Thrombotic thrombocytopenic purpura: report of fourteen cases--occurrence during pregnancy and response to plasma exchange

Plasma Therapies in Thrombotic Syndromes

Background

Plasma therapies are being applied to thombotic syndromes, but there are limited controlled studies.

Objective

To review the evidence and the current practices for plasma therapies in thrombotic syndromes.

Methods

Expert-enhanced evidence-based analysis. Evidence obtained as of Dec 31, 2002 using Pub Med electronic reference library and expert-obtained library for a total of > 3,000 references obtained using the terms plasma therapy or plasma exchange or plasmapheresis or plasmafiltration or sorbents each combined with the words thrombotic syndrome or sepsis or septic shock. The authors screened the abstracts, reviewed the agreed set of papers, and compiled the recommendations.

Results

Plasma therapies, which alter the plasma components in patients, have been applied in thrombotic syndromes worldwide. In these patients, there is a biologic plausibility for plasma therapies since they have molecules that are prothrombotic and/or antifibrinolytic which would put them at risk for microvascular thrombosis and end-organ damage. There are respectively one randomized controlled trial (RCT) in primary thrombotic syndrome, and secondary thrombotic syndrome, which showed an improvement in mortality in applying plasma therapies (plasma exchange by centrifugation). However, there are numerous non-randomized and case series. Plasma exchange is accepted as the standard therapy for primary thrombotic syndrome as in thrombotic thrombocytopenic purpura (TTP). However, no consensus has been reached for plasma exchange in secondary thrombotic syndromes such as in sepsis, hemolytic uremic syndrome (HUS), thrombocytopenia associated multiple organ failure, TTP/HUS, s/p bone marrow or solid organ transplant, HELLP syndrome, immunologic disorders, drug exposure, or pancreatitis.

Conclusions

As we understand more about the pathophysiology of thrombotic syndromes, specific plasma therapies can be applied for the specific need of a particular patient population. There are sufficient preliminary data to recommend a definitive RCT to evaluate the efficacy of the different types of plasma therapies in secondary thrombotic syndromes.

Thrombotic thrombocytopenic purpura

A 34-year old primipara was admitted to hospital with dichorionic-diamniotic twins in 26+3 weeks of gestation. In suspicion of HELLP-syndrome, caesarean section was performed at 27+4 weeks of gestation, because of platelet count was reduced to 44000/µl. A re-laparotomy had to be performed because of intra-abdominal bleedings. The patient was given seven packed thrombocytes and five packed erythrocytes. The patient complained about blurred vision. The right corner of the mouth was slightly depressed in terms of a facial nerve paresis. Further platelet counts were about 50000/µl. Haemoglobin: 7.8 mg/l. D-Dimer: 1066 mg/l. LDH was elevated to 1610 U/l, reticulocytes were elevated to 13.19% and haptoglobin was reduced to <0.08 g/l. The Coombs' test was negative. The ADAMTS-13 test showed a reduced activity. Hereby, the diagnoses of thrombotic thrombocytopenic purpura was confirmed. Plasma exchange is the most effective option; application of platelet concentrate should be avoided, because of worsening microangiopathy and subsequent neurological situation. After the patient has received plasma exchange, platelet count normalized. An ophthalmic examination showed a dysfunction in choroid perfusion as a cause for the blurred vision. After discharge regular lab tests were planned, but no further treatment was necessary at that point of time. The premature twins survived after ventricular haemorrhage, severe sepsis, bronchopulmonary dysplasia and other complications of neonates.

Plasma exchange therapy for thrombotic microangiopathies

Thrombotic microangiopathies (TMAs) are syndromes associated with thrombocytopenia and multiple organ failure. Plasma exchange is a proven therapy for primary TMA such as thrombotic thrombocytopenic purpura (TTP). There is growing evidence that plasma exchange therapy might also facilitate resolution of organ dysfunction and improve outcomes for secondary TMAs such as disseminated intravascular coagulation (DIC) and systemic inflammation-induced TTP. In this review, we survey the current available evidence and practice of plasma exchange therapy for TMAs.

Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006

A review of pregnancy-associated thrombotic thrombocytopenic purpura (TTP) in 166 pregnancies was undertaken using 92 English-language publications from 1955 to 2006. Initial and recurrent TTP presents most often in the second trimester (55.5%) after 1-2 days of signs/symptoms; postpartum TTP usually occurs following term delivery. TTP with preeclampsia (n = 28) exhibits 2-4 times higher aspartate aminotransferase (AST) values and lower total lactate dehydrogenase (LDH) to AST ratios (LDH to AST ratio = 13:1), compared with TTP without preeclampsia (LDH to AST ratio = 29:1). Maternal mortality is higher with initial TTP (26% vs 10.7%), especially with concurrent preeclampsia (44.4% vs 21.8%, P < .02). Although maternal mortality with TTP has substantially declined when plasma therapy is utilized, delay of diagnosis and therapy for initial TTP confounded by preeclampsia/hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome remains a significant maternal-perinatal threat. Rapid and readily available laboratory testing to quickly diagnose TTP and HELLP syndrome/preeclampsia is desperately needed to improve care.

Pregnancy outcomes after recovery from thrombotic thrombocytopenic purpura-hemolytic uremic syndrome

BACKGROUND

Recurrent thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) during a subsequent pregnancy is an important concern because pregnancy may increase the risk for relapse.

STUDY DESIGN AND METHODS

Outcomes of all pregnancies after recovery from TTP-HUS in the Oklahoma TTP-HUS Registry, a cohort of 301 consecutive patients during the period of 1989 through 2003, were assessed and compared to the total published experience.

RESULTS

In the Oklahoma Registry, 3 of 7 (43%) women with idiopathic TTP-HUS, 2 of 11 (18%) women who were pregnant/postpartum, and 0 of 1 (0%) woman with a bloody diarrhea prodrome at their initial presentation were diagnosed with TTP-HUS during a subsequent pregnancy; all 5 women recovered. In published reports, 10 of 11 (91%) women with idiopathic TTP-HUS and 11 of 18 (61%) women who were pregnant/postpartum at their initial presentation, and all 11 (100%) women with congenital TTP-HUS were diagnosed with TTP-HUS during a subsequent pregnancy. Rates of recurrence in the Oklahoma Registry may be less because of case report bias for exceptional patients. Recurrent TTP-HUS was difficult to diagnose because other pregnancy-related complications were frequent.

CONCLUSIONS

Although pregnancies in these women were often complicated, a future pregnancy may be a safe and appropriate decision for women who have recovered from TTP-HUS.

Apheresis and the thrombotic thrombocytopenic purpura syndrome: current advances in diagnosis, pathophysiology, and management

Endeavors to optimize the management of thrombotic thrombocytopenic purpura (TTP) syndrome and improve mortality and relapse rates are hindered by its poorly understood pathophysiology. Variability in the application of therapeutic plasma exchange (TPE), including replacement fluid strategies, desirable endpoints in the platelet count, serum lactate dehydrogenase concentration, and the use of a TPE taper, limit comparisons among published studies. The diversity of adjunctive therapies such as antiplatelet agents, steroids, and splenectomy further clouds comparisons. Recent progress in the diagnosis, pathophysiology, and management of TTP syndrome are summarized. The possible role of occult infection and newly emerging associations such as ticlopidine therapy are discussed. Advances in possible pathogenic mechanisms, the rationale for different replacement fluids including the recently licensed solvent-detergent treated plasma, and progress in the apheresis management of TTP syndrome are presented.

Management of complicated preeclampsia

The complicated preeclamptic patient represents a challenge for the clinician faced with her antepartum or postpartum care. The most serious sequelae of preeclampsia account for a significant portion of maternal morbidity and mortality. Severe preeclampsia also results in an appreciable portion of perinatal morbidity and mortality. In this review, developing trends in the treatment of severe preeclampsia are discussed. Expectant treatment of the patient remote from term, anesthesia choices, and delivery route are reviewed. Developing trends in the pharmacological approach to complicated preeclampsia are discussed. New concepts in the treatment of cerebrovascular preeclampsia and hepatic rupture are outlined and reviewed.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Thrombocytopenia in pregnancy

Thrombocytopenia is a common finding in normal pregnancy. The introduction of routine automated complete blood counting has clearly documented this. In the past, these patients would go undetected and be spared unnecessary testing, procedures, or medications. This article reviews the common causes of thrombocytopenia and offers criteria on which the diagnosis of clinically significant thrombocytopenia can be made. In addition, we will discuss therapeutic approaches to manage patients with pathologic thrombocytopenia.

