (P
thrombocytopenia group (47.37%) as compared to other 2 value <0.05). In a study conducted by Tirupath K et al, an
groups and it was not statistically significant (p value association has been documented between anaemia and
0.2286). The mortality was high in late onset neonatal thrombocytopenia. PROM in mother is a cause of early
thrombocytopenia group (40.82%) as compared to early onset neonatal sepsis eventually leading to neonatal
onset neonatal thrombocytopenia group (27.45%) but it thrombocytopenia.14
was statistically not significant. Out of 34 deaths, 23
(67.64%) due to sepsis followed by NEC 3 (8.82%), RDS In present study, 51% had early onset neonatal
3 (8.82%), MAS 2 (5.88%), birth asphyxia 2 (5.88%) and thrombocytopenia and 49% babies had late onset
neonatal hyperbilirubinemia 1 (2.9%). Death due to neonatal thrombocytopenia. Early onset neonatal
sepsis was significantly high (Table 4). thrombocytopenia was more common, and it was
associated with mild to moderate neonatal
Table 4: Correlation of etiology with outcome. thrombocytopenia. In studies conducted by Khalessi N et
al, Eslami Z et al, Ghamdi AM et al, show early onset
No. of No. of thrombocytopenia was more common. Authors also
Etiology %
cases deaths found early onset thrombocytopenia was more
Sepsis 53 23 67.64% common.7,8,15
Birth Asphyxia 11 2 5.88%
RDS 15 3 8.82% Among neonatal risk factors sepsis was the most common
Neonatal cause of neonatal thrombocytopenia which was found in
6 1 2.9% 53% babies and was associated with severe neonatal
hyperbilirubinemia
MAS 10 2 5.88% thrombocytopenia. In studies conducted by Basil M et al,
and Gupta A et al, sepsis was associated with
NEC 5 3 8.82%
thrombocytopenia which was similar to this study.3,16
Septicaemia leads to thrombocytopenia due to both
DISCUSSION
decreased production and increased consumption of
platelets and hence results usually in severe
Neonatal thrombocytopenia (platelet count <1.5 lacs/µl) thrombocytopenia.
is one of the commonest haematological abnormality
encountered in NICU and if it is not detected and RDS was in 15%, birth asphyxia was present in 11%,
managed properly can result in devastating
MAS in 10% and neonatal hyper bilirubinemia in 6%
complications.
babies. Birth asphyxia was associated with mild to
moderate thrombocytopenia. In studies conducted by
The severity of neonatal thrombocytopenia in this study Nandyal SS et al, and Gupta A et al, birth asphyxia was
was mild in (46%), moderate in (35%) and severe in associated with severe thrombocytopenia.3,4
(19%). The results were similar to studies conducted by
Khalessi N et al, and Ghamdi AM et al.7,8 The high In this study, sepsis was significantly associated with late
prevalence of moderate and sever thrombocytopenia in
onset thrombocytopenia and birth asphyxia was
this study was probably because of higher proportion of
significantly associated with early onset neonatal
septicemic babies in our NICU which is a tertiary care
thrombocytopenia.
centre.
In Nandyal SS et al study, both sepsis and birth asphyxia
The high proportion of male babies (male: female ratio
were associated with late onset neonatal
1.7:1) with thrombocytopenia in this study is probably thrombocytopenia.4 According to Murray NA et al, one
due to high incidence of sepsis among male babies.
of the most common causes of early onset
Khalessi N et al, Sheikh MA et al, Chandra A et al,
thrombocytopenia in term neonates is perinatal asphyxia.1
Antoniette BWM et al, Schuchat A et al, and Kuruvilla
Neonates with birth asphyxia have impaired
KA et al, noted that the incidence of neonatal sepsis was megakaryopoiesis and platelet production. In a recent
higher in males than female neonates. This is probably Cochrane meta-analysis, therapeutic hypothermia was
due to the fact that the factors regulating the synthesis of
reported to increase the relative risk of thrombocytopenia
gamma globulin are situated on the X- chromosone and
in neonates with perinatal asphyxia.
male has only one X- chromosone.8-12
Blood transfusion was given in 5%, platelet transfusion in
In this study, anaemia was the commonest maternal risk
13% and FFP in 27% babies. Severe neonatal
factor. 48% mother had anaemia and it was associated
thrombocytopenia required platelet and FFP transfusion.
with all type thrombocytopenia. Other maternal risk
factors were PROM in 30%, PIH 19%, oligohydramnios
The overall mortality in thrombocytopenic babies in this
in 2% and eclampsia in 2% babies. All these risk factors
study was 34%. Mortality in this study was more as
were associated with severe thrombocytopenia. Among
compared to other studies. Mortality was high (40.82%)
all these factors, association of anaemia with severe

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 Meena SL et al. Int J Contemp Pediatr. 2019 May;6(3):1344-1348

in late onset neonatal thrombocytopenia group, however 2. Roberts I, Murray NA. Neonatal thrombocytopenia:
it was statistically not significant. new insights into pathogenesis and implications for
clinical management. Current Opinion Pediatr.
