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\title{Hospital based Prospective Study of Thrombocytopenia in Pregnancy}
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             \author[1]{Dr. Swati Motilal  Maraskolhe}

             \author[2]{Dr. Ashok Ramchandra  Anand}

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\date{\small \em Received: 6 June 2021 Accepted: 4 July 2021 Published: 15 July 2021}

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\begin{abstract}
        


Background: Thrombocytopenia is the second most common hematologic abnormality after anemia during pregnancy and is usually a benign condition. Thrombocytopenia affects 7% to 10% of all pregnant women. All pregnant women with platelet counts less than 100000/mm3 require careful hematological and obstetric consultation to rule out other more serious disorders.Objectives: To study the various etiological factors associated the effect and outcome of the mother and neonates born, to study the Management in pregnancy. Methods:The study was conducted in this tertiary institute over a period of two years and three months. 130 pregnant patients with a platelet count of or less than 100000/mL were included. The course of pregnancy was studied and the investigation profile and maternal and fetal outcome was monitored.

\end{abstract}


\keywords{thrombocytopenia, pregnancy.}

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\section[{Hospital based Prospective Study of Thrombocytopenia in Pregnancy}]{Hospital based Prospective Study of Thrombocytopenia in Pregnancy}\par
Dr. Swati Motilal Maraskolhe ? \& Dr. Ashok Ramchandra Anand ? Abstract-Background: Thrombocytopenia is the second most common hematologic abnormality after anemia during pregnancy and is usually a benign condition. Thrombocytopenia affects 7\% to 10\% of all pregnant women. All pregnant women with platelet counts less than 100000/mm3 require careful hematological and obstetric consultation to rule out other more serious disorders.\par
Objectives: To study the various etiological factors associated the effect and outcome of the mother and neonates born, to study the Management in pregnancy.\par
Methods: The study was conducted in this tertiary institute over a period of two years and three months. 130 pregnant patients with a platelet count of or less than 100000/mL were included. The course of pregnancy was studied and the investigation profile and maternal and fetal outcome was monitored.\par
Result : Out of 130 cases 107 cases (17.69\%) had severe thrombocytopenia and 23 cases (82.3\%) had moderate thrombocytopenia. Total incidence of thrombocytopenia in prganncy is 2.8 \%.In this study 42.3\% cases were primigravidas, 58 \% cases were multigravida. In this study gestational thrombocytopenia was the most common etiological factor with 42\% cases followed by other infectious diseases, 1.5\% for pregnancy induced hypertension and for eclampsia, 25.5\% cases for HELLP syndrome. 3.07\% cases of severe thrombocytopenia had deranged liver function tests and 21.5\% cases of moderate thrombocytopenia had deranged liver function tests. In this study out of the total 4.8\% acute febrile illness cases 1.5\% had P. vivax Malaria. And Among the 6 cases of dengue in this study, 0.7 \% were IgM positive, 3.8\% were NS1Ag positive. Most of the 63.7\% cases were of ?36 weeks of gestation. In this study out of 130 cases there were 10 (7.69\%) neonatal deaths.\par
Conclusion: Conclusion from this study is the incidence of thrombocytopenia during pregnancy is quite uncommon that is 2.8\% and if present with thrombocytopenia then it is considered as an emergency for an obstetrician mostly during labor or whenever she having bleeding Fetal outcome in pregnant patients with thrombocytopenia was favourable; it was dependent on the gestation of delivery. 
\section[{Introduction}]{Introduction}\par
latelet abnormalities may precede pregnancy, developed during pregnancy coincidentally or be induced by pregnancy. Pregnancy is associated with physiological and pathological changes in platelet numbers and function which can be of clinical concern. Inherited defects in platelet function and number may also manifest during pregnancy with the risk of bleeding dependent on the underlying problem. Thrombocytopenia affects 7\% to 10\% of all pregnant women and other than anemia is the most common hematologic disorder in pregnancy.  {\ref 2} Thrombocytopenia in pregnancy may occur secondary to a variety of causes ranging from benign disorders such as gestational thrombocytopenia to syndromes associated with significant morbidity such as eclampsia, HELLP, ITP, TTP-HUS. Other causes of thrombocytopenia in pregnancy are rare such as Type II von Wiillebrand Disease (vWD), and disseminated intravascular coagulation.\par
Among the all causes most common cause is Gestational Thrombocytopenia, Which is 75 \% occure mostly in third trimester and is through to be predominantly due to hemodilution. All pregnant women with platelet counts less than 100000/mL require careful hematological and obstetric consultation to rule out other more serious disorders.\par
