[Multiple phlebothrombosis following cesarean section due to heterozygous factor V Leiden mutation detected post partum]

Activated protein C resistance in factor V Leiden mutation is currently the most frequent hereditary defect accompanied by high risk of thromboembolism. Thromboembolism often develops in the presence of additional risk factors such as pregnancy, birth, taking oral contraceptives, immobilization and surgical operations. A case of multiple phlebothrombosis following caesarean section in heterozygous factor V Leiden mutation evidenced post partum is reported. The patient developed extensive phlebothrombosis in both legs on postoperative day three despite preventive thrombosis treatment with low-molecular heparin. She also suffered from short-term incomplete paresis of her left arm and epileptic seizure with typical grand mal symptoms. MRI showed partial thrombosis of the superior sagittal sinus and the transverse sinus.

[Prevention, diagnosis and treatment of blood group immunization during pregnancy]

In the Netherlands last year two important policy changes were introduced to prevent haemolytic disease of the newborn: antenatal administration of anti RhD immunoglobulin and screening for antibodies against irregular erythrocyte antigens in all pregnant women. As the predictive value of such antibodies for the detection of hemolytic disease of the newborn is limited, it is uncertain if this measure is really cost-effective. Because blood transfusion is the most important probable cause of the immunization, and because of the clinical severity of anti-K antibodies, it is advised to give exclusively K negative blood to girls and women under the age of 45 years. In addition there is a need for a uniform protocol to deal with women who have been exposed to immunization.

ACOG practice bulletin: Thrombocytopenia in pregnancy. Number 6, September 1999. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists

Thrombocytopenia in pregnant women is diagnosed frequently by obstetricians because platelet counts are now included with automated complete blood cell counts (CBCs) obtained during routine prenatal screening (1). The condition is common, occurring in 7-8% of pregnancies (2). Thrombocytopenia can result from a variety of physiologic or pathologic conditions, several of which are unique to pregnancy. Some causes of thrombocytopenia are serious medical disorders that have the potential for profound maternal and fetal morbidity. In contrast, other conditions, such as gestational thrombocytopenia, are benign and pose no maternal or fetal risks. Because of the increased recognition of maternal and fetal thrombocytopenia, there are numerous controversies regarding obstetric management. Clinicians must weigh the risks of maternal and fetal bleeding complications against the costs and morbidity of diagnostic tests and invasive interventions.

Activated protein C resistance and lupus anticoagulant in pregnancy

Thrombophilias, both inherited and acquired, have been reported to be associated with thromboembolic events and severe obstetric complications. This case report examines the case of a patient with two thrombophilias, activated protein C resistance secondary to Factor V Leiden mutation and lupus anticoagulant.

Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy

OBJECTIVE

To estimate the incidence, timing, and associated clinical characteristics of objectively diagnosed pregnancy-associated venous thromboembolism.

METHODS

We retrospectively reviewed venous thromboembolism cases (deep venous thrombosis and pulmonary embolism) that occurred between 1978 and 1996. Study inclusion criteria required the objective diagnosis with either Doppler ultrasound, venography, impedance plethysmography, pulmonary angiography, ventilation-perfusion scanning, or computed tomography or magnetic resonance imaging.

RESULTS

Among 268,525 deliveries there were 165 (0.06%) episodes of venous thromboembolism (one per 1627 births). There were 127 cases of deep venous thrombosis and 38 cases of pulmonary embolism. Only 14% (23 of 165 patients) had a history of venous thromboembolism. Most cases of deep venous thrombosis were in the left leg (104 of 127, 81.9%), with nearly three quarters of them (94 of 127, 74.8%) occurring during the antepartum period. Among cases of antepartum deep venous thrombosis, half were detected before 15 weeks' gestation (47 of 95, 49.5%), and only 28 cases occurred after 20 weeks (P < .001). Most of the pulmonary embolisms occurred in the postpartum period (23 of 38, 60.5%) and were strongly associated with cesarean delivery (19 of 36,470 compared with four of 232,032, P < .001).

CONCLUSION

The incidence of venous thromboembolism during pregnancy is lower than has been previously described. Most cases occurred in the antepartum period, with the risk of deep venous thrombosis appearing to begin even before the second trimester.

