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Tiller H, Ahlen MT, Akkök ÇA, Husebekk A. Fetal and neonatal alloimmune thrombocytopenia - The Norwegian management model. Transfus Apher Sci 2019; 59:102711. [PMID: 31911047 DOI: 10.1016/j.transci.2019.102711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In Norway, the management strategy for fetal and neonatal alloimmune thrombocytopenia (FNAIT) has for more than two decades differed from most other countries. The focus of this paper is to describe and discuss the Norwegian FNAIT management program. We recommend antenatal IVIg to women who previously have had a child with FNAIT-induced ICH, and usually not to HPA-1a alloimmunized pregnant women where a previous child had FNAIT, but not ICH. When deciding management strategy, we use not only the obstetric history but also the antenatal anti-HPA-1a antibody level as a tool for risk stratification. The Norwegian National Unit for Platelet Immunology (NNUPI) at the University Hospital of North Norway in Tromsø provides diagnostic and consulting service for the clinicians and the blood banks all over the country, and serves as a national reference laboratory for FNAIT investigations.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.
| | - Maria Therese Ahlen
- Department of Laboratory Medicine, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Çiğdem Akalın Akkök
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Anne Husebekk
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
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Venkatesh HA, Paul A, Kantharaj A, Chandrashekar S. A case report of neonatal alloimmune thrombocytopenia: The utility of platelet crossmatch studies in the diagnosis and management. GLOBAL JOURNAL OF TRANSFUSION MEDICINE 2019. [DOI: 10.4103/gjtm.gjtm_50_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Herrmann A, Samelson-Jones BJ, Brake S, Samelson R. IVIG-Associated Maternal Pancytopenia during Treatment for Neonatal Alloimmune Thrombocytopenia. AJP Rep 2017; 7:e197-e200. [PMID: 28970962 PMCID: PMC5621970 DOI: 10.1055/s-0037-1607055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/22/2017] [Indexed: 11/13/2022] Open
Abstract
Background Treatment for neonatal alloimmune thrombocytopenia (NAIT) primarily involves maternal administration of intravenous immunoglobulin (IVIG) therapy and prednisone according to protocols based on risk stratification. While IVIG is generally well tolerated, hematologic side effects are a potential complication. Case We present the successful management of a rare complication of maternal pancytopenia following standard IVIG treatment. Diagnosis was made during routine obstetric exams. Management included reducing IVIG dosage and adding daily prednisone. Additionally, infusion Lots possibly associated with the event were identified and avoided. Interventions resulted in the resolution of pancytopenia and the birth of a healthy infant without thrombocytopenia. Conclusion Pancytopenia is a rare complication of IVIG treatment in women with pregnancies complicated by NAIT. Serial complete blood counts at the time of treatment would allow for early detection and timely management of the patient. Additionally, limiting the number of infusion Lots may decrease the chance of the described complications.
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Affiliation(s)
- Alyssa Herrmann
- Albany Medical College, Albany, New York.,The Cleveland Clinic Women's Health Institute, Cleveland, Ohio
| | | | - Sami Brake
- New York Hematology and Oncology, Albany, New York
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Abstract
Thrombocytopenia in pregnant women is diagnosed frequently by obstetricians because platelet counts are included with automated complete blood cell counts (CBCs) obtained during routine prenatal screening (). Although most U.S. health care providers are trained using U.S. Conventional Units, most scientists, journals, and countries use Système International (SI) units. The laboratory results reported in U.S. Conventional Units can be converted to SI Units or vice versa by using a conversion factor. The conversion factor for platelet count results is 1.0 (ie, to convert from x 103/µL, multiply by 1.0, to get x 109/L). Thrombocytopenia, defined as a platelet count of less than 150 x 109/L, is common and occurs in 7-12% of pregnancies (). 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 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 about obstetric management of this condition. Clinicians must weigh the risks of maternal and fetal bleeding complications against the costs and morbidity of diagnostic tests and invasive interventions.