To reduce the platelet disorder related complications during pregnancy, there should be stratification done regarding the predictors, frequency and their effects on the foetus.\par
In this study we study the various etiological factors associated, the effect and outcome of the mother and neonates borne to study the Management in pregnancy.\par
a) Aims and objectives of the study 1. To study the various etiological factors associated with thrombocytopenia in pregnancy 2. To study the number and percentage of cases of moderate and severe thrombocytopenia in pregnancy. 3. To study the different diseases in which thrombocytopenia manifests in ANC patients. 4. To study the effect and outcome of the mother and neonates borne to them. 5. To study the management of cases of thrombocytopenia in pregnancy.\par
6. To study the morbidity and mortality associated with thrombocytopenia in pregnancy.\par
II. 
\section[{Methods}]{Methods} 
\section[{Study-Hospital based prospective study}]{Study-Hospital based prospective study}\par
Inclusion criteria 1. Pregnant patients with 2 nd and 3 rd trimester with low platelet count. 2. Platelet count equal to or below 100000 per microliter were included in the study in Pregnant women.\par
Exclusion Criteria-1) Patients on steroid, NSAIDS therapy or who underwent for splenomegaly.\par
The study was conducted in the tertiary institute over a period of two years and three months, from. 130 pregnant patients with a platelet count of or less than 100000/mL were included in the study group. Patients with 2 nd And 3 rd trimester of pregnancy were included. On admission a thorough history was taken and a detailed clinical examination was carried out. All the patients were subjected to biochemical investigations, special investigations and ultrasonography.\par
Patients were grouped into 2 categories-one with moderate thrombocytopenia (platelet count >50000 or less than or equal to 100000/ml and one with severe thrombocytopenia (platelet count equal to or less than 50000/ml).\par
The course of pregnancy was studied and the investigation profile was monitored. The obstetric outcome was noted. The entire hospital stay course was noted. Final outcome of all cases and complications if any was studied.  
\section[{Result}]{Result}\par
The total number of deliveries in our institute over the period from Jan 2017 to July 2018 was 4669. Out of deliveries, there were 130 cases of Thrombocytopenia.\par
Thus the incidence of Thrombocytopenia in the present study is 2.8\%.\par
In this study 42.3\% cases were primigravidas, 58 \% cases were multigravida. 
\section[{Table no. 2: Distribution of case according to weeks of gestation}]{Table no. 2: Distribution of case according to weeks of gestation}\par
In this study 10.7\% cases were of 26-30 weeks of gestation, 26.1\% cases were of 31-35 weeks of gestation, 63.7\% cases were of ?36 weeks of gestation. In this study gestational thrombocytopenia was the most common etiological factor with 42\% cases followed by 1.5\% for malaria followed by 6.6\% for dengue, 1.5\% for pregnancy induced hypertension and for eclampsia, 25.5\% cases for HELLP syndrome. 3.07\% cases of severe thrombocytopenia had deranged liver function tests and 21.5\% cases of moderate thrombocytopenia had deranged liver function tests.\par
In this study out of the total 4.8\% Acute febrile illness cases, 1.5\% had P. vivax Malaria. And Among the 6 cases of dengue in this study, 0.7 \% were IgM positive, 3.8\% were NS1Ag positive.\par
Out of the 130 cases, 107 cases (82.3\%) had moderate thrombocytopenia and 23 cases (17.69\%) had severe thrombocytopenia.\par
Vaginal delivery was the most common mode of delivery seen in 87\% of the patients. 13.07\% of the cases had LSCS, with 5 Still birth with 24 are FTND with episiotomy, 50 are FTND with intact perineum, and 34 are PTVGD.  This analysis reveals that, 14.61\% of the cases were registered in Antenatal clinic followed by 78.46\% of the patients came as referrals from other hospitals and 6.9 \% of the cases were unregistered.\par
This data reveals that, 1.53\% of the cases had 1 antenatal.\par
Visits followed by 14.61\% of the patients had 2-4 antenatal visits and 6.8 \% of the patients had 5-6 antenatal visits and 0.76 \%of the patient had >6 visit.\par
In this study 1.5 \% cases had deranged renal function tests. 98.46 \% cases had renal function tests within normal limit. 1.5 \% cases of moderate thrombocytopenia had deranged RFTs.\par
In this study 24.6 \% cases had deranged liver function tests.75.4 \% cases had liver function tests within normal limit. 21.5\% cases of moderate thrombocytopenia had deranged LFTs.\par
As per this data, 5.38 \% of the cases had Previous 1 LSCS followed by 2.3\% of the cases had IUGR with with Fetoplacental Insufficiency and of Postdatism with thick MSAF.\par
As per this data, 39.23\% of the babies were in the range of <1.5 followed by 31.53\% of the babies were in the range of 2.1 -2.5kg.\par