Plasma exchange for preeclampsia: III. Immediate peripartal utilization for selected patients with HELLP syndrome

OBJECTIVE

To explore the potential efficacy of plasma exchange as an ancillary interventive therapeutic tool immediately before or after delivery in the patient with severe preeclampsia/eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.

STUDY DESIGN

Two gravidas with complicated severe preeclampsia/eclampsia/HELLP syndrome were treated emergently in the immediate peripartal period with single-volume plasma exchange and fresh frozen plasma fluid replacement using the IBM 2997 Cell Separator.

RESULTS

Despite multiple platelet unit infusions, one primigravida in active labor at 5 cm cervical dilation and 39 weeks' gestation remained at a platelet count of 14,000/microL and began to ooze from her guns. A second primigravida remained obtunded, oliguric, and thrombocytopenic with epistaxis and hematuria following cesarean delivery and platelet transfusions. A single expedited 3-liter plasma exchange procedure reversed the rapidly deteriorating clinical situation for each patient and accelerated recovery from HELLP syndrome. Both patients and progeny suffered no permanent sequelae.

CONCLUSION

Based on our experience, we believe that the therapeutic modality of plasma exchange with fresh frozen plasma can be employed effectively for the pregnant patient with severe atypical HELLP syndrome that progressively worsens during labor or the early puerperium despite the use of conventional transfusion therapy.

HELLP syndrome: laboratory parameters and clinical course in four patients treated with plasma exchange

We report our apheresis department's experience with four patients with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. The average age of the patients was 23.25 years (range 19-27). Three were in their second pregnancy while one was a primigravida. All had symptoms of pre-eclampsia prior to delivery. All experienced the syndrome postpartum. Plasma exchange was instituted an average of 3.25 days postpartum (range 1.08-7.33 days). All underwent plasmapheresis with fresh frozen plasma replacement. The average number of plasma exchange treatments was four (range 1-8). The first laboratory parameter to reach its peak/nadir was the aspartate aminotransferase (AST), followed by the lactate dehydrogenase (LDH) enzyme level, followed by the hemoglobin (HGB) level, and, finally, the platelet count (PLT). The AST was the first parameter to peak and the first to normalize. In the three cases in which more than one plasmapheresis procedure was performed, plasmapheresis was required for an average of 98 hours (range 39-206 hours) after a normal AST level was obtained in order to achieve a self-sustaining platelet count of > or = 100 x 10(9)/L. No additional exchanges were required to maintain the PLT once a PLT of over 100 x 10(9)/L was attained. The laboratory values normalized in the following order: AST, HGB, PLT, and LDH. Three patients were discharged anemic. One was discharged with a normal LDH level. By our experience, awaiting normal LDH levels as an indicator for cessation of plasma exchange therapy would mean subjecting the patients to many unnecessary procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Durable remissions following prolonged plasma exchange in thrombotic thrombocytopenic purpura

We evaluated the efficacy of prolonged plasma exchange (PEX) for attaining durable remissions in thrombotic thrombocytopenic purpura (TTP). A recent review using steroids or PEX in initial management showed an 80% response rate but produced a relapse rate of 67-84%. Records of 50 patients starting PEX treatment for TTP/HUS were reviewed to identify and select those whose course of treatment had ended over 1 year earlier, whether or not the result was satisfactory. Records were evaluated for outcome, especially remission associated with treatment by "prolonged" plasma exchange. "Prolonged" was defined as continuing PEX beyond the stage where a normal platelet count was attained and until evidence of hemolysis was "minimal or at least compensated." If disease activity as judged by the criteria of hemolysis became accelerated or resumed, PEX was increased by volume of FFP (e.g., from 3 to 4 L) or rate (from less than daily to daily). Of 50 consecutive patients treated by PEX for TTP/HUS there were 40 cases after which at least one year had passed since the end of treatment. These 40 patients were evaluated for the results of treatment by PEX. Eight failed to achieve remission, dying in hospital within 1 month of admission. Twenty-eight achieved remission, sustained for 1 year or more in all. These are the reasons for our enthusiasm about this report. Four achieved remission lasting less than 1 year. Splenectomy was performed to obtain a sustained remission in one patient following administration of three 2 mg doses of vincristine and two relapses.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without HELLP syndrome

