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Mulders G, Uitslager N, Kavanagh M, Birkedal MF, Nicolo G, Fenton R, Westesson LM. The role of the specialist nurse in comprehensive care for bleeding disorders in Europe: An integrative review. Haemophilia 2024; 30:598-608. [PMID: 38439128 DOI: 10.1111/hae.14974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Managing bleeding disorders (BDs) is complex, requiring a comprehensive approach coordinated by a multidisciplinary team (MDT). Haemophilia nurses (HNs) play a central role in the MDT, frequently coordinating care. As novel treatments bring change to the treatment landscape, ongoing education and development is key. However, understanding of the roles and tasks of HNs is lacking. AIM The EAHAD Nurses Committee sought to identify and describe the roles and tasks of the European HN. METHODS A five-step integrative review was undertaken, including problem identification, literature search, data evaluation, data synthesis and presentation. Relevant literature published from 2000 to 2022 was identified through database, hand and ancestry searching. Data were captured using extraction forms and thematically analysed. RESULTS Seven hundred and seventy-seven articles were identified; 43 were included. Five main roles were identified, with varied and overlapping associated tasks: Educator, Coordinator, Supporter, Treater and Researcher. Tasks related to education, coordination and support were most frequently described. Patient education was often 'nurse-led', though education and coordination roles concerned both patients and health care practitioners (HCPs), within and beyond the MDT. The HN coordinates care and facilitates communication. Long-term patient care relationships place HNs in a unique position to provide support. Guidelines for HN core competencies have been developed in some countries, but autonomy and practice vary. CONCLUSION As the treatment landscape changes, all five main HN roles will be impacted. Despite national variations, this review provides a baseline to anticipate educational needs to enable HNs to continue to fulfil their role.
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Affiliation(s)
- Greta Mulders
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Nanda Uitslager
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mary Kavanagh
- Children's Coagulation Centre, Children's Health Ireland, Dublin, Ireland
| | | | - Gabriella Nicolo
- Angelo Bianchi Bonomi Haemophilia and Trombosis Center, Milan, Italy
| | | | - Linda Myrin Westesson
- Department of Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, Institution for Nursing Science and Health at Gothenburg University, Gothenburg, Sweden
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2
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Gualtierotti R, Garagiola I, Mortarino M, Spena S, Romero-Lux O, Peyvandi F. Gender equity in hemophilia: need for healthcare, familial, and societal advocacy. Front Med (Lausanne) 2024; 11:1345496. [PMID: 38646558 PMCID: PMC11026857 DOI: 10.3389/fmed.2024.1345496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/11/2024] [Indexed: 04/23/2024] Open
Abstract
Hemophilia is a rare bleeding disorder caused by a genetic defect on chromosome X. It is inherited as an X-linked trait, and hence, it is more frequently diagnosed in males, whereas women have been traditionally considered only as carriers of the disease. However, the role of women in families of patients with hemophilia is pivotal. As mothers, sisters, daughters, and female partners of patients with hemophilia, they play a central role in the management of the patient, considering healthcare, social, and familial aspects, but they might be affected by the disease as well, particularly in regions where consanguinity is frequent. This paper aims to explore the involvement of women in hemophilia, including their carrier status, bleeding symptoms, treatment challenges, and psychosocial impact not only related to male patients, but also as patients affected with hemophilia themselves. We advocate health equity, equal access to healthcare for men and women with hemophilia and dedicated resources to improve the unique needs of the women dealing with hemophilia, ultimately leading to improved care and quality of life.
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Affiliation(s)
- Roberta Gualtierotti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Isabella Garagiola
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - Mimosa Mortarino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - Silvia Spena
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Miesbach W, von Drygalski A, Smith C, Sivamurthy K, Pinachyan K, Bensen-Kennedy D, Drelich D, Kulkarni R. The current challenges faced by people with hemophilia B. Eur J Haematol 2024; 112:339-349. [PMID: 38082533 DOI: 10.1111/ejh.14135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Hemophilia B (HB) is a rare, hereditary disease caused by a defect in the gene encoding factor IX (FIX) and leads to varying degrees of coagulation deficiency. The prevailing treatment for people with HB (PWHB) is FIX replacement product. The advent of recombinant coagulation products ushered in a new era of safety, efficacy, and improved availability compared with plasma-derived products. For people with severe HB, lifelong prophylaxis with a FIX replacement product is standard of care. Development of extended half-life FIX replacement products has allowed for advancements in the care of these PWHB. Nonetheless, lifelong need for periodic dosing and complex surveillance protocols pose substantive challenges in terms of access, adherence, and healthcare resource utilization. Further, some PWHB on prophylactic regimens continue to experience breakthrough bleeds and joint damage, and subpopulations of PWHB, including women, those with mild-to-moderate HB, and those with inhibitors to FIX, experience additional unique difficulties. This review summarizes the current challenges faced by PWHB, including the unique subpopulations; identifying the need for improved awareness, personalized care strategies, and new therapeutic options for severe HB, which may provide future solutions for some of the remaining unmet needs of PWHB.
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Affiliation(s)
| | | | | | | | | | | | | | - Roshni Kulkarni
- Michigan State University Center for Bleeding and Clotting Disorders, Lansing, Michigan, USA
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4
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Souza JP, Day LT, Rezende-Gomes AC, Zhang J, Mori R, Baguiya A, Jayaratne K, Osoti A, Vogel JP, Campbell O, Mugerwa KY, Lumbiganon P, Tunçalp Ö, Cresswell J, Say L, Moran AC, Oladapo OT. A global analysis of the determinants of maternal health and transitions in maternal mortality. Lancet Glob Health 2024; 12:e306-e316. [PMID: 38070536 DOI: 10.1016/s2214-109x(23)00468-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 01/22/2024]
Abstract
The reduction of maternal mortality and the promotion of maternal health and wellbeing are complex tasks. This Series paper analyses the distal and proximal determinants of maternal health, as well as the exposures, risk factors, and micro-correlates related to maternal mortality. This paper also examines the relationship between these determinants and the gradual shift over time from a pattern of high maternal mortality to a pattern of low maternal mortality (a phenomenon described as the maternal mortality transition). We conducted two systematic reviews of the literature and we analysed publicly available data on indicators related to the Sustainable Development Goals, specifically, estimates prepared by international organisations, including the UN and the World Bank. We considered 23 frameworks depicting maternal health and wellbeing as a multifactorial process, with superdeterminants that broadly affect women's health and wellbeing before, during, and after pregnancy. We explore the role of social determinants of maternal health, individual characteristics, and health-system features in the production of maternal health and wellbeing. This paper argues that the preventable deaths of millions of women each decade are not solely due to biomedical complications of pregnancy, childbirth, and the postnatal period, but are also tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. This paper underscores the need for broader, multipronged actions to improve maternal health and wellbeing and accelerate sustainable reductions in maternal mortality. For women who have pregnancy, childbirth, or postpartum complications, the health system provides a crucial opportunity to interrupt the chain of events that can potentially end in maternal death. Ultimately, expanding the health sector ecosystem to mitigate maternal health determinants and tailoring the configuration of health systems to counter the detrimental effects of eco-social forces, including though increased access to quality-assured commodities and services, are essential to improve maternal health and wellbeing and reduce maternal mortality.
