1
|
Leng Q, Wang W, Wang Y, Wu L. Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review. J Clin Pharm Ther 2020; 46:532-538. [PMID: 33277725 DOI: 10.1111/jcpt.13321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Severe thrombocytopenia associated with systemic lupus erythematosus (SLE) in pregnancy is infrequent. Its occurrence can lead to serious adverse pregnancy consequences and perinatal complications. The thrombopoietin (TPO) analogue eltrombopag has been successfully used in the treatment of autoimmune thrombocytopenia, but its safety and efficacy in severe thrombocytopenia during pregnancy remain unclear. CASE SUMMARY We report a 33-year-old woman with SLE at 29 + 3 weeks gestational age who developed severe thrombocytopenia with complaints of epistaxis, gum bleeding and haematuresis. Most conventional treatments including glucocorticoids, intravenous immunoglobulin (IVIG) and cyclosporine did not elevate her platelets, but eltrombopag worked well and her platelet count gradually recovered, allowing her to deliver a healthy baby at 36 + 3 weeks gestational age. WHAT IS NEW AND CONCLUSION This suggests that eltrombopag in combination with glucocorticoids has a good safety and efficacy profile in pregnant patients with SLE complicated by severe thrombocytopenia.
Collapse
Affiliation(s)
- Qianru Leng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Wei Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| |
Collapse
|
2
|
Affiliation(s)
- Renee Eslick
- Clinical and Laboratory Haematologist, Haematology Department, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Claire McLintock
- Clinical and Laboratory Haematologist, Obstetric Physician, National Women’s Health, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
3
|
|
4
|
Immune thrombocytopenia in pregnancy – a literature review. GINECOLOGIA.RO 2018. [DOI: 10.26416/gine.21.3.2018.1945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
5
|
Wang X, Xu Y, Luo W, Feng H, Luo Y, Wang Y, Liao H. Thrombocytopenia in pregnancy with different diagnoses: Differential clinical features, treatments, and outcomes. Medicine (Baltimore) 2017; 96:e7561. [PMID: 28723784 PMCID: PMC5521924 DOI: 10.1097/md.0000000000007561] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the clinical features and perinatal treatment of thrombocytopenia induced by different causes during pregnancy.Clinical data from 195 pregnant women with thrombocytopenia attending 2 tertiary hospitals from January 2014 to October 2016 were retrospectively studied. The obtained data were analyzed with SPSS 19.0 software.There were 117 (60.0%), 55 (28.2%), and 23 cases (11.8%) of pregnancy-associated thrombocytopenia (PAT), idiopathic thrombocytopenia (ITP), and hypertensive disorder in pregnancy (PIH), respectively. The percentage of nulliparous women, gestational age at delivery, date of diagnosis of thrombocytopenia, and delivery mode significantly differed between the patients in these 3 groups (P < .05). Patients with PIH had a higher percentage of premature delivery and of lower birth weight infants than patients in the other 2 groups. The 3 groups had similar incidences of postpartum hemorrhage, rates of stillbirth, and neonatal Apgar scores at 5 minutes. PAT and PIH patients had different platelet counts after delivery compared with at diagnosis, whereas the platelet counts of the ITP patients were similar at diagnosis and after delivery. ITP patients in the nontreatment group and the treatment group had significantly different platelet counts (P < .05), and in the treatment group, the maternal platelet count did not differ for treatment with intravenous immunoglobulin (IVIg) versus corticosteroids.The causes of thrombocytopenia in pregnancy are diverse, and the clinical features vary widely. Timely analysis is needed to determine the primary cause of thrombocytopenia, and appropriate therapy should then be selected to effectively improve the prognosis of pregnancies.
