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Inam Z, Nickel RS. An infant with severe neonatal immune thrombocytopenia and gradual resumption of breastfeeding. Pediatr Blood Cancer 2024; 71:e30839. [PMID: 38173087 DOI: 10.1002/pbc.30839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Zaina Inam
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, District of Columbia, USA
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Robert Sheppard Nickel
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Wada S, Matsubara K, Miyakoshi C, Iwata A, Isome K, Hori M, Kawasaki Y, Naito A, Kim K, Iio K, Yamaguchi Y. Effect of delivery mode on postnatal platelet count dynamics in neonates born to mothers with immune thrombocytopenia. Int J Hematol 2023:10.1007/s12185-023-03582-2. [PMID: 36947369 DOI: 10.1007/s12185-023-03582-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 03/23/2023]
Abstract
We aimed to determine the effect of delivery mode on postnatal platelet count dynamics in neonates born to mothers with immune thrombocytopenia (ITP). This single-center, retrospective study included 41 mothers with ITP and their 65 infants born by vaginal delivery (VD, n = 30) and cesarean section (CS, n = 35) between January 1997 and March 2022. The median difference in platelet counts from day 0 to day 2 (ΔPlt [D 0-2]) was significantly lower in the VD group (- 39 × 109/L, interquartile range [IQR]: - 47 to - 24 × 109/L) than the CS group (15 × 109/L, IQR: - 6.5 to 33 × 109/L) (p < 0.001). The median ΔPlt (D 0-5) was significantly lower in the VD group (- 55 × 109/L, IQR: - 85 to - 31 × 109/L) than the CS group (33 × 109/L, IQR: 1-69 × 109/L) (p < 0.001). Multivariate analysis also showed a significant association of delivery mode with ΔPlt (D 0-2) and ΔPlt (D 0-5) (both p < 0.001). VD neonates with platelet counts ≥ 100 × 109/L at birth were significantly more likely than CS neonates to develop thrombocytopenia < 100 × 109/L at nadir (1/26 vs. 6/25) (p = 0.0496). Our findings indicate that mode of delivery is a useful predictor of postnatal platelet count dynamics in neonates born to mothers with ITP.
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Affiliation(s)
- Shoichiro Wada
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Kousaku Matsubara
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan.
| | - Chisato Miyakoshi
- Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Aya Iwata
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Kenichi Isome
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Masayuki Hori
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Yu Kawasaki
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Akiyoshi Naito
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Kaya Kim
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Kyohei Iio
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
| | - Yoshimichi Yamaguchi
- Department of Pediatrics, Kobe City Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan
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Short and long-term outcomes of children with autoimmune congenital heart block treated with a combined maternal-neonatal therapy. A comparison study. J Perinatol 2022; 42:1161-1168. [PMID: 35717457 DOI: 10.1038/s41372-022-01431-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The short and long-term outcomes of children with anti-Ro/La-related congenital heart block treated with a combined maternal-neonatal therapy protocol were compared with those of controls treated with other therapies. STUDY DESIGN Sixteen mothers were treated during pregnancy with a therapy consisting of daily oral fluorinated steroids, weekly plasma exchange and fortnightly intravenous immunoglobulins and their neonates with intravenous immunoglobulins (study group); 19 mothers were treated with fluorinated steroids alone or associated to intravenous immunoglobulins or plasma exchange (control group). RESULT The combined-therapy children showed a significantly lower progression rate from 2nd to 3rd degree block at birth, a significant increase in heart rate at birth and a significantly lower number of pacemaker implants during post-natal follow-up with respect to those treated with the other therapies. CONCLUSION The combined therapy produced better short and long term outcomes with respect to the other therapies studied.
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Batton E, Leibel SL. Immune-Mediated Neonatal Thrombocytopenia. Neoreviews 2022; 23:e462-e471. [PMID: 35773506 DOI: 10.1542/neo.23-7-e462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Immune-mediated thrombocytopenia in neonates is caused by the transplacental passage of maternally derived antiplatelet antibodies. The 2 most common causes include neonatal alloimmune thrombocytopenia, which leads to significant thrombocytopenia and risk of intracranial hemorrhage, and autoimmune thrombocytopenia, which is generally less severe. No specific guidelines for prenatal management exist for either disease; however, intravenous immune globulin treatments and systemic steroids for women with at-risk pregnancies can be useful in both diseases. In this review, we discuss the current literature and management strategies for both pregnant women and newborns with immune-mediated thrombocytopenia.