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Affiliation(s)
- João Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil; BIREME, Department of Evidence and Intelligence for Action in Health, Pan American Health Organization (PAHO)-World Health Organization Americas Regional Office, São Paulo, Brazil.
| | - Louise Tina Day
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Clara Rezende-Gomes
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Jun Zhang
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rintaro Mori
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya-HDSS), Research Institute for Health Sciences (IRSS), Ouagadougou, Burkina Faso
| | | | - Alfred Osoti
- Department of Obstetrics, University of Nairobi, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Oona Campbell
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Kidza Y Mugerwa
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
| | - Pisake Lumbiganon
- Department of Obstetrics & Gynecology, Khon Kaen University, Khon Kaen, Thailand
| | - Özge Tunçalp
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jenny Cresswell
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lale Say
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Allisyn Carol Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Niu B, Duffett L, El-Chaâr D, Tinmouth A, Wang TF, Khalife R. Bleeding disorders and postpartum hemorrhage by mode of delivery: a retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100166. [PMID: 37255855 PMCID: PMC10225912 DOI: 10.1016/j.rpth.2023.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 06/01/2023] Open
Abstract
Background Pregnant persons with bleeding disorders and their potentially affected newborns are at a higher risk of peripartum bleeding complications. The safest mode of delivery for persons with bleeding disorders remains debated, leading to uncertainties in decision-making between the patient and her multidisciplinary team. Objectives This study aimed to describe maternal outcomes for pregnant persons with bleeding disorders by mode of delivery and to examine whether postpartum hemorrhage (PPH) and neonatal hemorrhagic manifestations are associated with the mode of delivery. Methods We collected retrospective data on pregnant persons with bleeding disorders who delivered at a single center from 2010 to 2021. Descriptive statistics, Fisher exact test, and odds ratios were used for analysis. Results A total of 82 pregnancies in 56 subjects were included. Hemophilia A and von Willebrand disease represented the largest cohort, at 30% (17/56) each. Overall rates of primary and secondary PPH were 7.3% (6/82) and 17.4% (12/69), respectively. We did not find a statistically significant difference between mode of delivery and PPH. Upon comparing vaginal and cesarian deliveries, we found an odds ratio of 0.7 (95% CI, 0.1-3.4) for primary PPH and 2.6 (95% CI, 0.4-16.4) for secondary PPH. One male newborn with severe hemophilia A was treated for a suspected intracranial hemorrhage. Conclusion In our cohort, high rates of PPH remained an important complication for pregnant persons with bleeding disorders. There was no significant difference in PPH based on modes of delivery. The small sample size likely limited the power of our study, and consequently, future larger studies are needed.
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Affiliation(s)
- Bonnie Niu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Duffett
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Darine El-Chaâr
- Department of Obstetrics and Gynecology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Roy Khalife
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Young A, Lim MY, Sanders J, Branch DW, Simonsen SE. Pregnancy and childbirth in women with bleeding disorders: A retrospective cohort study. Haemophilia 2023; 29:240-247. [PMID: 36395791 DOI: 10.1111/hae.14688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Reproductive-age women with bleeding disorders (BDs) are underdiagnosed and understudied, despite their increased risk for adverse health outcomes and pregnancy complications. AIM This study examines pregnancy outcomes and obstetric complications of Utah women with BDs. METHODS This retrospective cohort study utilized linked birth records and clinical billing data from two large Utah healthcare systems. Utah residents who had their first birth at > 20 weeks gestation (2008-2015) and who received non-emergent care within either system before delivery were included (n = 61 226). Multivariable logistic regression models were used to examine relationships between BDs and neonatal and obstetric outcomes. RESULTS A total of 295 women (.48%) were included in the BD study population. Women with BDs had significantly increased odds of preterm birth (aOR 1.85, 95% CI 1.32-2.60), Caesarean delivery (aOR 1.38, 95% CI 1.06-1.79), postpartum blood transfusion (aOR 2.55, 95% CI 1.05-6.22), unplanned postpartum hysterectomy (aOR 33.96, 95% CI 7.30-157.89) and transfer to an intensive care unit (aOR 18.18, 95% CI 7.17-46.08). All of the women with BDs who experienced these serious complications were not diagnosed with a BD until the year of their first birth. Additionally, those with BDs were more likely to experience maternal and infant mortality. CONCLUSION Women with BDs had an increased risk for preterm birth, Caesarean delivery, blood transfusion, unplanned hysterectomy, intensive care unit admission, maternal and infant mortality. Those who were not diagnosed with a BD before the year of their first birth were at an increased risk for serious pregnancy complications.
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Affiliation(s)
- Ashli Young
- University of Utah Health, Salt Lake City, Utah, USA
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Sara E Simonsen
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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7
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Swaminathan N, Sharathkumar A, Dowlut-McElroy T. Reproductive Tract Bleeding in Adolescent and Young Adult Females with Inherited Bleeding Disorders: An Underappreciated Problem. J Pediatr Adolesc Gynecol 2022; 35:614-623. [PMID: 35830928 DOI: 10.1016/j.jpag.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.
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Affiliation(s)
- Neeraja Swaminathan
- Division of Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Anjali Sharathkumar
- Division of Pediatric Hematology Oncology, Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 1322 BT, 200 Hawkins Drive, Iowa City, IA 52242, United States.
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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9
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Ballmann J, Ewers M. Nurse-led education of people with bleeding disorders and their caregivers: A scoping review. Haemophilia 2022; 28:e153-e163. [PMID: 35850204 DOI: 10.1111/hae.14629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION People with bleeding disorders (PwBd) and their caregivers face many challenges in developing viable self-management strategies for living with the condition. Nurse-led education can support them to overcome these challenges. However, it is often unclear what educational needs are addressed, how nurses educate PwBd and what didactic concepts they follow. AIM To gain deeper insights into nurse-led patient education in haemophilia care and provide a basis for a more systematic and evidence-based approach to this task. METHODS A scoping review methodology was used. A systematic search for relevant publications on this topic was conducted in various databases between November 2020 and April 2021. Data sets were analysed following the PRISMA-ScR-checklist and using content analysis. RESULTS Of 588 studies identified, 23 sources of evidence met the inclusion criteria. The educational needs of PwBd and their families are extensive, multifaceted, and variable but rarely assessed systematically. These needs were met at certain times throughout their lifetimes. Nurse-led education differed in content, duration, and modality, including interventions such as information, consultation and instruction. An improvement in treatment-oriented self-management and self-efficacy was the most reported outcome. The didactic concepts on which the educational interventions were based were rarely specified. CONCLUSIONS There is a lack of systematic approaches in assessing and addressing the educational needs of PwBd and their caregivers. High variability was found in the literature regarding nurse-led patient education in haemophilia care. This suggests that more research is needed on this topic - not least on the interventions' conceptual foundations and impact models.
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Affiliation(s)
- Julia Ballmann
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
| | - Michael Ewers
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
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10
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How I manage pregnancy in women with Glanzmann thrombasthenia. Blood 2022; 139:2632-2641. [PMID: 35286390 DOI: 10.1182/blood.2021011595] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
Glanzmann thrombasthenia (GT) is a rare inherited platelet function disorder caused by a quantitative and/or qualitative defect of the αIIbβ3 integrin. Pregnancy and delivery is a recognized risk period for bleeding in women with GT. The newborn may also be affected by fetal and neonatal immune thrombocytopenia induced by the transplacental passage of maternal anti-αIIbβ3 antibodies, which can lead to severe hemorrhage and fetal loss. Pregnancy in GT women thus requires a multidisciplinary approach, including prepregnancy counseling, and a treatment plan for delivery for both the mother and child. In this article, we summarize the current knowledge on pregnancy in women with GT and describe how we manage this severe platelet disorder in our clinical practice.
