[Constitutional anomalies of hemostasis and management in surgical situation. Evaluation of 10 years' activity at the Hospital Centers of Aulnay-sous-Bois and Saint-Denis]

A ten-year retrospective study was conducted in 4 women in labor and 23 surgical patients with congenital clotting factor deficiency. Appropriate use of replacement therapy and good cooperation between biologists, anesthesiologists, and surgeons are essential to ensure a favorable outcome.

[Molecular biological approach for congenital abnormality of blood coagulation]

Proteins of blood coagulation are categorized into three major groups, coagulation proteins, regulatory proteins and fibrinolytic proteins, in terms of their physiologic functions. Congenital deficiencies or abnormalities of these proteins elicit bleeding or thrombotic disorders. In general, defects of coagulation proteins are associated with a predisposition to bleeding disorders. By contrast, both defects of regulatory and fibrinolytic proteins are associated with a predisposition to thrombosis. The marked advances in molecular biology in the 1980s has allowed us to detect gene defects in most patients with congenital bleeding or thrombotic disorders. The information has contributed to our understanding of the structure and function relationship of the blood coagulation proteins. We have reported patients with congenital deficiencies or abnormalities of blood coagulation proteins. Herein, we describe the general approach for elucidating gene defects in patients with congenital bleeding or thrombotic disorders and provide a case of a Japanese family with congenital plasminogen deficiency in whom the genetic abnormality was identified.

[Cesarean section in a patient with a congenital deficit of antithrombin III: apropos of a case]

Antithrombin III (AT III) is a physiological inhibitor of coagulation. AT III deficit, whether congenital or acquired, results in a state of hypercoagulability characterized by recurring instances of venous thrombosis in young people. Although AT III levels normally change little during pregnancy, a deficit can be associated to the appearance of recurring thromboembolism and the need to perform cesarean section increases the risk. We report a cesarean section under general anesthesia in a patient with congenital AT III, reviewing the etiology and pathophysiology of this entity as well as its treatment.

Fibrinogen Lincoln: a new truncated alpha chain variant with delayed clotting

A patient referred for preoperative investigation of prolonged bleeding and easy bruising was found to have increased thrombin and reptilase times; however, the thrombin catalysed release of fibrinopeptides A and B was normal. Analysis of five other family members, spanning three generations, indicated that three had a similar defect and suggested autosomal dominant inheritance. Non-reducing SDS-PAGE of purified fibrinogen from affected individuals showed that the 340 kD form of their fibrinogen ran as a doublet. SSCP (single-stranded conformational polymorphism) analysis of exon 5 of the A alpha gene, which encodes the C-terminal half of the chain, confirmed the presence of a mutation. Cycle sequencing of PCR amplified DNA revealed a 13 base pair deletion (nt 4758-4770), resulting in a frame-shift at Ala 475, which translates as four new amino acids before terminating at a new stop codon (-476His-Cys-Leu-Ala-Stop). The presence of a circulating truncated A alpha chain was confirmed when SDS-PAGE gels were probed with an alpha chain specific antisera; which showed that the variant A alpha chain comigrated with gamma chains. The truncation results in a variant A alpha chain with a deletion of 131 amino acids (480-610), and four new amino acids at the C-terminal.

[Extracorporeal lithotripsy in patients with acquired or congenital coagulopathies]

Post ESWL haemorragic complications are frequent and most patients experience temporary haematuria and focal intrarenal bleeding or perirenal haematoma are detected by NMR or US imaging. By tradition coagulation troubles have been a contraindication for ESWL but literature describes cases of coagulopathic patients treated with ESWL. From January 1992 to July 1993, 4 of our patients with severe haemostatis troubles (severe haemophilia A in two cases, acquired deficit of coagulation factors and mild thrombocytopenia secondary to post-necrotic hepatitis in 1 case and Glanzmann's thrombasthenia in 1 case) underwent ESWL using Dornier HM3 mod. or MPL 9000. An extensive haematological and clinical evaluation pre and post-ESWL with an adequate haematological prophylaxis (transfusion of blood derivatives) has been performed depending on the coagulation disorder. In our patients we did not observe any haemorragic complication and we propose a reappraisal of the contraindications of ESWL in subjects with coagulation disorders: careful evaluation of haemorragic risk factors, by suitable correction measures and close clinical and instrumental monitoring, allows a reduction of the risk of haemorragic complications in coagulopathic patients who undergo ESWL treatment.