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Affiliation(s)
- Emily Batton
- Division of Neonatology, Department of Pediatrics, University of California San Diego-Rady Children's Hospital, San Diego, CA
| | - Sandra L Leibel
- Division of Neonatology, Department of Pediatrics, University of California San Diego-Rady Children's Hospital, San Diego, CA
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Point F, Terriou L, Rakza T, Drumez E, Alluin G, Garabedian C, Houfflin‐Debarge V. Risk factors for severe neonatal thrombocytopenia in cases of maternal immune thrombocytopenia. Acta Paediatr 2022; 111:985-991. [PMID: 35028970 DOI: 10.1111/apa.16252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
AIM Maternal immune thrombocytopenia (ITP) may induce neonatal thrombocytopenia (nTP), which carries a risk of neonatal haemorrhagic complications. Some risk factors for nTP have reached consensus such as maternal splenectomy and previous severe nTP, while others such as maternal platelet count have not. METHODS We conducted a retrospective cohort study in a university hospital, including 145 neonates of mothers with ITP. We assessed the risk of severe nTP and bleeding complications. RESULTS Severe nTP in the first 24 h after birth was more common in case of maternal splenectomy (OR = 4.4) and a previous severe nTP (OR = 46.9). Severe nTP at nadir (lowest platelet count during the initial postnatal days) was more frequent in cases of a previous neonate with severe nTP (OR = 42), maternal treatment during pregnancy (OR = 2.4) and a low maternal platelet count during pregnancy or at delivery. These risk factors were not significantly associated with an increased risk of neonatal haemorrhagic complications. CONCLUSION In our population, we confirm the risk of severe nTP in case of maternal splenectomy or previous nTP. By monitoring the platelet count to its nadir, we identified three additional risk factors: maternal treatment during pregnancy and low maternal platelet count during pregnancy or low maternal platelet count at delivery.
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Affiliation(s)
- Florian Point
- Department of Obstetrics Lille University Hospital Lille France
| | - Louis Terriou
- Department of Internal Medicine and Clinical Immunology Referral Center for Rare Systemic Autoimmune Diseases North and Northwest of France Lille University Hospital Lille France
- Lille University Inserm U995‐LIRIC‐Lille Inflammation Research International Center Lille France
| | - Thameur Rakza
- Department of Obstetrics Lille University Hospital Lille France
| | - Elodie Drumez
- Department of Biostatistics Lille University Hospital Lille France
- Lille University ULR 2694 ‐ METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales Lille France
| | - Gauthier Alluin
- Etablissement Français du Sang Hauts‐de‐France‐Normandie Loos France
| | - Charles Garabedian
- Department of Obstetrics Lille University Hospital Lille France
- Lille University ULR 2694 ‐ METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales Lille France
| | - Véronique Houfflin‐Debarge
- Department of Obstetrics Lille University Hospital Lille France
- Lille University ULR 2694 ‐ METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales Lille France
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Borhany M, Abid M, Zafar S, Zaidi U, Munzir S, Shamsi T. Thrombocytopenia in Pregnancy: Identification and Management at a Reference Center in Pakistan. Cureus 2022; 14:e23490. [PMID: 35475097 PMCID: PMC9035312 DOI: 10.7759/cureus.23490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/05/2022] Open
Abstract
Objective: The study aimed to evaluate the causes of thrombocytopenia in pregnancy and its management along with the outcome in the COVID-19 era. Methods: Recruitment for this prospective, cross-sectional observational study of thrombocytopenia in pregnancy (platelet counts <100x109/L) was done from January 2017 to August 2020 at the National Institute of Blood Diseases (NIBD) after taking the patients’ informed consent. Complete clinical and lab profile of patients was also collected. Results: A total of 150 pregnant women with thrombocytopenia were enrolled, with the mean age being 27.3±4.64 years. Mean platelet counts at baseline were 48.0±24. Main clinical manifestations at baseline included: anemia 65.9%, bruises 23.25%, and edema 9.3%. Causes of thrombocytopenia were gestational thrombocytopenia (GT) 72 (48%), acute fatty liver five (3.3%), pre-eclampsia in 11 (7.3%), and eclampsia seven (4.6%). Causes not specific to pregnancy included 30 (20%) cases of ITP, hepatitis C, and nutritional deficiency was reported in nine (6%) patients each. 72/150 received supportive care treatment to manage thrombocytopenia and were closely monitored and given supplements. Twenty (66.6%) ITP patients received treatment with steroids, with complete response in 70% of them seen. Overall, 38 (25.3%) women with bleeding symptoms and platelet count <50x109/L received platelet transfusions. Conclusion: The study shows that pre-eclampsia and eclampsia are serious conditions with a high risk for complications, while GT is a benign and the most common cause of thrombocytopenia in pregnancy which requires no active treatment. The other causes such as ITP and infections require individualized management.