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11
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Clarke L, Curnow J, Cutts B, Ross B, Kidson-Gerber G. Pregnancy, childbirth and neonatal outcomes in women with inherited bleeding disorders: A retrospective analysis. BJOG 2022; 129:1772-1778. [PMID: 35157368 DOI: 10.1111/1471-0528.17125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
Women with inherited bleeding disorders can deliver without complication when best practices are maintained.
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Affiliation(s)
- Lisa Clarke
- Department of Haematology, Sydney Adventist Hospital, Sydney, New South Wales, Australia.,Transfusion Policy and Education, Australian Red Cross Lifeblood, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Briony Cutts
- Department of Obstetrics, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetric Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | - Bryony Ross
- Department of Haematology, Calvary Mater Newcastle, Waratah, New South Wales, Australia.,NSW Health Pathology, Newcastle, New South Wales, Australia
| | - Giselle Kidson-Gerber
- Department of Haematology, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Royal Hospital for Woman, Sydney, New South Wales, Australia
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12
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van Galen K, Lavin M, Skouw-Rasmussen N, Fischer K, Noone D, Pollard D, Mauser-Bunschoten E, Khair K, Gomez K, van Loon E, Bagot CN, Elfvinge P, d'Oiron R, Abdul-Kadir R. European principles of care for women and girls with inherited bleeding disorders. Haemophilia 2021; 27:837-847. [PMID: 34343384 DOI: 10.1111/hae.14379] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Despite increasing awareness of issues faced by women and girls with inherited BDs (WGBD), standards of care are lacking, with disparities in diagnosis and treatment for WGBD across Europe. We aimed to develop practical principles of care (PoC) to promote standardization of care for WGBD within European Haemophilia Treatment and Comprehensive Care Centres (HTC/CCCs). METHODS The co-creation process, supported by the European Association for Haemophilia and Allied Disorders, consisted of four multidisciplinary meetings with health care providers (HCPs) experienced in WGBD care, and European Haemophilia Consortium representatives, combined with broad patient and HCP consultations in the European haemophilia community. Relevant medical societies outside Europe were contacted for confirmation. RESULTS We developed ten PoC for WGBD, stressing the importance and benefits of a centralized, multidisciplinary, comprehensive, family-centred approach to support and manage WGBD during all life stages. These PoC emphasise the right to equitable access and quality of care for all people with BDs, irrespective of gender. Multiple medical societies outside Europe also confirmed their support for endorsement. CONCLUSIONS Ten PoC for WGBD evolved from an iterative process among stakeholders, supported by relevant medical societies worldwide. These PoC can serve as a benchmark for diagnosis and comprehensive multidisciplinary management of WGBD, and improve awareness of their unique challenges. They offer a framework to guide HTC/CCCs in providing equitable care for all WGBD, both in their own services and in other healthcare settings. Implementation of these principles aims to positively impact the health, wellbeing and quality of life for WGBD.
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Affiliation(s)
- Karin van Galen
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin and National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | | | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Declan Noone
- President, European Haemophilia Consortium, Brussels, Belgium
| | - Debra Pollard
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Kate Khair
- Director of Research, Haemnet, London, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Elfvinge
- Department of Haematology, Karolinska University, Stockholm, Sweden
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles, APHP Paris Saclay - Hôpital Bicêtre and Inserm, U 1176 Le Kremlin Bicêtre, France
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust and Institute for Women's Health, University College London, London, UK
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13
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Abstract
Congenital dysfibrinogenemia (CD) is caused by structural changes in fibrinogen that modify its function. Diagnosis is based on discrepancy between decreased fibrinogen activity and normal fibrinogen antigen levels and is confirmed by genetic testing. CD results from monoallelic mutations in fibrinogen genes leading to clinically heterogenous disorders. Most patients with CD are asymptomatic at time of diagnosis but the clinical course may be complicated by a tendency to bleeding and/or thrombosis. Patients with a thrombotic-related fibrinogen variant are particularly at risk and in such patients long-term anticoagulation should be considered. Management of surgery and pregnancy raise important and difficult issues. The mainstay of CD treatment remains fibrinogen supplementation. Antifibrinolytic agents are part of the treatment in some specific clinical settings. In this article, we discuss five clinical scenarios to highlight common clinical challenges. We detail our approach to establish a diagnosis of CD and discuss strategies for the management of bleeding, thrombosis, surgery and pregnancy.
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14
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Chaudhury A, Sidonio R, Jain N, Tsao E, Tymoszczuk J, Oviedo Ovando M, Kulkarni R. Women and girls with haemophilia and bleeding tendencies: Outcomes related to menstruation, pregnancy, surgery and other bleeding episodes from a retrospective chart review. Haemophilia 2020; 27:293-304. [PMID: 33368856 PMCID: PMC8220814 DOI: 10.1111/hae.14232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022]
Abstract
Introduction Women or girls with haemophilia (WGH) represent a group of female symptomatic carriers who experience bleeding events more frequently than non‐carriers. Bleeding events include spontaneous/traumatic bleeds and prolonged bleeding related to surgery, menstruation and pregnancy. Challenges for the treatment of WGH include lack of screening, diagnosis and treatment guidelines. Aim Evaluate clinical characteristics, haemostasis management and clinical outcomes regarding menstruation, childbirth, dental procedures, surgeries and other bleeding events in WGH. Methods A retrospective, non‐interventional review of medical records from WGH among three haemophilia treatment centres (HTCs) was conducted in the United States (2012–2018). Patients with ≥2 visits to the HTC and who had undergone intervention for haemostasis management with the outcome documented were included. Descriptive statistics were used. Results Of 47 women and girls included in the chart review (37 with factor VIII deficiency, 10 with factor IX deficiency), median age at diagnosis was 22.6 years. Approximately 79% (n = 37) were diagnosed with mild haemophilia. Events of interest were primarily managed by factor concentrates or antifibrinolytics. Most treatment approaches were successful across clinical scenarios, except for heavy menstrual bleeding being insufficiently controlled in 8 (57%) of the 14 patients who experienced it. Conclusions Bleeding events in WGH, such as excessive and prolonged bleeding during menstruation, demonstrate a unique burden and require specific medical intervention. These results highlight the importance of assessing the need for haemostasis management in WGH and may contribute to future prospective study designs.