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Tiller H, Husebekk A, Ahlen MT, Stuge TB, Skogen B. Current perspectives on fetal and neonatal alloimmune thrombocytopenia - increasing clinical concerns and new treatment opportunities. Int J Womens Health 2017; 9:223-234. [PMID: 28458583 PMCID: PMC5402885 DOI: 10.2147/ijwh.s90753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Differences in platelet type between the fetus and the mother can lead to maternal immunization and destruction of the fetal platelets, a condition named fetal and neonatal alloimmune thrombocytopenia (FNAIT). FNAIT is reported to occur in ~1 per 1,000 live born neonates. The major risk is intracranial hemorrhage in the fetus or newborn, which is associated with severe neurological complications or death. Since no countries have yet implemented a screening program to detect pregnancies at risk, the diagnosis is typically established after the birth of a child with symptoms. Reports on broader clinical impact have increased clinical concern and awareness. Along with new treatment options for FNAIT, the debate around antenatal screening to detect pregnancies at risk of FNAIT has been revitalized.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Anne Husebekk
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | | | - Tor B Stuge
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Bjørn Skogen
- Department of Laboratory Medicine, Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
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Curtis BR. Recent progress in understanding the pathogenesis of fetal and neonatal alloimmune thrombocytopenia. Br J Haematol 2015; 171:671-82. [PMID: 26344048 DOI: 10.1111/bjh.13639] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) occurs in c. 1 in 1000 births and is caused by maternal antibodies against human platelet alloantigens that bind incompatible fetal platelets and promote their clearance from the circulation. Affected infants can experience bleeding, bruising and, in severe cases, intracranial haemorrhage and even death. As maternal screening is not routinely performed, and first pregnancies can be affected, most cases are diagnosed at delivery of a first affected pregnancy. Unlike its erythrocyte counterpart, Haemolytic Disease of the Fetus and Newborn, there is no prophylactic treatment for FNAIT. This report will review recent advances made in understanding the pathogenesis of FNAIT: the platelet alloantigens involved, maternal exposure and sensitization to fetal platelet antigens, properties of platelet Immunoglobulin G antibodies, maternal-fetal antibody transport mechanisms and efforts to develop an effective FNAIT prophylaxis.
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Affiliation(s)
- Brian R Curtis
- Platelet & Neutrophil Immunology Laboratory and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
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Pathogenicity of Bovine Neonatal Pancytopenia-associated vaccine-induced alloantibodies correlates with Major Histocompatibility Complex class I expression. Sci Rep 2015; 5:12748. [PMID: 26235972 PMCID: PMC4522679 DOI: 10.1038/srep12748] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/08/2015] [Indexed: 11/11/2022] Open
Abstract
Bovine Neonatal Pancytopenia (BNP), a fatal bleeding syndrome of neonatal calves, is caused by maternal alloantibodies absorbed from colostrum and is characterized by lymphocytopenia, thrombocytopenia and bone marrow hypoplasia. An inactivated viral vaccine is the likely source of alloantigens inducing BNP-associated alloantibodies in the dam. In this study the specificity of BNP alloantibodies was assessed and was linked to the pathology of BNP. We demonstrated that Major Histocompatibility Complex class I (MHC I) and Very Late Antigen-3, an integrin α3/β1 heterodimer, were the major targets of BNP alloantibodies. However, alloantibody binding to various bovine cell types correlated with MHC I expression, rather than integrin β1 or α3 expression. Likewise, alloantibody-dependent complement-mediated cell lysis correlated strongly with MHC I expression. Examination of several tissues of third trimester bovine foetuses revealed that cells, shown to be affected in calves with BNP, were characterized by high MHC class I expression and high levels of alloantibody binding. We conclude that in spite of the heterogeneous specificity of BNP associated maternal alloantibodies, MHC I-specific antibodies mediate the pathogenicity of BNP in the calf and that cells with high MHC I expression were preferentially affected in BNP.