Collapse
Affiliation(s)
- Xiaoyue Wang
- Department of Hematology, No. 454 Hospital of PLA, Nanjing
| | - Yan Xu
- Department of Obstetrics and Gynecology, Huai’an Second People's Hospital, Huai’an, Jiangsu
| | - Wenxiang Luo
- Department of Obstetrics and Gynecology, No. 454 Hospital of PLA, Nanjing, People's Republic of China
| | - Hui Feng
- Department of Hematology, No. 454 Hospital of PLA, Nanjing
| | - Yizhou Luo
- Department of Hematology, No. 454 Hospital of PLA, Nanjing
| | - Yanli Wang
- Department of Hematology, No. 454 Hospital of PLA, Nanjing
| | - Hui Liao
- Department of Hematology, No. 454 Hospital of PLA, Nanjing
| |
Collapse
|
6
|
Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2017. [DOI: 10.1007/s00464-017-5637-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
7
|
Kim BJ, Kim HS, Kim JH, Lee KY. Moderate to Severe Thrombocytopenia During Pregnancy: A Single Institutional Experience. Indian J Hematol Blood Transfus 2017; 33:581-585. [PMID: 29075073 DOI: 10.1007/s12288-017-0784-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/18/2017] [Indexed: 10/20/2022] Open
Abstract
Most of thrombocytopenic pregnant women present mild decrease of platelet counts and have favorable outcome. However, small portion of these cases can show moderate to severe thrombocytopenia and may increase the risk of bleeding during delivery. We investigated the prevalence, causes, and outcomes of pregnancies complicated by moderate to severe thrombocytopenia. We reviewed medical records of pregnant women who were diagnosed with moderate to severe thrombocytopenia (<100 × 109/L) during their pregnancies. A total of 4822 deliveries were performed and 26 patients (0.54%) with moderate to severe thrombocytopenia were identified. The most common cause of moderate to severe thrombocytopenia was immune thrombocytopenia (ITP) (42.3%), followed by gestational thrombocytopenia (GT) (34.6%). Compared to GT, ITP showed lower platelet counts at presentation (52.4 × 109/L vs. 80.5 × 109/L, P = 0.041). Patients with GT could conduct successful delivery without specific management, and patients with ITP showed favorable delivery outcomes with adequate treatment. In conclusion, the incidence of moderate to severe thrombocytopenia during pregnancy was very low and most common causes were ITP and GT. Patients with moderate to severe thrombocytopenia could have favorable delivery outcomes with adequate treatment.
Collapse
Affiliation(s)
- Bum Jun Kim
- Division of Hemato-Oncology, Department of Internal Medicine, Kangnam Sacred-Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Shingil-ro 1st, Youngdeungpo-Gu, Seoul, 07441 South Korea
| | - Hyeong Su Kim
- Division of Hemato-Oncology, Department of Internal Medicine, Kangnam Sacred-Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Shingil-ro 1st, Youngdeungpo-Gu, Seoul, 07441 South Korea
| | - Jung Han Kim
- Division of Hemato-Oncology, Department of Internal Medicine, Kangnam Sacred-Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Shingil-ro 1st, Youngdeungpo-Gu, Seoul, 07441 South Korea
| | - Keun Young Lee
- Department of Obstetrics and Gynecology, Kangnam Sacred-Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, South Korea
| |
Collapse
|
8
|
Jakiel G, Ciebiera M, Słabuszewska-Jóźwiak A, Horosz B, Bińkowska M, Wilińska M, Malec-Milewska M. Successful obstetric and hematologic outcome of aplastic anemia in a pregnant Jehovah's Witness. Int J Immunopathol Pharmacol 2016; 29:543-8. [PMID: 27381285 DOI: 10.1177/0394632016656188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Grzegorz Jakiel
- Department of Obstetrics and Gynecology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Michał Ciebiera
- Department of Obstetrics and Gynecology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | | | - Bartosz Horosz
- Department of Anesthesiology and Intensive Care, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Małgorzata Bińkowska