Out of 34, deaths due to sepsis were 23 (43.40%) 2001;13(1):16-21.
followed by NEC 3 (60%), RDS 3 (20%), MAS 2 (20%), 3. Gupta A, Mathai SS, Kanitkar M. Incidence of
birth asphyxia 2 (18.18%) and neonatal thrombocytopenia in neonatal intensive care unit.
hyperbilirubinemia 1 (16.67%). Med J Armed Forces India. 2011;67(3):234-6.
4. Sonam S. Nandyal, Shashikala P, Vidhushi Sahgal.
CONCLUSION Study of thrombocytopenia in neonatal intensive
care unit. Ind J Pathology Oncol. 2016;3(1);55-9.
Neonatal thrombocytopenia is a treatable and reversible 5. Israels SJ, Rand ML, Michelson AD. Neonatal
condition. Hence, it is important to identify neonates at platelet function. Semin Thromb Hemost.
risk and initiate transfusion therapy to prevent severe 2003;29(4):363-72.
bleeding and potentially significant morbidity. The 6. Nathan DG, Stuart HO, Look AT. Nathan and
severity of neonatal thrombocytopenia in the NICU was Oski’s hematology of infancy and childhood. 6th ed.
moderate to severe type. Late onset neonatal Philadelphia: Saunders; 2003.
thrombocytopenia was more common than early onset 7. Ghamdi AM, Umran KA, Buali WA. A practical
neonatal thrombocytopenia. Low birth weight babies approach to assessment of neonatal
were more prone to severe thrombocytopenia. Preterm thrombocytopenia in NICU. J Neonatal-Perinatal
babies had severe thrombocytopenia whereas term babies Med. 2008;1(3);175-80.
had moderate thrombocytopenia. Anaemia and PROM 8. Khalessi N, Khosravi N, Sanni S. The prevalence
were the commonest maternal risk factors. Therefore, and risk factors for neonatal thrombocytopenia
authors recommended that babies born to mothers with amoug newborns asmitted to intensive care unit of
these risk factors should be closely monitored for aliasghar children’s hospital. Iran J Blood Cancer.
thrombocytopenia. 2013;5(2):41-5.
9. Younis S, Sheikh MA, Raza AA. Diagnostic
Sepsis and RDS were the commonest neonatal factors accuracy of C-reactive protein in neonatal sepsis. J
associated with thrombocytopenia. Sepsis was associated Biores Man. 2014;1(1):33-42.
with late onset thrombocytopenia and RDS was 10. Chandra A, Rao MN, Srinivas M, Shyamala S.
associated with early onset thrombocytopenia. The most Rapid diagnostic test in neonatal septicemia. Ind J
common symptom in all forms of thrombocytopenia was Pediatr. 1988;55(6);947-53.
apnoea. The most common sign was cutaneous bleeding 11. Antoniette BWM, Flora DIP. Clinical correlation of
(petechiae/purpura). Mortality was significantly high in neonatal and maternal haematological parameters as
babies with severe neonatal thrombocytopenia, in those predictors of neonatal sepsis. Pediatric infect Dis
with early onset neonatal thrombocytopenia and in cases Soc Philippines J. 2005;9(2)36-43.
where thrombocytopenia was due to sepsis and birth 12. Schuchat A, Zywicki SS, Dinsmoor MJ. Mercer B,
asphyxia. Romagurea J, O’ Sullivan MJ. Risk factors and
opportunities for the prevention of prevention of
Severe thrombocytopenia can be used as a prognostic early onset neonatal sepsis: a multicenter case-
indicator in sick neonates. But to generalize this control study. Paediatrics. 2000;105:21-6.
statement and apply to all neonatal admission, more 13. Kuruvilla KA, Pillai S, Jesudasan M, Jana AK. The
studies are required in this regard with similar results. bacterial profile of sepsis in a neonatal unit in south
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ACKNOWLEDGEMENTS 14. Tirupathi K, Swarnkar K, Vagha J. Study of risk
factors of neonatal thrombocytopenia. Int J
Authors would like to thank all newborn’s parents and Contemp Pedaitr. 2017;4:191-6.
hospital staff who provide unconditional support during 15. Eslami Z, Lookzadeh MH, Noorishadkam M,
study. Hashemi A, Ghilian R, Dehghan PA.
Thrombocytopenia and associated factors in
Funding: No funding sources neonates asmitted to NICU during years 2010-2011.
Conflict of interest: None declared Iran J Ped Hematol Oncol. 2013;3(1);205-15.
Ethical approval: The study was approved by the 16. Basil M. Hanoudi CABP. Study of risk factors for
Institutional Ethics Committee neonatal thrombocytopenia in preterm infants.
Mustansiriya Med J. 2015;14(1):64-9.
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