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Conti FM, Hibner S, Costa TH, Dezan MR, Aravechia MG, Pereira RADA, Kondo AT, D'Amico ÉA, Mota M, Kutner JM. Successful management of neonatal alloimmune thrombocytopenia in the second pregnancy: a case report. EINSTEIN-SAO PAULO 2014; 12:96-9. [PMID: 24728253 PMCID: PMC4898246 DOI: 10.1590/s1679-45082014rc2729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/03/2013] [Indexed: 12/04/2022] Open
Abstract
Neonatal alloimmune thrombocytopenia is a serious disease, in which the mother produces antibodies against fetal platelet antigens inherited from the father; it is still an underdiagnosed disease. This disease is considered the platelet counterpart of the RhD hemolytic disease of the fetus and newborn, yet in neonatal alloimmune thrombocytopenia the first child is affected with fetal and/or neonatal thrombocytopenia. There is a significant risk of intracranial hemorrhage and severe neurological impairment, with a tendency for earlier and more severe thrombocytopenia in subsequent pregnancies. This article reports a case of neonatal alloimmune thrombocytopenia in the second pregnancy affected and discusses diagnosis, management and the clinical importance of this disease.
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Affiliation(s)
| | - Sergio Hibner
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Mariza Mota
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Bouwmans EE, Smethurst PA, Garner SF, Ouwehand WH, Morley SL. Expression of a single-chain human leukocyte antigen-DRA/DRB3*01:01 molecule and differential binding of a monoclonal antibody in the presence of specifically bound human platelet antigen-1a peptide. Transfusion 2013; 54:1478-85. [DOI: 10.1111/trf.12502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 10/06/2013] [Accepted: 10/10/2013] [Indexed: 11/26/2022]
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Strong NK, Eddleman KA. Diagnosis and management of neonatal alloimmune thrombocytopenia in pregnancy. Clin Lab Med 2013; 33:311-25. [PMID: 23702120 DOI: 10.1016/j.cll.2013.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neonatal alloimmune thrombocytopenia (NAIT) is the most common cause of severe thrombocytopenia in the healthy newborn, occurring in 1 in 1000 live births. NAIT is analogous to rhesus alloimmunization in pathophysiology; however, it often presents unexpectedly in first pregnancies. Presentation of NAIT varies from mild thrombocytopenia to life-threatening intracranial hemorrhage. It has been observed to be more severe in subsequent affected pregnancies. It is important that the diagnosis of NAIT be considered in the work-up of all cases of neonatal thrombocytopenia to determine the risk to future pregnancies and corresponding management plans. This article discusses the pathogenesis and incidence of NAIT and the antenatal and postnatal management of this condition.
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Affiliation(s)
- Noel K Strong
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY 10029, USA.
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An QX, Li CY, Xu LJ, Zhang XQ, Bai YJ, Shao ZJ, Zhang W. High-throughput simultaneous genotyping of human platelet antigen-1 to -16 by using suspension array. Transfusion 2013; 53:2722-8. [PMID: 23550657 DOI: 10.1111/trf.12164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 12/15/2012] [Accepted: 01/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Comprehensive and accurate detection of human platelet antigens (HPAs) plays a significant role in diagnosis and prevention of the platelet (PLT) alloimmune syndromes and ensuring clinical safety of patients undergoing PLT transfusion. The majority of the available methods are incapable of performing high-throughput simultaneous detection of HPA-1 to -16, and the accuracy of many methods needs to be further enhanced. STUDY DESIGN AND METHODS We have developed a new HPA-genotyping method for simultaneous detection of HPA-1 to -16 based on suspension array technology. A total of 216 samples from Chinese Han donors in Xi'an were genotyped using the developed method, and all the samples again were genotyped using polymerase chain reaction (PCR) sequence-based typing (PCR-SBT), which is considered the gold standard. RESULTS All 216 samples were successfully genotyped for HPA-1 to -16 using both our method and PCR-SBT. Results showed that the genotype and allele frequencies obtained using our method were fully consistent with those obtained using PCR-SBT. CONCLUSION Our method provides accurate, high-throughput, and simultaneous genotyping of HPA-1 to -16 and will serve as the foundation for large-scale clinical genotyping of HPAs and for the establishment of an HPA-typed PLT donor registry.
