12 J Gandhara Med Dent Sci

July - September 2025

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ORIGINAL ARTICLE

FREQUENCY AND RISK FACTORS FOR HEMATOMA FORMATION FOLLOWING BONE
MARROW BIOPSY IN PATIENTS WITH SEVERE AND VERY SEVERE THROMBOCYTOPENIA

3 4 5
Ayesha Bangash1, Fawad Rahim2, Sheema Tariq , Khushal Nadir Hadi , Sobia Ahmed Qureshi ,

Ayesha Hamid6

How to cite this article

Bangash A, Rahim F, Tariq S, Hadi
KN, Qureshi SA, Hamid A. Frequency
and Risk Factors for Hematoma
Formation Following Bone Marrow
Biopsy in Patients with Severe and
Very Severe Thrombocytopenia. J
Gandhara Med Dent Sci.
2025;12(3):12-16.https://doi.org/

Date of Submission: 26-04-2025
Date Revised: 24-05-2025
Date Acceptance: 02-06-2025
1Postgraduate Resident, Department of
Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

3Postgraduate Resident, Department of
Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

4Postgraduate Resident, Department of
Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

5Postgraduate Resident, Department of
Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

6Postgraduate Resident, Department of
Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

Correspondence

2Fawad Rahim, Associate Professor,
Dept. of Medicine, Hayatabad Medical
Complex, Peshawar, Pakistan

+92-333-9351983
drfawadrahim@outlook.com

ABSTRACT
OBJECTIVES
To determine the frequency and risk factors of hematoma formation after
bone marrow biopsy in patients with severe and very severe
thrombocytopenia.
METHODOLOGY
This cross-sectional study was conducted at Hayatabad Medical Complex,
Peshawar, from 1st April 2024 to 31st January 2025. Patients over the age of
18 years with severe and very severe thrombocytopenia who underwent bone
marrow biopsy were included. Age, gender, clinical bleeding at presentation,
history of bone marrow biopsy at the same site, body mass index, and platelet
count at the time of biopsy were documented. Participants were screened for
hematoma twenty-four hours after the procedure. Data analysis was carried
out in SPSS.
RESULTS
Most patients had severe thrombocytopenia (60.3%, n = 132), while the
remaining patients had very severe thrombocytopenia (39.7%, n = 87). Only
eight patients (3.7%) developed a hematoma. Patients who had clinical
bleeding (95% CI: 1.93 – 168.45; p = 0.011) and who had repeat biopsy from
a site of previous biopsy (AOR: 18.03; 95% CI: 1.93 – 168.45; p = 0.011)
were significantly more likely to develop hematoma. The development of
hematoma was not influenced by age, gender, body mass index, or the
severity of thrombocytopenia.
CONCLUSION
Hematoma formation after bone marrow biopsy is uncommon. Patients with
clinical bleeding and previous biopsy at the same site have a higher risk.
Factors like age, gender, body mass index, and severity of thrombocytopenia
did not significantly impact hematoma formation. Prophylactic platelet
transfusion before bone marrow biopsy may largely be unnecessary and can
be avoided.
KEYWORDS: Bone Marrow, Biopsy, Thrombocytopenia, Hematoma,
Bleeding, Risk Factors, Pakistan

INTRODUCTION

Bone marrow biopsy is a commonly performed
procedure. It is invasive but indicated for unexplained
pancytopenia, anemia, leucopenia, thrombocytopenia,
and to evaluate cases of fever of undetermined origin,
lymphoma and leukemia.1 It is almost always
performed percutaneously. There are many sites for
percutaneous bone marrow biopsy, like sternum,
posterior iliac crest, anterior iliac crest, tibia, femur,
vertebral bodies and ribs. The preferred site is the
posterior iliac crest as it is accessible and less
traumatic.2,3 Bleeding at the biopsy site is an expected
complication of bone marrow biopsy. The frequency of
biopsy site bleeding ranges from 0.03% to 0.2%.4,6 It is
mostly encountered in patients with thrombocytopenia,
platelet function disorders, and coagulation disorders.7
There is disagreement on the minimum platelet count at

