Congenital and acquired bleeding disorders in pregnancy

Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas)

Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.

Pregnancy, childbirth and neonatal outcomes of women with rare inherited coagulation disorders

Background

We aimed to describe the characteristics and the pregnancy outcomes of women with rare inherited coagulation factor disorders managed at a tertiary obstetric-haematology unit in the United Kingdom.

Methods

A retrospective service evaluation was conducted using routinely collected medical records. Descriptive analyses were applied to investigate pregnancy, childbirth and neonatal management and outcomes.

Results

Overall, 20 patients with rare inherited coagulation disorders were included who birthed 30 live infants from 29 pregnancies. Regarding maternal bleeding outcomes, 3% experienced antepartum haemorrhage, 38% of pregnancies experienced primary post-partum haemorrhage, and none experienced secondary post-partum haemorrhage. Five (17%) neonates had cranial ultrasound scans for imaging to investigate for a neonatal haemorrhage, which were all normal.

Conclusions

Although women with rare inherited coagulation disorders may be more susceptible to complications in pregnancy, within this cohort there was no evidence that the condition led to increased morbidity or mortality when best practices were observed.

Pregnancy and childbirth in women with bleeding disorders: A retrospective cohort study

INTRODUCTION

Reproductive-age women with bleeding disorders (BDs) are underdiagnosed and understudied, despite their increased risk for adverse health outcomes and pregnancy complications.

AIM

This study examines pregnancy outcomes and obstetric complications of Utah women with BDs.

METHODS

This retrospective cohort study utilized linked birth records and clinical billing data from two large Utah healthcare systems. Utah residents who had their first birth at > 20 weeks gestation (2008-2015) and who received non-emergent care within either system before delivery were included (n = 61 226). Multivariable logistic regression models were used to examine relationships between BDs and neonatal and obstetric outcomes.

RESULTS

A total of 295 women (.48%) were included in the BD study population. Women with BDs had significantly increased odds of preterm birth (aOR 1.85, 95% CI 1.32-2.60), Caesarean delivery (aOR 1.38, 95% CI 1.06-1.79), postpartum blood transfusion (aOR 2.55, 95% CI 1.05-6.22), unplanned postpartum hysterectomy (aOR 33.96, 95% CI 7.30-157.89) and transfer to an intensive care unit (aOR 18.18, 95% CI 7.17-46.08). All of the women with BDs who experienced these serious complications were not diagnosed with a BD until the year of their first birth. Additionally, those with BDs were more likely to experience maternal and infant mortality.

CONCLUSION

Women with BDs had an increased risk for preterm birth, Caesarean delivery, blood transfusion, unplanned hysterectomy, intensive care unit admission, maternal and infant mortality. Those who were not diagnosed with a BD before the year of their first birth were at an increased risk for serious pregnancy complications.

Recurrent miscarriage in a woman with congenital factor V deficiency: a case report

BACKGROUND

Factor V deficiency is a rare bleeding disorder that can be either congenital or acquired. Factor V deficiency mostly present with mucosal bleeding. Coagulation factor V does not increase considerably during normal gestation. Since pregnancy can be threatened by blood clotting disorders, abnormal changes in coagulation factors level can pose challenges to pregnant women.

CASE PRESENTATION

We report a 40-year-old pregnant woman with prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy. Her past medical history included two unexplained abortions. Physical examination was unremarkable, but the blood test showed elevated PT and PTT with a considerable decrease in factor V activity, while other factors were within normal range. Subsequently, the patient was diagnosed with congenital factor V deficiency. After treatment with fresh frozen plasma, she underwent vaginal delivery and a baby with factor V deficiency was born.

CONCLUSIONS

This is the second report of recurrent miscarriage in congenital factor V deficiency patients. Clinicians should consider the possibility of factor V deficiency in women with a history of idiopathic miscarriage even in patients without any symptoms.

Eltrombopag treatment for severe immune thrombocytopenia during pregnancy: a case report

Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia (platelet count <100 × 109/l) in the absence of other causes or disorders associated. The incidence of ITP in pregnancy is one to two cases per 1000 gestations. ITP could be diagnosed before or during pregnancy; sometimes a relapse of a previously diagnosed ITP can occur. Intravenous immune globulins (IVIg) and corticosteroids are the standard frontline therapy because of their well known safety profile either for the mother or for the neonate. Treatments for refractory patients are limited by potential fetal risk. We report the case of a patient with ITP along pregnancy, refractory to corticosteroids and IVIg, successfully treated with, the thrombopoietin receptor agonist (TPO-RA) eltrombopag. Patient received this compound for almost the whole pregnancy and in particular for the whole first trimester, without any complication for the mother and the neonate. Although transient administration of TPO-RAs in pregnancy seems to be well tolerated, their use during the whole gestation is still controversial; this is the reason of the description of this case, which did not show any complications, and thus it could add useful information on this field.

Hematologic Findings in Pregnancy: A Guide for the Internist

Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.

Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review

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.

Thrombocytopenia in pregnancy: Diagnosis and approach to management

Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.