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Affiliation(s)
| | - Robert Sidonio
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | | | | | - Roshni Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
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15
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Presky KO, Kadir RA. Women with inherited bleeding disorders – Challenges and strategies for improved care. Thromb Res 2020; 196:569-578. [DOI: 10.1016/j.thromres.2019.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/26/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
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16
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Nau A, Gillet B, Guillet B, Beurrier P, Ardillon L, Cussac V, Guillou S, Raj L, Trossaërt M, Horvais V, Bayart S, Potin J, Rose J, Macchi L, Couturaud F, Lacut K, Pan-Petesch B. Bleeding complications during pregnancy and delivery in haemophilia carriers and their neonates in Western France: An observational study. Haemophilia 2020; 26:1046-1055. [PMID: 32842170 DOI: 10.1111/hae.14117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/25/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pregnancy, delivery and the postpartum period expose haemophilia carriers, as well as their potentially affected neonates to a high risk of haemorrhagic complications. OBJECTIVES To describe bleeding complications in haemophilia carriers and their newborns throughout pregnancy and postpartum and to identify potential factors increasing the risk of bleeding in this population. PATIENTS/METHODS The ECHANGE multicentre observational cohort study was conducted between January 2014 and February 2019 using the BERHLINGO database comprised of patients from seven French haemophilia centres. RESULTS During the 5 years study period, a total of 104 haemophilia carriers and 119 neonates were included, representing 124 pregnancies and 117 deliveries. Thirty-five (30%) bleeding events were observed, most of them (83%) occurred during the postpartum period, and 37% were reported during the secondary postpartum. Neuraxial anaesthesia was not complicated by spinal haematoma. Three (2.5%) neonates experienced cerebral bleeding. Caesarean section was associated with an increased risk of maternal bleeding in primary and secondary postpartum periods. Basal factor level <0.4 IU/mL was also found to be associated with an increased risk of bleeding during secondary postpartum. CONCLUSION In our cohort, bleeding events occurred in more than a third of haemophilia carriers mainly in the postpartum period, and a significant portion of this bleeding occurred during the secondary postpartum. Haemophilia carriers warrant specific attention during primary and secondary postpartum, in particular in case of caesarean section and low basal factor level. The ECHANGE study is registered at clinicaltrials.gov identifier: NCT03360149.
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Affiliation(s)
- Alice Nau
- Département de Médecine Interne, Pneumologie et Médecine Vasculaire, CHU Brest, Brest, France
| | - Benjamin Gillet
- Centre de traitement de l'hémophilie, CHU Hôtel-Dieu Nantes, Nantes, France
| | - Benoît Guillet
- Centre de traitement des maladies hémorragiques, CHU Rennes, Rennes, France.,INSERM, U1085, IRSET, Université Rennes 1, Rennes, France
| | | | - Laurent Ardillon
- Service d'hématologie - hémostase, Hôpital Trousseau, CHU Tours, Tours, France
| | | | - Sophie Guillou
- Service d'hématologie biologique, CHU Poitiers, Poitiers, France.,INSERM, U1082, IRTOMIT, Université de Poitiers, Poitiers, France
| | - Leela Raj
- EA3878, Université de Bretagne Occidentale, Brest, France
| | - Marc Trossaërt
- Centre de traitement de l'hémophilie, CHU Hôtel-Dieu Nantes, Nantes, France
| | - Valérie Horvais
- Centre de traitement de l'hémophilie, CHU Hôtel-Dieu Nantes, Nantes, France
| | - Sophie Bayart
- Centre de traitement des maladies hémorragiques, CHU Rennes, Rennes, France
| | - Jérôme Potin
- Service d'obstétrique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Johan Rose
- Laboratoire d'hématologie, CH Le Mans, Le Mans, France
| | - Laurent Macchi
- Service d'hématologie biologique, CHU Poitiers, Poitiers, France.,INSERM, U1082, IRTOMIT, Université de Poitiers, Poitiers, France
| | - Francis Couturaud
- Département de Médecine Interne, Pneumologie et Médecine Vasculaire, CHU Brest, Brest, France.,EA3878, Université de Bretagne Occidentale, Brest, France
| | - Karine Lacut
- Département de Médecine Interne, Pneumologie et Médecine Vasculaire, CHU Brest, Brest, France.,EA3878, Université de Bretagne Occidentale, Brest, France
| | - Brigitte Pan-Petesch
- EA3878, Université de Bretagne Occidentale, Brest, France.,Centre de traitement des maladies hémorragiques, Hémostase clinique, Service d'hématologie clinique, CHU Brest, Brest, France
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17
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Ciampa EJ, Liu N, Stiles J, Carani JL, Li Y, Hess PE. Heterozygote carriers of mutations in the F11 gene, encoding Factor XI, have normal coagulation by thromboelastography during pregnancy. Int J Obstet Anesth 2019; 42:57-60. [PMID: 31791878 DOI: 10.1016/j.ijoa.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 11/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Evidence to guide clinical decision-making in pregnant women who are usually asymptomatic, but identified as heterozygote carriers of F11 mutations, is lacking. We hypothesized that women identified on prenatal screening as heterozygous for a mutation in the F11 allele would have minimal evidence of an in vitro coagulation abnormality. METHODS We prospectively enrolled women identified by prenatal screening as F11 mutation carriers and pregnant women who were presumed to be normal as controls. We collected blood during antepartum visits or at presentation for delivery and assessed Factor XI (FXI) coagulant activity level, as well as whole-blood coagulation, by thromboelastography. RESULTS F11 mutation carriers had lower serum FXI activity levels than controls (51.2 ± 8.5% vs 94.1 ± 19.4%; P <0.0001). Thromboelastography values of all control subjects and F11 mutation carriers were within the normal range. The R-time was slightly longer in F11 mutation carriers (5.3 ± 1.0 s vs 4.2 ± 0.8 s, P <0.002), but no other statistically significant differences in thromboelastogram parameters were identified between groups. CONCLUSIONS Despite lower FXI activity in the F11 mutation group, we found minimal differences in whole-blood measures of coagulation using thromboelastography. These findings support our hypothesis that a single copy of an F11 mutation does not produce significant evidence of an in vitro coagulation abnormality. Thromboelastography might be useful in determining the risk of neuraxial anesthesia in pregnant women, but additional work is required to establish the validity of this test.
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Affiliation(s)
- E J Ciampa
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA
| | - N Liu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA; Department of Anesthesia, Weill Cornell Medicine New York, NY, USA
| | - J Stiles
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA
| | - J L Carani
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA; Department of Anesthesia, Roper St. Francis Healthcare, Mount Pleasant, SC, USA
| | - Y Li
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA
| | - P E Hess
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center. Boston, USA.
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18
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Fujii T, Fujii T, Miyakoshi Y. Mothers' intentions and behaviours regarding providing risk communication to their daughters about their possibility of being haemophilia carriers: A qualitative study. Haemophilia 2019; 25:1059-1065. [PMID: 31639264 DOI: 10.1111/hae.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Prophylactic replacement therapy has enabled improvements in the quality of life of patients with haemophilia. However, these patients and their families continue to report psychosocial problems regarding pregnancy and childbirth. In a situation where there is little medical support for haemophilia carriers (HCs), parents must inform their children regarding their possibility of being HCs. AIM This study aimed to elucidate intentions and challenges among mothers with daughters who may be HCs, regarding providing them with carrier risk communication (RC). METHODS Study participants were mothers with daughters who have the possibility of being HCs. Semi-structured interviews were conducted with 20 mothers and were fully transcribed. The analysis was undertaken using a grounded theory-informed approach, through a process of repeated inductive and deductive qualitative coding. RESULTS The study included 14 mothers who had already provided RC to their daughters, five who had not yet provided RC but who intended to do so, and one with no intention of providing RC. Mothers who had already provided RC included those who were not troubled and those who experienced psychological difficulties regarding the RC. Participants who had not provided RC experienced difficulties with 'not knowing what to do' and feelings of 'anxiety due to uncertainty' and reported not knowing the best RC method or timing. CONCLUSION The study revealed a need for support for persons experiencing difficulties with informing their daughters of their possibility of being HCs. Healthcare professionals can advise parents to reduce the burden of providing carrier RC to their daughters.
