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Coucheron T, Uhrynowska M, Guz K, Orzińska A, Debska M, Gierszon A, Ahlen MT, Bertelsen EL, Berge G, Husebekk A, Brojer E, Tiller H. What's with the boys? Lower birth weight in boys from HPA-1a alloimmunized pregnancies - New insights from a large prospective screening study in Poland. J Reprod Immunol 2023; 160:104168. [PMID: 37992463 DOI: 10.1016/j.jri.2023.104168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 11/24/2023]
Abstract
Fetomaternal incompatibility in human platelet antigens (HPAs) can cause maternal alloimmunization, which in turn may lead to thrombocytopenia with or without intracranial hemorrhage (ICH) in the fetus or newborn. Retrospective studies suggest that boys from alloimmunized mothers may have higher risk of ICH and lower birth weight than girls. The objective of this study was to assess how maternal HPA-1a alloimmunization, sex of the neonate and birth weight relates in a large prospective cohort. Through a national screening study in Poland (PREVFNAIT) involving HPA-1 typing of 24,259 pregnant women during 2013-2017, 606 HPA-1a negative pregnant women and their offspring were identified and included. Various multivariate models were used to assess if and how maternal HPA-1a alloimmunization status was associated with birth weight and risk of having a small for gestational age (SGA) neonate, and if and how sex of the neonate mattered. Most immunized pregnancies had male fetuses (69 %). Women carrying a male fetus had increased likelihood of having an SGA newborn if they were HPA-1a alloimmunized compared to non-immunized mothers. Increasing maternal anti-HPA-1a antibody levels were significantly associated with reduced birth weight and SGA risk among male-fetus pregnancies, but not if the fetus was female. In conclusion, anti-HPA-1a antibodies in a male fetus pregnancy is associated with increased risk of SGA and lower birth weight, especially if the antibody level is high. Sex of the fetus may therefore be considered as a new clinical predictor of more severe FNAIT neonatal outcome.
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Affiliation(s)
- Tina Coucheron
- Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Malgorzata Uhrynowska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Katarzyna Guz
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Orzińska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Marzena Debska
- Medical Centre of Postgraduate Education, 2nd Department of Obstetrics and Gynaecology, Warsaw, Poland
| | - Agnieszka Gierszon
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Maria Therese Ahlen
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | | | - Gerd Berge
- Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Husebekk
- Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ewa Brojer
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Heidi Tiller
- Department of Gynecology and Obstetrics, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
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Kjeldsen-Kragh J, Bein G, Tiller H. Pregnant Women at Low Risk of Having a Child with Fetal and Neonatal Alloimmune Thrombocytopenia Do Not Require Treatment with Intravenous Immunoglobulin. J Clin Med 2023; 12:5492. [PMID: 37685558 PMCID: PMC10488101 DOI: 10.3390/jcm12175492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare condition in which maternal alloantibodies to fetal platelets cause fetal thrombocytopenia that may lead to intracranial hemorrhage (ICH). Off-label intravenous immunoglobulin (IVIg) has for 30 years been the standard of care for pregnant women who previously have had a child with FNAIT. The efficacy of this treatment has never been tested in a placebo-controlled clinical trial. Although IVIg treatment may improve the neonatal outcome in women who previously have had a child with FNAIT-associated ICH, the question is whether IVIg is necessary for all immunized pregnant women at risk of having a child with FNAIT. The results from some recent publications suggest that antenatal IVIg treatment is not necessary for women who are (1) HPA-1a-immunized and HLA-DRB3*01:01-negative, (2) HPA-1a-immunized with a previous child with FNAIT but without ICH or (3) HPA-5b-immunized. If IVIg is not used for these categories of pregnant women, the amount of IVIg used in pregnant women with platelet antibodies would be reduced to less than ¼ of today's use. This is important because IVIg is a scarce resource, and the collection of plasma for the treatment of one pregnant woman is not only extremely expensive but also requires tremendous donor efforts.