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Affiliation(s)
- Qun-Xing An
- Department of Blood Transfusion, Xijing Hospital, Xi'an, China; Department of Epidemiology, Faculty of Preventive Medicine, Fourth Military Medical University, Xi'an, China; State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, Fourth Military Medical University, Xi'an, China; Department of Blood Transfusion, Chengdu Military General Hospital, Chengdu, China; Department of Blood Transfusion, 307 Hospital of PLA, Beijing, China
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Foucras G, Corbière F, Tasca C, Pichereaux C, Caubet C, Trumel C, Lacroux C, Franchi C, Burlet-Schiltz O, Schelcher F. Alloantibodies against MHC class I: a novel mechanism of neonatal pancytopenia linked to vaccination. THE JOURNAL OF IMMUNOLOGY 2011; 187:6564-70. [PMID: 22084436 DOI: 10.4049/jimmunol.1102533] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Fetal/neonatal alloimmune thrombocytopenia is a frequent disease in humans where alloantibodies against platelet Ags lead to platelet destruction and hemorrhage. Although a role in the disease for Abs against MHC has been suspected, this has not been formally demonstrated. Since 2007, a hemorrhagic syndrome due to thrombocytopenia and designated as bovine neonatal pancytopenia (BNP) has been recognized in calves in several European countries. An inactivated antiviral vaccine is strongly suspected to be involved in this syndrome because of its highly frequent use in the dams of affected calves. In this study, we show that BNP is an alloimmune disease, as we reproduced the signs by transferring serum Abs from vaccinated BNP dams into healthy neonatal calves. Ab specificity was strongly associated with the presence of allogeneic MHC class I Abs in the dams. MHC class I staining was also observed on Madin-Darby bovine kidney cells, a cell line related to the one used to produce the vaccine Ag. Our report emphatically demonstrates that alloimmunization against MHC class I is associated with a substantial risk of developing cytopenia-associated syndromes in neonates when a cell line of the same species is used to produce an inactivated vaccine injected into the mother.
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Affiliation(s)
- Gilles Foucras
- Université de Toulouse, Institut National Polytechnique de Toulouse, Ecole Nationale Vétérinaire de Toulouse, F-31076 Toulouse, France.
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Abstract
This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.
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Affiliation(s)
- Ferenc Péter
- Department of Pediatrics, Division of Endocrinology, St Johns Hospital and United Hospitals of North-Buda, Buda Children's Hospital, 1023 Bolyai-u. 5-9 Budapest, Hungary.
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Silva F, Morais S, Sevivas T, Veiga R, Salvado R, Taborda A. Severe intracranial haemorrhage in neonatal alloimmune thrombocytopenia. BMJ Case Rep 2011; 2011:bcr.07.2011.4563. [PMID: 22679192 DOI: 10.1136/bcr.07.2011.4563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Neonatal alloimmune thrombocytopenia is a rare (1/1000-5000 births) life-threatening disorder, caused by fetomaternal incompatibility for a fetal human platelet alloantigen inherited from the father, with production of maternal alloantibodies against fetal platelets, leading to severe thrombocytopenia and potential bleeding. Intracranial haemorrhage is the most feared complication. This report presents the case of a term newborn infant, born from caesarean section after a normal pregnancy, presenting signs of skin bleeding with different ages. Obstetric history included a previous spontaneous abortion after amniocentesis. Severe thrombocytopenia (4×10(9)/l platelets) was found and brain ultrasound showed multiple intracranial haemorrhages. Human platelet antigen (HPA) phenotyping showed maternal negative HPA-1a and paternal positive HPA-1a platelets. Strongly positive anti-HPA-1a and weakly positive anti-human leukocyte antigen class I alloantibodies were found in the mother. Multiple platelet transfusions, intravenous immunoglobulin and corticosteroid were given but favourable response was accomplished only after a compatible platelet transfusion. Brain MRI showed multiple subacute and chronic haemorrhages.