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Mantas P, Félix N, Oliveira E, Malcata C, Palaré MJ, Ferrão A. Neonatal Thrombocytopenia Due to Dual Alloimmune and Autoimmune Mechanisms. J Pediatr Hematol Oncol 2022; 44:e310-e312. [PMID: 35200219 DOI: 10.1097/mph.0000000000002352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
Alloantibody-mediated and autoantibody-mediated immune destruction are common causes of early neonatal thrombocytopenia. The authors report a case of severe, early-onset thrombocytopenia with mucocutaneous bleeding in an otherwise well-appearing full-term neonate. Recurrence of thrombocytopenia following initial treatment and its persistence after 2 weeks of life suggested a dual immune mechanism. This is a rare case of immune thrombocytopenia caused by human platelet antigen-5b alloimmunization and passive transfer of maternal antiplatelet antibodies. Appropriate, timely treatment and absence of severe bleeding complications, namely intracranial hemorrhage, conferred a good overall prognosis.
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MESH Headings
- Antigens, Human Platelet
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Intracranial Hemorrhages/etiology
- Isoantibodies
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Thrombocytopenia, Neonatal Alloimmune/etiology
- Thrombocytopenia, Neonatal Alloimmune/therapy
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Affiliation(s)
- Pedro Mantas
- Pediatric Department, Hospital Santarém, Santarém
| | - Nuno Félix
- Pediatric Department, Hospital Santarém, Santarém
| | | | | | - Maria J Palaré
- Pediatric Department, Hospital Santa Maria, Lisbon, Portugal
| | - Anabela Ferrão
- Pediatric Department, Hospital Santa Maria, Lisbon, Portugal
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Luo H, Li D, Gao F, Hong P, Feng W. A meta-analysis of neonatal outcomes in pregnant women with immune thrombocytopenic purpura. J Obstet Gynaecol Res 2021; 47:2941-2953. [PMID: 34137128 DOI: 10.1111/jog.14890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/10/2021] [Accepted: 06/01/2021] [Indexed: 01/11/2023]
Abstract
AIM Thrombocytopenia is an autoimmune disorder characterized by reduced platelet counts. Neonatal thrombocytopenia incidence has been linked with immune thrombocytopenic purpura in mothers during pregnancy, possibly because antiplatelet antibodies can cross the placental barrier. To date, no study has attempted to evaluate the actual prevalence of neonatal thrombocytopenia in infants born to mothers with immune thrombocytopenic purpura. In this meta-analysis of the available literature, we attempt to fill this gap. We want to evaluate the overall prevalence of neonatal thrombocytopenia, its severity, and the incidence of hemorrhage in infants with thrombocytopenia born from mothers with immune thrombocytopenic purpura. METHODS Adhering to PRISMA guidelines, we systematically scanned four academic databases including EMBASE, CENTRAL, Scopus, and MEDLINE to identify relevant literature. We performed a meta-analysis to summarize thrombocytopenia incidence rate and severity in newborn infants of mothers with immune thrombocytopenic purpura. RESULTS We identified 21 eligible studies involving 1951 mothers and 1844 neonates. Meta-analysis showed high prevalence for neonatal thrombocytopenia (24%). Within these, severe cases were the most prevalent (41.2%), followed by moderate (37.7%) and mild (17.6%) cases. Hemorrhage was only reported in 4.1% of the observed neonatal thrombocytopenia cases. CONCLUSION This review provides preliminary evidence that neonatal thrombocytopenia incidence is high in infants born to mothers with immune thrombocytopenic purpura. This study further reports that the largest proportion of these cases are severe.