Intravenous drug abuse is an indication for antepartum screening for RH alloimmunization. A case report and review of literature

Intravenous drug abuse is a risk for alloimmunization in pregnancy. One case is presented of a nulliparous Rhesus-negative parturient who shared her Rhesus-positive partner's needles for the injection of heroin; she subsequently developed elevated antepartum anti-D titers despite routine anti-D prophylaxis.

[Severe autoimmune thrombocytopenia in pregnancy]

Maternal thrombocytopenia is a frequent finding in pregnancy. The clinically important causes of maternal thrombocytopenia in pregnancy are gestational thrombocytopenia and autoimmune thrombocytopenia. We report a case of refractory idiopathic thrombocytopenic purpura by a 30-year-old pregnant woman, gravida 3, para 2, successfully treated with high dose corticosteroids and immune globulins.

Factor VII deficiency detected in pregnancy: a case report

Factor VII deficiency is a rare hereditary coagulation disorder with an incidence estimated at 1 in 500,000 individuals. In this report, we describe the 13th case in pregnancy. The diagnosis of severe factor VII deficiency (factor VII level <5%) was established at 10 weeks' gestation after initial laboratory testing showed a markedly prolonged prothrombin time and a normal activated partial thromboplastin time. There was a history of two preterm deliveries, but there was no evidence of previous bleeding manifestations. Antenatal progress of the index pregnancy was unremarkable. Prophylactic treatment with fresh frozen plasma was started at the onset of labor and the patient had a vaginal delivery of a live girl at 36 weeks' gestation. There was no postpartum hemorrhage and mother and newborn were discharged in good condition. The patient's postpartum level of factor VII remained undetectable. Two aspects are outlined: the absence of any significant increase in factor VII clotting activity during this pregnancy and the need to give replacement therapy at labor in patients with severe factor VII deficiency to decrease the risk of postpartum hemorrhage.

A laboratory method for determination of overall haemostatic potential in plasma. I. Method design and preliminary results

The aim of this study was to design a simple laboratory method that can screen the overall haemostatic potential in plasma (OHPP) when a hyper- or hypocoagulable state is present. A fibrin time curve was made via spectrophotometric registration of fibrin generation and lysis in plasma, to which exogenous thrombin and tissue type plasminogen activator was added. The area under the curve, calculated by the sum of absorbance (ABS-sum), varied in correlation to the concentrations of platelets or purified pro-/anticoagulants: tissue factor, von Willebrand factor, fibrinogen, antithrombin, plasminogen, or plasminogen activator inhibitor type 1. The ABS-sums also changed in positive relation to the haemostatic function investigated in 16 menopausal women and 14 young healthy nonpregnant women (controls). The findings imply that the ABS-sums not only offer a general information about fibrin generation and lysis in vitro, but also reflect the OHPP (i.e., final combined effects of platelet activity, coagulation, and fibrinolysis in vivo). Preliminary results were satisfactory; the levels of OHPP, expressed as the ABS-sums, were higher in normal pregnant women than in the controls, and even higher in preeclamptic patients than in pregnant women with no complications, which corresponds to the different grades of hypercoagulability in the three groups. Moreover, the level of OHPP was considerably lower in an untreated infant with von Willebrand's disease type 3 and in factor VIII- or factor IX-deficient plasma samples.

[Nursing care to pregnant women with iron deficiency anemia]

This study was carried out with the following objectives: to set up a protocol of data survey and nursing diagnosis, and to detect the most frequent nursing diagnosis among pregnant women with iron deficiency anemia. The protocol was applied in 52 nursing visits to pregnant women who presented hemoglobin values lower than 11.0 g/dl. The most frequent nursing diagnosis were: altered nutrition, risk to infection, impaired maintenance of the home; knowledge deficit on adequate feeding; risk to fetal injury regarding decrease in uteroplacental perfucion; non-compliance risk. Based on nursing diagnoses, interventions and nursing expected results with its application were planned.

[Congenital factor XIII deficiency in pregnancy. A case report]

Congenital factor XIII deficiency is a rare hemorrhagic syndrome with an altered fibrin stability, hemorrhagic diathesis and habitual abortions. After a short introduction, a case report is described and the clinical differences between plasmatic and platelet deficiency pointed out.