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Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Akutgatan 8, 221 85 Lund, Sweden
- Department of Laboratory Medicine, University Hospital of North Norway, 9019 Tromsø, Norway
| | - Gregor Bein
- Institute for Clinical Immunology, Transfusion Medicine and Hemostasis, Justus-Liebig-University, 35392 Giessen, Germany;
- German Center for Feto-Maternal Incompatibility, University Hospital Giessen and Marburg, Campus Giessen, 35392 Giessen, Germany
| | - Heidi Tiller
- Department of Obstetrics and Gynecology, University Hospital of North Norway, 9019 Tromsø, Norway;
- Women’s Health and Perinatology Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9019 Tromsø, Norway
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de Vos TW, Winkelhorst D, Árnadóttir V, van der Bom JG, Canals Surís C, Caram-Deelder C, Deschmann E, Haysom HE, Hverven HBC, Lozar Krivec J, McQuilten ZK, Muñiz-Diaz E, Nogués N, Oepkes D, Porcelijn L, van der Schoot CE, Saxonhouse M, Sola-Visner M, Tiblad E, Tiller H, Wood EM, Young V, Železnik M, de Haas M, Lopriore E. Postnatal treatment for children with fetal and neonatal alloimmune thrombocytopenia: a multicentre, retrospective, cohort study. Lancet Haematol 2022; 9:e844-e853. [PMID: 36108655 DOI: 10.1016/s2352-3026(22)00243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Children affected by fetal and neonatal alloimmune thrombocytopenia (FNAIT) are at risk of severe intracranial haemorrhage. Management in the postnatal period is based on sparse evidence. We aimed to describe the contemporary management and outcomes of patients with FNAIT in high-income countries. METHODS In this multicentre, retrospective, cohort study, we set up a web-based registry for the collection of deidentified data on the management and course of neonates with FNAIT. Eight centres from seven countries (Australia, Norway, Slovenia, Spain, Sweden, the Netherlands, and the USA) participated. Eligibility criteria comprised neonates with FNAIT being liveborn between Jan 1, 2010, and Jan 1, 2020; anti-human platelet antigen (HPA) alloantibodies in maternal serum; confirmed maternal and fetal HPA incompatibility; and bleeding detected at antenatal ultrasound, neonatal thrombocytopenia (<150 × 109 platelets per L), or both in the current or previous pregnancy. Clinical data were retrieved from local medical records of the first neonatal admission and entered in the registry. The key outcome was the type of postnatal treatment given to neonates with FNAIT. Other outcomes were daily median platelet counts in the first week of life, median platelet count increment after first unmatched versus first matched transfusions, and the proportion of neonates with mild or severe bleeding. FINDINGS 408 liveborn neonates with FNAIT were entered into the FNAIT registry, of whom 389 from Australia (n=74), Norway (n=56), Slovenia (n=19), Spain (n=55), Sweden (n=31), the Netherlands (n=138), and the USA (n=16) were included in our analyses. The median follow-up was 5 days (IQR 2-9). More neonates were male (241 [64%] of 379) than female (138 [36%]). Severe thrombocytopenia (platelet count <50 × 109 platelets per L) was reported in 283 (74%) of 380 neonates, and extreme thrombocytopenia (<10 × 109 platelets per L) was reported in 92 (24%) neonates. Postnatal platelet count nadir was higher in the no-treatment group than in all other groups. 163 (42%) of 389 neonates with FNAIT received no postnatal treatment. 207 (53%) neonates received platelet transfusions, which were either HPA-unmatched (88 [43%] of 207), HPA-matched (84 [41%]), or a combination of both (35 [17%]). The proportion of neonates who received HPA-matched platelet transfusions varied between countries, ranging from 0% (Slovenia) to 63% (35 of 56 neonates; Norway). Postnatal intravenous immunoglobulin treatment was given to 110 (28%) of 389 neonates (alone [n=19] or in combination with platelet transfusions [n=91]), with the proportion receiving it ranging from 12% (17 of 138 neonates; the Netherlands) to 63% (ten of 16 neonates; the USA) across countries. The median platelet increment was 59 × 109 platelets per L (IQR 35-94) after HPA-unmatched platelet transfusions and 98 × 109 platelets per L (67-134) after HPA-matched platelet transfusions (p<0·0001). Severe bleeding was diagnosed in 23 (6%) of 389 liveborn neonates, with one having a severe pulmonary haemorrhage and 22 having severe intracranial haemorrhages. Mild bleeding was diagnosed in 186 (48%) neonates. INTERPRETATION Postnatal management of FNAIT varies greatly between international centres, highlighting the absence of consensus on optimal treatments. Our data suggest that HPA-matched transfusions lead to a larger median platelet count increment than HPA-unmatched transfusions, but whether HPA matching is also associated with a reduced risk of bleeding remains unknown. FUNDING Sanquin.
