1
|
de Vos TW, Winkelhorst D, Porcelijn L, Beaufort M, Oldert G, van der Bom JG, Lopriore E, Oepkes D, de Haas M, van der Schoot E. Natural history of human platelet antigen 1a-alloimmunised pregnancies: a prospective observational cohort study. Lancet Haematol 2023; 10:e985-e993. [PMID: 38407610 DOI: 10.1016/s2352-3026(23)00271-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare disease that untreated can lead to intracranial haemorrhage or death. The natural history of FNAIT is still unclear; therefore, the benefits of screening cannot be estimated and no routine screening is yet in place. We aimed to assess the incidence of clinically detectable FNAIT among pregnancies in human platelet antigen-1a (HPA-1a)-immunised women. METHODS We did a prospective observational cohort study of pregnant women negative for rhesus D (RhD) and rhesus c (Rhc) antigens, without age limits, who underwent routine antenatal screening for red cell antibodies at 27 weeks' gestation and were typed for HPA-1a between March 1, 2017, and May 1, 2020. HPA-1a-negative women were tested for HPA alloantibodies. Health-care professionals were masked to all test results. The main outcome was the proportion of neonates with severe, clinically detectable FNAIT, defined as having an intracranial bleed, organ bleed, or bleeding-related death observed during pregnancy or within the first week of life. Cases of clinically detectable FNAIT not categorised as severe were categorised as mild. This study is registered with ClinicalTrials.gov (NCT04067375). FINDINGS Of 153 106 women typed for HPA-1a, 3722 (2·4%) were negative for HPA-1a. 913 HPA-1a-negative women gave informed consent, underwent HPA-1a antibody screening, and were included in the study. Anti-HPA-1a antibodies were detected in 85 HPA-1a-negative participants, among whom three with HPA-1a-negative fetuses and one with a previous child with FNAIT were excluded. As controls, 820 HPA-1a-negative, non-immunised pregnancies and 2704 randomly selected pregnancies of women negative for RhD and Rhc who were typed HPA-1a positive were included. Of 81 fetuses included, one (1·2%) was diagnosed with severe HPA-1a-mediated intracranial haemorrhage and three (3·7%) had mild FNAIT. Gravidity and parity did not seem to be risk factors for HPA-1a immunisation. 73 (90·1%) of 81 HPA-1a-immunised women were positive for HLA-DRB3*01:01. INTERPRETATION Our data suggest that, without intervention, the incidence of major clinically detectable bleeding in FNAIT is estimated as 11 (95% CI 0-32) per 10 000 HPA-1a-negative pregnancies. These findings imply that severe bleeding is a rare event that potentially could be prevented by a screening programme. FUNDING Landsteiner Foundation for Blood Transfusion Research and Sanquin.
Collapse
Affiliation(s)
- Thijs W de Vos
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands; Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands
| | - Dian Winkelhorst
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands; Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Mila Beaufort
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Gonda Oldert
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Dick Oepkes
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Masja de Haas
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands; Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands; Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands.
| |
Collapse
|
2
|
Karanth L, Abas AB. Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers. Cochrane Database Syst Rev 2021; 12:CD011059. [PMID: 34881425 PMCID: PMC8655611 DOI: 10.1002/14651858.cd011059.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. This is an update of a previously published review. OBJECTIVES To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews. Date of last search of the Group's Trials Registers: 21 June 2021. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus. Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.
Collapse
Affiliation(s)
- Laxminarayan Karanth
- Department of Obstetrics and Gynaecology, Melaka-Manipal Medical College, Manipal Academy of Higher Education (MAHE), Melaka, Malaysia
| | - Adinegara Bl Abas
- Department of Community Medicine, Melaka-Manipal Medical College (Manipal Academy of Higher Education), Melaka, Malaysia
| |
Collapse
|
3
|
Abstract
The neonatal hemostatic system is strikingly different from that of adults. Among other differences, neonates exhibit hyporeactive platelets and decreased levels of coagulation factors, the latter translating into prolonged clotting times (PT and PTT). Since pre-term neonates have a high incidence of bleeding, particularly intraventricular hemorrhages, neonatologists frequently administer blood products (i.e., platelets and FFP) to non-bleeding neonates with low platelet counts or prolonged clotting times in an attempt to overcome these "deficiencies" and reduce bleeding risk. However, it has become increasingly clear that both the platelet hyporeactivity as well as the decreased coagulation factor levels are effectively counteracted by other factors in neonatal blood that promote hemostasis (i.e., high levels of vWF, high hematocrit and MCV, reduced levels of natural anticoagulants), resulting in a well-balanced neonatal hemostatic system, perhaps slightly tilted toward a prothrombotic phenotype. While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelets. In this review, we will present a clinical overview of bleeding in neonates (incidence, sites, risk factors), followed by a description of the key developmental differences between neonates and adults in primary and secondary hemostasis. Next, we will review the clinical tests available for the evaluation of bleeding neonates and their limitations in the context of the developmentally unique neonatal hemostatic system, and will discuss current and emerging approaches to more accurately predict, evaluate and treat bleeding in neonates.
Collapse
Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
| |
Collapse
|
4
|
Resch B. Thrombocytopenia in Neonates. Platelets 2020. [DOI: 10.5772/intechopen.92857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thrombocytopenia defined as platelet count below 150,000/μL is not an uncommon event at the neonatal intensive care unit (NICU). In our region we calculated a prevalence of nearly 2 of 1000 live births. Early-onset neonatal thrombocytopenia (NT) occurring within the first 72 hours of life is more common than late-onset NT. Preterm infants are affected more often than term infants and bacterial infection is the most common diagnosis associated with NT. There are a lot of maternal, perinatal, and neonatal causes associated with NT and complications include bleedings with potentially life-threatening intracranial hemorrhage. Alloimmune thrombocytopenia (NAIT) often presents with severe thrombocytopenia (<30,000/μL) in otherwise healthy newborns and needs careful evaluation regarding HPA-1a antigen status and HLA typing. Platelet transfusions are needed in severe NT and threshold platelet counts might be at ≤25,000/μL irrespective of bleeding or not. Immune mediated NT recovers within 2 weeks with a good prognosis when there happened no intracranial hemorrhage. This short review gives an overview on etiology and causes of NT and recommendations regarding platelet transfusions.
Collapse
|
5
|
Winkelhorst D, de Vos TW, Kamphuis MM, Porcelijn L, Lopriore E, Oepkes D, van der Schoot CE, de Haas M. HIP (HPA-screening in pregnancy) study: protocol of a nationwide, prospective and observational study to assess incidence and natural history of fetal/neonatal alloimmune thrombocytopenia and identifying pregnancies at risk. BMJ Open 2020; 10:e034071. [PMID: 32690731 PMCID: PMC7375633 DOI: 10.1136/bmjopen-2019-034071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Fetal and neonatal alloimmune thrombocytopenia (FNAIT) may lead to severe fetal or neonatal bleeding and/or perinatal death. Maternal alloantibodies, targeted against fetal human platelet antigens (HPAs), can result thrombocytopenia and bleeding complications. In pregnancies with known immunisation, fetal bleeding can be prevented by weekly maternal intravenous immunoglobulin infusions. Without population-based screening, immunisation is only detected after birth of an affected infant. Affected cases that might have been prevented, when timely identified through population-based screening. Implementation is hampered by the lack of knowledge on incidence, natural history and identification of pregnancies at high risk of bleeding. We designed a study aimed to obtain this missing knowledge. METHODS AND ANALYSIS The HIP (HPA-screening in pregnancy) study is a nationwide, prospective and observational cohort study aimed to assess incidence and natural history of FNAIT as well as identifying pregnancies at high risk for developing bleeding complications. For logistic reasons, we invite rhesus D-negative or rhesus c-negative pregnant women, who take part in the Dutch population-based prenatal screening programme for erythrocyte immunisation, to participate in our study. Serological HPA-1a typing is performed and a luminex-based multiplex assay will be performed for the detection of anti-HPA-1a antibodies. Results will not be communicated to patients or caregivers. Clinical data of HPA-1a negative women and an HPA-1a positive control group will be collected after birth. Samples of HPA-1a immunised pregnancies with and without signs of bleeding will be compared with identify parameters for identification of pregnancies at high risk for bleeding complications. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the Medical Ethical Committee Leiden-The Hague-Delft (P16.002). Study enrolment began in March 2017. All pregnant women have to give informed consent for testing according to the protocol. Results of the study will be disseminated through congresses and publication in relevant peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04067375.