[Hemorrhagic disorders in pregnancy]

When bleeding disorders coincide with pregnancy, they might be congenital or acquired diseases, if not arising as a more acute complication of the pregnancy itself. The paper gives a review of the most common bleeding disorders out of internal medical constellations. History taking is the most effective way to open the diagnostic approach. If childbearing is desired the couple in question should be counselled accordingly in collaboration with a hematologist. Some conditions might be unfavourable, e.g. hemophila in male offspring, others might be serious but manageable, as in v. Willebrand-Disease or autoimmunologic thrombocytopenic purpura. Prenatal invasive diagnostics with fetal blood sampling at an early stage of pregnancy may reduce the hazards for the baby insofar, as it allows the more precise estimation of fetal risks at birth. Cesarean section will not in all cases be the way of choice (e.g. in v. Willebrand-Disease), in others it might be the better way to deliver a fetus at risk in order to avoid intracranial hemorrhage (in severe cases of ITP). Always both, mother and fetus, are at risk, but almost in any cases in different shades and grades of severeness. There is rarely a firm correlation of the maternal and the fetal hemostatic parameters in cases of connatal or acquired hemorrhagic disorders. Pregnancy itself leads to a certain compensation of defects in clotting factors, since the synthesis of factors increase or they are circulating more in activated form. Pregnancy is a state of a silently ongoing intravascular coagulation at least in the uteroplacental circulation. From there it is linked with the general circulation of the maternal organism. When immunologic etiologies in thrombocytopenias play a role, there will always be the incalculable rate of placental transfer of antiplatelet-antibodies to the fetus. The entire field requires knowledge, counseling, collaboration and foresight.

[A management program for primary thrombocytopenia]

Essential thrombocythemia is a chronic myeloproliferative disease characterized by persistent thrombocytosis and an increased risk of thromboembolic complications. Most patients are asymptomatic at the time of diagnosis. In this article guidelines for diagnosis and treatment of this disorder are presented on behalf of the Norwegian Society of Hematology. On the basis of a literature search in international databases (Medline) and international medical journals, articles have been selected according to their clinical relevance. The risk of major thrombosis is higher in patients older than 60 years and highest among those with a previous occlusive event. In individual patients there is no clear relationship between platelet count and risk of thrombosis. Low-dose aspirin (75-100 mg/day) is recommended to all patients with platelet count < 1,000 x 10(9)/l and in the absence of previous bleeding episodes. All patients with disease-related complications and asymptomatic patients with platelet count above 1,000-1,500 x 10(9)/l should receive cytoreductive treatment. Hydroxyurea is recommended for patients over 60 years of age. In younger patients, potential leukemogens should be avoided, and anagrelide or interferon-alpha is recommended.

[Prenatal typing of Rh- and Kell- blood group system antigens]

Rhesus (Rh) and Kell blood group immunisations are the most frequent causes of haemolytic disease of the newborn. Recently, the molecular bases of the Rh and Kell antigens have been elucidated. Subsequently, specific polymerase chain reactions (PCRs) could be developed to determine the RhD, RhC/Rhc and RhE/Rhe genotypes as well as the KI genotype (from the Kell blood group) with genomic DNA. The tests were applied to genomically determine the foetal Rh and Kell blood groups with DNA obtained from amniotic fluid cells. The genotypes obtained were compared with the Rh phenotypes established by cord blood red cell serology. The PCRs to determine the RhD, Rhc, RhE and Rhe and KI genotypes were found to be reliable. The test for RhC however, resulted in false-positive C genotypes. Indeed, more than half of the subsequently tested C-negative Negroid donors were false-positive with the DNA test. Thus, except for RhC, it is possible to reliably determine the Rh and KI genotypes of a foetus with DNA isolated from amniotic fluid cells. Amniocentesis, however, carries a risk for the pregnancy and therefore the tests will only be justified in pregnant women in whom an antibody has been detected and the father of the foetus is heterozygous for the specific antigen. Recently foetal RhD genotypes were determined in foetal DNA circulating in the plasma of RhD-negative pregnant women. This could eventually lead to the introduction of assays with which the foetal blood group can be determined without any risk to the foetus.

Spontaneous resolution of disseminated intravascular coagulopathy in the second trimester

Disseminated intravascular coagulopathy is a serious complication of pregnancy. Therapy includes treating the underlying cause, maintenance of blood volume, replacement of depleted clotting factors, and often delivery of the fetus and placenta. We present a case of disseminated intravascular coagulopathy occurring at 19 weeks' gestation that resolved spontaneously with conservative management.