- Department of Obstetrics and Gynecology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Maria Wilińska
- Clinical Ward of Neonatology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Małgorzata Malec-Milewska
- Department of Anesthesiology and Intensive Care, Medical Centre for Postgraduate Education, Warsaw, Poland
| |
Collapse
|
9
|
Li Y, Zhang D, Hua F, Gao S, Wu Y, Xu J. Factors associated with the effect of open splenectomy for immune thrombocytopenic purpura. Eur J Haematol 2016; 98:44-51. [PMID: 27245379 DOI: 10.1111/ejh.12783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect and complications of open splenectomy (OS) for immune thrombocytopenic purpura (ITP) and determine preoperative factors associated with surgical effect. METHODS This was a retrospective analysis of ITP patients who failed medical therapy and were treated with OS between 1997 and 2014 at the Jinshan Hospital, China. Follow-up was 60 months. Surgical effect was determined from platelet counts and bleeding episodes. Complications were assessed including bleeding episodes. Preoperative factors were identified by logistic regression analysis. RESULTS Fifty-six patients (48.2 ± 16.2 yr old; 39 females) were included. Disease course was 31.2 ± 48.2 months; 91.1% patients had preoperative platelet count <20 × 109 /L. OS effect at 1 wk, 1 month, 1 yr, and 5 yrs was in 91.1%, 92.9%, 91.1%, and 89.3% patients, respectively. Pneumonia or lower extremity thrombosis occurred in 7.1% patients. Postoperative mild, moderate, and severe bleeding occurred in 33.9%, 50.0%, and 16.1% patients, respectively. No patients required blood transfusion. Mortality was zero. Larger spleen size associated with surgical effect at 1 wk, 1 month, and 1 yr, and lower preoperative minimum platelet count associated with effect at 5 yrs (P < 0.05). CONCLUSIONS Open splenectomy is an effective treatment with less complications for the management of ITP. Lower preoperative minimum platelet count associated with successful OS at 5 yrs.
Collapse
Affiliation(s)
- Ying Li
- Department of Hematology, Jinshan Hospital Fudan University, Shanghai, China
| | - Dawei Zhang
- Department of Hematology, Jinshan Hospital Fudan University, Shanghai, China
| | - Fanli Hua
- Department of Hematology, Jinshan Hospital Fudan University, Shanghai, China
| | - Song Gao
- Department of Hematology, Jinshan Hospital Fudan University, Shanghai, China
| | - Yangjiong Wu
- Department of Hematology, Jinshan Hospital Fudan University, Shanghai, China
| | - Jianmin Xu
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, China
| |
Collapse
|
10
|
Yan M, Malinowski AK, Shehata N. Thrombocytopenic syndromes in pregnancy. Obstet Med 2015; 9:15-20. [PMID: 27512485 DOI: 10.1177/1753495x15601937] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/29/2015] [Indexed: 11/16/2022] Open
Abstract
The physiological changes in pregnancy result in platelet counts that are lower than in nonpregnant women. Consequently, thrombocytopenia is a common finding occurring in 7-12% of pregnant women. Gestational thrombocytopenia, the most common cause of low platelet counts, tends to be mild in most women and does not affect maternal, fetal or neonatal outcomes. Gestational thrombocytopenia needs to be distinguished from other less common causes of isolated thrombocytopenia, such as immune thrombocytopenia, which affects approximately 3% of thrombocytopenic pregnant women and can lead to neonatal thrombocytopenia. Hypertensive disorders of pregnancy and thrombotic microangiopathies are both associated with thrombocytopenia. They share a considerable number of similar characteristics and are associated with significant maternal and neonatal morbidity and rarely mortality. Accurate identification of the aetiology of thrombocytopenia and appropriate management are integral to optimizing the pregnancy, delivery and neonatal outcomes of this population. Clinical cases are described to illustrate the various aetiologies of thrombocytopenia in pregnancy and their treatment.