Mechanisms of platelet dysfunction and response to DDAVP in patients with congenital platelet function defects. A double-blind placebo-controlled trial

To examine the impact of the underlying defective platelet mechanism on the response to 1-desamino-8-D-arginine vasopressin (DDAVP, Desmopressin), we studied the effect of intravenous infusion of 0.3 microgram/kg of DDAVP in a randomized double blind placebo-controlled trial with cross-over in 18 carefully characterized patients with congenital platelet defects (CPD) and BT > or = 9 min. Eleven patients had normal dense granule stores and normal thromboxane A2 (TxA2) production (Group I), 3 patients had normal granule stores but impaired TxA2 production (Group II), and 4 had delta-storage pool deficiency (Group III). DDAVP shortened BT at 50 min (DDAVP 14.6 +/- 2.2 vs placebo 19.6 +/- 2.3 min; n = 18; mean +/- SE; p = 0.003) and 4 h (17.0 +/- 2.2 vs 19.6 +/- 2.1 min, p = 0.055), and raised plasma FVIIIC and von Willebrand factor (vWF). At 50 min DDAVP shortened BT by > or = 5 min in 8 of 11 Group I patients (mean 9.7 +/- 1.3 vs 16.3 +/- 2.8 min; p < 0.008), 1 of 3 Group II patients (11.9 +/- 3.9 vs 17.7 +/- 6.6; p = NS) and none of Group III patients (mean 30 min both arms). Ten patients (Group I or II) were managed successfully during surgical procedures with DDAVP alone. We conclude that DDAVP shortens BT in majority of CPD patients with normal dense granule stores and suggest that BT response may be dependent on the underlying platelet defect. DDAVP is a useful modality in management of selected patients, particularly those with normal dense granule stores.

Inherited disorders of coagulation in pregnancy

Normal physiology has been reviewed to serve as a basis for understanding the abnormalities leading to the inherited coagulation disorders. These abnormalities involve each of the three arms of the coagulation process: platelets, the coagulation cascade, and the clot prevention/lysis pathways. Pregnancy presents a unique challenge to women with these disorders. However, with close attention to the natural course of the disorder and appropriate therapy instituted in a timely fashion, many of these women can achieve successful pregnancies.

Pregnancy induced hypertension: changes in coagulation profile of newborns

Coagulation parameters and platelet count were studied in 30 neonates of mothers with pregnancy induced hypertension (PIH). 30 neonates born to normotensive mothers were taken as controls. The test group was further subdivided as neonates born to mothers with gestational hypertension, pre-eclamptic toxemia and eclampsia. The values of Prothrombin Time, Partial Thromboplastin Time with Kaolin, Thrombin Time, Fibrinogen Degradation Products were significantly raised and Fibrinogen and Platelet count were reduced significantly in both term and preterm test groups as compared to controls. The derangement in coagulation parameters was more marked with increasing severity of PIH.

Transfusion therapy in congenital coagulopathies

Transfusion therapy for the congenital coagulopathies has changed considerably in recent years. Improved donor screening, purification, and virucidal methodologies have resulted in much safer plasma-derived clotting factor concentrates. Additionally, synthetic products such as rF VIII and DDAVP are licensed and available. For persons with hemophilia B, nonthrombogenic coagulation F IX concentrates are available. Treatment recommendations for each of the congenital coagulopathies are discussed.

Anti-hepatitis C virus serology in patients affected with congenital coagulation defects: a comparative study using three second generation ELISA tests

We determined the prevalence of anti-hepatitis C virus (HCV) antibodies in 34 patients affected with congenital coagulation disorders attending the Haemophilia Centre of Padua, Italy. Serological tests were carried out by three second generation enzyme linked immunosorbent assays (ELISA), two based on recombinant proteins (Ortho and Abbott) and one based on synthetic peptides (Behring) as antigenic substrate. The repeatedly reactive specimens were further assayed by the supplemental 4-antigen recombinant immunoblot assay (RIBA) (Chiron and Ortho). Moreover, we performed the dot-blot Matrix test (Abbott) on the samples showing discrepant results by the three ELISA tests. Twenty-six patients (76.5%) were anti-HCV positive using all three ELISA tests; 25 were confirmed by the supplemental RIBA test, the other one was indeterminate. Two samples were in a gray-zone only using the anti-HCV ELISA Abbott. These were positive by the RIBA; in contrast, such samples showed no reactivity with the Matrix test. In accordance with the current literature, these data show an equivalence between the 2nd generation screening tests (ELISA), at least when applied to a high risk population as in the present study. Further, these screening tests demonstrated a reliable specificity, since most of the ELISA-reactive specimens were confirmed by the supplemental RIBA test. In contrast, combined use of the anti-HCV tests could be useful when high sensitivity is requested, as in the case of blood donor pretransfusion screening.