Collapse
Affiliation(s)
- Dian Winkelhorst
- Obstetrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Experimental Immunohematology, Sanquin, Amsterdam, The Netherlands
| | - Thijs W de Vos
- Department of Experimental Immunohematology, Sanquin, Amsterdam, The Netherlands
- Pediatrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marije M Kamphuis
- Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Noord-Holland, The Netherlands
| | - Leendert Porcelijn
- Immunohaematology Diagnostics, Sanquin Blood Supply Foundation, Amsterdam, Noord-Holland, The Netherlands
| | - Enrico Lopriore
- Pediatrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Dick Oepkes
- Obstetrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin, Amsterdam, The Netherlands
- Landsteiner Laboratory, Academic Medical Center Amsterdam and Department of Experimental Immunohematology, University of Amsterdam and Sanquin, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Immunohaematology Diagnostics, Sanquin, Amsterdam, The Netherlands
- Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, Noord-Holland, The Netherlands
| |
Collapse
|
6
|
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a disease in pregnancy characterized by maternal alloantibodies directed against the human platelet antigen (HPA). These antibodies can cause intracranial hemorrhage (ICH) or other major bleeding resulting in lifelong handicaps or death. Optimal fetal care can be provided by timely identification of pregnancies at risk. However, this can only be done by routinely antenatal screening. Whether nationwide screening is cost-effective is still being debated. HPA-1a alloantibodies are estimated to be found in 1 in 400 pregnancies resulting in severe burden and fetal ICH in 1 in 10.000 pregnancies. Antenatal treatment is focused on the prevention of fetal ICH and consists of weekly maternal IVIg administration. In high-risk FNAIT treatment should be initiated at 12-18 weeks gestational age using high dosage and in standard-risk FNAIT at 20-28 weeks gestational age using a lower dosage. Postnatal prophylactic platelet transfusions are often given in case of severe thrombocytopenia to prevent bleedings. The optimal threshold and product for postnatal transfusion is not known and international consensus is lacking. In this review practical guidelines for antenatal and postnatal management are offered to clinicians that face the challenge of reducing the risk of bleeding in fetuses and infants affected by FNAIT.
Collapse
|
7
|
Lieberman L, Greinacher A, Murphy MF, Bussel J, Bakchoul T, Corke S, Kjaer M, Kjeldsen-Kragh J, Bertrand G, Oepkes D, Baker JM, Hume H, Massey E, Kaplan C, Arnold DM, Baidya S, Ryan G, Savoia H, Landry D, Shehata N. Fetal and neonatal alloimmune thrombocytopenia: recommendations for evidence-based practice, an international approach. Br J Haematol 2019; 185:549-562. [PMID: 30828796 DOI: 10.1111/bjh.15813] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) may result in severe bleeding, particularly fetal and neonatal intracranial haemorrhage (ICH). As a result, FNAIT requires prompt identification and treatment; subsequent pregnancies need close surveillance and management. An international panel convened to develop evidence-based recommendations for diagnosis and management of FNAIT. A rigorous approach was used to search, review and develop recommendations from published data for: antenatal management, postnatal management, diagnostic testing and universal screening. To confirm FNAIT, fetal human platelet antigen (HPA) typing, using non-invasive methods if quality-assured, should be performed during pregnancy when the father is unknown, unavailable for testing or heterozygous for the implicated antigen. Women with a previous child with an ICH related to FNAIT should be offered intravenous immunoglobulin (IVIG) infusions during subsequent affected pregnancies as early as 12 weeks gestation. Ideally, HPA-selected platelets should be available at delivery for potentially affected infants and used to increase the neonatal platelet count as needed. If HPA-selected platelets are not immediately available, unselected platelets should be transfused. FNAIT studies that optimize antenatal and postnatal management, develop risk stratification algorithms to guide management and standardize laboratory testing to identify high risk pregnancies are needed.
Collapse
Affiliation(s)
- Lani Lieberman
- University of Toronto, Toronto, Canada.,University Health Network, Toronto, Canada
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Michael F Murphy
- National Health Service (NHS) Blood and Transplant and the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, United Kingdom
| | | | | | | | - Mette Kjaer
- Finnmark Hospital Trust, Hammerfest, Norway.,University Hospital of North Norway, Tromsø, Norway
| | - Jens Kjeldsen-Kragh
- University Hospital of North Norway, Tromsø, Norway.,University and Regional Laboratories Region Skåne, Lund, Sweden
| | - Gerald Bertrand
- Blood Center of Brittany - EFS L'Établissement Français du Sang, Rennes, France
| | - Dick Oepkes
- Leiden University Medical Center, Leiden, the Netherlands
| | - Jillian M Baker
- Hospital for Sick Children and St. Michael's Hospital, Toronto, Canada
| | - Heather Hume
- CHU Sainte-Justine, Université de Montréal, Montréal, Canada
| | | | - Cécile Kaplan
- Retired and formerly Institut National de la Transfusion Sanguine, Paris, France
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, McMaster University and Canadian Blood Services, Hamilton, Canada
| | - Shoma Baidya
- Australian Red Cross Blood Service, Brisbane, Australia
| | - Greg Ryan
- University of Toronto, Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada
| | | | | | - Nadine Shehata
- University of Toronto, Toronto, Canada.,Mount Sinai Hospital, Toronto, Canada.,Canadian Blood Services, Toronto, Canada
| | | |
Collapse
|
8
|
Kjeldsen-Kragh J, Olsen KJ. Risk of HPA-1a-immunization in HPA-1a-negative women after giving birth to an HPA-1a-positive child. Transfusion 2019; 59:1344-1352. [PMID: 30729532 DOI: 10.1111/trf.15152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/15/2018] [Accepted: 12/15/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories Region Skåne, Lund, Sweden.,Department of Laboratory Medicine, University Hospital of North-Norway, Tromsø, Norway
| | | |
Collapse
|
9
|
Kjaer M, Bertrand G, Bakchoul T, Massey E, Baker JM, Lieberman L, Tanael S, Greinacher A, Murphy MF, Arnold DM, Baidya S, Bussel J, Hume H, Kaplan C, Oepkes D, Ryan G, Savoia H, Shehata N, Kjeldsen-Kragh J. Maternal HPA-1a antibody level and its role in predicting the severity of Fetal/Neonatal Alloimmune Thrombocytopenia: a systematic review. Vox Sang 2018; 114:79-94. [PMID: 30565711 DOI: 10.1111/vox.12725] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In Caucasians, fetal/neonatal alloimmune thrombocytopenia (FNAIT) is most commonly due to maternal HPA-1a antibodies. HPA-1a typing followed by screening for anti-HPA-1a antibodies in HPA-1bb women may identify first pregnancies at risk. Our goal was to review results from previous published studies to examine whether the maternal antibody level to HPA-1a could be used to identify high-risk pregnancies. MATERIALS AND METHODS The studies included were categorized by recruitment strategies: screening of unselected pregnancies or samples analyzed from known or suspected FNAIT patients. RESULTS Three prospective studies reported results from screening programmes, and 10 retrospective studies focused on suspected cases of FNAIT. In 8 studies samples for antibody measurement, performed by the monoclonal antibody immobilization of platelet antigen (MAIPA) assay, and samples for determining fetal/neonatal platelet count were collected simultaneously. In these 8 studies, the maternal antibody level correlated with the risk of severe thrombocytopenia. The prospective studies reported high negative predictive values (88-95%), which would allow for the use of maternal anti-HPA-1a antibody level as a predictive tool in a screening setting, in order to identify cases at low risk for FNAIT. However, due to low positive predictive values reported in prospective as well as retrospective studies (54-97%), the maternal antibody level is less suited for the final diagnosis and for guiding antenatal treatment. CONCLUSION HPA-1a antibody level has the potential to predict the severity of FNAIT.
Collapse
Affiliation(s)
- Mette Kjaer
- Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, Tromsø, Norway
- Finnmark Hospital Trust, Finnmark, Norway
| | - Gerald Bertrand
- Platelet Immunology Department, French Blood Services of Brittany, Rennes, France
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University of Tuebingen, Tuebingen, Germany
- Institute of Immunology and Transfusion Medicine, University Hospital Greifswald, Greifswald, Germany
| | | | - Jillian M Baker
- Hospital for Sick Children, St. Michael's Hospital, Toronto, ON, Canada
| | - Lani Lieberman
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Susano Tanael
- Center for Innovation, Canadian Blood Services, Toronto, ON, Canada
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - Donald M Arnold
- Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada
| | - Shoma Baidya
- Australian Red Cross Blood Service, Brisbane, QLD, Australia
| | | | - Heather Hume
- Division of Hematology-Oncology, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Cécile Kaplan
- Institut National de la Transfusion Sanguine, Paris, France
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, Toronto, ON, Canada
| | - Helen Savoia
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nadine Shehata
- Center for Innovation, Canadian Blood Services, Toronto, ON, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetric Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Jens Kjeldsen-Kragh
- Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Immunology and Transfusion Medicine, Regional and University Laboratories Region Skåne, Lund, Sweden
| |
Collapse
|
10
|
Christino Luiz MF, Baschat AA, Delp C, Miller JL. Massive Fetomaternal Hemorrhage Remote from Term: Favorable Outcome after Fetal Resuscitation and Conservative Management. Fetal Diagn Ther 2018; 45:361-364. [PMID: 30199875 DOI: 10.1159/000492750] [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: 03/22/2018] [Accepted: 08/06/2018] [Indexed: 11/19/2022]
Abstract
Fetomaternal hemorrhage (FMH) is a rare condition that requires early diagnosis and appropriate treatment due to its potentially severe consequences. We report a case of massive FMH presenting as decreased fetal movement, fetal hydrops, and intracranial hemorrhage at 24 weeks. Treatment considerations were made and amniocentesis, fetal blood sampling, and fetal blood transfusion via cordocentesis were performed. Recurrent FMH required subsequent fetal transfusion 2 days later. Surveillance was continued twice weekly until the patient delivered a viable infant at 38 weeks after spontaneous labor. Recurrent FMH was unpredictable due to its unclear etiology and absence of precipitating events, however close surveillance proved effective.
