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Kranzhöfer D, Pavlova A, Schneider H, Franck P, Glonnegger H, Büchsel M, Yoshimi-Nöllke A, Oldenburg J, Zieger B. Type 2B von Willebrand Disease: Early Manifestation as Neonatal Thrombocytopenia. Hamostaseologie 2021; 41:469-474. [PMID: 34942660 DOI: 10.1055/a-1665-6185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Here, we report about a preterm female newborn with a prolonged course of severe thrombocytopenia and hematomas. The family history was positive for von Willebrand disease type 2B (VWD 2B). Diagnosis of VWD 2B was identified analyzing von Willebrand factor (VWF) parameters (VWF:antigen, VWF:activity, VWF multimer analyses) and performing light transmission aggregometry (with half concentration of ristocetin). In addition, the diagnosis was confirmed by molecular genetic analysis: identification of a disease-causing missense mutation (Val1316Met) in the VWF gene associated with a severe course of VWD 2B, which had been previously reported. Treatment with a VWF-containing plasma concentrate was initiated. Because the combination of prematurity and very low platelet count is often associated with intracranial bleeding, at the beginning platelet concentrates were transfused. Fortunately, the patient did not develop serious bleeding episodes. Interestingly, the patient had a mutation in the VWF gene, which had been described to be associated with aggravation of thrombocytopenia especially in stressful situations. Therefore, we replaced venous blood withdrawals by capillary blood samplings when possible and, consequently, we observed an increase of the platelet count after this change in management. At the age of 2 months, the patient was discharged after stabilization of the platelet count without any bleeding signs and without a need of long-term medication.
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Affiliation(s)
- David Kranzhöfer
- Department for General Pediatrics, Adolescent Medicine and Neonatology, University Medical Center Freiburg, Freiburg, Germany
| | - Anna Pavlova
- Institute of Experimental Haematology and Transfusion Medicine (IHT), University Hospital Bonn, Bonn, Germany
| | - Hendryk Schneider
- Department for General Pediatrics, Adolescent Medicine and Neonatology, University Medical Center Freiburg, Freiburg, Germany
| | - Peter Franck
- Department for General Pediatrics, Adolescent Medicine and Neonatology, University Medical Center Freiburg, Freiburg, Germany
| | - Hannah Glonnegger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Büchsel
- Clinical Chemistry, University Medical Center Freiburg, Freiburg, Germany
| | - Ayami Yoshimi-Nöllke
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine (IHT), University Hospital Bonn, Bonn, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany
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2
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Makhamreh MM, Russo ML, Karl T, Delgado N, Lackritz K, Skupski DW, Al-Kouatly HB. Type 2B von Willebrand Disease in Pregnancy: A Systematic Literature Review. Semin Thromb Hemost 2021; 47:201-216. [PMID: 33636751 DOI: 10.1055/s-0041-1723799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Our objective was to review the maternal characteristics and obstetric complications in women with type 2B von Willebrand disease (VWD). A systematic literature search was conducted using PubMed, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included all publications that addressed type 2B VWD in pregnancy. Our primary and secondary outcomes were incidence of postpartum hemorrhage (PPH) and incidence of thrombocytopenia in pregnancy. Two reviewers independently identified eligible studies and abstracted data including maternal characteristics, hematologic characteristics, treatment, and delivery outcomes. Twenty studies met inclusion criteria. There were 27 women (32 pregnancies) with type 2B VWD. Primary PPH was reported in 9/20 women (45%) and secondary PPH was reported in 6/13 women (46%). Thrombocytopenia in pregnancy was present in 27/28 women (96%); 23/27 women (85%) had platelet count <100 × 109/L, mean 33.7 ± 22.7 × 109/L. Factor concentrate treatment was administered before delivery (n = 16) and postpartum (n = 18), some women received both. Seventeen deliveries required blood products postpartum with 13/17 (76%) platelet transfusions and 6/17 (35%) red blood cell transfusions. No maternal mortality was reported. Women with type 2B VWD have significant morbidity in pregnancy related to high incidence of severe thrombocytopenia and primary and secondary PPH.