Collapse
Affiliation(s)
- Matthew Yan
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada
| | - Ann K Malinowski
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Nadine Shehata
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| |
Collapse
|
11
|
Piatek CI, El-Hemaidi I, Feinstein DI, Liebman HA, Akhtari M. Management of immune-mediated cytopenias in pregnancy. Autoimmun Rev 2015; 14:806-11. [DOI: 10.1016/j.autrev.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/07/2015] [Indexed: 10/24/2022]
|
12
|
Abstract
Pregnancy induces a number of physiologic changes that affect the hematologic indices, either directly or indirectly. Recognizing and treating hematologic disorders that occur during pregnancy is difficult owing to the paucity of evidence available to guide consultants. This review discusses specifically the diagnosis and management of benign hematologic disorders occurring during pregnancy. Anemia secondary to iron deficiency is the most frequent hematologic complication and is easily treated with oral iron formulations; however, care must be taken not to miss other causes of anemia, such as sickle cell disease. Thrombocytopenia is also a common reason for consulting the hematologist, and distinguishing gestational thrombocytopenia from immune thrombocytopenia (ITP), preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), or thrombotic thrombocytopenic purpura (TTP) is essential since the treatment differs widely. Occasionally the management of mother and infant involves the expeditious recognition of neonatal alloimmune thrombocytopenia (NAIT), a condition that is responsible for severe life-threatening bleeding of the newborn. Additionally, inherited and acquired bleeding disorders affect pregnant women disproportionately and often require careful monitoring of coagulation parameters to prevent bleeding in the puerperium. Finally, venous thromboembolism (VTE) during pregnancy is still largely responsible for mortality during pregnancy, and the diagnosis, treatment options and guidelines for prevention of VTE during pregnancy are explored.
Collapse
Affiliation(s)
- Danielle M Townsley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
13
|
Nicoll LM, Nezhat C. Laparoscopic management of pelvic pathology during pregnancy. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.1.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
14
|
Mahey R, Kaur SD, Chumber S, Kriplani A, Bhatla N. Splenectomy during pregnancy: treatment of refractory immune thrombocytopenic purpura. BMJ Case Rep 2013; 2013:bcr-2013-201778. [PMID: 24363245 DOI: 10.1136/bcr-2013-201778] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) complicates 1-2/10 000 pregnancies and accounts for 5% of cases of pregnancy-associated thrombocytopenia. Corticosteroids and intravenous immunoglobulin remain the first-line therapy in pregnancy, and a majority of pregnant women respond to this conventional therapy. Other cytotoxic and immunosuppressive agents used for treatment in non-pregnant patients, for example, danazol, cyclophosphamide, vinca alkaloids and azathioprine, are potential teratogens and cannot be administered during pregnancy. For pregnant women with ITP who fail to respond to medical management and are at a significant risk of haemorrhage due to thrombocytopenia, splenectomy may be considered as an option. We report two cases of splenectomy during pregnancy for refractory ITP. In one patient, it was carried out at 24 weeks, and in the second patient it was carried out during the caesarean section. Splenectomy as a second-line option in cases of refractory severe ITP in pregnancy is discussed.
Collapse
Affiliation(s)
- Reeta Mahey
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | |
Collapse
|
15
|
Zhou J, Wu Z, Zhou Z, Wang Z, Liu Y, Huang XY, Peng B. Efficacy and safety of laparoscopic splenectomy in thrombocytopenia secondary to systemic lupus erythematosus. Clin Rheumatol 2013; 32:1131-8. [PMID: 23549638 DOI: 10.1007/s10067-013-2230-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/11/2013] [Accepted: 02/27/2013] [Indexed: 02/05/2023]
Abstract
This study aims to investigate the efficacy and safety of laparoscopic splenectomy (LS) in the management of refractory thrombocytopenia associated with systemic lupus erythematosus (SLE). From January 2003 to February 2012, 20 patients underwent splenectomy for thrombocytopenia associated with SLE. Of these, 11 underwent open (SLE-OS group) and 9 underwent laparoscopic splenectomy (SLE-LS group). Another 15 patients with ITP underwent LS (ITP-LS group) were categorized as the control group. Surgical indications, perioperative details, and short- (90 days) and long- (median, 42 months) term hematological outcomes were assessed. Splenectomy was successful in all 20 SLE patients. The mean platelet count increased from 23 × 10(9)/L before splenectomy to 289.2 × 10(9)/L and 144.2 × 10(9)/L after 3 and 6 months, respectively, and was 115.5 × 10(9)/L at the last visit, with a 3-month complete response (CR) rate of 100 %. After a median follow-up of 42 months, 17 patients (85 %) had a CR or partial response (PR) to splenectomy plus medical therapy. SLEDAI score and dosage of steroids decreased significantly after splenectomy. None of these patients experienced any postoperative infection, bleeding, or thrombotic events. SLE-LS group had lower volumes of estimated blood loss and postoperative drainage and shorter postoperative hospital stay than SLE-OS group. There were no statistically significant differences between the SLE-LS and ITP-LS groups in operation time, estimated blood loss, and postoperative hospital stay. Splenectomy is effective and safe in the management of refractory thrombocytopenia secondary to SLE. LS may be safe and effective in thrombocytopenia associated with SLE.