Collapse
Affiliation(s)
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cassandra Delp
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jena L Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| |
Collapse
|
11
|
Refsum E, Håkansson S, Mörtberg A, Wikman A, Westgren M. Intracranial hemorrhages in neonates born from 32 weeks of gestation-low frequency of associated fetal and neonatal alloimmune thrombocytopenia: a register-based study. Transfusion 2017; 58:223-231. [DOI: 10.1111/trf.14394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Erle Refsum
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics; Umeå University; Umeå Sweden
| | - Anette Mörtberg
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Agneta Wikman
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
| |
Collapse
|
12
|
Karanth L, Kanagasabai S, Abas ABL. Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers. Cochrane Database Syst Rev 2017; 8:CD011059. [PMID: 28776324 PMCID: PMC6483261 DOI: 10.1002/14651858.cd011059.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. This is an update of a previously published review. OBJECTIVES To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews.Date of last search of the Group's Trials Registers: 16 February 2017. SELECTION CRITERIA Randomised controlled trials and all types of controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion MAIN RESULTS: No results from randomised controlled trials were found. AUTHORS' CONCLUSIONS The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus.Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.
Collapse
Affiliation(s)
- Laxminarayan Karanth
- Melaka Manipal Medical CollegeDepartment of Obstetrics and GynecologyBukit Baru, Jalan BatuHamparMelakaMalaysia75150
| | - Sachchithanantham Kanagasabai
- Melaka Manipal Medical CollegeDepartment of Obstetrics and GynecologyBukit Baru, Jalan BatuHamparMelakaMalaysia75150
| | - Adinegara BL Abas
- Melaka‐Manipal Medical CollegeDepartment of Community MedicineJalan Batu HamparBukit BaruMelakaMalaysia75150
| | | |
Collapse
|
13
|
Solh Z, Breakey V, Murthy P, Smith JW, Arnold DM. Triplets with neonatal alloimmune thrombocytopenia due to antibodies against human platelet antigen 1a. Transfusion 2016; 56:1166-1170. [PMID: 26813079 DOI: 10.1111/trf.13494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/25/2015] [Accepted: 12/17/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neonatal alloimmune thrombocytopenia (NAIT) has been reported only rarely in twins and not at all, to our knowledge, in triplets. CASE REPORT Nonidentical triplets were born with severe thrombocytopenia. Nadir platelet (PLT) counts were 17 × 109 , 12 × 109 , and 10 × 109 /L. NAIT was confirmed by an incompatibility for human PLT antigen (HPA)-1a and the presence of maternal anti-HPA-1a. The maternal genotype was HPA-1bb and the paternal genotype was HPA-1aa; thus, all children were affected. RESULTS PLT counts for each infant improved with the administration of random-donor PLT transfusions. All three infants also received intravenous immunoglobulin. None had major bleeding. A small isolated subependymal hemorrhage was found incidentally in one infant; this remained stable on repeat imaging. CONCLUSIONS This is the first report of triplets with NAIT. Anti-HPA-1a is sufficiently potent to affect three infants simultaneously. Random-donor PLTs were effective in improving PLT counts in all three infants.
Collapse
Affiliation(s)
- Ziad Solh
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, McMaster Children's Hospital, McMaster University, Hamilton, ON
| | - Vicky Breakey
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, McMaster Children's Hospital, McMaster University, Hamilton, ON
| | - Prashanth Murthy
- Department of Pediatrics, Division of Neonatology, University of Calgary, Calgary, AB
| | - James W Smith
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - Donald M Arnold
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON
| |
Collapse
|
14
|
Vadasz B, Chen P, Yougbaré I, Zdravic D, Li J, Li C, Carrim N, Ni H. Platelets and platelet alloantigens: Lessons from human patients and animal models of fetal and neonatal alloimmune thrombocytopenia. Genes Dis 2015; 2:173-185. [PMID: 28345015 PMCID: PMC5362271 DOI: 10.1016/j.gendis.2015.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. Emerging evidence indicates that they are versatile cells and also involved in many other physiological processes and disease states. Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a life threatening bleeding disorder caused by fetal platelet destruction by maternal alloantibodies developed during pregnancy. Gene polymorphisms cause platelet surface protein incompatibilities between mother and fetus, and ultimately lead to maternal alloimmunization. FNAIT is the most common cause of intracranial hemorrhage in full-term infants and can also lead to intrauterine growth retardation and miscarriage. Proper diagnosis, prevention and treatment of FNAIT is challenging due to insufficient knowledge of the disease and a lack of routine screening as well as its frequent occurrence in first pregnancies. Given the ethical difficulties in performing basic research on human fetuses and neonates, animal models are essential to improve our understanding of the pathogenesis and treatment of FNAIT. The aim of this review is to provide an overview on platelets, hemostasis and thrombocytopenia with a focus on the advancements made in FNAIT by utilizing animal models.
Collapse
Affiliation(s)
- Brian Vadasz
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Pingguo Chen
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Issaka Yougbaré
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Darko Zdravic
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - June Li
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Conglei Li
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Naadiya Carrim
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - Heyu Ni
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
15
|
Karanth L, Kanagasabai S, Abas ABL. Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers. Cochrane Database Syst Rev 2015:CD011059. [PMID: 25835707 DOI: 10.1002/14651858.cd011059.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. OBJECTIVES To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews.Date of last search of the Group's Trials Registers: 13 January 2015. SELECTION CRITERIA Randomised controlled trials and all types of controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion MAIN RESULTS No results from randomized controlled trials were found. AUTHORS' CONCLUSIONS The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus.Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.
Collapse
Affiliation(s)
- Laxminarayan Karanth
- Department of Obstetrics and Gynecology, Melaka Manipal Medical College, Bukit Baru, Jalan Batu, Hampar, Melaka, Malaysia, 75150
| | | | | |
Collapse
|
16
|
Jackson DJ, Eastlake JL, Kumpel BM. Human platelet antigen (HPA)-1a peptides do not reliably suppress anti-HPA-1a responses using a humanized severe combined immunodeficiency (SCID) mouse model. Clin Exp Immunol 2014; 176:23-36. [PMID: 24261689 DOI: 10.1111/cei.12242] [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] [Accepted: 11/19/2013] [Indexed: 12/21/2022] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) occurs most frequently when human platelet antigen (HPA)-1a-positive fetal platelets are destroyed by maternal HPA-1a immunoglobulin (Ig)G antibodies. Pregnancies at risk are treated by administration of high-dose intravenous Ig (IVIG) to women, but this is expensive and often not well tolerated. Peptide immunotherapy may be effective for ameliorating some allergic and autoimmune diseases. The HPA-1a/1b polymorphism is Leu/Pro33 on β3 integrin (CD61), and the anti-HPA-1a response is restricted to HPA-1b1b and HLA-DRB3*0101-positive pregnant women with an HPA-1a-positive fetus. We investigated whether or not HPA-1a antigen-specific peptides that formed the T cell epitope could reduce IgG anti-HPA-1a responses, using a mouse model we had developed previously. Peripheral blood mononuclear cells (PBMC) in blood donations from HPA-1a-immunized women were injected intraperitoneally (i.p.) into severe combined immunodeficient (SCID) mice with peptides and HPA-1a-positive platelets. Human anti-HPA-1a in murine plasma was quantitated at intervals up to 15 weeks. HPA-1a-specific T cells in PBMC were identified by proliferation assays. Using PBMC of three donors who had little T cell reactivity to HPA-1a peptides in vitro, stimulation of anti-HPA-1a responses by these peptides occurred in vivo. However, with a second donation from one of these women which, uniquely, had high HPA-1a-specific T cell proliferation in vitro, marked suppression of the anti-HPA-1a response by HPA-1a peptides occurred in vivo. HPA-1a peptide immunotherapy in this model depended upon reactivation of HPA-1a T cell responses in the donor. For FNAIT, we suggest that administration of antigen-specific peptides to pregnant women might cause either enhancement or reduction of pathogenic antibodies.