which bone marrow biopsy can be performed safely
without bleeding at the biopsy site.8 Some authorities
do not consider thrombocytopenia, regardless of its
severity, as a contraindication to bone marrow
biopsy.9,10 However, others recommend a platelet count
of at least 20,000/mcL for safely performing a bone
marrow biopsy.11,12 A survey of 104 hematologists
revealed that before bone marrow biopsy, 48% do not
transfuse platelets, 49% selectively transfuse platelets,
and 3% routinely transfuse platelets to increase the
platelet count to 20,000/mcL.12 A retrospective study
comparing patients with platelet counts of less than
20,000/mcL with those with platelet counts between
20,000 to 50,000/mcL demonstrated no difference in
post-procedure biopsy site hematoma frequency.13
Given the infrequent occurrence of hematoma
formation following bone marrow biopsy in
thrombocytopenic patients, existing data on this subject

10.37762/jgmds.12-3.723

13J Gandhara Med Dent SciJuly - September 2025

are limited, and expert opinions vary. The
inconsistencies in recommendations contribute to
prolonged hospital stays and delays in diagnosing
patients who undergo transfusions to achieve a safer
platelet count before biopsy. Additionally, these
patients are exposed to the risks associated with
transfusions. This study aims to establish the frequency
of hematoma formation after bone marrow biopsy in
patients with severe (20,000 - 50,000/mcL) and very
severe thrombocytopenia (< 20,000/mcL), and to
identify risk factors associated with hematoma
formation. The findings of this study will assist in
generating evidence-based guidelines for institutions or
local practices, thereby helping physicians avoid
unnecessary platelet transfusions before performing
bone marrow biopsies. Consequently, this would
facilitate earlier diagnosis of bone marrow disorders
and result in shorter hospital stays.

METHODOLOGY

This cross-sectional study was approved by the
Institutional Review and Ethical Board (IREB) of
Hayatabad Medical Complex, Peshawar. It was
conducted from 1st April 2024 to 31st January 2025.
Patients, 18 years and older, with severe
thrombocytopenia (platelet count between 20 × 109 per
mm3 and 50 × 109 per mm3) and very severe
thrombocytopenia (platelet count below 20 × 109 per
mm3) who underwent bone marrow biopsy at
Hayatabad Medical Complex, Peshawar, were included
in the study after informed consent. Those having
coagulopathy (defined as International Normalized
Ratio > 1.5), renal failure (defined as serum creatinine
> 1.5 mg/dl), a history of platelet function disorders, or
those who have had antiplatelet and/or anticoagulant
medications within the last 7 days were excluded from
the study. A total of 219 patients met the inclusion and
exclusion criteria and were enrolled in the study. All
bone marrow biopsies were performed by the same
operator under the supervision of a clinical
hematologist. All patients received standard care guided
by their clinical condition before and after the bone
marrow biopsy. None of the patients were transfused
with platelets before or after the biopsy. Participants
were screened for hematoma at the biopsy site via
ultrasound by the same radiologist twenty-four hours
after the procedure. Age, gender, history of bleeding at
presentation, history of bone marrow biopsy at the same
site, body mass index, platelet count at the time of
biopsy, and the presence or absence of hematoma were
documented on a structured proforma. Data was
analyzed through the Statistical Package for Social
Sciences, version 21. Descriptive statistics were
performed for all the variables and presented as mean ±

standard deviation, and frequency/percentages. The
presence of post-biopsy hematoma was stratified by
mean age, mean BMI, and mean platelet count; the
statistical significance of between-group differences
was estimated using the Mann-Whitney Test. Similarly,
the significance of the association between hematoma
formation and risk factor categories like gender, degree
of thrombocytopenia, BMI category, bleeding at
admission, and previous biopsy from the same site was
determined by Fisher‘s Exact test. Multivariate logistic
regression analysis was used to identify independent
predictors of hematoma formation by controlling for
confounders. A p-value of less the 0.05 was considered
significant for all analyses.