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Affiliation(s)
- Francisco Silva
- Paediatric Department, Hospital Dr Nélio Mendonça, Funchal, Portugal.
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McQuilten ZK, Wood EM, Savoia H, Cole S. A review of pathophysiology and current treatment for neonatal alloimmune thrombocytopenia (NAIT) and introducing the Australian NAIT registry. Aust N Z J Obstet Gynaecol 2011; 51:191-8. [PMID: 21631435 DOI: 10.1111/j.1479-828x.2010.01270.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fetomaternal or neonatal alloimmune thrombocytopenia (NAIT) is a rare but serious condition associated with significant fetal and neonatal morbidity and mortality. The most useful predictor of severe disease is a history of a sibling with an antenatal intracranial haemorrhage. However, NAIT can occur during the first pregnancy and may not be diagnosed until the neonatal period. Antenatal treatment options include maternal intravenous immunoglobulin (IVIG) and corticosteroid treatment, fetal blood sampling (FBS) and intrauterine platelet transfusion (IUT) and early delivery. FBS (with or without IUT) can be used to direct and monitor response to therapy, and to inform mode and timing of delivery. However, this procedure is associated with significant risks, including fetal death, and is generally now reserved for high-risk pregnancies. This review highlights the current understanding of the epidemiology and pathophysiology of NAIT and summarises current approaches to investigation and management. It also introduces the newly established Australian NAIT registry. Owing to the relative rarity of NAIT, accruing sufficient patient numbers for studies and clinical trials at an institutional level is difficult. This national registry will provide an opportunity to collect valuable information and inform future research on this condition.
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Affiliation(s)
- Zoe K McQuilten
- Transfusion Medicine Services, Australian Red Cross Blood Service, South Melbourne, Victoria 3205, Australia.
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Giers G, Wenzel F, Riethmacher R, Lorenz H, Tutschek B. Repeated intrauterine IgG infusions in foetal alloimmune thrombocytopenia do not increase foetal platelet counts. Vox Sang 2011; 99:348-53. [PMID: 20624268 DOI: 10.1111/j.1423-0410.2010.01367.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Foetal alloimmune thrombocytopenia (FNAIT) is often treated transplacentally with maternally administered i.v. immunoglobulins, but not all foetuses show a consistent platelet increase during such treatment. MATERIALS AND METHODS We retrospectively analysed data from a cohort of ten foetuses with FNAIT treated by direct foetal immunoglobulin infusion. Foetal treatment was begun between 17 and 25 weeks and continued until 36 weeks with weekly cordocenteses and foetal immunoglobulin infusions. RESULTS While foetal IgG levels increased steadily during weekly IgG infusions, foetal platelet counts remained unchanged. CONCLUSION Our retrospective study presents a unique analysis of a historical cohort, contributing to the ongoing debate about the treatment of choice for foetal alloimmune thrombocytopenia.
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Affiliation(s)
- G Giers
- Clinical Hemostaseology and Transfusion Medicine, Düsseldorf, Germany.