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Affiliation(s)
- Hongqiang Luo
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Dan Li
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Feidan Gao
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Pan Hong
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Weiying Feng
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
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Kinney S. Pediatric Transfusion Medicine. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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10
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Agarwal N, Mangla A. Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review. Ther Adv Hematol 2021; 12:20406207211001139. [PMID: 33796239 PMCID: PMC7983475 DOI: 10.1177/20406207211001139] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.
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Affiliation(s)
- Nikki Agarwal
- Division of Pediatric Hematology and Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ankit Mangla
- Division of Hematology and Oncology, Seidman Cancer Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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11
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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12
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Zhang L, DeBoer C, Ellison-Barnes A, Berger J, Lawrence CE, Stewart RW, Pecker LH. Thrombocytopenia in a 7-day-old Male. Pediatr Rev 2021; 42:S10-S14. [PMID: 33386351 DOI: 10.1542/pir.2018-0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Lindy Zhang
- Departments of Pediatric Hematology, .,Pediatric Oncology
| | | | | | - Jessica Berger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Courtney E Lawrence
- Departments of Pediatric Hematology.,Division of Transfusion Medicine, Department of Pathology, and
| | | | - Lydia H Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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Alsaleem M. Intravenous Immune Globulin Uses in the Fetus and Neonate: A Review. Antibodies (Basel) 2020; 9:E60. [PMID: 33158209 PMCID: PMC7709108 DOI: 10.3390/antib9040060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/07/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
Intravenous immune globulin (IVIG) is made after processing plasma from healthy donors. It is composed mainly of pooled immunoglobulin and has clinical evidence-based applications in adult and pediatric populations. Recently, several clinical applications have been proposed for managing conditions in the neonatal population, such as hemolytic disease of the newborn, treatment, and prophylaxis for sepsis in high-risk neonates, enterovirus parvovirus and COVID-19 related neonatal infections, fetal and neonatal immune-induced thrombocytopenia, neonatal hemochromatosis, neonatal Kawasaki disease, and some types of immunodeficiency. The dosing, mechanism of action, effectiveness, side effects, and adverse reactions of IVIG have been relatively well studied in adults but are not well described in the neonatal population. This review aims to provide the most recent evidence and consensus guidelines about the use of IVIG in the fetus and neonate.
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Affiliation(s)
- Mahdi Alsaleem
- Pediatrics Department, Neonatology, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
- Pediatrics Department, University of Kansas, Wichita, KS 67208, USA
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15
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16
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Seifoleslami M. Report on the management of thrombocytopenia in obstetric patients: A retrospective study. Interv Med Appl Sci 2017; 9:204-207. [PMID: 29951286 PMCID: PMC6016207 DOI: 10.1556/1646.9.2017.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Thrombocytopenia occurs to approximately 8%–10% of pregnant women and this condition is a notable source of morbidity and mortality during pregnancy. In the recent years, our comprehension of thrombocytopenia has progressed on pregnancy. Nevertheless, there has not been adequate information about thrombocytopenia outcomes in obstetric patients. With regard to this topic, we reviewed published reports as an update from the managements on these cases. Nevertheless, recommendations for management of delivery in obstetric women with thrombocytopenia are based on several hypotheses requiring critical analysis. For this cause, we reviewed the management of pregnant patients with thrombocytopenia treated over a period of 37 years.
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Affiliation(s)
- Mehri Seifoleslami
- Department of Gynecology, Khanevadeh Hospital, AJA University of Medical Sciences, Tehran, Iran
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17
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Care A, Pavord S, Knight M, Alfirevic Z. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG 2017; 125:604-612. [PMID: 28432736 DOI: 10.1111/1471-0528.14697] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To quantify the incidence of severe autoimmune thrombocytopenia (ITP) in pregnancy in the UK, determine current treatment strategies, and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy. DESIGN A prospective national cohort study. SETTING UK. POPULATION Women with severe ITP, defined as platelets <50 × 109 /L in pregnancy or antenatal treatment of isolated low platelets. METHODS Data collected via the UK Obstetric Surveillance System (UKOSS) between 1 June 2013 and 31 January 2015 from all UK consultant-led obstetric units. MAIN OUTCOME MEASURE Incidence of severe ITP in pregnancy. RESULTS The estimated incidence of severe ITP in pregnancy is 0.83 per 10 000 maternities (95% CI 0.68-1.00). A total of 22 pregnant women (21%) did not receive any antenatal therapy, and 85 pregnant women (79%) received therapy. There was no difference between asymptomatic treated and untreated cohorts in severity of disease or outcome. Postpartum haemorrhage (51%) and severe postpartum haemorrhage (21%) was reported more frequently than the rate reported in the general pregnant population (5-10%). No neonates required treatment for thrombocytopenia and there were no cases of neonatal intracranial bleeding. CONCLUSIONS Current UK management of severe ITP in pregnancy results in an exceptionally low morbidity and mortality for the neonate. Mothers with ITP remain at increased risk of severe postpartum haemorrhage, and should be delivered at units that have the capacity to manage severe PPH effectively. Whilst balancing the risks for pregnancy from prophylactic antenatal treatment in asymptomatic women against observed low disease morbidity, we may be over treating asymptomatic patients. TWEETABLE ABSTRACT UKOSS study of severe ITP in pregnancy shows exceptionally low neonatal morbidity with current UK management.