RESULTS

Most of the study participants (55.3%, n = 121) were
males. The mean age was 41.1 ± 19.1 years, and the
mean platelet count was 28.9 ± 16.7 × 109 per mm3.
Most patients had severe thrombocytopenia (60.3%, n =
132), while the remaining patients had very severe
thrombocytopenia (39.7%, n = 87). All biopsies were
performed from the posterior superior iliac spine. Out
of 219 patients, only eight (3.7%) developed a
hematoma after undergoing a bone marrow biopsy. The
characteristics of the study participants are summarized
in Table 1.

Table 1: Comparison of Electric Pulp Testing (EPT) Readings
between Maxillary and Mandibular Teeth

Variables

Age, (Years)
Body mass index, (kg/m2)
Platelet count, (× 109 per mm3)
Gender
Male
Female
BMI category, (g/dl)
Normal
Overweight & obese
Bleeding at admission, No. (%)
Yes
No
Previous bone marrow biopsy, No. (%)
Yes
No
Degree of thrombocytopenia, No. (%)
Severe thrombocytopenia
Very severe thrombocytopenia
Post-biopsy hematoma, No. (%)
Yes
No

Mean ± SD / No.
(%)
41.1 ± 19.1
26.1 ± 4.0
28.9 ± 16.7

121 (55.3%)
98 (44.7%)

99 (45.2%)
120 (54.8%)

58 (26.5%)
161 (73.5%)

08 (3.7%)
211 (96.3%)

132 (60.3%)
87 (39.7%)

08 (3.7%)
211 (97.3%)

There was no significant difference in the mean age
(36.6 ± 8.0 versus 41.3 ± 19.4 years, p = 0.737) and the
mean body mass index (25.2 ± 4.4 versus 28.1 ± 4.0
Kg/m2, p = 0.591) between those with and without
hematoma. Those with hematoma had a lower platelet

Frequency and Risk Factors for Hematoma Formation

14 J Gandhara Med Dent Sci

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count at the time of biopsy (19.1 ± 17.5 × 109 per mm3)
than those without hematoma (29.3 ± 16.6 × 109 per
mm3), but the difference was not significant (p =
0.057). Univariate analysis showed that a significantly
higher proportion (10.3%) of patients who presented
with bleeding at the time of admission developed
hematoma than those without bleeding (1.2%) (p =
0.005). Patients with severe thrombocytopenia and very
severe thrombocytopenia experienced similar rates of
hematoma formation after biopsy (3.0% vs 4.6%,
respectively, p = 0.716). Likewise, factors like gender,
body mass index, and prior bone marrow biopsy at the
same site did not significantly impact the frequency of
hematoma formation. (Table 2)

Table 2: Univariate Analysis Comparing Risk Factors for Post
Biopsy Hematoma Formation

Variables Post-biopsy hematoma P-value
Yes
(n = 08)

No
(n = 211)

Age, (Years) 36.6 ±
8.0

41.3 ± 19.4 0.737*

Body mass index,
(kg/m2)

25.2 ±
4.4

28.1 ± 4.0 0.591*

Platelet count, (× 109
per mm3)

19.1 ±
17.5

29.3 ± 16.6 0.057*

Degree of thrombocytopenia, No. (%)
Severe
thrombocytopenia

04(3.0%) 128(97%) 0.716#

Very severe
thrombocytopenia

04(4.6%) 83(95.4%)

Gender
Male 02(1.7%) 119(98.3%) 0.144#
Female 06(6.1%) 92(93.9%)
BMI category, (g/dl)
Normal 03(3.0%) 96(97%) 0.732#
Overweight & obese 05(4.2%) 115(95.8%)
Bleeding at admission, No. (%)
Yes 06(10.3%) 52(89.7%) 0.005#
No 02(1.2%) 159(98.8%)
Previous bone marrow biopsy, No. (%)
Yes 01(12.5%) 07(87.5%) 0.261#
No 07(3.3%) 204(96.7%)