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Affiliation(s)
- Tomie Fujii
- Nursing Practice and Research Center,Nihon Fukushi University, Tokai, Japan
| | - Teruhisa Fujii
- Division of Blood Transfusion, Hiroshima University Hospital, Hiroshima, Japan
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19
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Veen CSB, van der Reijken IS, Jansen AJG, Schipaanboord CWA, Visser W, de Maat MPM, Leebeek FWG, Duvekot JJ, Kruip MJHA. Severe postpartum haemorrhage as first presenting symptom of an inherited bleeding disorder. Haemophilia 2019; 25:1051-1058. [PMID: 31583797 DOI: 10.1111/hae.13846] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/11/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Postpartum haemorrhage (PPH) is the major cause of maternal death worldwide. Haemostatic abnormalities are independently associated with a significantly increased risk for severe PPH. In this study, the value of haemostatic evaluation in women with severe PPH was explored. AIM To investigate the occurrence of previously unknown inherited bleeding disorders in women with severe PPH. METHODS Women with severe PPH (blood loss of ≥2000 mL) between 2011 and 2017, referred to the haematology outpatient clinic for haemostatic evaluation, were retrospectively included. A bleeding disorder was diagnosed based on (inter)national guidelines, or when having a clear bleeding phenotype, not fulfilling any diagnostic criteria or laboratory abnormalities, this being classified as Bleeding of Unknown Cause (BUC). Logistic regression was used to model the association between diagnosis and obstetrical causes and risk factors for PPH. RESULTS In total, 85 women with PPH were included. In 23% (n = 16), a mild bleeding disorder was diagnosed, including low von Willebrand factor (Low VWF 8/16), platelet function disorders (PFD 5/16), BUC (2/16) and von Willebrand disease type 1 (1/16). No significant associations were found between obstetrical causes or risk factors for PPH and the presence of a bleeding disorder. CONCLUSION In 23% of women with severe PPH, a mild bleeding disorder was diagnosed, independent of obstetrical causes or risk factors for PPH. This implies that severe PPH can be the first clinical symptom of an inherited bleeding disorder. Therefore, to optimize clinical management, haemostatic evaluation after severe PPH is recommended.
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Affiliation(s)
- Caroline S B Veen
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Irene S van der Reijken
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A J Gerard Jansen
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - Willy Visser
- Department of Obstetrics & Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Vascular Medicine, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics & Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
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20
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Winikoff R, Scully MF, Robinson KS. Women and inherited bleeding disorders - A review with a focus on key challenges for 2019. Transfus Apher Sci 2019; 58:613-622. [PMID: 31582329 DOI: 10.1016/j.transci.2019.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The area of women and inherited bleeding disorders has undergone quick expansion in recent years. More patients are being identified and expertise to diagnose and manage these patients is now essential for practising physicians. Programs to help educate and empower patients and caregivers are now in place. Common inherited bleeding disorders affecting women include von Willebrand disease (VWD), inherited platelet disorders, and rare inherited bleeding disorders such as factor VII (FVII) deficiency and factor XI (FXI) deficiency. Specific clinical tools have been developed to help clinicians and patients screen for the presence of these bleeding disorders in both adult and pediatric populations. Affected women can experience heavy menstrual bleeding and resulting iron deficiency anemia, postpartum hemorrhage, and hemorrhagic ovarian cysts which need to be properly managed. Excessive bleeding can adversely affect quality of life in these women. Front line therapy for bleeding in mild cases focuses on the use of non-specific hemostatic agents such as DDAVP ®, tranexamic acid and hormonal agents but specific factor replacement and/or blood products may be required in more severe cases, in severe bleeding or as second line treatment when bleeding is not responsive to first line agents. Iron status should be optimised in these women especially in pregnancy and use of an electronic app can now help clinicians achieve this. These patients should ideally be managed by a multidisciplinary team whenever possible even remotely. Although clinical research has closed some knowledge gaps regarding the diagnosis and management of these women, there remains significant variation in practise and lack of evidence-based guidelines still exists in many spheres of clinical care in which caregivers must rely on expert opinion. Ongoing efforts in education and research will continue to improve care for these women and restore quality of life for them.
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Affiliation(s)
- R Winikoff
- Division of Hematology-Oncology, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - M F Scully
- Department of Medicine, Memorial University of Newfoundland Medical School, NL, Canada.
| | - K S Robinson
- Division of Hematology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Department of Medicine, Halifax, NS, Canada.
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21
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Dunkley S, Curtin JA, Marren AJ, Heavener RP, McRae S, Curnow JL. Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210:326-332. [PMID: 30924538 PMCID: PMC6850504 DOI: 10.5694/mja2.50123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There have been significant advances in the understanding of the management of inherited bleeding disorders in pregnancy since the last Australian Haemophilia Centre Directors' Organisation (AHCDO) consensus statement was published in 2009. This updated consensus statement provides practical information for clinicians managing pregnant women who have, or carry a gene for, inherited bleeding disorders, and their potentially affected infants. It represents the consensus opinion of all AHCDO members; where evidence was lacking, recommendations have been based on clinical experience and consensus opinion. MAIN RECOMMENDATIONS During pregnancy and delivery, women with inherited bleeding disorders may be exposed to haemostatic challenges. Women with inherited bleeding disorders, and their potentially affected infants, need specialised care during pregnancy, delivery, and postpartum, and should be managed by a multidisciplinary team that includes at a minimum an obstetrician, anaesthetist, paediatrician or neonatologist, and haematologist. Recommendations on management of pregnancy, labour, delivery, obstetric anaesthesia and postpartum care, including reducing and treating postpartum haemorrhage, are included. The management of infants known to have or be at risk of an inherited bleeding disorder is also covered. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT Key changes in this update include the addition of a summary of the expected physiological changes in coagulation factors and phenotypic severity of bleeding disorders in pregnancy; a flow chart for the recommended clinical management during pregnancy and delivery; guidance for the use of regional anaesthetic; and prophylactic treatment recommendations including concomitant tranexamic acid.
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Affiliation(s)
- Scott Dunkley
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW
| | - Julie A Curtin
- The Children's Hospital at Westmead, Sydney, NSW.,Australian Haemophilia Centres Directors' Organisation, Melbourne, VIC
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22
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Stefanovic V. The importance of pre- and post-test counseling for prenatal cell-free DNA screening for common fetal aneuploidies. Expert Rev Mol Diagn 2019; 19:201-215. [PMID: 30657716 DOI: 10.1080/14737159.2019.1571912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Prenatal cell-free DNA screening for common fetal aneuploidies has rapidly changed the paradigm of prenatal care. Despite its advantages compared to conventional screening methods, its unexpectedly rapid implementation in clinical practice has generated several ethical and medical issues and misconceptions. Aggressive commercial marketing of cell-free DNA screening and media dissemination of misleading information have added confusion. Areas covered: This review provides an extensive update and will focus on the importance of pre-and post-test counseling for prenatal cell-free DNA screening not previously discussed extensively in the available literature. Additionally, we report cell-free DNA screening implementation in the largest obstetrical tertiary unit in Finland which is one of few countries that provides all prenatal screening methods free of charge for all women and has a very high uptake of first-trimester screening. This is not a systematical review, but rather a narrative overview which includes the most relevant and recent original publications and reviews covering this issue. Expert opinion: Despite being the most accurate method for screening of common fetal aneuploidies, the knowledge and counseling should be substantially improved. Cell-free DNA screening is not a replacement for diagnostic testing and its use in prenatal testing is complex and limited.