An analysis of relative costs and potential benefits of different policies for antenatal screening for beta thalassaemia trait and variant haemoglobins

AIMS

To investigate the costs and potential benefits of different policies for antenatal screening for haemoglobinopathies in two multiethnic London communities.

METHODS

1000 consecutive antenatal patient samples referred to each of two London teaching hospital laboratories for haemoglobinopathy testing were investigated using the standard procedures of the laboratory in question. When the standard procedures did not include high performance liquid chromatography (HPLC), this technique was added, in order to assess its diagnostic value and cost-effectiveness. A comparison was made between the costs and potential benefits of universal testing for variant haemoglobins and beta thalassaemia trait using HPLC and the costs and potential benefits of universal testing for variant haemoglobins and selective testing for beta thalassaemia trait using the mean cell haemoglobin (MCH) as a screening test and less automated techniques than HPLC for definitive diagnosis.

RESULTS

The costs of the two policies were found to be comparable, as the higher reagent/instrument costs of HPLC were offset by the lower labour costs. Universal testing of 2000 consecutive samples did not disclose any extra cases of beta thalassaemia trait which would not have been detected by universal screening and selective testing. However, six patients were found to have a haemoglobin A2 variant which can interfere with the diagnosis of beta thalassaemia trait.

CONCLUSIONS

The introduction of universal testing by HPLC into British laboratories could be cost neutral and has potential benefits. If a higher cost is accepted then the greater degree of automation could be used to release skilled staff for other tasks within the laboratory.

[Idiopathic thrombocytopenic purpura: diagnostic-therapeutic approach in adults, children and pregnant women]

Idiopathic thrombocytopenic purpura (ITP) is an acquired haematologic disorder, common among children and adults, with unknown etiology and autoimmune pathogenesis. Nowadays, appropriate diagnostic and treatment strategies are still uncertain; therefore, the attending physicians behaviour in front of thrombocytopenic patients remains heterogeneous. Through a Medline research, we selected eighteen scientific works with practical application. Some of these studies tried to settle the diagnostic-therapeutic approach to thrombocytopenic patient by adopting specific guidelines developed by skilled medical panels. In this review we describe the main features of ITP in adults, in children and pregnant women and we also synthetize the diagnostic-therapeutic behaviours for which there is a sufficient agreement in order to standardize ITP patients management reducing unsuitable diagnostic tests and therapies and the costs too.

Hemoglobinopathy screening in pregnancy: comparison of two protocols

This study was designed to determine the ability of a hemoglobinopathy screening protocol involving sickle solubility testing and red blood cell (RBC) indices to identify at-risk pregnancies. Retrospective chart review of all patients registering for prenatal care at the New York Hospital/Cornell Medical Center prenatal clinic in 1996 was the study design. All patients had RBC indices as well as hemoglobin electrophoresis. RBC indices of those with normal and abnormal electrophoreses were compared. Comparison of protocols involving universal hemoglobin electrophoresis and selective use of hemoglobin electrophoresis were compared. Student's t-test was used for statistical analysis. There were 36 carriers of hemoglobinopathy traits in 631 patients screened (5.7%). Four (three with hemoglobin C trait and one with hemoglobin D trait) had normal RBC indices and presumably would have had negative sickle solubility testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a protocol with selective use of hemoglobin electrophoresis would have been 88.9, 79.4, 20.8, and 99.2%, respectively. Cost analysis reveals a difference of $11,384 or $18/patient less in a protocol with selective use of hemoglobin electrophoresis. Although a protocol involving solubility testing with RBC indices will not identify every carrier of a hemoglobinopathy trait, it may be appropriate in some populations.

Essential thrombocythaemia

Essential thrombocythaemia (ET) is a clonal stem cell disorder that frequently presents as an incidental finding of elevated platelet counts. Diagnosis depends on exclusion of other myeloproliferative disorders and reactive thrombocytosis. Patients with platelet counts above 1000 x 10(9)/L should receive platelet-lowering therapy, even if asymptomatic. Definitive recommendations cannot yet be made for asymptomatic patients with lower platelet counts. ET can be treated with alkylating agents, radioactive phosphorus or hydroxyurea, but there is evidence that these agents increase transformation to acute leukaemia. Interferon alfa-2a and anagrelide are useful treatment agents, particularly in younger patients.