*Mann-Whitney U test
#Fisher’s Exact test

On multivariate logistic regression analysis, patients
who presented with bleeding had an 18 times higher
likelihood (95% CI: 1.93 – 168.45; p = 0.011) of
developing post-biopsy hematoma compared to those
who did not have bleeding at admission. Likewise,
patients who underwent a repeat biopsy at the site of a
previous biopsy were more likely to develop a
hematoma than those without a history of biopsy at the
same site (AOR: 18.03; 95% CI: 1.93 – 168.45; p =
0.011). The gender, platelet category, and BMI
category remained insignificant. (Table 3)

Table 3: Multivariate Logistic Regression Analysis of the Factors
Predicting Post-Biopsy Hematoma

Variables AOR 95% CI P-value
Gender Female*

Male 0.43 0.08–2.33 0.326
Platelet
category

Severe
thrombocytopenia*

Very severe
thrombocytopenia

0.67 0.15–
3.11

0.610

BMI
category

Normal*
Overweight &
Obese

1.68 0.34–
8.27

0.523

Bleeding
at present
ation

No*
Yes 18.03

1.93 –
168.45

0.011

History
of biopsy

No*
Yes 26.41

1.28 -
546.51

0.034

*Reference category

DISCUSSION

Bone marrow biopsy is a routine medical procedure.
Although it is invasive, it is frequently necessary. One
common reason for the procedure is unexplained
thrombocytopenia, either alone or alongside
bicytopenia or pancytopenia. Bleeding after a bone
marrow biopsy is a concern for both patients and
clinicians. The optimal platelet count threshold for a
safe bone marrow biopsy is not well established. The
lack of clear guidelines often leads to unnecessary
platelet transfusions before a bone marrow biopsy,
which can result in adverse effects, increased costs, and
longer hospital stays. This study aimed to identify the
frequency and risk factors for biopsy site bleeding in
patients with severe and very severe thrombocytopenia.
Hematoma after bone marrow biopsy was observed in
eight patients, accounting for 3.7% of cases. A low rate
of bleeding complications following the procedure has
been consistently reported. Bain et al., in a review of
19,259 bone marrow biopsy procedures performed in
2003, found that only 11 cases (0.06%) developed local
hematoma.4 Likewise, in a similar review of bone
marrow biopsies performed between 1995 and 2001,
hematoma was reported in 14 out of 54,890 biopsies.5
Similarly, Salem et al. stated that biopsy site hematoma
rarely complicates bone marrow biopsy, occurring in
one out of 500 cases.6 The frequency of hematoma in
this study is notably higher than that reported
previously. Multiple factors might have contributed to
this. These include patient-related factors: a higher
proportion of our patients may have had platelet
dysfunction; procedure-related factors: variation in
bone marrow biopsy technique and post-procedure
compression time, in addition to the operator’s

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experience; and differences in the study protocol:
discrepancies in the operational definitions used to
diagnose hematoma and the inherently higher
likelihood of reporting a hematoma when patients are
monitored systematically for complications compared
to a retrospective review of records. Age, gender, and
body mass index were not significantly associated with
the risk of hematoma formation. There is limited
literature assessing the association of age and gender
with hematoma formation. A case report highlights age
as a risk factor, but none of the comparative studies or
reviews have mentioned age or gender as risk factors
for hematoma formation.14 In contrast, obesity has been
identified as a risk factor for bleeding complications by
some researchers, owing to technical difficulties posed
by the weight of the patient.5,15,16 Computed
tomography-guided biopsy has been proposed as a safer
alternative to manual biopsy in obese patients.15,17
Although lower in patients who developed hematoma,
the mean platelet count was not significantly different
between those with and without hematoma. Likewise,
patients with severe thrombocytopenia and very severe
thrombocytopenia had comparable rates of hematoma
formation in univariate and multivariate analysis.
Opinions are divided on the risk of post-biopsy
hematoma posed by low platelet count. A case report by
Salem et al. and reviews by Bain et al. have reported
thrombocytopenia as a risk factor.4,6 In contrast, Story
et al. did not identify thrombocytopenia as a risk factor
for hematoma.18 Imaging-guided biopsy has been
determined safe in patients with platelet count as low as
20 × 109 per mm3 without the need for pre-procedural
platelet transfusions. Clinical bleeding at the time of
presentation increased the risk of post-biopsy bleeding.
It was an independent predictor of hematoma
formation, as this association remained significant after
adjustment for the degree of thrombocytopenia and
other confounders in multivariate analysis. There is a
paucity of literature comparing patients with and
without bleeding at presentation for post-bone marrow
biopsy hematoma. Myeloproliferative disorders and
functional abnormalities of platelets have been reported
as predictors of post-biopsy bleeding.4,5 It is possible
that the subset of patients who presented with clinical
bleeding might have had an underlying diagnosis of
myeloproliferative disorder, leading to an acquired von
Willebrand syndrome or had impaired platelet function
secondary to the primary disease, which resulted in
both clinical as well as post-biopsy bleeding despite
reasonable platelet counts. Comparing patients stratified
by platelet function for post-biopsy bleeding can be an
area for further research. Patients who had a repeat
biopsy at the site of a previous biopsy were more likely
to develop a hematoma at the biopsy site. Reviews of
bone marrow biopsies carried out between 1995 and