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Affiliation(s)
- A Care
- Centre for Women and Children's Health Research, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - S Pavord
- Oxford University Hospitals, Headington, Oxford, UK
| | - M Knight
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Headington, Oxford, UK
| | - Z Alfirevic
- Centre for Women and Children's Health Research, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
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Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia. Blood 2017; 129:2829-2835. [PMID: 28416506 PMCID: PMC5813736 DOI: 10.1182/blood-2017-03-754119] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 12/25/2022] Open
Abstract
Immune thrombocytopenia (ITP) occurs in 2 to 4/100 000 adults and results in variable bleeding symptoms and thrombocytopenia. In the last decade, changes in our understanding of the pathophysiology of the disorder have led to the publication of new guidelines for the diagnosis and management of ITP and standards for terminology. Current evidence supports alternatives to splenectomy for second-line management of patients with persistently low platelet counts and bleeding. Long-term follow-up data suggest both efficacy and safety, in particular, for the thrombopoietin receptor agonists and the occurrence of late remissions. Follow-up of patients who have undergone splenectomy for ITP reveals significant potential risks that should be discussed with patients and may influence clinician and patient choice of second-line therapy. Novel therapeutics are in development to address ongoing treatment gaps.
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MESH Headings
- Adult
- Female
- Hemorrhage/blood
- Hemorrhage/diagnosis
- Hemorrhage/physiopathology
- Hemorrhage/therapy
- Humans
- Male
- Platelet Count
- Practice Guidelines as Topic
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/metabolism
- Splenectomy
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Affiliation(s)
- Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA; and
| | - Terry B Gernsheimer
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
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Gernsheimer TB. Congenital and acquired bleeding disorders in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:232-235. [PMID: 27913485 PMCID: PMC6142506 DOI: 10.1182/asheducation-2016.1.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Obstetrical hematology represents challenges not only for the patient, but also for her progeny. In particular, bleeding disorders, both congenital and acquired, not only present problems both for delivery and in the immediate postpartum period, but also may have significant implications for the fetus and neonate. Women with congenital bleeding disorders or who are carriers of X-linked or autosomal disorders should be counseled prior to conception so that pregnancy can be safely undertaken with careful preparation. A treatment plan should be set up by a specialized care team that includes the hematologist, obstetrician, and anesthesiologist; the patient should be followed closely during pregnancy, through delivery, and in the immediate postpartum period. Acquired disorders of hemostasis that occur with pregnancy may present particular diagnostic difficulties and require rapid diagnosis and management.