This data reveals that 7.61\% of the patients had Low birth weight with respiratory distress was the commonest indication for admission of the NICU.\par
This data indicates that, Postnatal course was uneventful in 96.9 \% of the patients.\par
As per this data, 2.30 \% of the cases were admitted for Critical monitoring followed by 1.53\% of the patient's was admitted for Ventilator Support.\par
As per this data, 2.30 \% were admitted in the CCU for < 2 days.\par
Respiratory distress was the most common complication seen in 3.8\% of the babies.\par
As per this data, 83.07\% of the patients had duration of hospital stay < 10 days followed by 16.15\% of the patients had hospital stay 11 -20 days. The reason for prolonged stay was to monitor vital parameters, to look for signs and symptoms of bleeding and hypertension, to look for growth of baby. 
\section[{Outcome}]{Outcome}\par
No The neonatal mortality with Severe birth asphyxia was 3.9\% and with Cardiorespiratory arrest was 2.30\% with the perinatal mortality rate was 8.5\%.\par
The most common cause of stillbirth was prematurity. followed by 22.30\% had required blood transfusion other 10 \% need conservative treatment.\par
This data reveals that 88.28\% of the babies had Apgar score in the range of 7 to 9.  
\section[{Discussion}]{Discussion}\par
In this prospective study of all pregnant patients with thrombocytopenia with platelet count less than or equal to one lakh per mL were included.\par
The present study was aimed at investigating thrombocytopenia during pregnancy.\par
Their detailed history, examination findings, investigations were noted. Course of pregnancy was followed up and the maternal, obstetric and fetal outcome was studied.\par
The results of the study were then compared with the available literature and the following points were noted.\par
The total number of deliveries in our institute over the period from Jan 2017 to Aug 2018 was 4669. Out of deliveries, there were 130 cases of Thrombocytopenia.\par
Thus the incidence of Thrombocytopenia in the present study is 2.8\%.\par
From the above studies our study and Zahida Parveen Brohi etall shows similar findings of Incidence among the patient. 
\section[{Age}]{Age}\par
In our study, most of the patients (n=60) i.e. 44.1\% cases were of 21-25 yrs. of Age group with mean age of 30.7 ± 2.08 years in the study group.\par
Out of 130 patient total 14.61\% of the cases were registered in Antenatal clinic followed by 78.46\% of the patients came as referrals from other hospitals and 6.9 \% of the cases were unregistered.14.61 \% had 2-4 antenatal OPD visit and 6.9 \% had no visit.\par
In this study 42.3\% cases were primigravidas, 58 \% cases were multigravida. most of the studies shows similar findings that most patient reported are primigravida.\par
In this study 26.1\% cases were of 31-35 weeks of gestation with mean gestational age 34 +/-5 Similar findings consistent with the study conducted by Michal Parnas etall 2005 1 <36 weeks-25.6\%, In this study, 63.7\% cases were of ?36 weeks of gestation. The study conducted by Michal Parnas etall 2005 1 observed that 37-39 weeks -46.2\% which shows opposite findings to our study.\par
In our study gestational thrombocytopenia (42\%) was the most common etiological factor with 42\% cases followed by 1.5\% for malaria followed by 6.6\% for dengue, 1.5\% for pregnancy induced hypertension and for eclampsia, 25.5\% cases for HELLP syndrome.\par
Michal Parnas etall 20051 Observed that the main causes of thrombocytopenia were gestational thrombocytopenia 118 patient (GT) (59.3\%),22 immune thrombocytopenic purpura (ITP) (11.05\%), 20 with severe pre-eeclampsia (10.05\%), and 24 with HELLP (Hemolysis, elevated liver enzymes and low platelet count) syndrome (12.06\%).10 with DIC, 1 with TTP, 6.2\% with APH.\par
In our study vaginal delivery was the most common mode of delivery seen in 87\% of the patients. 13.07\% of the cases had LSCS, with 5 Still birth with 24 are FTND with episiotomy, 50 are FTND with intact perineum, and 34 are PTVGD.\par
Michal Parnas 1etall 2005 conclude that most common mode is Vaginal delivery. and LSCS is done only in case of any obstetric emergency.\par
Michal Parnas 1etall 2005 observed that most of the patient had vaginal deliveries 64 \% and Cesarean section -36.2\% preterm deliveries with higher rates of labor induction.\par
In our study the neonatal mortality with severe birth asphyxia was 3.9\% and with Cardiorespiratory arrest was 2.30\% with the perinatal mortality rate was 8.5 \%. The most common cause of stillbirth was prematurity.\par
50 patients (38.46\%) had preterm deliveries out of which 60 patients (56.07\%) belonged to the severe thrombocytopenia group. This was due to the associated obstetric and medical complications that indicate preterm delivery.\par
