Normal pregnancy in a patient with a postpartum factor VIII inhibitor

Acquired haemophilia A diagnosed during pregnancy

Pregnancy-associated haemophilia A is an uncommon, acquired bleeding disorder which usually presents post-partum; very rarely it may present during pregnancy. No consensus guidelines exist on the management of this condition in pregnancy and very few cases have been reported in the literature. Here we describe the case of a woman presenting with acquired haemophilia A during pregnancy and outline the management of her bleeding disorder. We contrast her case with that of two other women, presenting to the same tertiary referral centre, with acquired haemophilia A presenting post-partum. These cases highlight the heterogeneous management of this condition and how it may be successfully managed in pregnancy.

Acquired Haemophilia A: A Review of What We Know

Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.

Successful management of acquired hemophilia A onset during pregnancy: A case report

Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies that inhibit coagulation factor VIII. Pregnancy could be associated with AHA in younger women. Because of its rarity, the optimal management for pregnancy-related AHA has not yet been established. Herein, we present the case of a 32-year-old woman with AHA diagnosed during pregnancy because of elevated activated partial prothrombin time, decreased factor VIII activity, and the presence of a factor VIII inhibitor. She was treated with immunosuppressive therapy consisting of corticosteroid and cyclosporine administration. Although complete remission could not be induced in the peripartum period, she gave birth safely by cesarean delivery in combination with prophylactic bypass hemostatic therapy. This work would provide helpful information to guide better recognition and treatment of pregnancy-related AHA cases.

Transplacental hemophilia A and prophylactic treatment with intravenous immunoglobulin and recombinant factor VIIa in the newborn period: a case report

Acquired hemophilia due to inhibitor antibodies to factor VIII (FVIII) is a very rare entity in neonatal period. Maternal IgG antibodies may cross the placenta and can cause life-threatening hemorrhages in newborns. Here, we represent a newborn who diagnosed as a transplacental acquired hemophilia A. A very high titer of inhibitor level (320 Nijmegen-Bethesda unit) was detected in plasma due to transplasental transfer in this case. According to the best of our knowledge the baby had the highest inhibitor level in neonatal period in the literature. Bleeding complications including intracranial hemorrhage secondary to this condition were reported before. Therefore, to prevent possible life complications, prophylactic recombinant FVIIa was administered in the presenting case and any bleeding event was not observed during follow-up. In conclusion, using prophylactic recombinant FVIIa in newborns is a safe choice for transplacental acquired hemophilia A.

Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review

BACKGROUND

About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting.

AIMS

This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies.

METHODS

Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases).

RESULTS

Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy.

CONCLUSION

This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.

Acquired hemophilia in pediatrics: a systematic review

Acquired hemophilia A is a rare but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies directed mostly against coagulation factor VIII. Acquired hemophilia is frequently associated with several underlying conditions such as malignancy, autoimmune disorders, drug reactions, and pregnancy, although the pathogenesis remains undetermined (idiopathic) in up to 50% of reported cases. The disorder occurs most commonly in the elderly and only rarely affects pediatric patients, who might however experience severe, and sometimes life-threatening, hemorrhage. The maternal transplacental transfer of the autoantibody to the neonate occurs very rarely and also in this circumstance it may be associated with clinically significant bleeding. The management of acute bleeding and the inhibitor eradication are the mainstay of the treatment. The outcome in pediatric patients seems more favorable than in adults because the inhibitors usually resolve more quickly and in a higher rate of patients. The epidemiology, diagnosis, clinical course, and management of this hemorrhagic disorder in children will be addressed in this systematic review.

Transplacental transfer of postpartum inhibitors to factor VIII

Acquired haemophilia due to antibodies directed against coagulation factor VIII is a well-recognized cause of severe haemorrhage in adults but an uncommon cause of bleeding in children. We present the cases of a mother with a life-threatening postpartum haemorrhage due to an autoantibody to factor VIII and her newborn who developed symptomatic bleeding after a minor surgical intervention as a result of transplacental transfer of the autoantibody. Both patients were treated with infusions of recombinant factor VIIa to control bleeding. The mother required immunosuppressive therapy to decrease inhibitor levels and the infant's levels decreased over time without specific treatment. We also provide a concise review of postpartum haemophilia and transplacental transmission of factor VIII autoantibodies to the neonate--a rare but potentially life-threatening complication of acquired haemophilia in women of childbearing age.