Collapse
Affiliation(s)
- Jin Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
Abstract
A mild thrombocytopenia is relatively frequent during pregnancy and has generally no consequences for either the mother or the fetus. Although representing no threat in the majority of patients, thrombocytopenia may result from a range of pathologic conditions requiring closer monitoring and possible therapy. Two clinical scenarios are particularly relevant for their prevalence and the issues relating to their management. The first is the presence of isolated thrombocytopenia and the differential diagnosis between primary immune thrombocytopenia and gestational thrombocytopenia. The second is thrombocytopenia associated with preeclampsia and its look-alikes and their distinction from thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome. In this review, we describe a systematic approach to the diagnosis and treatment of these disease entities using a case presentation format. Our discussion includes the antenatal and perinatal management of both the mother and fetus.
Collapse
|
17
|
Abstract
Abstract
Thrombocytopenia is a common finding in pregnancy. Establishing the diagnosis of immune thrombocytopenia (ITP) in a pregnant patient is similar to doing so in a nonpregnant patient, except that the evaluation must specifically rule out other disorders of pregnancy associated with low platelet counts that present different risks to the mother and fetus and may require alternate distinct therapy. Many of the same treatment modalities are used to manage the pregnant patient with ITP, but others have not been determined to be safe for the fetus, are limited to a particular gestational period, or side effects may be more problematic during pregnancy. The therapeutic objective differs from that in chronic ITP in the adult because many pregnant patients recover or improve spontaneously after delivery and therefore maintenance of a safe platelet count, rather than prolonged remission, is the goal. Thrombocytopenia may the limit choices of anesthesia, but does not guide mode of delivery, and the fetus is rarely severely affected at birth. Patients should be advised that a history of ITP or ITP in a previous pregnancy is not a contraindication to future pregnancies and that, with proper management and monitoring, positive outcomes can be expected in the majority of patients.
Collapse
|
18
|
Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25:3479-92. [PMID: 21938570 DOI: 10.1007/s00464-011-1927-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/24/2011] [Indexed: 12/11/2022]
|
19
|
Gall B, Yee A, Berry B, Bircham D, Hayashi A, Dansereau J, Hart J. Rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 32:1167-1171. [PMID: 21176329 DOI: 10.1016/s1701-2163(16)34741-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rituximab is a novel therapy for immune thrombocytopenic purpura (ITP); however, information about its safety in pregnancy is limited. This case illustrates the successful use of rituximab to treat pregnancy-associated ITP. CASE A 34-year-old woman presented with severe ITP at 23 weeks' gestation. Standard treatment with corticosteroids, intravenous immune globulin, and splenectomy failed to raise the platelet count. Due to ongoing bleeding, rituximab was given in the 26th week of pregnancy. The platelet count rose to over 100 × 10(9)/L after four weeks. The neonatal B-lymphocyte count normalized at four months after delivery. There were no neonatal complications of rituximab therapy. CONCLUSION Rituximab may be safe for use in treating pregnancy-associated ITP. This case highlights the need to investigate further the safety and efficacy of rituximab in pregnancy.