A long-term follow-up of hepatitis B vaccination in patients with congenital clotting disorders

All patients with congenital clotting disorders attending our centre routinely receive hepatitis B vaccination. We have assessed retrospectively the vaccine responses in 167 such individuals, with a follow-up period of up to 7.5 years. The initial postvaccine anti-HBs response was lower in older patients (p = 0.001), those infected with human immunodeficiency virus (HIV) (p = 0.05), and those who received intradermal rather than subcutaneous administration of vaccine (p = 0.08). It was estimated that the median time for anti-HBs levels to fall to 100 IU l-1 was between 36 and 42 months, with a shorter period for older or HIV-infected patients. Although the persistence of protective antibody levels can be predicted to some extent from the absolute levels of initial postvaccine anti-HBs, the wide variation in antibody decline between individuals precludes recommendation of the timing of vaccine booster doses solely based on this value.

[Hepatitis B and C virus infections in children with congenital coagulation disorders]

The prevalence of hepatitis B and C virus infections, transmitted by blood transfusions, was studied in 79 children with congenital coagulation disorders. Twenty nine percent had evidences of hepatitis B virus infection and 52% evidences of hepatitis C virus infection. Older children and those with the higher number of transfusions had the highest rates of infections. It is concluded that children with congenital coagulation disorders constitute a high risk group for hepatitis B and C virus infections.

Prevalence of antithrombin deficiency in the healthy population

In a cohort of 9669 blood donors we have identified 16 cases of congenital AT deficiency (1 in 600) by way of family studies and AT gene analysis. Two donors had type I AT deficiency (prevalence 0.21 per 1000; 95% CI = 0.03/1000 to 0.75/1000), their families displaying a symptomatic phenotype. 14 donors had a type II deficiency (prevalence 1.45 per 1000; 95% CI = 0.79/1000 to 2.43/1000): one recurring and three unique mutations. None of these type II deficiencies appeared to confer a high thrombotic risk despite many of the affected individuals having experienced potentially prothrombotic challenges. The high frequency of these relatively asymptomatic variants may reflect a selection bias in the study population. However, their existence should not only add to our understanding of structure-function relationships of AT but may also influence our management of asymptomatic deficient individuals identified in epidemiological or presurgical screening programmes.

Surgery in patients with congenital coagulation disorders

BACKGROUND

Surgery is occasionally necessary in patients with congenital coagulation disorders. Major surgery for patients with haemophilia was not being done in India until recently. This paper reports the experience of a single referral centre.

METHODS

The data of 52 patients who were operated upon were collected from the hospital records retrospectively between 1984 and 1986 and prospectively thereafter. They included the surgical procedure performed, replacement therapy used and complications encountered.

RESULTS

Fifty-nine procedures were performed of which 26 were major, 30 minor and 3 were diagnostic angiograms. Blood components produced in the hospital blood bank were commonly used for replacement and primary haemostasis was achieved in all patients. Delayed bleeding due to inadequate factor levels occurred in 12 procedures and was controlled by increasing the factor replacement. One patient died of suspected acute myocardial ischaemia.

CONCLUSION

In India surgical procedures can be safely performed in patients with congenital coagulation disorders.