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Affiliation(s)
- Vedran Stefanovic
- a Department of Obstetrics and Gynecology , Fetomaternal Medical Center, Helsinki University and Helsinki University Hospital , Helsinki , Finland
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23
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Xu Z, Dargaud Y, Chamouard V, Le Quellec S, Lienhart A, Meunier S, Rugeri L. A single-centre study of management of pregnant women with von Willebrand disease. Haemophilia 2018; 25:e54-e57. [DOI: 10.1111/hae.13653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Zizhen Xu
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
- Department of Laboratory Medicine, Ruijin Hospital; Shanghai Jiao Tong University School of Medicine; Shanghai China
| | - Yesim Dargaud
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Valérie Chamouard
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Sandra Le Quellec
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Anne Lienhart
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Sandrine Meunier
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Lucia Rugeri
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
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24
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Moorehead PC, Chan AKC, Lemyre B, Winikoff R, Scott H, Hawes SA, Shroff M, Thomas A, Price VE. A Practical Guide to the Management of the Fetus and Newborn With Hemophilia. Clin Appl Thromb Hemost 2018; 24:29S-41S. [PMID: 30373387 PMCID: PMC6714852 DOI: 10.1177/1076029618807583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Newborns with hemophilia are at risk of intracranial hemorrhage, extracranial hemorrhage,
and other bleeding complications. The safe delivery of a healthy newborn with hemophilia
is a complex process that can begin even before conception, and continues throughout
pregnancy, birth, and the newborn period. This process involves the expectant parents and
a wide variety of health-care professionals: genetic counselors, obstetricians,
neonatologists, pediatricians, radiologists, adult and pediatric hematologists, and nurses
with expertise in hemophilia. Because of this multidisciplinary complexity, the relative
rarity of births of newborns with hemophilia, and the lack of high-quality evidence to
inform decisions, there is considerable variation in practice in this area. We present a
comprehensive multidisciplinary approach, from preconception counseling to discharge
planning after birth, and describe available options for management decisions. We
highlight a number of areas of important uncertainty and controversy, including the
preferred mode of delivery, the appropriate use and timing of neuroimaging tests, and the
appropriate use of clotting factor concentrates in the newborn period. While the approach
presented here will aid clinicians in planning and providing care, further research is
required to optimize the care of newborns with hemophilia.
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Affiliation(s)
- Paul C Moorehead
- Section of Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre, St. John's, Canada.,Discipline of Pediatrics, Faculty of Medicine, Memorial University, St. John's, Canada
| | - Anthony K C Chan
- McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Brigitte Lemyre
- Department of Pediatrics, Division of Neonatology, University of Ottawa, Ottawa, Canada
| | - Rochelle Winikoff
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Ste-Justine University Health Center, University of Montreal, Montreal, Canada
| | - Heather Scott
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Canada
| | - Sue Ann Hawes
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Canada
| | - Manohar Shroff
- Department of Radiology, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Aidan Thomas
- Maritime Medical Genetics Service, IWK Health Centre, Halifax, Canada
| | - Victoria E Price
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Canada
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25
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Abstract
: Severe form of haemophilia in women is an extremely rare condition. Owing to the rarity of the disease there are no precise recommendations concerning the optimal management of pregnancy and delivery in these patients. We are reporting the clinical course and management of a 30-year-old woman with a severe form of haemophilia A (factor VIII <1 IU/dl) during her first pregnancy and delivery. Antepartum, she was treated on demand by FVIII concentrate and she delivered at 37 weeks of gestation by cesarean section. In postpartal period an excellent control of bleeding was obtained by regularly administering FVIII concentrate for several days as well by concomitant use of tranexamic acid and oral contraceptive pills in the next 6 weeks.
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26
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Hermans C, Kulkarni R. Women with bleeding disorders. Haemophilia 2018; 24 Suppl 6:29-36. [DOI: 10.1111/hae.13502] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/26/2022]
Affiliation(s)
- C. Hermans
- Haemostasis and Thrombosis Unit; Division of Haematology; Cliniques universitaires Saint-Luc; Brussels Belgium
| | - R. Kulkarni
- Department of Pediatrics and Human Development; Michigan State University; East Lansing MI USA
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Tabibian S, Shams M, Naderi M, Dorgalaleh A. Prenatal diagnosis in rare bleeding disorders-An unresolved issue? Int J Lab Hematol 2018; 40:241-250. [PMID: 29476647 DOI: 10.1111/ijlh.12789] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Abstract
Intracranial haemorrhage (ICH) is the most dreadful complication, and the main cause of death among patients with rare bleeding disorders (RBD) and prenatal diagnosis (PND) is a preventative lifesaving program. A total of 39 PNDs were reported in the literature through a search on PubMed, EMBASE, SCOPUS and Web of Science databases, most often for congenital factor (F) XIII and FVII deficiencies and rarely in FX, FV deficiencies and afibrinogenemia. The main cause to request a PND is ICH and related morbidity and mortality. Different molecular methods including direct sequencing and linkage analysis as well as polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for a specific mutation are the most common used methods for PND, while factor assay and combination of molecular and factor assay also were used. In this research, 7 severely affected foetuses were identified during PND including 3 foetuses with FXIII deficiency, 3 with FVII deficiency and 1 with FX deficiency. Out of these 7 cases, intrauterine ICH occurred in 1 case with FXIII deficiency, 1 was electively aborted and 1 case with severe FVII deficiency received intrauterine factor transfusion. Postdelivery ICH was reported for 1 patient with severe FVII deficiency within the first month of life. All other pregnancies were uneventful.