10 patients (7.68\%) had neonatal deaths (NNDs) as opposed to the study of  {\ref Parnas et al. in 2006 1} in which 2.5\% patients had NNDs. Out of that 2 patients (1.53\%) belonged to the severe thrombocytopenia group. The association of NNDs with severe thrombocytopenia was not statistically significant and in the moderate thrombocytopenia group there were 6.15 \% neonatal deaths.\par
Similar findings also reported in the study conducted by Kasturi V. Donimath etall in 2014-2015.  {\ref 2} According to Kasturi V. Donimath 2 etall Prospective observational study was done during November 2014 to June 2015.Out of 100 cases 56\% had thrombocytopenia. There was very high significant relationship between the degree of thrombocytopenia with the severity of the PIH (at p <0.001). 12\% of the fetuses had IUD, 10\% had IUGR, 4\% died after birth and 2\% had severe birth asphyxia.\par
In our study Out of the 130 cases, 107 cases (82.3\%) had moderate thrombocytopenia and 23 cases (17.7\%) had severe thrombocytopenia.\par
In the present study, Postnatal course was uneventful in 96.9 \% of the patients. peurperal complications were seen in 3.07\% patients. As per this data, 53.07\% of the patients had required platelet transfusion followed by 22.30\% had required blood transfusion other 10 \% need conservative treatment.\par
As per this data, 2.30 \% of the cases were admitted for Critical monitoring followed by 1.53\% of the patient's was admitted for Ventilator Support.\par
V. 
\section[{Conclusion}]{Conclusion}\par
Conclusion from this study is the incidence of thrombocytopenia during pregnancy is quite uncommon that is 2.8\% and if present with thrombocytopenia then it is considered as an emergency for an obstetrician mostly during labor or whenever she having bleeding .There are decreased in platelets count at different stages of pregnancy, most low platelet counts observed in the pregnant patients are due to normal physiologic changes and various pathological changes also.\par
This Study conclude that, Thrombocytopenia in pregnancy may occur secondary to a variety of causes. Most of these cases occur during specific periods of gestation. Out of the etiological factors most common cause of thrombocytopenia in pregnancy is gestational thrombocytopenia with the rate of 42\%.\par
Early diagnosis and management play a key role in decreasing the adverse outcome by sunderstanding the auto-pathology. Treatment of thrombocytopenia depends upon the severity and condition of the patients.\par
The above observations show that failure can occur at any time during pregnancy or in the puerperium.\par
Hence, constant vigilance and multidisciplinary approach. is required throughout antenatal, intrapartum and post-partum period.\par
Vaginal delivery is safer and caesarean section should be reserved only for Obstetric indications with access to intensive care units.\par
In my study emergency LSCS was done in fetal jeopardy and resulted favourable outcome.\par
Need of platelet transfusion depends on severity and the type of platelet disorder that patient have.\par
Cases of ITP is also observed which is diagnosed as an diagnosis of an exclusion and treated with Corticosteroids it is the first line of therapy for thrombocytopenia usually prednisone drug is used.\par
Patients with gestational thrombocytopenia and ITP have better maternal and perinatal outcomes as compared to preeclampsia and HELLP syndrome, which are associated with adverse feto-maternal outcome.\par
Fetal outcome in pregnant patients with thrombocytopenia was favourable; it was dependent on the gestation of delivery.\par
Prematurity and its complications with a rate of 7.61\% were with most common associated with thrombocytopenia in pregnant patients. 
\section[{Acknowledgment}]{Acknowledgment}\par
I would like to express my special thanks of gratitude to my teacher Dr. Ashok Ramchandra Anand who gave me the wonderful opportunity to do this thesis project on the topic of hospital based prospective study of thrombocytopenia in pregnancy and I came to know and learn many new things for this I am really thankful to them.  
\section[{Bibilography}]{Bibilography} \begin{figure}[htbp]
\noindent\textbf{no} \par 
\begin{longtable}{}
\end{longtable} \par
  {\small\itshape [Note: 1: Distribution according to parity III.]} 
\caption{\label{tab_0}Table no .}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{no3} \par 
\begin{longtable}{P{0.4522641509433962\textwidth}P{0.15075471698113208\textwidth}P{0.24698113207547168\textwidth}}
Parity\tabcellsep No.\tabcellsep Percentage\\
Primigravida\tabcellsep 55\tabcellsep 42.3\\
Multigravida\tabcellsep 75\tabcellsep 58\\
Total\tabcellsep 130\tabcellsep 100\\
Weeks of gestation\tabcellsep No.\tabcellsep Percentage\\
26-30\tabcellsep 14\tabcellsep 10.7\\
31-35\tabcellsep 34\tabcellsep 26.1\\
36-41\tabcellsep 82\tabcellsep 63.07\\
Total\tabcellsep 100\tabcellsep 100\%\\
Obstetric high risk condition\tabcellsep No. of patients(50)\tabcellsep Percentage (\%)\\
HELLP\tabcellsep 33\tabcellsep 25.53\\
Severe PIH\tabcellsep 2\tabcellsep 1.54\\
DIC\tabcellsep 10\tabcellsep 7.6\\
Antepartum hemorrhage\tabcellsep 5\tabcellsep 3.8\end{longtable} \par
 