OBJECTIVE

To explore the efficacy of plasmapheresis/plasma exchange as the primary therapy to arrest and reverse the progression of severe preeclampsia with or without HELLP syndrome in order to postpone delivery and improve perinatal outcome in very preterm pregnancies.

STUDY DESIGN

In this case series of patients managed over a 4-year period from 1984 to 1987, seven gravidas with severe preterm preeclampsia underwent 1-2 plasmaphereses/plasma exchange procedures using the IBM 2997 Cell Separator with continuous electronic fetal heart rate monitoring (n = 7 patients) and central cardiovascular monitoring (n = 3 patients).

RESULTS

The seven patients (one with HELLP syndrome, six without HELLP) presented between 24 and 30 weeks gestation and, despite plasmapheresis/plasma exchange, the severity of each study subject's preeclampsia persisted without clinically significant improvement. Maternal-fetal deterioration required cesarean delivery in all cases within 48 (in four patients within < 36) hours of therapy. No clinically significant adverse effect of plasma exchange therapy was recorded during cardiovascular and laboratory monitoring; two fetuses developed repetitive late decelerations during exchange despite adequate maternal fluid preload. The only patient with HELLP syndrome developed eclampsia as her third plasma exchange within 25 hours was being initiated. Significant problems with fluid retention and displacement (variable amounts of pulmonary edema, pleural effusions, large volume ascites) were encountered in all patients. Four neonates died (24-27 weeks/438-820 g) and three survived intact (740, 950, and 1,280 g). One mother (case 5) developed end-stage renal disease 21 months postpartum.

CONCLUSIONS

The application of plasmapheresis/plasma exchange therapy as described in order to prolong very preterm pregnancies in the undelivered patient with severe preeclampsia/eclampsia with or without HELLP syndrome did not produced encouraging results. Patients in general were exposed to additional medical and surgical risk without a corresponding improvement in perinatal outcome.

Thrombotic thrombocytopenic purpura in early pregnancy with maternal and fetal survival

Thrombotic thrombocytopenic purpura (TTP) is a hematologic disorder which is clinically characterized by thrombocytopenia, microangiopathic hemolytic anemia, fever, neurologic symptoms, and cardiac and renal involvement. The pathogenic mechanisms of this disease are poorly understood. It is well known that TTP is associated with pregnancy and that prognosis for the mother and child is poor. We present the first case of a severe TTP diagnosed in the first trimester of pregnancy (13th week of gestation) with maternal survival and birth of a healthy child which required continuous and intensive treatment with plasma therapy until delivery. During a period of 24 weeks several attempts to discontinue plasma therapy failed because of continuous active disease, and it became evident that plasma infusions were not as effective as plasma exchanges. The fact that the patient entered into remission soon after delivery of a healthy child by cesarean section in the 37th gestational week shows that in this case pregnancy activated an unknown factor which does not cross the placenta and which can be removed by plasmapheresis.

Severe post-partum eclampsia: response to plasma exchange

In their severest forms, pre-eclampsia and eclampsia may be life-threatening complications of pregnancy. We describe a patient with severe post-partum eclampsia characterized by seizures, deep coma, hypertension, renal insufficiency, coagulopathy, and microangiopathic hemolysis. The patient responded to treatment that included intensive plasma exchange, and she achieved full recovery. Our case supports the use of plasma exchange in patients with severe pre-eclampsia and eclampsia.

Improved survival in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Clinical experience in 108 patients

BACKGROUND AND METHODS

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, central nervous system abnormalities, and renal dysfunction. In early reports the mortality approached 100 percent. A treatment protocol was introduced in 1979 for patients admitted to Johns Hopkins Hospital with the diagnosis of TTP-HUS. Treatment regimens included 200 mg of prednisone a day, for patients with minimal symptoms and no central nervous system symptoms, and prednisone plus plasma exchange, for patients with rapid clinical deterioration who did not improve after 48 hours of prednisone alone and for patients presenting with central nervous system symptoms and rapidly declining hematocrit values and platelet counts.