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Affiliation(s)
- S Tabibian
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - M Shams
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran.,Department of Medical Laboratory, Faculty of Paramedical Sciences, Babol University of Medical Sciences, Babol, Iran
| | - M Naderi
- Genetic Research Center in Non-Communicable Disease, Zahedan University of Medical sciences, Zahedan, Iran
| | - A Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
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29
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Hudecova I, Jiang P, Davies J, Lo YMD, Kadir RA, Chiu RWK. Noninvasive detection of F8 int22h-related inversions and sequence variants in maternal plasma of hemophilia carriers. Blood 2017; 130:340-347. [PMID: 28490568 PMCID: PMC5532756 DOI: 10.1182/blood-2016-12-755017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/19/2017] [Indexed: 12/15/2022] Open
Abstract
Direct detection of F8 and F9 sequence variants in maternal plasma of hemophilia carriers has been demonstrated by microfluidics digital PCR. Noninvasive prenatal assessment of the most clinically relevant group of sequence variants among patients with hemophilia, namely, those involving int22h-related inversions disrupting the F8 gene, poses additional challenges because of its molecular complexity. We investigated the use of droplet digital PCR (ddPCR) and targeted massively parallel sequencing (MPS) for maternal plasma DNA analysis to noninvasively determine fetal mutational status in pregnancies at risk for hemophilia. We designed family-specific ddPCR assays to detect causative sequence variants scattered across the F8 and F9 genes. A haplotype-based approach coupled with targeted MPS was applied to deduce fetal genotype by capturing a 7.6-Mb region spanning the F8 gene in carriers with int22h-related inversions. The ddPCR analysis correctly determined fetal hemophilia status in 15 at-risk pregnancies in samples obtained from 8 to 42 weeks of gestation. There were 3 unclassified samples, but no misclassification. Detailed fetal haplotype maps of the F8 gene region involving int22h-related inversions obtained through targeted MPS enabled correct diagnoses of fetal mutational status in 3 hemophilia families. Our data suggest it is feasible to apply targeted MPS to interrogate maternally inherited F8 int22h-related inversions, whereas ddPCR represents an affordable approach for the identification of F8 and F9 sequence variants in maternal plasma. These advancements may bring benefits for the pregnancy management for carriers of hemophilia sequence variants; in particular, the common F8 int22h-related inversions, associated with the most severe clinical phenotype.
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Affiliation(s)
- Irena Hudecova
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Peiyong Jiang
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Joanna Davies
- Department of Obstetrics and Gynaecology and
- Katharine Dormandy Haemophilia and Thrombosis Center, Royal Free Hospital, London, United Kingdom
| | - Y M Dennis Lo
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Rezan A Kadir
- Department of Obstetrics and Gynaecology and
- Katharine Dormandy Haemophilia and Thrombosis Center, Royal Free Hospital, London, United Kingdom
| | - Rossa W K Chiu
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
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30
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Malin GL, Swallow G, Rutherford J. Two rare risk factors for post-partum haemorrhage: a case report of a carrier of severe haemophilia A with a uterine arteriovenous malformation. J OBSTET GYNAECOL 2017; 37:948-949. [DOI: 10.1080/01443615.2017.1308319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Gemma L. Malin
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gillian Swallow
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane Rutherford
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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31
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Abdel-Samad N. Treatment with Recombinant Factor XIII (Tretten) in a Pregnant Woman with Factor XIII Deficiency. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:436-439. [PMID: 28432284 PMCID: PMC5408647 DOI: 10.12659/ajcr.901502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patient: Female, 37 Final Diagnosis: Factor XIII deficiency Symptoms: Bleeding • miscarriage Medication: — Clinical Procedure: — Specialty: Hematology
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Affiliation(s)
- Nizar Abdel-Samad
- Department of Internal Medicine, The Moncton Hospital, Moncton, NB, Canada
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Gernsheimer TB. Congenital and acquired bleeding disorders in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:232-235. [PMID: 27913485 PMCID: PMC6142506 DOI: 10.1182/asheducation-2016.1.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Obstetrical hematology represents challenges not only for the patient, but also for her progeny. In particular, bleeding disorders, both congenital and acquired, not only present problems both for delivery and in the immediate postpartum period, but also may have significant implications for the fetus and neonate. Women with congenital bleeding disorders or who are carriers of X-linked or autosomal disorders should be counseled prior to conception so that pregnancy can be safely undertaken with careful preparation. A treatment plan should be set up by a specialized care team that includes the hematologist, obstetrician, and anesthesiologist; the patient should be followed closely during pregnancy, through delivery, and in the immediate postpartum period. Acquired disorders of hemostasis that occur with pregnancy may present particular diagnostic difficulties and require rapid diagnosis and management.
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Affiliation(s)
- Terry B Gernsheimer
- Division of Hematology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
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33
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Kouides PA. Present day management of inherited bleeding disorders in pregnancy. Expert Rev Hematol 2016; 9:987-95. [DOI: 10.1080/17474086.2016.1216312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
INTRODUCTION Inherited fXI deficiency has been an enigma since its discovery in 1953. The variable and relatively mild symptoms in patients with even the most severe form of the disorder seem out of step with the marked abnormalities in standard clotting assays. Indeed, the contribution of factor XI to hemostasis in an individual is not adequately assessed by techniques available in modern clinical laboratories. AREAS COVERED We discuss clinical studies, genetic/genomic analyses, and advances in laboratory medicine that are reshaping our views on the role of factor XI in pathologic coagulation. We review how the disorder associated with factor XI deficiency has contributed to changes in blood coagulation models, and discuss the complex genetics of the deficiency state and its relationship to bleeding. Finally, we cover new laboratory approaches that may distinguish deficient patients who are prone to bleeding from those without such predisposition. Expert commentary: Advances in understanding the biology of factor XI have led to modifications in treatment of factor XI-deficient patients. Factor replacement is used more judiciously, and alternative approaches are gaining favor. In the future, better laboratory tests may allow us to target therapy to those patients who would benefit most.
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Affiliation(s)
- Allison P Wheeler
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University , Nashville , TN , USA.,b The Department of Pediatrics , Vanderbilt University , Nashville , TN , USA
| | - David Gailani
- a Department of Pathology, Microbiology and Immunology , Vanderbilt University , Nashville , TN , USA.,c The Department of Medicine , Vanderbilt University , Nashville , TN , USA
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35
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Lavee O, Kidson-Gerber G. Update on inherited disorders of haemostasis and pregnancy. Obstet Med 2016; 9:64-72. [PMID: 27512496 PMCID: PMC4950409 DOI: 10.1177/1753495x15624307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/30/2015] [Indexed: 12/18/2022] Open
Abstract
Inherited bleeding disorders have the potential to cause bleeding complications during pregnancy, childbirth and the postpartum period as well as effect fetal outcomes. There is an evolving understanding of the need for specialised and individualised care for affected women during these times. The aim for each patient is to estimate the risk to mother, fetus and neonate; to implement measures to minimise these risks; and to anticipate complications and develop contingencies for these scenarios. This includes accurate diagnosis, preconceptual care, prenatal diagnostic options, antenatal care, delivery and postpartum care as well as care of an affected neonate. An understanding of the physiologic haemostatic changes associated with pregnancy as well as the scope of defects, inheritance and management of inherited bleeding disorders is paramount when caring for these women. Collaborative and prospective management in conjunction with haematology services underpins the approach advocated. This review draws on the available literature, and outlines the principles of care for women with inherited bleeding disorders before, during and after pregnancy, as well as their babies, based on both available data and collective clinical experience.
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Affiliation(s)
- Orly Lavee
- Department of Haematology, South Eastern Sydney Local Health District, Prince of Wales Hospital, New South Wales, Australia
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Abstract
PURPOSE OF REVIEW The morbidity and mortality of postpartum hemorrhage (PPH) in women with an underlying bleeding disorder requires vigilance by the hematologist. RECENT FINDINGS Recent studies suggest that women with underlying bleeding disorders may be 'undertreated' at the time of delivery in aiming for too low a target elevation that historically per numerous society guidelines has aimed for VWF/FVIII:C levels to be 'only' greater than 50% when in actuality the levels should be akin to what is achieved in a normal pregnancy. The result appears to be an increase in the rate and degree of PPH. In this context, although recent studies imply DDAVP is well tolerated, DDAVP may not be appropriate because it may not raise the levels into the normal supraphysiological range nor maintain it for several days. Particularly in women with rare bleeding disorders, i.e., non- FVIII C or VWF deficient, adjunctive antifibrinolytic therapy, e.g., tranexamic acid, appears to be in order as a prophylactic measure. SUMMARY Women with an underlying bleeding disorder appear to be at a heightened risk for PPH if the respective coagulation factor level is not appropriately replaced to the level that is physiologically achieved in a normal pregnancy. Furthermore, there appears to be underuse of tranexamic acid for prophylaxis of PPH in this population.