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Affiliation(s)
- Mona M Makhamreh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Melissa L Russo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Taylor Karl
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Natalie Delgado
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Lackritz
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel W Skupski
- Departments of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York, and New York Presbyterian-Queens, Flushing, New York
| | - Huda B Al-Kouatly
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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3
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Punt M, Waning M, Mauser-Bunschoten E, Kruip M, Eikenboom J, Nieuwenhuizen L, Makelburg A, Driessens M, Duvekot J, Peters M, Middeldorp J, Bloemenkamp K, Schutgens R, Lely A, Van Galen K. Maternal and neonatal bleeding complications in relation to peripartum management in women with Von Willebrand disease: A systematic review. Blood Rev 2020; 39:100633. [DOI: 10.1016/j.blre.2019.100633] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/06/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
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4
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How I treat type 2B von Willebrand disease. Blood 2018; 131:1292-1300. [PMID: 29378695 DOI: 10.1182/blood-2017-06-742692] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 01/04/2018] [Indexed: 12/26/2022] Open
Abstract
Type 2B von Willebrand disease (VWD) is an inherited bleeding disorder caused by changes in von Willebrand factor (VWF) that enhance binding of VWF to GPIb on platelets. Although this disorder is seemingly well defined because of this single molecular defect, in reality type 2B VWD is a clinically heterogeneous disorder that can be difficult to identify and manage. Diagnostic criteria include a history of mucocutaneous bleeding, laboratory studies showing enhanced VWF binding of platelets and/or a 2B VWD genetic variant, and a family history consistent with autosomal dominant inheritance. Thrombocytopenia, although not always present, is common and can be exacerbated by physiologic stressors such as pregnancy. The mainstay of therapy for type 2B VWD is VWF replacement therapy. Adjunct therapies useful in other types of VWD, such as antifibrinolytics, are also used in type 2B VWD. 1-Desamino-8-d-arginine vasopressin (DDAVP) is controversial because of exacerbation of thrombocytopenia, but is, in practice, sometimes used for minor bleeding. Here we review the available evidence and provide 3 clinical cases to illustrate the intricacies of diagnosing type 2B VWD to describe the response to DDAVP and to review complexities and management during pregnancy.
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Martingano D, Guan X, Martingano FX. Management of pregnancy and emergency caesarean delivery in a patient with type IIB von Willebrand disease and severe preeclampsia: A case report and literature review. Obstet Med 2017; 11:92-94. [PMID: 29997693 DOI: 10.1177/1753495x17720626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 06/21/2017] [Indexed: 11/16/2022] Open
Abstract
Main purposes of the study To report an example of how concurrent von Willebrand disease type IIB disease and severe preeclampsia can be safely managed to and to review the current literature to evaluate management approaches that have proven safe and effective. The basic procedures used Report of case with a review of literature. Conclusions Through regular von Willebrand factor and platelet replacement during the prenatal period, immediately pre-delivery, and as needed intraoperatively and postoperatively, women with von Willebrand disease type IIB can safely undergo both normal spontaneous vaginal deliveries and caesarean deliveries, even with concurrent disorders like preeclampsia. Further studies with larger sample size are required to solidify management concepts in this disease concurrent with pregnancy.
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Affiliation(s)
- Daniel Martingano
- Department of Obstetrics & Gynecology, NYU Lutheran Medical Center, New York, USA
| | - Xin Guan
- Department of Obstetrics & Gynecology, NYU Lutheran Medical Center, New York, USA
| | - Francis X Martingano
- Department of Obstetrics & Gynecology, NYU Lutheran Medical Center, New York, USA
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6
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Proud L, Ritchey AK. Management of type 2b von Willebrand disease in the neonatal period. Pediatr Blood Cancer 2017; 64:103-105. [PMID: 27468167 DOI: 10.1002/pbc.26168] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 11/10/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder, affecting one in 1,000 people. Type 2b VWD is a less common subtype caused by a gain-of-function mutation in von Willebrand factor (VWF) that leads to the formation of large, ineffective VWF-platelet multimers in circulation. This unique pathophysiology creates diagnostic and treatment dilemmas. There is limited information on the management of type 2b VWD in the neonatal period. This report describes the management of a neonate with type 2b VWD with an emphasis on the added benefit of concomitant platelet transfusion and factor replacement therapy over factor replacement therapy alone.