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Affiliation(s)
- Terry B Gernsheimer
- Division of Hematology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
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Transfusion Therapy in Specific Clinical Situations. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lieberman L, Spradbrow J, Keir A, Dunn M, Lin Y, Callum J. Use of intravenous immunoglobulin in neonates at a tertiary academic hospital: a retrospective 11-year study. Transfusion 2016; 56:2704-2711. [PMID: 27459953 DOI: 10.1111/trf.13721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/20/2016] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) is used to treat a variety of diseases in the neonatal intensive care unit (NICU). Although audits have reported on the spectrum of IVIG use in adults, the indications and utilization in neonates has not been investigated. The objectives of this study were to describe the usage pattern of and indications for IVIG in a tertiary care NICU. STUDY DESIGN AND METHODS A retrospective chart review was performed of all neonates who received IVIG in the NICU from January 2003 to December 2013. Data collected included patient demographic features, antenatal maternal details, neonatal laboratory results, treatment details, adverse events, and patient outcome. RESULTS Thirty-seven neonates received IVIG over the 11-year period. Twenty-three (67%) were treated for hemolytic disease of the newborn (HDN); 13 treatments were ABO related, six were anti-D related, and four were for clinically significant antibodies. Fourteen (33%) were treated for non-HDN causes, including eight for septic neonates, two for neonates with necrotizing enterocolitis, two for neonates with a clinically significant antibody but without evidence of hemolysis, and two for neonates with glucose 6-phosphate dehydrogenase deficiency. A complete hemolytic workup was not performed consistently before the receipt of IVIG. CONCLUSIONS This novel assessment of IVIG use in the NICU revealed the spectrum of disease for which IVIG is ordered. This study also found that key diagnostic tests needed to confirm an immune etiology for idiopathic jaundice are not performed routinely before IVIG receipt. Neonatal transfusion-related databases are needed to carry out pragmatic clinical trials to establish better evidence-based guidelines for IVIG therapy in the NICU.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jordan Spradbrow
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre
| | - Amy Keir
- Robinson Research Institute, School of Medicine, University of Adelaide, South Australia, Australia
| | - Michael Dunn
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yulia Lin
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, University Health Network.,Department of Clinical Pathology, Sunnybrook Health Sciences Centre.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Melekoğlu NA, Bay A, Aktekin EH, Yilmaz M, Sivasli E. Neonatal Outcomes of Pregnancy with Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2016; 33:211-215. [PMID: 28596653 DOI: 10.1007/s12288-016-0708-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/09/2016] [Indexed: 11/28/2022] Open
Abstract
Neonates born to mothers with immune thrombocytopenia (ITP) have an increased risk for neonatal thrombocytopenia and hemorrhagic complications. The aim of this study was to determine the maternal and neonatal outcomes of pregnancies with ITP and also to identify risk factors that predicts neonatal thrombocytopenia. We performed a retrospective analysis of 40 pregnancies with ITP and their 40 neonates. Among the 40 neonates, thrombocytopenia (platelet count of less than 150 × 109/L) was detected in 15 neonates (37.5 %) whom 8 of them had severe thrombocytopenia (platelet count of less than 50 × 109/L). Ten of the 15 neonates with thrombocytopenia required treatment to increase the platelet counts. There was statistically significant association between neonatal thrombocytopenia and maternal splenectomy history and maternal duration of thrombocytopenia. There was no statistically significant correlation between maternal platelet count and neonatal platelet count. Clinicians should pay special attention in these neonates because of risk for development of neonatal thrombocytopenia. Maternal and neonatal outcomes in patients with idiopathic thrombocytopenic purpura is generally good.
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Affiliation(s)
- Nuriye Aslı Melekoğlu
- Division of Neonatology, Department of Pediatrics, Gaziantep University, Gaziantep, Turkey
| | - Ali Bay
- Division of Pediatric Hematology, Department of Pediatrics, Gaziantep University, Gaziantep, Turkey
| | - Elif H Aktekin
- Division of Pediatric Hematology, Department of Pediatrics, Gaziantep University, Gaziantep, Turkey
| | - Mehmet Yilmaz
- Department of Internal Medicine, Gaziantep University, Gaziantep, Turkey
| | - Ercan Sivasli
- Division of Neonatology, Department of Pediatrics, Gaziantep University, Gaziantep, Turkey
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Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy. Blood 2016; 128:1329-35. [PMID: 27402971 DOI: 10.1182/blood-2016-04-710285] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/05/2016] [Indexed: 11/20/2022] Open
Abstract
Treatment options for immune thrombocytopenia (ITP) in pregnancy are limited, and evidence to guide management decisions is lacking. This retrospective study of singleton pregnancies from 2 tertiary centers compared the effectiveness of intravenous immunoglobulin (IVIg) and corticosteroids in treatment of ITP. Data from 195 women who had 235 pregnancies were reviewed. Treatment was not required in 137 pregnancies (58%). Of the remaining 98 pregnancies in 91 women, 47 (48%) were treated with IVIg and 51 were treated with corticosteroids as the initial intervention. Mean maternal platelet count at birth did not differ between groups (IVIg 69 × 10(9)/L vs corticosteroids 77 × 10(9)/L; P = .71) nor did the proportion of mothers who achieved a platelet count response (IVIg 38% vs corticosteroids 39%; P = .85). There were no fatal or severe maternal, fetal, or neonatal hemorrhages. Of 203 neonates in whom platelet counts were available, 56 (28%) had a birth platelet count <150 × 10(9)/L and 18 (9%) had platelet counts <50 × 10(9)/L. Nadir platelet counts for most affected neonates occurred at birth, although for some neonates, nadir platelet counts occurred up to 6 days postnatally. Intracranial hemorrhage was noted in 2 neonates (nadir platelet counts were 135 and 18 × 10(9)/L). There were no neonatal deaths. The majority of pregnant women with a history of ITP did not require treatment, and neonatal outcomes were comparable for mothers who received IVIg or corticosteroids for treatment of maternal ITP.