Collapse
Affiliation(s)
- D J Jackson
- International Blood Group Reference Laboratory, Bristol Institute for Transfusion Sciences, NHS Blood and Transplant, Bristol, UK
| | | | | |
Collapse
|
17
|
Kunishima S, Hayakawa A, Fujita K, Saito H. Transient macrothrombocytopenia associated with maternal-neonatal HPA-21bw incompatibility. Thromb Res 2013; 131:e286-8. [PMID: 23721693 DOI: 10.1016/j.thromres.2013.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 04/16/2013] [Accepted: 05/05/2013] [Indexed: 11/27/2022]
|
18
|
Peterson JA, McFarland JG, Curtis BR, Aster RH. Neonatal alloimmune thrombocytopenia: pathogenesis, diagnosis and management. Br J Haematol 2013; 161:3-14. [PMID: 23384054 DOI: 10.1111/bjh.12235] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Neonatal alloimmune thrombocytopenia, (NAIT) is caused by maternal antibodies raised against alloantigens carried on fetal platelets. Although many cases are mild, NAIT is a significant cause of morbidity and mortality in newborns and is the most common cause of intracranial haemorrhage in full-term infants. In this report, we review the pathogenesis, clinical presentation, laboratory diagnosis and prenatal and post-natal management of NAIT and highlight areas of controversy that deserve the attention of clinical and laboratory investigators.
Collapse
Affiliation(s)
- Julie A Peterson
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI 53226-3548, US.
| | | | | | | |
Collapse
|
19
|
Kumpel BM. Would it be possible to prevent HPA-1a alloimmunization to reduce the incidence of fetal and neonatal alloimmune thrombocytopenia? Transfusion 2012; 52:1393-7. [PMID: 22780891 DOI: 10.1111/j.1537-2995.2012.03700.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Crosstalk between Platelets and the Immune System: Old Systems with New Discoveries. Adv Hematol 2012; 2012:384685. [PMID: 23008717 PMCID: PMC3447344 DOI: 10.1155/2012/384685] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 08/15/2012] [Indexed: 11/17/2022] Open
Abstract
Platelets are small anucleate cells circulating in the blood. It has been recognized for more than 100 years that platelet adhesion and aggregation at the site of vascular injury are critical events in hemostasis and thrombosis; however, recent studies demonstrated that, in addition to these classic roles, platelets also have important functions in inflammation and the immune response. Platelets contain many proinflammatory molecules and cytokines (e.g., P-selectin, CD40L, IL-1β, etc.), which support leukocyte trafficking, modulate immunoglobulin class switch, and germinal center formation. Platelets express several functional Toll-like receptors (TLRs), such as TLR-2, TLR-4, and TLR-9, which may potentially link innate immunity with thrombosis. Interestingly, platelets also contain multiple anti-inflammatory molecules and cytokines (e.g., transforming growth factor-β and thrombospondin-1). Emerging evidence also suggests that platelets are involved in lymphatic vessel development by directly interacting with lymphatic endothelial cells through C-type lectin-like receptor 2. Besides the active contributions of platelets to the immune system, platelets are passively targeted in several immune-mediated diseases, such as autoimmune thrombocytopenia, infection-associated thrombocytopenia, and fetal and neonatal alloimmune thrombocytopenia. These data suggest that platelets are important immune cells and may contribute to innate and adaptive immunity under both physiological and pathological conditions.
Collapse
|
21
|
Abstract
Neonatal alloimmune thrombocytopenia (NAIT), with an incidence of one in 1000 live births, is the most common cause of severe thrombocytopenia and intra-cerebral haemorrhage in term neonates. NAIT results from trans-placental passage of maternal antibodies against a paternally derived fetal platelet alloantigen. Clinical presentation varies from unexpected thrombocytopenia on a blood film in a well newborn to intracranial haemorrhage (ICH). In contrast to haemolytic disease of the newborn, NAIT can present in a first pregnancy, and subsequent pregnancies are usually more severely affected. The role of antenatal screening for maternal alloantibodies instead of fetal blood sampling to identify at-risk fetuses remains uncertain, but there is a trend towards less invasive maternally directed treatment for at-risk pregnancies. Neonatal management is aimed at preventing or limiting thrombocytopenic bleeding with transfusion of antigen-matched platelets.
Collapse
Affiliation(s)
- David C Risson
- Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | | | | |
Collapse
|
22
|
Li C, Piran S, Chen P, Lang S, Zarpellon A, Jin JW, Zhu G, Reheman A, van der Wal DE, Simpson EK, Ni R, Gross PL, Ware J, Ruggeri ZM, Freedman J, Ni H. The maternal immune response to fetal platelet GPIbα causes frequent miscarriage in mice that can be prevented by intravenous IgG and anti-FcRn therapies. J Clin Invest 2011; 121:4537-47. [PMID: 22019589 PMCID: PMC3204841 DOI: 10.1172/jci57850] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 08/26/2011] [Indexed: 11/17/2022] Open
Abstract
Fetal and neonatal immune thrombocytopenia (FNIT) is a severe bleeding disorder caused by maternal antibody-mediated destruction of fetal/neonatal platelets. It is the most common cause of severe thrombocytopenia in neonates, but the frequency of FNIT-related miscarriage is unknown, and the mechanism(s) underlying fetal mortality have not been explored. Furthermore, although platelet αIIbβ3 integrin and GPIbα are the major antibody targets in immune thrombocytopenia, the reported incidence of anti-GPIbα-mediated FNIT is rare. Here, we developed mouse models of FNIT mediated by antibodies specific for GPIbα and β3 integrin and compared their pathogenesis. We found, unexpectedly, that miscarriage occurred in the majority of pregnancies in our model of anti-GPIbα-mediated FNIT, which was far more frequent than in anti-β3-mediated FNIT. Dams with anti-GPIbα antibodies exhibited extensive fibrin deposition and apoptosis/necrosis in their placentas, which severely impaired placental function. Furthermore, anti-GPIbα (but not anti-β3) antiserum activated platelets and enhanced fibrin formation in vitro and thrombus formation in vivo. Importantly, treatment with either intravenous IgG or a monoclonal antibody specific for the neonatal Fc receptor efficiently prevented anti-GPIbα-mediated FNIT. Thus, the maternal immune response to fetal GPIbα causes what we believe to be a previously unidentified, nonclassical FNIT (i.e., spontaneous miscarriage but not neonatal bleeding) in mice. These results suggest that a similar pathology may have masked the severity and frequency of human anti-GPIbα-mediated FNIT, but also point to possible therapeutic interventions.
Collapse
MESH Headings
- Abortion, Spontaneous/etiology
- Abortion, Spontaneous/immunology
- Abortion, Spontaneous/prevention & control
- Animals
- Blood Platelets/immunology
- Disease Models, Animal
- Female
- Histocompatibility Antigens Class I/immunology
- Histocompatibility, Maternal-Fetal/immunology
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Integrin beta3/genetics
- Integrin beta3/immunology
- Mice
- Mice, Inbred BALB C
- Mice, Knockout
- Platelet Glycoprotein GPIb-IX Complex/genetics
- Platelet Glycoprotein GPIb-IX Complex/immunology
- Pregnancy
- Receptors, Fc/antagonists & inhibitors
- Receptors, Fc/immunology
- Thrombocytopenia, Neonatal Alloimmune/etiology
- Thrombocytopenia, Neonatal Alloimmune/immunology
Collapse
Affiliation(s)
- Conglei Li
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Siavash Piran
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Pingguo Chen
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Sean Lang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Alessandro Zarpellon
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Joseph W. Jin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Guangheng Zhu
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Adili Reheman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Dianne E. van der Wal
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Elisa K. Simpson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Ran Ni
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Peter L. Gross
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Jerry Ware
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Zaverio M. Ruggeri
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - John Freedman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| | - Heyu Ni
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
Toronto Platelet Immunobiology Group and Department of Laboratory Medicine, Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
Canadian Blood Services, Toronto, Ontario, Canada.
Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
Department of Medicine and
Department of Physiology, University of Toronto, Ontario, Canada
| |
Collapse
|
23
|
Rayment R, Brunskill SJ, Soothill PW, Roberts DJ, Bussel JB, Murphy MF. Antenatal interventions for fetomaternal alloimmune thrombocytopenia. Cochrane Database Syst Rev 2011:CD004226. [PMID: 21563140 DOI: 10.1002/14651858.cd004226.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fetomaternal alloimmune thrombocytopenia results from the formation of antibodies by the mother which are directed against a fetal platelet alloantigen inherited from the father. The resulting fetal thrombocytopenia (reduced platelet numbers) may cause bleeding, particularly into the brain, before or shortly after birth. Antenatal treatment of fetomaternal alloimmune thrombocytopenia includes the administration of intravenous immunoglobulin (IVIG) and/or corticosteroids to the mother to prevent severe fetal thrombocytopenia. IVIG and corticosteroids both have short-term and possibly long-term side effects. IVIG is also costly and optimal regimens need to be identified. OBJECTIVES To determine the optimal antenatal treatment of fetomaternal alloimmune thrombocytopenia to prevent fetal and neonatal haemorrhage and death. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2011) and bibliographies of relevant publications and review articles. SELECTION CRITERIA Randomised controlled studies comparing any intervention with no treatment, or comparing any two interventions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, trial quality and extracted data. MAIN RESULTS We included four trials involving 206 people. One trial involving 39 people compared a corticosteroid (prednisone) versus IVIG alone. In this trial, where analysable data were available, there was no statistically significant differences between the treatment arms for predefined outcomes. Three trials involving 167 people compared IVIG plus a corticosteroid (prednisone in two trials and dexamethasone in one trial) versus IVIG alone. In these trials there was no statistically significant difference in the findings between the treatment arms for predefined outcomes (intracranial haemorrhage; platelet count at birth and preterm birth). Lack of complete data sets and important differences in interventions precluded the pooling of data from these trials. AUTHORS' CONCLUSIONS The optimal management of fetomaternal alloimmune thrombocytopenia remains unclear. Lack of complete data sets for two trials and differences in interventions precluded the pooling of data from these trials which may have enabled a more developed analysis of the trial findings. Further trials would be required to determine optimal treatment (the specific medication and its dose and schedule). Such studies should include long-term follow up of all children and mothers.
Collapse
Affiliation(s)
- Rachel Rayment
- Arthur Bloom Haemophilia Centre, University Hospital of Wales, Cardiff and Vale NHS Trust, Heath Park, Cardiff, UK, CF14 4XW
| | | | | | | | | | | |
Collapse
|
24
|
Shehata N, Denomme GA, Hannach B, Banning N, Freedman J. Mass-scale high-throughput multiplex polymerase chain reaction for human platelet antigen single-nucleotide polymorphisms screening of apheresis platelet donors. Transfusion 2011; 51:2028-33. [DOI: 10.1111/j.1537-2995.2011.03082.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
McQuilten ZK, Wood EM, Savoia H, Cole S. A review of pathophysiology and current treatment for neonatal alloimmune thrombocytopenia (NAIT) and introducing the Australian NAIT registry. Aust N Z J Obstet Gynaecol 2011; 51:191-8. [PMID: 21631435 DOI: 10.1111/j.1479-828x.2010.01270.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fetomaternal or neonatal alloimmune thrombocytopenia (NAIT) is a rare but serious condition associated with significant fetal and neonatal morbidity and mortality. The most useful predictor of severe disease is a history of a sibling with an antenatal intracranial haemorrhage. However, NAIT can occur during the first pregnancy and may not be diagnosed until the neonatal period. Antenatal treatment options include maternal intravenous immunoglobulin (IVIG) and corticosteroid treatment, fetal blood sampling (FBS) and intrauterine platelet transfusion (IUT) and early delivery. FBS (with or without IUT) can be used to direct and monitor response to therapy, and to inform mode and timing of delivery. However, this procedure is associated with significant risks, including fetal death, and is generally now reserved for high-risk pregnancies. This review highlights the current understanding of the epidemiology and pathophysiology of NAIT and summarises current approaches to investigation and management. It also introduces the newly established Australian NAIT registry. Owing to the relative rarity of NAIT, accruing sufficient patient numbers for studies and clinical trials at an institutional level is difficult. This national registry will provide an opportunity to collect valuable information and inform future research on this condition.
Collapse
Affiliation(s)
- Zoe K McQuilten
- Transfusion Medicine Services, Australian Red Cross Blood Service, South Melbourne, Victoria 3205, Australia.
| | | | | | | |
Collapse
|
26
|
Kamphuis MM, Paridaans N, Porcelijn L, De Haas M, van der Schoot CE, Brand A, Bonsel GJ, Oepkes D. Screening in pregnancy for fetal or neonatal alloimmune thrombocytopenia: systematic review. BJOG 2010; 117:1335-43. [DOI: 10.1111/j.1471-0528.2010.02657.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
27
|
Peterson JA, Gitter ML, Kanack A, Curtis B, McFarland J, Bougie D, Aster R. New low-frequency platelet glycoprotein polymorphisms associated with neonatal alloimmune thrombocytopenia. Transfusion 2009; 50:324-33. [PMID: 19821948 DOI: 10.1111/j.1537-2995.2009.02438.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent reports suggest that maternal immunization against low-frequency, platelet (PLT)-specific glycoprotein (GP) polymorphisms is a more common cause of neonatal alloimmune thrombocytopenia (NATP) than previously thought. STUDY DESIGN AND METHODS Serologic and molecular studies were performed on PLTs and DNA from three families in which an infant was born with apparent NATP not attributable to maternal immunization against known PLT-specific alloantigens. RESULTS Antibodies reactive only with paternal PLTs were identified in each mother. In Cases 2 (Kno) and 3 (Nos), but not Case 1 (Sta), antibody recognized paternal GPIIb/IIIa in solid-phase assays. Unique mutations encoding amino acid substitutions in GPIIb (Case 2) or GPIIIa (Cases 1 and 3) were identified in paternal DNA and in DNA from two of the affected infants. Antibody from all three cases recognized recombinant GPIIIa (Case 1 [Sta] and Case 3 [Nos]) and GPIIb (Case 2, Kno) mutated to contain the polymorphisms identified in the respective fathers. None of 100 unselected normal subjects possessed the paternal mutations. Enzyme-linked immunosorbent assay and flow cytometric studies suggested that failure of maternal serum from Case 1 (Sta) to react with paternal GPIIIa in solid-phase assays resulted from use of a monoclonal antibody AP2, for antigen immobilization that competed with the maternal antibody for binding to the Sta epitope. CONCLUSION NATP in the three cases was caused by maternal immunization against previously unreported, low-frequency GP polymorphisms. Maternal immunization against low-frequency PLT-specific alloantigens should be considered in cases of apparent NATP not resolved by conventional serologic and molecular testing.
Collapse
Affiliation(s)
- Julie A Peterson
- Blood Research Institute and Platelet & Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, Wisconsin 53201-2178, USA.
| | | | | | | | | | | | | |
Collapse
|
28
|
Jallu V, Merel P, Morel-Kopp MC, Comeau F, Pigeonnier V, Vezon G, Kaplan C, Hourdillé P, Nurden AT. Studies on the HLA Class-II Antigens of a Patient Presenting a Double Alloimmunization Following Posttransfusion Purpura. Platelets 2009; 4:322-31. [DOI: 10.3109/09537109309013235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
29
|
Taaning E, Petersen S, Reinholdt J, Bock J, Svejgaard A. Neonatal Immune Thrombocytopenia Due to Allo-or Autoantibodies: Clinical and Immunological Analysis of 83 Cases. Platelets 2009; 5:53-8. [DOI: 10.3109/09537109409006041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
30
|
Mackenzie F, Brennand J, Peterkin M, Cameron A. Management of fetal alloimmune thrombocytopenia-a less invasive option? J OBSTET GYNAECOL 2009; 19:119-21. [PMID: 15512247 DOI: 10.1080/01443619965372] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Fetal alloimmune thrombocytopenia (FAITP) is a condition associated with significant infant morbidity and mortality. We report on the West of Scotland experience of 30 pregnancies complicated by FAITP over a 17-year period (1982-98). Management options included serial cordocentesis together with platelet transfusion, and maternal intravenous gammaglobulin (IVIgG) therapy. Of those pregnancies managed by serial cordocentesis all had poor outcomes. Weekly IVIgG was administered to the remaining pregnancies, all of which had a good outcome although four infants were thrombocytopenic at birth. None of these cases had previously been complicated by intracranial haemorrhage. In the milder end of the spectrum of FAITP we would suggest that IVIgG is an alternative treatment option.
Collapse
Affiliation(s)
- F Mackenzie
- Department of Fetal Medicine, The Queen Mother's Hospital, Yorkhill, Glasglow, UK
| | | | | | | |
Collapse
|
31
|
Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is the commonest cause of severe thrombocytopenia in neonates, and of intracranial hemorrhage (ICH) in term neonates [1] (J Trop Pediatr, 1999; 45: 237). If a newborn is affected with AIT, the next child will likely be more severely affected, and therefore fetal thrombocytopenia will begin early in gestation [2, 3] (Arch Neurol, 1984; 41: 30; N Engl J Med 1997; 337: 22). This creates a risk of in utero ICH even if there was not one in the previous pregnancy. There are new developments in AIT in regard to diagnosis, treatment, and screening which will be the focus of this review.