Head trauma in children with congenital coagulation disorders

Bleeding is the most frequent cause of death in children with congenital coagulation disorders, and intracranial (IC) hemorrhage accounts for the majority of mortality in all age groups. Even minor head trauma may produce significant IC pathology. Immediate diagnosis and rapid medical management are mandatory if morbidity and mortality are to be minimized. Although computed tomographic (CT) scans provide accurate diagnostic information, reliable criteria for the use of this expensive technology in children with hemophilia and von Willebrand's disease have not been defined. In this study the clinical symptoms and the time of initial assessment and therapy of head-injured children with congenital coagulopathies were evaluated and correlated with CT findings. Between 1985 and 1992, 123 patients with hemophilia A, hemophilia B, or von Willebrand's's disease received follow-up at this institution. One hundred nine episodes of head injury were recorded in 43 patients, and 66 CT scans were obtained. The most frequent mechanism of injury was a simple fall at play (62%). Only 5 patients had an IC injury demonstrable with CT (4.5% of 110 episodes). Vomiting was reported in 4 of 5 patients with IC hemorrhage (ICH), and all 5 presented with an altered mental status (Glasgow coma scale [GCS] (mean) = 10) and focal neurological deficit. These findings were infrequently observed (vomiting, 5 of 105; GCS (mean) = 15; neurological deficits 0 of 105) in children who either did not undergo CT or whose CT scan results were normal.(ABSTRACT TRUNCATED AT 250 WORDS)

The pathologist as a clinical consultant for hemostasis in the community hospital

Most of the clinically recognized disorders of hemostasis were described before the availability of today's sensitive and specific molecular assays. Even though many of these newer assays are not yet technically practical for the average community hospital, in certain situations they are indispensable to accurate diagnosis and treatment. The most significant advances, however, have come not from the tests themselves but from the new insights they have provided into the basic mechanisms of hemostasis, thereby extending the usefulness of the widely available older global clotting assays. Pathologists who are able to integrate this increased understanding of the pathophysiology of various disorders with the history and physical findings will be better able to assist their clinical counterparts in the most cost-effective approach to the care of their patients.

[Neonatal testicular ischemic necrosis without torsion, associated with antithrombin III deficit]

There have been few reports of neonatal ischemic necrosis of the testis without torsion of the spermatic cord, which may be caused either by compression in utero or by transient torsion of the spermatic cord resolving spontaneously before surgery. The patient reported herein developed an inflammatory swelling of the right scrotum and an ecchymotic plaque over the left thigh at four days of age. Ischemic necrosis of the right testis without torsion was found upon surgery. When the patient was ten days of age, he developed an inflammatory swelling in the left scrotum; ischemic necrosis of the left testis without torsion was again found upon surgery. Thrombosis of the spermatic vessels was suspected. Postoperatively, ecchymotic and necrotic skin lesions developed, followed by pulmonary embolism and cerebral thrombosis. Outcome was fatal. Hematologic tests in the neonate and his parents established the diagnosis of inherited antithrombin III deficiency. Ischemic necrosis of the testes was thus probably due to hypercoagulability. No similar cases have been reported to date.

Congenital coagulopathies in the pediatric population

Congenital coagulopathies in the pediatric population continue to be a serious cause of morbidity and mortality. Familiarity with such disorders is essential for individuals responsible for the care of children. This article discusses a variety of congenital and inherited coagulation disorders, classifying them in either the vascular, platelet, or plasma phase.

Effect on lymphocyte subsets of clotting factor therapy in human immunodeficiency virus-1-negative congenital clotting disorders. The Transfusion Safety Study Group

Patients with hemophilia A without human immunodeficiency virus type 1 (HIV-1) infection have lower CD4+ counts and CD4+/CD8+ ratios than controls. This is usually interpreted as a therapy-induced immunodeficiency. Our data re-examine the effect of therapy on peripheral blood mononuclear cell immunophenotypic subpopulations in all congenital clotting disorders. Since late 1985 we have prospectively observed HIV-1 uninfected persons with all types and severity of disorder. Controls were household members without clotting disorders or HIV-1 infection. Analyses of immunophenotype and treatment included a longitudinal random effects model. Compared with controls, age-adjusted CD4+ counts were significantly lower in treated patients (P < .0001) and in patients with all types of clotting disorders who were seldom or never treated (P = .0005). Significantly lower values among both treated and untreated clotting disorder subjects (P < .05) were likewise found for total lymphocytes, several other T-cell subsets, and the CD4+/CD8+ ratio. For most indexes, including the CD4+ count and CD4+/CD8+ ratio, the type of clotting deficiency was not a significant variable. Comparing persons who had no or minimal therapy with those having the most showed increases in CD8+ (P = .0017) and CD20+ CD21- counts (P = .0255), and a lower CD20+ CD21+/CD20+ ratio (P = .0106) in the latter. Controls and persons with clotting disorders differ in CD4+ count. Among those with clotting factor disorders, there is no difference attributable to type of clotting disorder or factor therapy. Large amounts of treatment increased CD8+ and CD20+ CD21- counts, but were not associated with a change in CD4+ count.