Collapse
Affiliation(s)
- Brent Gall
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Adrian Yee
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Brian Berry
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Deborah Bircham
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Allen Hayashi
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Jerome Dansereau
- Faculty of Medicine, University of British Columbia Vancouver BC
| | - Jason Hart
- Faculty of Medicine, University of British Columbia Vancouver BC
| |
Collapse
|
20
|
Abstract
Management of immune thrombocytopenia in pregnancy can be a complex and challenging task and may be complicated by fetal-neonatal thrombocytopenia. Although fetal intracranial hemorrhage is a rare complication of immune thrombocytopenia in pregnancy, invasive studies designed to determine the fetal platelet count before delivery are associated with greater risk than that of fetal intracranial hemorrhage and are discouraged. Moreover, the risk of neonatal bleeding complications does not correlate with the mode of delivery, and cesarean section should be reserved only for obstetric indications.
Collapse
Affiliation(s)
- Evi Stavrou
- Division of Hematology-Oncology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | | |
Collapse
|
21
|
Abstract
Secondary thrombocytopenia is similar to primary or idiopathic thrombocytopenia (ITP) in that it is characterized by reduced platelet production or increased platelet destruction resulting in platelet levels<60,000/microL. Thrombocytopenia can occur from secondary causes associated with chronic disorders or with disturbed immune function due to chronic infections, lymphoproliferative and myeloproliferative disorders, pregnancy, or autoimmune disorders. Diagnosis of secondary ITP in some cases is complex, and the thrombocytopenia can often be resolved by treating the underlying disorder to the extent this is possible. In most cases, treatment is focused on reducing platelet destruction, but, in some cases, treatment may also be directed at stimulating platelet production. The most problematic cases of thrombocytopenia may be seen in pregnant women. This review will address various agents and their utility in treating ITP from secondary causes; in addition, thrombocytopenia in pregnancy, ITP in immunodeficiency conditions, and drug-induced thrombocytopenia will be discussed. Unlike primary ITP, treatment often must be tailored to the specific circumstance underlying the secondary ITP, even if the condition itself is incurable.
Collapse
Affiliation(s)
- James B Bussel
- Platelet Disorders Center, Division of Pediatric Hematology-Oncology, Weill Cornell Medical College of Cornell University, New York, NY 10021, USA.
| |
Collapse
|
22
|
Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W, Fanelli R. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 2008; 22:1917-27. [PMID: 18553201 DOI: 10.1007/s00464-008-9989-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 05/05/2008] [Indexed: 12/16/2022]
Abstract
Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.
Collapse
Affiliation(s)
- Heidi Jackson
- Department of Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations.
Collapse
|
24
|
Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2008; 22:849-61. [DOI: 10.1007/s00464-008-9758-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 01/08/2008] [Indexed: 01/06/2023]
|
25
|
|
26
|
Felbinger TW, Posner M, Eltzschig HK, Kodali BS. Laparoscopic splenectomy in a pregnant patient with immune thrombocytopenic purpura. Int J Obstet Anesth 2007; 16:281-3. [PMID: 17399979 DOI: 10.1016/j.ijoa.2006.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 10/01/2006] [Indexed: 11/19/2022]
Abstract
We describe the perioperative management of a pregnant woman at 19 weeks' gestation with idiopathic thrombocytopenic purpura requiring laparoscopic splenectomy. The preoperative platelet count ranged between 1 and 5 x 10(9)/L and did not respond to conventional medical therapy. To reduce the risk of intracerebral hemorrhage, platelets were transfused before induction of anesthesia to maintain platelet count closer to 20 x 10(9)/L. The blood pressure was monitored continuously via an arterial line and remifentanil was infused to prevent a hypertensive response to induction/intubation, carbon dioxide insufflation, and surgery. After the splenic artery was clamped, additional platelet units were transfused to assure surgical hemostasis.
Collapse
Affiliation(s)
- T W Felbinger
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | | | | |
Collapse
|