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Olmedillas López S, Garcia-Arranz M, Garcia-Olmo D, Liras A. Preliminary study on non-viral transfection of F9 (factor IX) gene by nucleofection in human adipose-derived mesenchymal stem cells. PeerJ 2016; 4:e1907. [PMID: 27114871 PMCID: PMC4841220 DOI: 10.7717/peerj.1907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022] Open
Abstract
Background. Hemophilia is a rare recessive X-linked disease characterized by a deficiency of coagulation factor VIII or factor IX. Its current treatment is merely palliative. Advanced therapies are likely to become the treatment of choice for the disease as they could provide a curative treatment. Methods. The present study looks into the use of a safe non-viral transfection method based on nucleofection to express and secrete human clotting factor IX (hFIX) where human adipose tissue derived mesenchymal stem cells were used as target cells in vitro studies and NOD. Cg-Prkdcscid Il2rgtm1Wjl/SzJ mice were used to analyze factor IX expression in vivo studies. Previously, acute liver injury was induced by an injected intraperitoneal dose of 500 mg/kg body weight of acetaminophen. Results. Nucleofection showed a percentage of positive cells ranging between 30.7% and 41.9% and a cell viability rate of 29.8%, and cells were shown to secrete amounts of hFIX between 36.8 and 71.9 ng/mL. hFIX levels in the blood of NSG mice injected with ASCs transfected with this vector, were 2.7 ng/mL 48 h after injection. Expression and secretion of hFIX were achieved both in vitro cell culture media and in vivo in the plasma of mice treated with the transfected ASCs. Such cells are capable of eventually migrating to a previously damaged target tissue (the liver) where they secrete hFIX, releasing it to the bloodstream over a period of at least five days from administration. Conclusions. The results obtained in the present study may form a preliminary basis for the establishment of a future ex vivo non-viral gene/cellular safe therapy protocol that may eventually contribute to advancing the treatment of hemophilia.
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Affiliation(s)
| | - Mariano Garcia-Arranz
- Health Research Institute-Jiménez Diaz Foundation (iiS-FJD), Madrid, Spain; Department of Surgery, School of Medicine, Autonoma University of Madrid, Spain
| | - Damian Garcia-Olmo
- Health Research Institute-Jiménez Diaz Foundation (iiS-FJD), Madrid, Spain; Department of Surgery, School of Medicine, Autonoma University of Madrid, Spain
| | - Antonio Liras
- Department of Physiology, School of Biology, Complutense University of Madrid, Spain; Victoria Eugenia Royal Hemophilia Foundation, Madrid, Spain; Health Research Institute-Hospital 12 de Octubre Foundation (iiS-i+12O), Madrid, Spain
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Shanbhag S, Ghosh K, Shetty S. Genetic basis of severe factor XIII deficiency in a large cohort of Indian patients: Identification of fourteen novel mutations. Blood Cells Mol Dis 2016; 57:81-4. [DOI: 10.1016/j.bcmd.2016.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Behboudi-Gandevani S, Moghaddam-Banaem L, Shahbazi S, Ekhtesari F. Maternal rare inherited bleeding disorders and neonatal complications. J Obstet Gynaecol Res 2015; 42:172-7. [PMID: 26627666 DOI: 10.1111/jog.12884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 08/13/2015] [Accepted: 09/08/2015] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to examine the association between maternal inherited bleeding disorders and neonatal complications. MATERIAL AND METHODS This was a historical cohort study. The rare inherited bleeding disorders (RIBD) group consisted of a total of 100 women suffering from inherited bleeding disorders, aged 20-45 years who experienced pregnancy. In the healthy control group, 200 age- and body mass index-matched women were selected. Details of demographic and obstetric characteristics of the samples in both groups were collected using their medical records. RESULTS The mean ages of the women in the RIBD and healthy control groups were 32.6 (7.07) and 32.4 (7.3) years, respectively. No statistically significant differences were found in terms of age and other demographic characteristics of the women between the groups. The mean neonatal birthweight in the RIBD group was statistically lower than that in the healthy control group, 3018.2 (546.9) g vs. 3299.4 (456.8) g, respectively (P = 0.021). The prevalence of low birthweight in the RIBD group was statistically higher in comparison to that in the healthy control group (P = 0.041). After adjustment for potential confounders, it was found that maternal bleeding disorder had significant negative effects on birthweight in newborns (odds ratio, 1.05; 95% confidence interval, 1.01-3.43, P = 0.001). Those infants were statistically more likely to experience head bleeding, early hyperbilirubinemia and hospitalization than the healthy group (P = 0.001). CONCLUSIONS Maternal rare inherited bleeding disorders may have a devastating consequence for neonates.
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Affiliation(s)
- Samira Behboudi-Gandevani
- Reproductive Endocrine Research Center, Research Institute of Endocrine Science, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Lida Moghaddam-Banaem
- Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Shirin Shahbazi
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Ekhtesari
- Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Abstract
Abstract
Worldwide, ∼800 women die every day from preventable causes related to pregnancy or childbirth. The single most common cause is severe bleeding, which can kill a healthy woman within hours if care is substandard or delayed. Improved antenatal practices have led to the early identification of at-risk women and modern technology and new techniques have enabled effective management strategies so that now, in the western world, most of the morbidity and mortality arises from those cases which occur unexpectedly and could not have been predicted. Prompt and effective management and multidisciplinary involvement is paramount to save the lives of these women. We use a case report to illustrate and discuss the main elements of management of this condition.
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Rodger M, Sheppard D, Gándara E, Tinmouth A. Haematological problems in obstetrics. Best Pract Res Clin Obstet Gynaecol 2015; 29:671-84. [PMID: 25819750 DOI: 10.1016/j.bpobgyn.2015.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 02/02/2023]
Abstract
Physiologic changes occur during pregnancy, which influence normal haematologic values and impact the diagnosis and management of haematologic disease in pregnancy. Physiologic changes of pregnancy also commonly lead to mimicking symptoms of haematologic disease that may prompt investigations for haematologic disease. The toxicity and radiation associated with the diagnostic imaging and pharmacologic management of both benign and malignant haematological conditions during pregnancy present unique challenges. Strategies for diagnosis and treatment must weigh the benefits and risks to the mother while also taking foetal outcome into consideration. In this review, we highlight the common haematologic diseases encountered by obstetricians and try to provide guidance for the most prevalent diagnostic and therapeutic questions. At the other end of the spectrum, we also comment on less common but very challenging haematologic diseases in pregnancy that require multidisciplinary effort to arrive at difficult individual diagnostic and treatment decisions.
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Affiliation(s)
- Marc Rodger
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Dawn Sheppard
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Esteban Gándara
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Alan Tinmouth
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Canadian Blood Services, Ottawa, Canada.
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