[Regional anesthesia techniques and hemostasis disorders]

Hereditary or acquired disorders of coagulation often lead to the question of whether it is permissible to perform regional anaesthetic techniques. Disorders of coagulation that cannot be treated are generally contraindications to regional anaesthesia. The history and clinical findings represent the most important measures before employing a regional anaesthetic technique. The use of anticoagulant agents as well as non-steroidal antirheumatics and acetylsalicylic acid should be determined. In addition to coagulation studies, the use of regional anaesthetic techniques during simultaneous anticoagulant treatment requires a clear arrangement with the operative department in question. In most instances there will be a tendency to perform general anaesthesia, however, considering the fact that general anaesthesia is also associated with complications (intratracheal bleeding), regional anaesthesia represents an alternative method, especially in patients with significant concomitant disorders. In this situation the possibility of peripheral nerve blockade should be taken into consideration.

Congenital bleeding disorders. Rational treatment options

There are rational, effective choices available for the treatment of common inherited bleeding disorders, according to assessment of safety, efficacy and cost. All currently available products for patients with haemophilia A (factor VIII deficiency) are comparable in terms of efficacy and viral safety. However, high purity products are recommended for those with coexisting human immunodeficiency virus (HIV) infection. Many patients with mild haemophilia A and most with von Willebrand's disease can be treated with desmopressin, which can be given as an intranasal spray in some countries. For the treatment of patients with factor XI deficiency, fresh frozen plasma remains the standard care, although solvent-detergent-treated fresh frozen plasma and factor XI concentrate are currently being investigated as alternatives. In the treatment of haemophilia B (factor IX deficiency), purified factor IX concentrates are particularly useful in clinical settings where large amounts of concentrate are to be used (e.g. surgical prophylaxis). Their usefulness in other contexts needs clarification. Treatment of inhibitors that may develop in response to administered coagulation factors is still limited to the use of prothrombin complex concentrates and porcine factor VIII. Active clinical trials are currently assessing the efficacy and safety of recombinant factor VIIa, Xa and tissue factor in this indication.

[Topical treatment of oral bleeding in children with clotting disturbances]

Owing to substitutive therapy an inhibition is possible of bleeding from oral mucosa as well as stomatological procedures in children with haemorrhagic diathesis. For elimination or limiting of substitutive therapy in 29 children with congenital haemorrhagic diathesis caused by plasma or platelet disorders, tissue glue was used. The preparation Tissucol, IMMUNO, was given during 37 stomatological procedures in which 44 tooth were extracted, and for post-traumatic bleeding from oral mucosa. Very good and good results were obtained in 95% of the performed stomatological procedures. That makes possible a statement that Tissucol is effective in maintaining of local haemostasis in children with haemorrhagic diathesis. This method is safer and less expensive than blood-derived preparations used for substitutive therapy, and is especially valuable in the treatment of children with haemophilia type A with antibodies against factor VIII.

[Polymorphism MI detected through the enzyme MspI in the study of congenital protein C deficiency]

BACKGROUND

In order to find alternatives for the diagnosis of hereditary protein C (PC) deficiency, we have studied the diagnostic informativity of the restriction fragment length polymorphism (RFLP) MI, located 7 kb upstream of the PC gene and detected with the restriction enzyme MspI.

METHODS

The RFLP MI has been analysed in 77 individuals belonging to 27 families with congenital PC deficiency, as well as in a control group of 46 healthy donors. The analysis has been performed by PCR amplification and MspI digestion of the polymorphic DNA fragment.

RESULTS

The allelic frequencies of the RFLP MI in the population studied are 0.69 for the allele A1, without the MspI restriction site, and 0.31 for the allele A2, with the MspI site. No differences have been found between the control and the PC deficient groups. The informativity of the polymorphism has been calculated to be 33.8%. Consegregation studies between this RFLP and PC deficiency have allowed the determination of the allele associated to the polymorphism in 21 out of the 27 studied families. Furthermore, an asymptomatic PC deficient carrier, with normal PC levels, has been identified.

CONCLUSIONS

The study of this RFLP in families with hereditary PC deficiency may be useful for the identification of PC deficient carriers as well as for the prenatal diagnosis of the deficiency.