2001, and in 2003 in the United Kingdom, have not
described previous bone marrow biopsy among the risk
factors for post-biopsy bleeding.4,5 Risk of post-biopsy
bleeding at the site of a previous biopsy is a relevant
concern, especially in patients undergoing repeated
biopsies for hematological monitoring. Scarring and
fibrosis following a previous biopsy and the subsequent
reduced vascularity may theoretically reduce the risk of
bleeding. On the other hand, it may make the procedure
technically more difficul t, potentially increasing the
chances of trauma to the nearby vessels, leading to
hematoma formation. This needs further evaluation in
large-scale comparative studies.

LIMITATIONS

Most literature on the topic is limited to case reports or
retrospective reviews. It is one of the few studies, and
the first in Pakistan, to assess risk factors of biopsy site
hematoma formation in thrombocytopenic patients
undergoing bone marrow biopsy in a cross-sectional
design. We consider this the primary strength of this
study. It has identified some risk factors and given
future research directions for novel risk factors.
Moreover, advanced analysis, like multivariate logistic
regression analysis, was used to mitigate the effects of
confounders. We consider the single-center nature,
relatively small sample, exclusion of certain patient
groups, and the lack of a longer follow-up as limitations
of the study, which might limit the generalizability of
the study‘s findings.

CONCLUSIONS

Hematoma formation after bone marrow biopsy in
patients with severe and very severe thrombocytopenia
is relatively rare, occurring in only 3.7% of cases.
Clinical bleeding at the time of presentation and a
history of previous biopsy at the same site were
significant risk factors for post-biopsy hematoma
formation. However, factors like age, gender, body
mass index, and the degree of thrombocytopenia did not
significantly impact the frequency of hematoma
formation. The findings suggest that unnecessary
platelet transfusions before bone marrow biopsy can be
avoided, potentially leading to early diagnosis of bone
marrow disorders and shorter hospital stays. Large-
scale, multi-center studies are recommended to validate
the findings of this study to help shape guidelines for
optimal peri-procedure care of patients undergoing
bone marrow biopsy.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Frequency and Risk Factors for Hematoma Formation

Ayesha Bangash - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript;
Critical Revision; Final Approval
Fawad Rahim - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript;
Critical Revision; Final Approval
Sheema Tariq - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Final Approval
Khushal Nadir Hadi - Concept & Design;Data Acquisition
Drafting Manuscript; Critical Revision; Final Approval
Sobia Ahmed Qureshi - Concept & Design;Data Acquisition
Drafting Manuscript; Critical Revision; Final Approval
Ayesha Hamid - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Final Approval

AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.

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Anastasiadou KI, et al. Haematoma Caused by Bone Marrow
Aspiration and Trephine Biopsy. Hematol Rep. 2011;3(3).
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