شرح المدرسين
Hematologic Changes
Pregnancy induces significant adaptations within the hematologic system to meet the increased demands of both the mother and the developing fetus. These changes, which include alterations in blood volume, cell counts, and coagulation factors, are essential for ensuring a healthy pregnancy and delivery.
- ↑ Plasma volume → ↓ hematocrit, especially towards the end of pregnancy (30–34th week of gestation) → dilutional anemia
- Hypercoagulability is due to an increase in fibrinogen, factor VII, and factor VIII and a decrease in protein S (reduces the risk of intrapartum blood loss).
- ↓ Platelet count → gestational thrombocytopenia
- ↑ RBC mass (increases from 8–10th week of gestation until the end of pregnancy)
- ↓ Iron and folate levels due to increased vitamin and mineral requirements
- ↑ WBC count
- ↓ Albumin
- ↑ Alkaline phosphatase (placental isoenzymes)
| Summary of hematologic changes associated with normal pregnancy | |
| Plasma volume | Increased 30 to 50 percent |
| Red blood cell mass | Increased 20 to 30 percent |
| Hemoglobin concentration | Decreased |
| Red cell lifespan | Decreased slightly |
| Erythropoietin | Increased |
| Mean corpuscular volume | Increased slightly |
| Platelet count | No change to decreased slightly |
| White blood cell count | Increased (neutrophilia) |
| Lymphocyte count | No change |
| Monocyte count | No change |
| Basophil count | No change to decreased slightly |
| Eosinophil count | No change to increased slightly |
| Prothrombin time | Decreased slightly |
| Bleeding time | No change |
| Total protein S antigen, free protein S antigen, protein S activity | Decreased |
| Resistance to activated protein C | Increased |
| Fibrinogen, factors II, VII, VIII, X, XII, XIII | Increased 20 to 200 percent |
| Antithrombin, protein C, factor V, factor IX | No change to increased slightly |
| von Willebrand factor | Increased |
| Thrombin activatable fibrinolytic inhibitor, PAI-1, PAI-2 | Increased |
| D-dimer | Increased |
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Recommendations
- Physiologic Anemia
- Defined by the CDC as hemoglobin levels <11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester. Iron deficiency is the most common cause of more severe anemia.
- WBC Count
- Elevated WBC count, typically ranging from 9000 to 15,000 cells/μL, may indicate mild neutrophilia.
- Platelet Count
- Gestational thrombocytopenia is common but does not usually require intervention. Severe thrombocytopenia warrants further evaluation.
- Coagulation Testing
- Most pregnant individuals do not require routine coagulation testing, as PT and aPTT are often normal or slightly decreased. The accuracy of D-dimer tests for predicting VTE is diminished during pregnancy.
- Physiological hypercoagulability during pregnancy leads to an increased risk of thrombosis. Patients with thrombophilia should receive adequate thrombosis prophylaxis.
- Postpartum Resolution
- Hematologic changes generally return to baseline by six to eight weeks postpartum. Persistent abnormalities necessitate further evaluation.
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