Collapse
Affiliation(s)
- J Bussel
- Platelet Research & Treatment Program, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10065, USA.
| |
Collapse
|
32
|
Bussel JB, Sola-Visner M. Current approaches to the evaluation and management of the fetus and neonate with immune thrombocytopenia. Semin Perinatol 2009; 33:35-42. [PMID: 19167580 DOI: 10.1053/j.semperi.2008.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia is not a well-known disease, except among specialists in maternal-fetal medicine, neonatologists, and certain pediatricians (ie, hematologists). However, this is by far the most common cause of early severe thrombocytopenia in neonates and of intracranial hemorrhage in term neonates. In addition, if a newborn is affected with alloimmune thrombocytopenia, the next child in the family will likely be more severely affected. Thus, the accurate diagnosis and appropriate management of this disorder are of extreme importance in perinatal medicine and will constitute the focus of this review.
Collapse
Affiliation(s)
- James B Bussel
- Division of Pediatric Hematology Oncology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY 10065, USA.
| | | |
Collapse
|
33
|
Bessos H, Killie MK, Matviyenko M, Husebekk A, Urbaniak SJ. Direct comparison between two quantitative assays in the measurement of maternal anti-HPA-1a antibody in neonatal alloimmune thrombocytopenia (NAIT). Transfus Apher Sci 2008; 39:221-7. [DOI: 10.1016/j.transci.2008.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
34
|
Abstract
Fetal thrombocytopenia is most often caused by maternal alloantibodies against fetal platelets crossing the placenta and resulting in platelet destruction. This condition, known as fetal and neonatal alloimmune thrombocytopenia, is usually detected after the birth of a symptomatic child who shows signs of bleeding in the skin or in the brain. In the most severe cases, intracranial hemorrhage leads to severe handicap or death. The challenge for the clinician is to provide preventive treatment in the next pregnancy. The current cornerstone of this treatment is maternal intravenous administration of immunoglobulins during the second half of pregnancy.
Collapse
Affiliation(s)
- L Porcelijn
- Department of Immunohaematology Diagnostic Services, Sanquin Diagnostic Services (CLB), Amsterdam, The Netherlands
| | | | | |
Collapse
|
35
|
Kjeldsen-Kragh J, Husebekk A, Killie MK, Skogen B. Is it time to include screening for neonatal alloimmune thrombocytopenia in the general antenatal health care programme? Transfus Apher Sci 2008; 38:183-8. [DOI: 10.1016/j.transci.2008.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
36
|
Fetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT): Past, Present, and Future. Obstet Gynecol Surv 2008; 63:239-52. [DOI: 10.1097/ogx.0b013e31816412d3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
37
|
van den Akker ES, Oepkes D. Fetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2008; 22:3-14. [DOI: 10.1016/j.bpobgyn.2007.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
38
|
Bussel JB, Primiani A. Fetal and neonatal alloimmune thrombocytopenia: progress and ongoing debates. Blood Rev 2007; 22:33-52. [PMID: 17981381 DOI: 10.1016/j.blre.2007.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is a result of a parental incompatibility of platelet-specific antigens and the transplacental passage of maternal alloantibodies against the platelet antigen shared by the father and the fetus. It occurs in approximately 1 in 1000 live births and is the most common cause of severe thrombocytopenia in fetuses and term neonates. As screening programs are not routinely performed, most affected fetuses are identified after birth when neonatal thrombocytopenia is recognized. In severe cases, the affected fetus is identified as a result of suffering from an in utero intracranial hemorrhage. Once diagnosed, AIT must be treated antenatally as the disease can be more severe in subsequent pregnancies. While there have been many advances regarding the diagnosis and treatment of AIT, it is still difficult to predict the severity of disease and which therapy will be effective.
Collapse
Affiliation(s)
- James B Bussel
- Division of Hematology, Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021-4853, United States.
| | | |
Collapse
|
39
|
Kjeldsen-Kragh J, Killie MK, Tomter G, Golebiowska E, Randen I, Hauge R, Aune B, Øian P, Dahl LB, Pirhonen J, Lindeman R, Husby H, Haugen G, Grønn M, Skogen B, Husebekk A. A screening and intervention program aimed to reduce mortality and serious morbidity associated with severe neonatal alloimmune thrombocytopenia. Blood 2007; 110:833-9. [PMID: 17429009 DOI: 10.1182/blood-2006-08-040121] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The study's objective was to identify HPA 1a-negative women and to offer them an intervention program aimed to reduce morbidity and mortality of neonatal alloimmune thrombocytopenia (NAIT). HPA 1 typing was performed in 100 448 pregnant women. The HPA 1a-negative women were screened for anti-HPA 1a. In immunized women, delivery was performed by Cesarean section 2 to 4 weeks prior to term, with platelets from HPA 1a-negative donors reserved for immediate transfusion if petechiae were present and/or if platelet count was less than 35 x 10(9)/L. Of the women screened, 2.1% were HPA 1a negative, and anti-HPA 1a was detected in 10.6% of these. One hundred seventy pregnancies were managed according to the intervention program, resulting in 161 HPA 1a-positive children. Of these, 55 had severe thrombocytopenia (< 50 x 10(9)/L), including 2 with intracranial hemorrhage (ICH). One woman with a twin pregnancy missed the follow-up and had one stillborn and one severely thrombocytopenic live child. In 15 previous prospective studies (136 814 women) there were 51 cases of severe NAIT (3 intrauterine deaths and 7 with ICH). Acknowledging the limitation of comparing with historic controls, implementation of our screening and intervention program seemed to reduce the number of cases of severe NAIT-related complications from 10 of 51 to 3 of 57.
Collapse
MESH Headings
- Adult
- Antigens, Human Platelet/blood
- Antigens, Human Platelet/immunology
- Blood Grouping and Crossmatching
- Blood Transfusion
- Cesarean Section
- Female
- Fetal Death/blood
- Fetal Death/immunology
- Fetal Death/prevention & control
- Follow-Up Studies
- Humans
- Immunization
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/prevention & control
- Integrin beta3
- Intracranial Hemorrhages/blood
- Intracranial Hemorrhages/immunology
- Intracranial Hemorrhages/mortality
- Intracranial Hemorrhages/prevention & control
- Male
- Neonatal Screening
- Platelet Count
- Pregnancy
- Stillbirth
- Thrombocytopenia/blood
- Thrombocytopenia/immunology
- Thrombocytopenia/mortality
- Thrombocytopenia/prevention & control
Collapse
|
40
|
van den Akker ESA, Oepkes D, Lopriore E, Brand A, Kanhai HHH. Noninvasive antenatal management of fetal and neonatal alloimmune thrombocytopenia: safe and effective. BJOG 2007; 114:469-73. [PMID: 17309545 DOI: 10.1111/j.1471-0528.2007.01244.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the outcome of pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT) in relation to the invasiveness of the management protocol. DESIGN Retrospective analysis of prospectively collected data from a national cohort. SETTING Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation in pregnancy. POPULATION Ninety-eight pregnancies in 85 women with FNAIT having a previous child with thrombocytopenia with (n= 16) or without (n= 82) an intracranial haemorrhage (ICH). METHODS Our management protocol evolved over time from (1) serial fetal blood samplings (FBS) and platelet transfusion (n= 13) via (2) combined FBS with maternal intravenous immunoglobulins (n= 33) to (3) completely noninvasive treatment with immunoglobulins only (n= 52 pregnancies, resulting in 53 neonates). Perinatal outcome was assessed according to the three types of management. MAIN OUTCOME MEASURES Occurrence of ICH, perinatal survival, gestational age at birth and complications of FBS. RESULTS All but one of 98 pregnancies ended in a live birth; none of the neonates had an ICH. The median gestational age at birth was 37 weeks (range 32-40). In groups 1 and 2, three emergency caesarean sections were performed after complicated FBS, resulting in two healthy babies and one neonatal death. CONCLUSION Noninvasive antenatal management of pregnancies complicated by FNAIT appears to be both effective and safe.
Collapse
Affiliation(s)
- E S A van den Akker
- Department of Obstetrics, Lieden University Medical Centre, Leiden, The Netherlands.
| | | | | | | | | |
Collapse
|
41
|
Abstract
There have been considerable advances in the clinical and laboratory diagnosis of alloimmune thrombocytopenia (AIT), and its postnatal and antenatal management. The antenatal management of AIT has been particularly problematic, because severe haemorrhage occurs as early as 16 weeks gestation and there is no non-invasive investigation that reliably predicts the severity of AIT in utero. The strategies for antenatal treatment have included the use of serial platelet transfusions that, while effective, are invasive and associated with significant morbidity and mortality. Maternal therapy involving the administration of intravenous immunoglobulin and/or steroids is also effective and associated with fewer risks to the fetus. Significant recent progress has involved refinement of maternal treatment, stratifying it according to the likely severity of AIT based on the history in previous pregnancies. However, the ideal antenatal treatment, which is effective without causing significant side-effects to the mother or fetus, has yet to be determined, and further clinical trials are needed.