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Mechoulan A, Kaplan C, Muller JY, Branger B, Philippe HJ, Oury JF, Ville Y, Winer N. Fetal alloimmune thrombocytopenia: is less invasive antenatal management safe? J Matern Fetal Neonatal Med 2010; 24:564-7. [DOI: 10.3109/14767058.2010.511333] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Giers G, Wenzel F, Fischer J, Stockschläder M, Riethmacher R, Lorenz H, Tutschek B. Retrospective comparison of maternal vs. HPA-matched donor platelets for treatment of fetal alloimmune thrombocytopenia. Vox Sang 2010; 98:423-30. [DOI: 10.1111/j.1423-0410.2009.01268.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fernandez-Cruz E, Kaveri SV, Peter HH, Durandy A, Cantoni N, Quinti I, Sorensen R, Bussel JB, Danieli MG, Winkelmann A, Bayry J, Käsermann F, Späth P, Helbert M, Salama A, van Schaik IN, Yuki N. 6th International Immunoglobulin Symposium: poster presentations. Clin Exp Immunol 2010; 158 Suppl 1:60-7. [PMID: 19883425 DOI: 10.1111/j.1365-2249.2009.04028.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The posters presented at the 6th International Immunoglobulin Symposium covered a wide range of fields and included both basic science and clinical research. From the abstracts accepted for poster presentation, 12 abstracts were selected for oral presentations in three parallel sessions on immunodeficiencies, autoimmunity and basic research. The immunodeficiency presentations dealt with novel, rare class-switch recombination (CSR) deficiencies, attenuation of adverse events following IVIg treatment, association of immunoglobulin (Ig)G trough levels and protection against acute infection in patients with X-linked agammaglobulinaemia (XLA) and common variable immunodeficiency (CVID), and the reduction of class-switched memory B cells in patients with specific antibody deficiency (SAD). The impact of intravenous immunoglobulin on fetal alloimmune thrombocytopenia, pregnancy and postpartum-related relapses in multiple sclerosis and refractory myositis, as well as experiences with subcutaneous immunoglobulin in patients with multi-focal motor neuropathy, were the topics presented in the autoimmunity session. The interaction of dendritic cell (DC)-SIGN and alpha2,6-sialylated IgG Fc and its impact on human DCs, the enrichment of sialylated IgG in plasma-derived IgG, as wells as prion surveillance and monitoring of anti-measles titres in immunoglobulin products, were covered in the basic science session. In summary, the presentations illustrated the breadth of immunoglobulin therapy usage and highlighted the progress that is being made in diverse areas of basic and clinical research, extending our understanding of the mechanisms of immunoglobulin action and contributing to improved patient care.
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Affiliation(s)
- E Fernandez-Cruz
- Complutense University and University Hospital, Gregorio Marañón, Madrid, Spain.
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Vatopoulou T, Sorinola O. Prenatal treatment of fetomaternal thrombocytopenia. Br J Hosp Med (Lond) 2010; 70:660-1. [PMID: 20081598 DOI: 10.12968/hmed.2009.70.11.45062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is the commonest cause of severe thrombocytopenia in neonates, and of intracranial hemorrhage (ICH) in term neonates [1] (J Trop Pediatr, 1999; 45: 237). If a newborn is affected with AIT, the next child will likely be more severely affected, and therefore fetal thrombocytopenia will begin early in gestation [2, 3] (Arch Neurol, 1984; 41: 30; N Engl J Med 1997; 337: 22). This creates a risk of in utero ICH even if there was not one in the previous pregnancy. There are new developments in AIT in regard to diagnosis, treatment, and screening which will be the focus of this review.
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Affiliation(s)
- J Bussel
- Platelet Research & Treatment Program, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10065, USA.
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Bussel JB, Sola-Visner M. Current approaches to the evaluation and management of the fetus and neonate with immune thrombocytopenia. Semin Perinatol 2009; 33:35-42. [PMID: 19167580 DOI: 10.1053/j.semperi.2008.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia is not a well-known disease, except among specialists in maternal-fetal medicine, neonatologists, and certain pediatricians (ie, hematologists). However, this is by far the most common cause of early severe thrombocytopenia in neonates and of intracranial hemorrhage in term neonates. In addition, if a newborn is affected with alloimmune thrombocytopenia, the next child in the family will likely be more severely affected. Thus, the accurate diagnosis and appropriate management of this disorder are of extreme importance in perinatal medicine and will constitute the focus of this review.
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Affiliation(s)
- James B Bussel
- Division of Pediatric Hematology Oncology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY 10065, USA.