\caption{\label{tab_1}Table no . 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{no} \par 
\begin{longtable}{P{0.3717469879518072\textwidth}P{0.1433734939759036\textwidth}P{0.10240963855421686\textwidth}P{0.02457831325301205\textwidth}P{0.12289156626506023\textwidth}P{0.085\textwidth}}
\tabcellsep Etiology\tabcellsep \tabcellsep No.\tabcellsep Percentage\tabcellsep \\
\multicolumn{2}{l}{Gestational Thrombocytopenia}\tabcellsep \tabcellsep 55\tabcellsep 42\%\tabcellsep \\
\tabcellsep Dengue\tabcellsep \tabcellsep 8\tabcellsep 6.6\%\tabcellsep \\
\tabcellsep HEELP\tabcellsep \tabcellsep 33\tabcellsep 25.5\%\tabcellsep \\
\tabcellsep DIC\tabcellsep \tabcellsep 10\tabcellsep 7.6\%\tabcellsep \\
\tabcellsep ART Induced\tabcellsep \tabcellsep 1\tabcellsep 0.7\%\tabcellsep \\
\tabcellsep Heparin Induced\tabcellsep \tabcellsep 1\tabcellsep 0.7\%\tabcellsep \\
\tabcellsep Idiopathic\tabcellsep \tabcellsep 5\tabcellsep 3.8\%\tabcellsep \\
\tabcellsep Pancytopenia\tabcellsep \tabcellsep 2\tabcellsep 1.5\tabcellsep \\
\tabcellsep Severe PIH\tabcellsep \tabcellsep 2\tabcellsep 1.5\tabcellsep \\
\tabcellsep APH\tabcellsep \tabcellsep 5\tabcellsep 3.8\tabcellsep \\
\multicolumn{2}{l}{Acute Febrile Illness}\tabcellsep \tabcellsep 6\tabcellsep 4.8\%\tabcellsep \\
\tabcellsep P.Vivax Total-\tabcellsep \tabcellsep 2 130\tabcellsep 1.5\% 100\%\tabcellsep Year 2021\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep 27\\
\multicolumn{2}{l}{PLT Count Moderate (>50,000) Severe (<50000) Total}\tabcellsep \multicolumn{2}{l}{No. 107 23 130}\tabcellsep Percentage 82.3 17.69 100\%\tabcellsep Volume XXI Issue II Version I\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep D D D D )\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (\\
\multicolumn{2}{l}{Mode of delivery Vaginal FTND with episiotomy}\tabcellsep \multicolumn{2}{l}{. 6: Distribution according to mode of delivery No. of patients (N = 60) 24 113}\tabcellsep Percentage (\%) 87\tabcellsep Medical Research\\
LSCS\tabcellsep FTND with intact perineum PTVGD Still birth\tabcellsep 50 34 5\tabcellsep 17\tabcellsep 13.07\tabcellsep Global Journal of\\
\multicolumn{3}{l}{Vaginal delivery was the most common mode of}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{delivery seen in 87\% of the patients. 13.07\% of the}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{cases had LSCS, with 5 Still birth with 24 are FTND with}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{episiotomy, 50 are FTND with intact perineum, and 34}\tabcellsep \tabcellsep \tabcellsep \\
are PTVGD.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: E © 2021 Global Journals Hospital based Prospective Study of Thrombocytopenia in Pregnancy]} 
\caption{\label{tab_2}Table no}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Analysis of Platelet Transfusion\\
As per this data, 53.07\% of the patients had\\
required platelet transfusion followed by 22.30\% had\\
required blood transfusion other 10 \% need conservative\\
treatment.\\
In this study 7.2\% cases were of 19-20 years. of\\
Age group, 44.1\% cases were of 21-25 years of Age\\
group. 27.4\% cases were of 26 -30 years of Age\\
group.21.3\% cases were of 31-40 years of age group.\end{longtable} \par
 