Collapse
Affiliation(s)
- Michael F Murphy
- National Blood Service, Department of Haematology, John Radcliffe Hospital, University of Oxford, Oxford, UK.
| | | |
Collapse
|
42
|
Deruelle P, Wibaut B, Manessier L, Subtil D, Vaast P, Puech F, Valat AS. [Is a non-invasive management allowed for maternofetal alloimmune thrombocytopenia? Experience over a 10-year period]. ACTA ACUST UNITED AC 2007; 35:199-204. [PMID: 17306591 DOI: 10.1016/j.gyobfe.2007.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 01/09/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our purpose was to study a non-invasive management of fetomaternal alloimmune thrombocytopenia (FMAIT). PATIENTS AND METHODS Between 1996 and 2005, 18 women were treated. The population was divided into 2 groups: patients with a history of intracranial haemorrhage (ICH) in the older sibling received weekly intravenous immunoglobulin (IVIG) therapy to the mother (1 g/kg per week) without initial cordocentesis whereas patients with a history of neonatal thrombocytopenia did not undergo any treatment. RESULTS All pregnancies with a previous FMAIT were monitored with serial ultrasound scans without cordecentesis. 15 patients had HPA-1, 2 HPA-3 and 1 HPA-5 immunizations. Weekly intravenous immunoglobulin therapy was administered in 5 patients with a history of ICH in the older sibling. Two of these delivered thrombocytopenic children; one had a platelet count < 50 x 10(9)/l. For the 13 women (one twin) who had a sibling with neonatal thrombocytopenia, 11/14 newborns had a platelet count < 50 x 10(9)/l. Predelivery fetal blood sampling were performed in 8/18 pregnancies. The neonatal periods of the 19 children were uncomplicated and no ICHs were observed. DISCUSSION AND CONCLUSION Our results suggest that a non-invasive strategy avoiding serial cordocentesis may be an effective therapy in patients who are at risk of fetal and neonatal alloimmune thrombocytopenia.
Collapse
Affiliation(s)
- P Deruelle
- Clinique de Gynécologie, d'Obstétrique et de Néonatologie, Hôpital Jeanne-de-Flandre, Centre Hospitalier Régional Universitaire (CHRU) de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France.
| | | | | | | | | | | | | |
Collapse
|
43
|
Yinon Y, Spira M, Solomon O, Weisz B, Chayen B, Schiff E, Lipitz S. Antenatal noninvasive treatment of patients at risk for alloimmune thrombocytopenia without a history of intracranial hemorrhage. Am J Obstet Gynecol 2006; 195:1153-7. [PMID: 17000248 DOI: 10.1016/j.ajog.2006.06.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 05/31/2006] [Accepted: 06/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate noninvasive management of alloimmune thrombocytopenia that included only the blind administration of immunoglobulin. STUDY DESIGN Seventeen women with 30 pregnancies that were at risk of neonatal alloimmune thrombocytopenia were included. Except for 6 cases, in which the women refused treatment, 24 pregnancies were managed by the weekly administration of intravenous immunoglobulin without monitoring platelet count. RESULTS The mean platelet count at birth after intravenous immunoglobulin treatment was 118,000/microL, compared with 25,000/microL among the 17 first affected infants and 24,000/microL among the 6 infants whose mothers refused treatment (P < .05). Only 8% of the treated fetuses had platelet counts of <30,000/microL at birth, compared with 70% of the untreated infants (P < .05). None of the treated and nontreated fetuses had an intracranial hemorrhage. CONCLUSION Noninvasive management of alloimmune thrombocytopenia that consists of only immunoglobulin administration is highly effective and seems safe in women without a history of fetal/neonatal intracranial hemorrhage.
Collapse
Affiliation(s)
- Yoav Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
| | | | | | | | | | | | | |
Collapse
|
44
|
Turner ML, Bessos H, Fagge T, Harkness M, Rentoul F, Seymour J, Wilson D, Gray I, Ahya R, Cairns J, Urbaniak S. Prospective epidemiologic study of the outcome and cost-effectiveness of antenatal screening to detect neonatal alloimmune thrombocytopenia due to anti-HPA-1a. Transfusion 2006; 45:1945-56. [PMID: 16371049 DOI: 10.1111/j.1537-2995.2005.00645.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND To assess the value of antenatal screening to detect neonatal alloimmune thrombocytopenia (NAIT) due to anti-HPA-1a, a prospective study was carried out to quantify the potential clinical benefits and determine whether screening would be cost-effective. STUDY DESIGN AND METHODS An observational prospective controlled study was carried out on 26,506 pregnant women over 2 years. HPA-1a phenotyping was performed in the first trimester and women confirmed HPA-1a-negative were tested for anti-HPA-1a during pregnancy, at delivery, and 10 to 14 days after birth. Babies of HPA-1a-negative women were tested at delivery for thrombocytopenia and examined for signs of bleeding. Economic evaluation was undertaken on the basis of the data collected during the study. RESULTS Twenty-five of 318 women (7.9%) had anti-HPA-1a detected for the first time. Eight women (43 per 100,000) gave birth to babies with NAIT, and 5 (27 per 100,000) had severe thrombocytopenia. Three babies had mild signs of bleeding, and no cases of intracranial hemorrhage (ICH) or fetal loss were detected. It is estimated that it would cost 60,596 pounds (98,771 US dollars) to detect a case of severe NAIT, where anti-HPA-1a has been identified for the first time, and 1,151,323 pounds (1,876,656 US dollars) to prevent a case of ICH, assuming that detection allowed successful intervention. CONCLUSIONS Our data suggest that severe HPA-1a NAIT is underdiagnosed in the absence of routine antenatal screening. Serious bleeding complications and ICH, however, occur less frequently in first cases of NAIT than suspected from the literature, and the costs of screening and possible intervention must be balanced against the procedural risks.
Collapse
Affiliation(s)
- Marc L Turner
- Scottish National Blood Transfusion Service, Aberdeen & Edinburgh, United Kingdom
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Kanhai HHH, van den Akker ESA, Walther FJ, Brand A. Intravenous Immunoglobulins without Initial and Follow-Up Cordocentesis in Alloimmune Fetal and Neonatal Thrombocytopenia at High Risk for Intracranial Hemorrhage. Fetal Diagn Ther 2005; 21:55-60. [PMID: 16354976 DOI: 10.1159/000089048] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 12/10/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report on a less invasive treatment strategy in alloimmune fetal and neonatal thrombocytopenia (FNAIT) at high risk for either in utero or neonatal intracranial hemorrhage (ICH). METHODS In 7 pregnancies, with a history of ICH in the older sibling, weekly intravenous immunoglobulin (IVIG) therapy to the mother (1 g/kg) without initial cordocentesis was started at a median gestational age of 16 weeks. RESULTS In 4 pregnancies cordocentesis was avoided. One predelivery cordocentesis with platelet transfusion was performed in 3 further cases. Although none of the cases had a platelet count of >50 x 10(9)/l at cordocentesis, predelivery or birth, no ICHs were observed. The neonatal periods of the infants were uncomplicated. CONCLUSION IVIG treatment alone might be considered in patients with both severe platelet alloimmunization and an increased risk for morbidity and mortality at cordocentesis.
Collapse
Affiliation(s)
- Humphrey H H Kanhai
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | | |
Collapse
|
46
|
Peterson JA, Balthazor SM, Curtis BR, McFarland JG, Aster RH. Maternal alloimmunization against the rare platelet-specific antigen HPA-9b (Max a) is an important cause of neonatal alloimmune thrombocytopenia. Transfusion 2005; 45:1487-95. [PMID: 16131382 PMCID: PMC1602180 DOI: 10.1111/j.1537-2995.2005.00561.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonatal alloimmune thrombocytopenia (NATP) is an important cause of morbidity and mortality in the newborn. Optimal management of subsequent pregnancies requires knowledge of the alloantigen that caused maternal immunization, but this is possible only in a minority of cases. This study investigated whether this can be explained in part by maternal immunization against the "rare" alloantigen HPA-9b (Max(a)), implicated previously only in a single NATP case. STUDY DESIGN AND METHODS Archived paternal DNA from unresolved cases of NATP and normal individuals was typed for platelet (PLT)-specific antigens with real-time polymerase chain reaction and direct sequencing. PLT-specific alloantibodies were characterized by flow cytometry and solid-phase enzyme-linked immunosorbent assay. Recombinant GPIIb/IIIa was expressed in stably transfected Chinese hamster ovary cells. Clinical information was obtained directly from attending physicians. RESULTS Six of 217 fathers were positive for the presence of HPA-9b (Max(a)), an incidence about seven times that in the general population. In each of five cases studied, maternal serum samples reacted with intact paternal PLTs and paternal GPIIb/IIIa. Only one of three serum samples tested recognized recombinant GPIIb/IIIa carrying the HPA-9b (Max(a)) mutation. These seemingly discrepant reactions may reflect different requirements for oligosaccharides linked to residues close to the mutation in GPIIb that determines HPA-9b (Max(a)). NATP in the affected children was severe and was associated with intracranial hemorrhage in three of six infants on whom information was obtained. CONCLUSIONS Maternal immunization against HPA-9b (Max(a)) is an important cause of NATP and should be considered in cases of apparent NATP not resolved on the basis of maternal-fetal incompatibility for "common" PLT antigens.