RESULTS

A total of 108 patients were treated, and 91 percent survived. Prednisone alone was judged to be effective in 30 patients with mild TTP-HUS (two relapses and two deaths). Plasma exchange plus prednisone was given to 78 patients with complicated TTP-HUS, resulting in 67 relapses and 8 deaths. Relapses occurred in 22 of 36 patients given maintenance plasma infusions. Neither splenectomy nor treatment with aspirin and dipyridamole was effective in those with a poor response to plasma exchange. None of the 71 patients tested had positive cultures for O157:H7 Escherichia coli. Nine percent of the patients were pregnant, and none gave birth to infants with TTP-HUS.

CONCLUSIONS

Effective treatment with 91 percent survival is available for patients with TTP-HUS.

Thrombotic thrombocytopenic purpura related to ticlopidine

4 patients had typical features of thrombotic thrombocytopenic purpura (TTP) after 3 to 8 weeks of ticlopidine therapy. In 2 ticlopidine was the only medication taken before TTP; in another, rechallenge with drugs other than ticlopidine that the patient had been taking did not produce relapse. In all patients the delay between start of ticlopidine and TTP was in the same range as the latent period before ticlopidine-induced neutropenia. No relapse occurred in the 4 to 43 months of follow-up in the 3 surviving patients.

Efficacy of the high molecular weight fraction of plasma for the maintenance of pregnancy associated with thrombotic thrombocytopenic purpura

We have investigated the methods for the maintenance of a pregnancy in a patient with thrombotic thrombocytopenic purpura (TTP), said condition, since 1984, having been controlled by a plasma infusion every 3 to 4 weeks. In a preliminary trial it was confirmed that an infusion of the high molecular weight fraction (HMW-F) of plasma, separated by an Evaflux 2A fractionator, improved the patient's thrombocytopenia as the plasma infusion, and maintained its beneficial effect for about 2 weeks during early pregnancy. Though an occurrence of a toxemia-like syndrome responded to repeated plasma infusion, the dose of plasma required to improve the thrombocytopenia gradually increased and reached 5,040 ml by the 20th week of pregnancy. Thus, instead of periodic infusions of whole plasma, periodic infusions of the HMW-F of plasma were used. Under this regimen the platelet count remained above 10.0 x 10(4)/microliters during late pregnancy, and the total dose (2,600 ml) of HMW-F of plasma that was administered until delivery at full term was less than the dosage of whole plasma that was used during early pregnancy. In this manner we were able to obtain a healthy baby by controlling the patient's TTP during pregnancy. This method of preventing thrombocytopenia appears to be safer with respect to volume loading during pregnancy in the TTP patient.

Rapid improvement of thrombotic thrombocytopenic purpura with vincristine and plasmapheresis

Many patients with thrombotic thrombocytopenic purpura (TTP) fail to respond to daily plasmapheresis and the results of alternative treatments have been inconsistent. Vincristine was given weekly with continued plasmapheresis to eight patients who were refractory to plasmapheresis, antiplatelet agents, and/or corticosteroids. A rapid response to the vincristine occurred in all eight patients in 5 days with a marked rise in the platelet count and resolution of symptoms. The results in these patients suggest that early initiation of vincristine therapy in conjunction with plasmapheresis is useful in TTP.

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.

Successful pregnancies of two patients with relapsing thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a severe multisystemic disorder of unknown origin. The association of relapsing TTP with pregnancy is rare but well documented and high mortality rates of mothers and fetuses have been reported so far. Since the introduction of plasma therapy for treating the acute exacerbations of the disease, overall mortality rates have decreased significantly. It is now evident that the manifestations of the disease may reappear even after long disease-free intervals and as many as a third of the recovering patients may develop a relapse. Presented are two TTP patients with relapsing TTP complicating their pregnancies. Prophylactic treatment with aspirin and dipyridamole during their last three successful pregnancies prevented or minimized the severity of TTP relapses. The course of these pregnancies and the management of such patients is discussed.