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Arnold DM, Smith JW, Kelton JG. Diagnosis and Management of Neonatal Alloimmune Thrombocytopenia. Transfus Med Rev 2008; 22:255-67. [DOI: 10.1016/j.tmrv.2008.05.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ghevaert C, Wilcox DA, Fang J, Armour KL, Clark MR, Ouwehand WH, Williamson LM. Developing recombinant HPA-1a-specific antibodies with abrogated Fcgamma receptor binding for the treatment of fetomaternal alloimmune thrombocytopenia. J Clin Invest 2008; 118:2929-38. [PMID: 18654666 DOI: 10.1172/jci34708] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Accepted: 05/21/2008] [Indexed: 11/17/2022] Open
Abstract
Fetomaternal alloimmune thrombocytopenia (FMAIT) is caused by maternal generation of antibodies specific for paternal platelet antigens and can lead to fetal intracranial hemorrhage. A SNP in the gene encoding integrin beta3 causes a clinically important maternal-paternal antigenic difference; Leu33 generates the human platelet antigen 1a (HPA-1a), whereas Pro33 generates HPA-1b. As a potential treatment to prevent fetal intracranial hemorrhage in HPA-1a alloimmunized pregnancies, we generated an antibody that blocks the binding of maternal HPA-1a-specific antibodies to fetal HPA-1a1b platelets by combining a high-affinity human HPA-1a-specific scFv (B2) with an IgG1 constant region modified to minimize Fcgamma receptor-dependent platelet destruction (G1Deltanab). B2G1Deltanab saturated HPA-1a+ platelets and substantially inhibited binding of clinical HPA-1a-specific sera to HPA-1a+ platelets. The response of monocytes to B2G1Deltanab-sensitized platelets was substantially less than their response to unmodified B2G1, as measured by chemiluminescence. In addition, B2G1Deltanab inhibited chemiluminescence induced by B2G1 and HPA-1a-specific sera. In a chimeric mouse model, B2G1 and polyclonal Ig preparations from clinical HPA-1a-specific sera reduced circulating HPA-1a+ platelets, concomitant with transient thrombocytopenia. As the Deltanab constant region is uninformative in mice, F(ab')2 B2G1 was used as a proof of principle blocking antibody and prevented the in vivo platelet destruction seen with B2G1 and polyclonal HPA-1a-specific antibodies. These results provide rationale for human clinical studies.
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Affiliation(s)
- Cedric Ghevaert
- NHS Blood and Transplant, Department of Haematology, University of Cambridge, Cambridge, United Kingdom.
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Fetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT): Past, Present, and Future. Obstet Gynecol Surv 2008; 63:239-52. [DOI: 10.1097/ogx.0b013e31816412d3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van den Akker ES, Oepkes D. Fetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2008; 22:3-14. [DOI: 10.1016/j.bpobgyn.2007.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bussel JB, Primiani A. Fetal and neonatal alloimmune thrombocytopenia: progress and ongoing debates. Blood Rev 2007; 22:33-52. [PMID: 17981381 DOI: 10.1016/j.blre.2007.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is a result of a parental incompatibility of platelet-specific antigens and the transplacental passage of maternal alloantibodies against the platelet antigen shared by the father and the fetus. It occurs in approximately 1 in 1000 live births and is the most common cause of severe thrombocytopenia in fetuses and term neonates. As screening programs are not routinely performed, most affected fetuses are identified after birth when neonatal thrombocytopenia is recognized. In severe cases, the affected fetus is identified as a result of suffering from an in utero intracranial hemorrhage. Once diagnosed, AIT must be treated antenatally as the disease can be more severe in subsequent pregnancies. While there have been many advances regarding the diagnosis and treatment of AIT, it is still difficult to predict the severity of disease and which therapy will be effective.
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Affiliation(s)
- James B Bussel
- Division of Hematology, Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021-4853, United States.