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Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:795-802. [PMID: 26634939 PMCID: PMC4678382 DOI: 10.3238/arztebl.2015.0795] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge. METHODS In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed. RESULTS Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease. CONCLUSION The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.
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Affiliation(s)
| | - Werner Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
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Loustau V, Pourrat O, Mandelbrot L, Godeau B. Purpura thrombopénique immunologique et grossesse : état des connaissances actuelles et questions encore sans réponse. Rev Med Interne 2015; 36:167-72. [DOI: 10.1016/j.revmed.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/30/2014] [Indexed: 11/28/2022]
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Ngo ST, Steyn FJ, McCombe PA. Gender differences in autoimmune disease. Front Neuroendocrinol 2014; 35:347-69. [PMID: 24793874 DOI: 10.1016/j.yfrne.2014.04.004] [Citation(s) in RCA: 575] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/20/2014] [Accepted: 04/22/2014] [Indexed: 12/21/2022]
Abstract
Autoimmune diseases are a range of diseases in which the immune response to self-antigens results in damage or dysfunction of tissues. Autoimmune diseases can be systemic or can affect specific organs or body systems. For most autoimmune diseases there is a clear sex difference in prevalence, whereby females are generally more frequently affected than males. In this review, we consider gender differences in systemic and organ-specific autoimmune diseases, and we summarize human data that outlines the prevalence of common autoimmune diseases specific to adult males and females in countries commonly surveyed. We discuss possible mechanisms for sex specific differences including gender differences in immune response and organ vulnerability, reproductive capacity including pregnancy, sex hormones, genetic predisposition, parental inheritance, and epigenetics. Evidence demonstrates that gender has a significant influence on the development of autoimmune disease. Thus, considerations of gender should be at the forefront of all studies that attempt to define mechanisms that underpin autoimmune disease.
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Affiliation(s)
- S T Ngo
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia; University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
| | - F J Steyn
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia
| | - P A McCombe
- University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia; Department of Neurology, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia.
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Gunnink SF, Vlug R, Fijnvandraat K, van der Bom JG, Stanworth SJ, Lopriore E. Neonatal thrombocytopenia: etiology, management and outcome. Expert Rev Hematol 2014; 7:387-95. [PMID: 24665958 DOI: 10.1586/17474086.2014.902301] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Thrombocytopenia is a very common hematological abnormality found in newborns, especially in preterm neonates. Two subgroups can be distinguished: early thrombocytopenia, occurring within the first 72 hours of life, and late thrombocytopenia, occurring after the first 72 hours of life. Early thrombocytopenia is associated with intrauterine growth restriction, whereas late thrombocytopenia is caused mainly by sepsis and necrotizing enterocolitis (NEC). Platelet transfusions are the hallmark of the treatment of neonatal thrombocytopenia. Most of these transfusions are prophylactic, which means they are given in the absence of bleeding. However, the efficacy of these transfusions in preventing bleeding has never been proven. In addition, risks of platelet transfusion seem to be more pronounced in preterm neonates. Because of lack of data, platelet transfusion guidelines differ widely between countries. This review summarizes the current understanding of etiology and management of neonatal thrombocytopenia.
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Kawaguchi K, Matsubara K, Takafuta T, Shinzato I, Tanaka Y, Iwata A, Nigami H, Takeuchi Y, Fukaya T. Factors predictive of neonatal thrombocytopenia in pregnant women with immune thrombocytopenia. Int J Hematol 2014; 99:570-6. [DOI: 10.1007/s12185-014-1562-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/21/2014] [Accepted: 02/23/2014] [Indexed: 10/25/2022]
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