Collapse
Affiliation(s)
- Julie A Peterson
- The Blood Research Institute, The BloodCenter of Wisconsin, 8727 Watertown Plank Road, Wauwatosa, WI 53226, USA.
| | | | | | | | | |
Collapse
|
47
|
Bussel JB, Zacharoulis S, Kramer K, McFarland JG, Pauliny J, Kaplan C. Clinical and diagnostic comparison of neonatal alloimmune thrombocytopenia to non-immune cases of thrombocytopenia. Pediatr Blood Cancer 2005; 45:176-83. [PMID: 15828027 DOI: 10.1002/pbc.20282] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Affected patients with neonatal alloimmune thrombocytopenia (AIT) are often severely thrombocytopenic and, if so, may suffer an intracranial hemorrhage (ICH). This study was undertaken to compare the outcome of cases of AIT to cases of neonatal thrombocytopenia shown not to be AIT and to identify clinical features that would facilitate the diagnosis. PROCEDURE Two hundred twenty two cases of neonatal thrombocytopenia for which serologic testing was obtained by the referring physician were accrued for this study from 11 testing laboratories. The relevant clinical information was pursued. RESULTS The mean birth platelet count in 110 neonates with AIT was 26,000/mm(3) x 10(9)/L and the rate of ICH was 11% (not all neonates had head sonos). Three criteria distinguished cases of AIT from other causes of neonatal thrombocytopenia (n = 56): (1) severe thrombocytopenia <50,000/mm(3) x 10(9)/L; (2) ICH associated with 1 or more of: a 1-min Apgar score >5, birthweight >2,200 g, grade >1, antenatal occurrence, or signs of bleeding, that is, petechiae, ecchymoses; and (3) no additional, non-hemorrhagic neonatal medical problems. CONCLUSIONS AIT is a unique type of neonatal thrombocytopenia with significant hemorrhagic consequences. Identification of AIT at the bedside should guide institution of appropriate treatment and lead to serologic testing for confirmation.
Collapse
Affiliation(s)
- James B Bussel
- Department of Pediatrics, The New York Hospital, Cornell University Medical Center, New York, New York 10021, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Kulkarni B, Mohanty D, Ghosh K. Frequency distribution of human platelet antigens in the Indian population. Transfus Med 2005; 15:119-24. [PMID: 15859978 DOI: 10.1111/j.0958-7578.2005.00561.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was undertaken with an aim of establishing the frequency distribution of various human platelet antigens (HPA) in Indian populations by means of DNA-based technology. A total of 1164 people belonging to various population groups were studied for the frequency distribution of HPA. DNA extraction was performed from peripheral venous blood samples. Polymerase chain reaction allele-specific amplification technique was used for HPA genotyping. The HPA bands were visualized by using ethidium bromide-stained agarose gel, after electrophoresis. The homozygosity of the HPA-1b/1b genotype was found to be significantly higher (P < 0.05) in the Parsi population group and Vatalia Prajapati population group, compared to Maharashtrians. Frequency distribution of HPA-1b in our populations was found to be slightly lower than that reported in some western populations. This study has established a DNA technique to diagnose cases of NAITP definitively and to treat these cases during the neonatal period, and also gives the frequency distribution of HPA in some of the Indian population.
Collapse
Affiliation(s)
- B Kulkarni
- Institute of Immunohaematology, KEM Hospital, Mumbai, India
| | | | | |
Collapse
|
49
|
Rayment R, Brunskill SJ, Stanworth S, Soothill PW, Roberts DJ, Murphy MF. Antenatal interventions for fetomaternal alloimmune thrombocytopenia. Cochrane Database Syst Rev 2005:CD004226. [PMID: 15674934 DOI: 10.1002/14651858.cd004226.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Fetomaternal alloimmune thrombocytopenia occurs when the mother produces antibodies against a platelet alloantigen that the fetus has inherited from the father. A consequence of this can be a reduced number of platelets (thrombocytopenia) in the fetus, which can result in bleeding whilst in the womb or shortly after birth. In severe cases this bleeding may lead to long-lasting disability or death. Antenatal management of fetomaternal alloimmune thrombocytopenia centres on preventing severe thrombocytopenia in the fetus. Available management options include administration of intravenous immunoglobulins or corticosteroids to the mother or intrauterine transfusion of antigen compatible platelets to the fetus. All options are costly and need to be assessed in terms of potential risk and benefit to both the mother and an individual fetus. OBJECTIVES To determine the optimal antenatal treatment of fetomaternal alloimmune thrombocytopenia to prevent fetal and neonatal haemorrhage and death. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (February 2004), EMBASE (1980 to February 2004) and bibliographies of relevant publications and review articles. SELECTION CRITERIA Randomised controlled studies comparing any intervention, including corticosteroids with no treatment, or comparing any two interventions. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility, trial quality and extracted data. MAIN RESULTS One study met the inclusion criteria (54 pregnant women). This trial compared intravenous immunoglobulins plus corticosteroid (dexamethasone) with intravenous immunoglobulins alone. No significant differences were reported between the treatment and control groups, in any outcome measured: mean platelet count at birth (weighted mean difference (WMD) 14.10 x 10 9/l, 95% confidence interval (CI) -30.26 to 58.46), mean gestational age at birth (WMD -0.50 weeks, 95% CI -2.69 to 1.69), mean rise in platelet count from first to second fetal blood screen (WMD -3.50 x 10 9/l, 95% CI -24.62 to 17.62) and mean rise in platelet count from birth to first fetal blood screen (WMD 24.40 x 10 9/l (95% CI -14.17 to 62.97)). This trial had adequate methodological quality; however the method used to calculate sample size was inappropriate: therefore the power calculation was not sufficient to determine any significance in differences between the treatment groups. AUTHORS' CONCLUSIONS There are insufficient data from randomised controlled trials to determine the optimal antenatal management of fetomaternal alloimmune thrombocytopenia. Future trials should consider the dose of intravenous immunoglobulins, the timing of initial treatment, monitoring of response to treatment by fetal blood sampling, laboratory measures to define pregnancies with a high risk of intercranial haemorrhage, management of non-responders and long-term follow up of children.
Collapse
Affiliation(s)
- R Rayment
- Blood Research Laboratory, National Blood Service, Oxford Centre, John Radcliffe Hospital, Headley Way, Oxford, Oxon, UK, OX3 9BQ.
| | | | | | | | | | | |
Collapse
|
50
|
Ohto H, Miura S, Ariga H, Ishii T, Fujimori K, Morita S. The natural history of maternal immunization against foetal platelet alloantigens. Transfus Med 2004; 14:399-408. [PMID: 15569234 DOI: 10.1111/j.1365-3148.2004.00535.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Foetomaternal alloimmune thrombocytopenia (FMAIT) occurs when maternal antibodies of an antigen-negative mother cause destruction of sensitized foetal platelets. In Caucasian populations, 6-12% of human platelet antigen (HPA)-1a-negative women develop anti-HPA-1a, and the incidence of clinically affected cases is estimated to be 10-20% of immunized women. This study was performed in order to elucidate the rate of maternal immunization, incidence of FMAIT and the likely outcome of the condition in Asians. Excluding two or more pregnancies during the period, serum samples from 24 630 pregnant women, mainly Japanese, were screened for antibodies against platelet alloantigens by means of mixed passive haemagglutination (MPHA) (Anti-HPA-MPHA, Olympus, Tokyo). Antibodies were detected in 0.91% (223/24 630) of the women's samples and the immunization rate was correlated with the number of pregnancies. Antibody specificity included anti-HPA-4b (49), anti-HPA-5a (three), anti-HPA-5b (168), anti-HPA-4b + 5b (one) and anti-Nak(a) (CD36) (two). No alloimmunization was observed within the HPA-1, HPA-2, HPA-3 or HPA-6 systems. Among HPA-4b- or HPA-5b-negative women, 24% or 14% estimated, respectively, had antibodies and 26% (10/38) or 10% (12/125) of neonates, respectively, born to these mothers developed thrombocytopenia. Two neonates born to mothers having anti-HPA-4b developed generalized purpura. No cases of intracranial bleeding or death due to FMAIT were recorded. Generalized purpura due to FMAIT occurs in one in 9359 (95% CI: 1 in 77 519-1 in 2591) pregnancies solely because of HPA-4b incompatibility.
Collapse
Affiliation(s)
- H Ohto
- Division of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Hikariga-oka, Fukushima City, Fukushima 960-1295, Japan.
| | | | | | | | | | | |
Collapse
|