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Ringwald J, Schroth M, Faschingbauer F, Strobel J, Strasser E, Schild RL, Goecke TW. Intrauterine use of hyperconcentrated platelet concentrates collected with Trima Accel in a case of neonatal alloimmune thrombocytopenia. Transfusion 2007; 47:1488-93. [PMID: 17655593 DOI: 10.1111/j.1537-2995.2007.01288.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Due to the threat of serious or fatal bleedings, fetuses with neonatal alloimmune thrombocytopenia (NAIT) may need intrauterine platelet (PLT) transfusions. To prevent a volume overload or an ABO minor mismatch, standard PLT concentrates need to be washed to increase the PLT concentration and to reduce the plasma content. Hyperconcentrated single-donor PLT concentrates (HCPs) are a therapeutic alternative. The first case of NAIT successfully treated with HCPs collected with the Trima Accel (TA; Gambro BCT) is reported. CASE REPORT A 31-year-old woman with a history of NAIT in the preceding pregnancy underwent cordocentesis three times during her third pregnancy (30th, 31st, and 32nd weeks of gestation). NAIT was confirmed by marked fetal thrombocytopenia, a maternal anti-human PLT antigen (HPA)-1a-immunoglobulin G (titer 1:128), and the appropriate HPA genotype of the fetus and the parents. On each cordocentesis procedure, a distinct volume of a HPA-1a-negative HCP with a PLT concentration of 3 x 10(6) PLTs per microL was transfused resulting in high corrected count increments after 2 hours. The HCPs were transfused within 10 hours after collection. One day after the last cordocentesis procedure, a cesarean section was performed. The newborn did not show any bleeding signs, and the PLT count remained on normal levels and no further PLT transfusions were needed. CONCLUSION HCPs collected with TA are a useful alternative to washed standard PLT concentrates without the need for further manipulation of the product after collection. Further in vitro and in vivo studies are needed, however, to make definite recommendations for the shelf life of these HCP.
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Affiliation(s)
- Juergen Ringwald
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Krankenhausstrasse 12, D-91054 Erlangen, Germany.
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van den Akker ESA, Oepkes D, Lopriore E, Brand A, Kanhai HHH. Noninvasive antenatal management of fetal and neonatal alloimmune thrombocytopenia: safe and effective. BJOG 2007; 114:469-73. [PMID: 17309545 DOI: 10.1111/j.1471-0528.2007.01244.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the outcome of pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT) in relation to the invasiveness of the management protocol. DESIGN Retrospective analysis of prospectively collected data from a national cohort. SETTING Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation in pregnancy. POPULATION Ninety-eight pregnancies in 85 women with FNAIT having a previous child with thrombocytopenia with (n= 16) or without (n= 82) an intracranial haemorrhage (ICH). METHODS Our management protocol evolved over time from (1) serial fetal blood samplings (FBS) and platelet transfusion (n= 13) via (2) combined FBS with maternal intravenous immunoglobulins (n= 33) to (3) completely noninvasive treatment with immunoglobulins only (n= 52 pregnancies, resulting in 53 neonates). Perinatal outcome was assessed according to the three types of management. MAIN OUTCOME MEASURES Occurrence of ICH, perinatal survival, gestational age at birth and complications of FBS. RESULTS All but one of 98 pregnancies ended in a live birth; none of the neonates had an ICH. The median gestational age at birth was 37 weeks (range 32-40). In groups 1 and 2, three emergency caesarean sections were performed after complicated FBS, resulting in two healthy babies and one neonatal death. CONCLUSION Noninvasive antenatal management of pregnancies complicated by FNAIT appears to be both effective and safe.
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Affiliation(s)
- E S A van den Akker
- Department of Obstetrics, Lieden University Medical Centre, Leiden, The Netherlands.
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Intravenous Immunoglobulin (IVIG). Obstet Gynecol 2007; 109:991-3. [PMID: 17400865 DOI: 10.1097/01.aog.0000258240.48260.fd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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