Postpartum acquired factor VIII inhibitors

The development of factor VIII autoantibodies is a rare but severe complication of pregnancy. Although the natural history of postpartum acquired hemophilia A is usually benign, with a high percentage of spontaneous remissions and a low mortality, its quick recognition is important to control bleeding episodes. Based on an analysis of the literature, this review presents the current knowledge on the pathogenesis, diagnosis, epidemiology, natural history, clinical manifestations, and therapeutic management of postpartum acquired hemophilia A.

Postpartum acquired haemophilia: clinical recognition and management

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32-year-old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laparotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA(R) therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Postpartum acquired hemophilia (factor VIII inhibitors): a case report and review of the literature

Pathologic inhibitors of blood coagulation as a cause of postpartum acquired hemostatic failure are rare. Since 1937, 96 cases of postpartum factor VIII (FVIII) inhibitors, including the current case, have been reported. Suspicion for the diagnosis of this condition is often low. We report a case of postpartum FVIII inhibitor formation in a 24-year-old woman who developed intermittent postpartum bleeding that resulted from the inhibitors she formed to FVIII. A unique form of therapy was used in treatment of her disorder. She did not respond to conventional surgical or medical management of her bleeding until Autoplex T (Baxter Healthcare, Glendale, CA), an activated prothrombin complex concentrate (aPCC) was used. The literature concerning acquired hemophilia is reviewed, and new therapeutic medical advances are emphasized.

Hemorrhagic problems in obstetrics, exclusive of disseminated intravascular coagulation

During pregnancy many physiologic changes occur that result in an increase in coagulation factors and a decrease in fibrinolytic activity. Because hemorrhage during pregnancy is a major cause of maternal morbidity, it is important to recognize and understand the pathophysiology of hereditary and acquired bleeding disorders. This article reviews von Willebrand's disease types 1, 2, and 3 and acquired hemophilia.

Acquired hemophilia A in women postpartum: clinical manifestations, diagnosis, and treatment

Acquired hemophilia A in women postpartum is diagnosed by a prolonged activated partial thromboplastin time (APTT), low plasma levels of coagulant factor VIII, and the detection of an inhibitor against factor VIII in the Bethesda assay. Effective treatment of bleeding symptoms should be based upon the clinical situation and depends on the inhibitor characteristics against human and porcine factor VIII. Immunosuppression usually does not significantly affect the disappearance of the factor VIII inhibitor antibody. The natural history of acquired hemophilia postpartum is independent of immunosuppressive treatment and featured by spontaneous disappearance of the inhibitor against factor VIII in the majority of cases.

Severe intracranial hemorrhage in a newborn infant with transplacental transfer of an acquired factor VII:C inhibitor

We describe a woman in whom inhibitors to factor VIII:C developed in her first pregnancy. The neonate had a factor VIII:C level of 1% and an inhibitor titer of 5.2 Bethesda units. After an uneventful vaginal delivery, the boy had an intracranial hemorrhage at 5 days of age. To our knowledge, this is the first report of a bleeding complication in a newborn infant with transplacental transfer of an acquired factor VIII:C inhibitor.

Successful treatment of a patient with postpartum factor VIII inhibitor with recombinant human interferon alpha 2a

A patient who had developed a postpartum inhibitor to factor VIII and who did not respond to repeated therapy with steroid and high-dose intravenous gammaglobulin G was treated with one short course of low-dose recombinant interferon alpha 2a (rhIFN) s.c. Within 7 weeks from the start of rhIFN treatment, the inhibitor disappeared. It remains undetectable 8 months after therapy.

Simultaneous occurrence of factor VIIIC inhibitor and antinuclear antibody in postpartum period

We are describing a rare case of acquired factor VIIIC inhibitor in postpartum period who also had strongly positive antinuclear antibody. On immunosuppression with prednisolone and azathioprine, both antibodies disappeared after 4 months of therapy.

Antiphospholipid antibodies and recurrent pregnancy loss

Antiphospholipid antibodies (APA) have recently been linked to a variety of clinical findings including arterial and venous thrombosis, recurrent spontaneous abortions and fetal loss, as well as thrombocytopenia. These observations have stimulated multidisciplinary interest in the laboratory identification of APA and the clinical management of patients with positive tests for APA.