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Affiliation(s)
- Lindsay Proud
- Pediatrics Residency Program, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - A Kim Ritchey
- Division of Hematology/Oncology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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7
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Biguzzi E, Siboni SM, Ossola MW, Zaina B, Migliorini AC, Peyvandi F. Management of pregnancy in type 2B von Willebrand disease: case report and literature review. Haemophilia 2014; 21:e98-103. [DOI: 10.1111/hae.12580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2014] [Indexed: 12/17/2022]
Affiliation(s)
- E. Biguzzi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation and University of Milan; Milan Italy
| | - S. M. Siboni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation and University of Milan; Milan Italy
| | - M. W. Ossola
- Department of Obstetrics and Gynecology; IRCCS Fondazione Cà Granda Policlinico; University of Milan; Milan Italy
| | - B. Zaina
- Department of Obstetrics and Gynecology; IRCCS Fondazione Cà Granda Policlinico; University of Milan; Milan Italy
| | - A. C. Migliorini
- Laboratory of Haematology; IRCCS Fondazione Cà Granda Policlinico; University of Milan; Milan Italy
| | - F. Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation and University of Milan; Milan Italy
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8
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Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol 2009; 201:12.e1-8. [PMID: 19481722 DOI: 10.1016/j.ajog.2009.04.024] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 03/05/2009] [Accepted: 04/09/2009] [Indexed: 12/20/2022]
Abstract
Reproductive tract bleeding in women is a naturally occurring event during menstruation and childbirth. In women with menorrhagia, however, congenital bleeding disorders historically have been underdiagnosed. This consensus is intended to allow physicians to better recognize bleeding disorders as a cause of menorrhagia and consequently offer effective disease-specific therapies.
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Nichols WL, Hultin MB, James AH, Manco-Johnson MJ, Montgomery RR, Ortel TL, Rick ME, Sadler JE, Weinstein M, Yawn BP. von Willebrand disease (VWD): evidence-based diagnosis and management guidelines, the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel report (USA). Haemophilia 2008; 14:171-232. [PMID: 18315614 DOI: 10.1111/j.1365-2516.2007.01643.x] [Citation(s) in RCA: 570] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- W L Nichols
- Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN, USA.
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10
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Cherkaoui S, Laaloui A, Faiz S, Benchemsi N. [Pregnancy and delivery in a patient with Willebrand's disease. Apropos of a case]. Transfus Clin Biol 2008; 14:474-80. [PMID: 18295527 DOI: 10.1016/j.tracli.2007.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 12/13/2007] [Indexed: 10/22/2022]
Abstract
Willebrand's disease is the most frequent inborn coagulopathy and type 3 is its most severe form. Pregnancy and delivery are critical events in women with Willebrand's disease of type 3. Prophylactic treatment for delivery and early postpartum period is recommended. We report the management of pregnancy and successful delivery of a 32-year-old woman with type 3. Prophylactic treatment with 2000 IU of Willebrand's disease factor (WdF) was given twice a day during the delivery day and the day after, and 1000 IU per day during the next three days. The patient did not show any spontaneous metrorrhagia but anemia. No bleeding was observed in the newborn.
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Affiliation(s)
- S Cherkaoui
- Laboratoire d'hématologie, CHU Ibn Rochd, Casablanca, Maroc.
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11
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James AH, Jamison MG. Bleeding events and other complications during pregnancy and childbirth in women with von Willebrand disease. J Thromb Haemost 2007; 5:1165-9. [PMID: 17403089 DOI: 10.1111/j.1538-7836.2007.02563.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Case reports and case series suggest that women with von Willebrand disease (VWD) are at an increased risk of bleeding complications during pregnancy and delivery. OBJECTIVES To estimate the incidence of bleeding events and other complications in women with VWD during pregnancy and childbirth. METHODS The United States Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000-2003 was queried for all pregnancy-related discharges. Women with a diagnosis of VWD were compared with women without VWD. Data were analyzed based on the NIS sampling design. Logistic regression was used to compute odds ratios with 95% CI. RESULTS There were 4067 deliveries among women with VWD (1 in 4000 deliveries). Although women with VWD were more likely to experience antepartum bleeding [odds ratio (OR) 10.2, 95% CI: 7.1, 14.6], they were no more likely to experience premature labor, placental abruption, fetal growth restriction or intrauterine fetal demise. Women with VWD were more likely to experience a postpartum hemorrhage (OR, 1.5; 95% CI: 1.1, 2.0), and had a 5-fold increased risk of being transfused (OR, 4.7; 95% CI: 3.2, 7.0). Five of the 4067 women with VWD died, a maternal mortality rate 10 times higher than that for other women. CONCLUSIONS Although women with VWD do not appear to be at an increased risk of poor fetal outcomes, they are at an increased risk of bleeding events and possibly death during pregnancy and childbirth.