\caption{\label{tab_3}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{no8} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_5}Table no . 8 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.798542600896861\textwidth}P{0.01905829596412556\textwidth}P{0.007623318385650224\textwidth}P{0.015246636771300448\textwidth}P{0.00952914798206278\textwidth}}
\multicolumn{5}{l}{ObstetGynecolReprod Biol. 2006 Sep-Oct; 128(1-2):}\\
163-8.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{5}{l}{2. Kasturi V Donimath KV et al. Int J Reprod}\\
\multicolumn{5}{l}{Contracept Obstet Gynecol. 2016 Mar; 5(3): 808-}\\
\multicolumn{5}{l}{812 A study on association of thrombocytopenia with}\\
\multicolumn{3}{l}{pregnancy induced hypertension.}\tabcellsep \tabcellsep \\
\multicolumn{5}{l}{3. Sainio S, Kekomaki R, Rikonen S, Teramo K.}\\
\multicolumn{5}{l}{Maternal thrombocytopenia at term: a population-}\\
\multicolumn{5}{l}{based study. Acta ObstetrGynecol Scand. 2000,}\\
n78,142.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
4. Williams\tabcellsep Obstetrics\tabcellsep 25th\tabcellsep edition,\tabcellsep 2014.\\
\multicolumn{4}{l}{Cardiovascular diseases 1274-1276.}\tabcellsep \end{longtable} \par
 
\caption{\label{tab_6}}\end{figure}
 			\footnote{© 2021 Global JournalsHospital based Prospective Study of Thrombocytopenia in Pregnancy} 		 		\backmatter  			  				\begin{bibitemlist}{1}

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