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Affiliation(s)
- A H James
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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12
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Abstract
UNLABELLED Von Willebrand disease (VWD), the most common inherited bleeding disorder, results from a deficiency of von Willebrand factor (VWF), a protein required for the normal adhesion of platelets to the site of injured endothelium and for preservation of factor VIII in the circulation. The prevalence of VWD has been reported to be as high as 1.3%. Among women with VWD, menorrhagia is the most common symptom, affecting 32% to 100%. Treatments that have been reported to control menorrhagia in these women include combined oral contraceptives, 1-deamino-8-D-arginine vasopressin (DDAVP), tranexamic acid, and the levonorgestrel-releasing intrauterine system. With the exception of nonsteroidal antiinflammatory drugs, any treatments effective in the treatment of menorrhagia, including hysterectomy, may be suitable. Besides menorrhagia, women with VWD appear to be at an increased risk of developing hemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions that present with bleeding such as fibroids, endometrial hyperplasia, and polyps. During pregnancy, they may be at greater risk of miscarriage and bleeding complications, particularly delayed or secondary postpartum hemorrhage. Vaginal or vulvar hematomas, extremely rare in women without bleeding disorders, are not uncommon. Although women with VWD are at risk for the same obstetric and gynecologic problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to recall that Von Willebrand Disease (VWD) is a common inherited disease, especially in women with menorrhagia; state that prophylaxis therapies against bleeding in pregnant and nonpregnant women are available; and explain that, despite prophylaxis, miscarriage and bleeding complications can still occur.
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Affiliation(s)
- Andra H James
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
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13
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James AH. More than menorrhagia: a review of the obstetric and gynaecological manifestations of bleeding disorders. Haemophilia 2005; 11:295-307. [PMID: 16011580 DOI: 10.1111/j.1365-2516.2005.01108.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In women, menorrhagia may be the most common manifestation of a bleeding disorder, but it is not the only reproductive tract abnormality that women with bleeding disorders experience. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions, which present with bleeding such as fibroids, endometrial hyperplasia and polyps. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. Vaginal or vulvar haematomas, extremely rare in women without bleeding disorders, are not uncommon. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding.
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Affiliation(s)
- A H James
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
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14
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Affiliation(s)
- J L Kujovich
- Division of Hematology/Medical Oncology, Mail Code: L-586, Oregon Health and Science University, Portland, OR 97239, USA.
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Abstract
Thrombocytopenia in pregnant women can be associated with substantial maternal and neonatal morbidity. It may result from a range of conditions and early implementation of some specific treatment may improve both maternal and neonatal outcome. In this review we discuss the clinical features of the more common causes of thrombocytopenia associated with pregnancy, and provide an overview of the anaesthetic considerations.
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Affiliation(s)
- P C A Kam
- Department of Anaesthesia, University of NSW at St. George Hospital, Kogarah, NSW 2217, Australia.
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16
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Abstract
Thrombocytopenia in pregnant women may result from a number of diverse etiologies. While some of these are not associated with adverse pregnancy outcomes, others are associated with substantial maternal and/or neonatal morbidity and mortality. However, specific therapies, if instituted promptly, may significantly improve the outcomes of affected patients and their offspring. Since the clinical features of many of these disorders often overlap, identifying a specific cause of thrombocytopenia in a pregnant patient may be difficult. However, through familiarity with the more common clinical and laboratory features of each of these disorders, accurate diagnosis may be achieved, and appropriate treatment instituted in most cases. In this review, we discuss the differential diagnosis of the more common causes of pregnancy-associated thrombocytopenia, and provide an overview of approaches to hematologic management.
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Affiliation(s)
- Keith R McCrae
- Hematology-Oncology, BRB3, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, 10900 Euclid Avenue, OH 44106-4937, USA.
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17
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Current Awareness. Prenat Diagn 2001. [DOI: 10.1002/pd.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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