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Affiliation(s)
- Thijs W de Vos
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands; Center of Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands; Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands.
| | - Dian Winkelhorst
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands; Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands
| | - Valgerdur Árnadóttir
- Department of Pediatrics, Division of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Center of Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands
| | - Emöke Deschmann
- Department of Pediatrics, Division of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Helen E Haysom
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Hem Birgit C Hverven
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Jana Lozar Krivec
- Department of Neonatology, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Clinical Haematology, Monash Health, Melbourne, VIC, Australia
| | | | - Núria Nogués
- Immunohematology Laboratory, Blood and Tissue Bank, Barcelona, Spain
| | - Dick Oepkes
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | - Matthew Saxonhouse
- Division of Neonatology, Levine Children's Hospital, Atrium Healthcare, Wake Forest School of Medicine, Charlotte, NC, USA
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eleonor Tiblad
- Center for Fetal Medicine, Pregnancy Care and Delivery, Women's Health, Karolinska University Hospital, Stockholm, Sweden; Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Heidi Tiller
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway; Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, Arctic University of Norway, Tromsø, Norway
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Clinical Haematology, Monash Health, Melbourne, VIC, Australia
| | - Vanessa Young
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mojca Železnik
- Department of Neonatology, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Masja de Haas
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands; Department of Experimental Immunohematology, Sanquin Research, Amsterdam, Netherlands; Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Enrico Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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Kajdy A, Sys D, Pokropek A, Shaw SW, Chang T, Calda P, Acharya G, Ben‐Zion M, Biron‐Shental T, Borowski D, Czuba B, Etchegaray A, Feduniw S, Garcia‐Mandujano R, Santacruz MG, Gil MM, Hassan S, Kwiatkowski S, Martin‐Arias A, Martinez‐Portilla RJ, Prefumo F, Rabijewski M, Salomon LJ, Tiller H, Verlohren S, Voon HY, Yanque‐Robles OF, Yong SL, Poon LC. Risk factors for anxiety and depression among pregnant women during the COVID-19 pandemic: Results of a web-based multinational cross-sectional study. Int J Gynaecol Obstet 2022; 160:167-186. [PMID: 35932096 PMCID: PMC9538861 DOI: 10.1002/ijgo.14388] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/24/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess risk factors for anxiety and depression among pregnant women during the COVID-19 pandemic using Mind-COVID, a prospective cross-sectional study that compares outcomes in middle-income economies and high-income economies. METHODS A total of 7102 pregnant women from 12 high-income economies and nine middle-income economies were included. The web-based survey used two standardized instruments, General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). RESULT Pregnant women in high-income economies reported higher PHQ-9 (0.18 standard deviation [SD], P < 0.001) and GAD-7 (0.08 SD, P = 0.005) scores than those living in middle-income economies. Multivariate regression analysis showed that increasing PHQ-9 and GAD-7 scales were associated with mental health problems during pregnancy and the need for psychiatric treatment before pregnancy. PHQ-9 was associated with a feeling of burden related to restrictions in social distancing, and access to leisure activities. GAD-7 scores were associated with a pregnancy-related complication, fear of adverse outcomes in children related to COVID-19, and feeling of burden related to finances. CONCLUSIONS According to this study, the imposed public health measures and hospital restrictions have left pregnant women more vulnerable during these difficult times. Adequate partner and family support during pregnancy and childbirth can be one of the most important protective factors against anxiety and depression, regardless of national economic status.
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Affiliation(s)
- Anna Kajdy
- Department of Reproductive HealthCenter of Postgraduate Medical EducationWarsawPoland
| | - Dorota Sys
- Department of Reproductive HealthCenter of Postgraduate Medical EducationWarsawPoland
| | - Artur Pokropek
- Institute of Philosophy and Sociology of the Polish Academy of SciencesWarsawPoland
| | - Steven W. Shaw
- Department of ObstetricsChang Gung Memorial HospitalTaipeiTaiwan
| | | | - Pavel Calda
- Fetal Medicine CenterFirst Medical Faculty of the Charles University and General Teaching HospitalPragueCzech Republic
| | - Ganesh Acharya
- Division of Obstetrics and GynecologyDepartment of Clinical Science, Intervention and Technology (CLINTEC), Karolinska InstitutetStockholmSweden,Women's Health and Perinatology Research Group Institute of Clinical Medicine Faculty of Health Sciences UiT‐The Arctic University of NorwayTromsøNorway
| | - Maya Ben‐Zion
- Women's Health and Perinatology Research Group Institute of Clinical Medicine Faculty of Health Sciences UiT‐The Arctic University of NorwayTromsøNorway,Meir Medical CenterTel Aviv UniversityIsrael
| | - Tal Biron‐Shental
- Women's Health and Perinatology Research Group Institute of Clinical Medicine Faculty of Health Sciences UiT‐The Arctic University of NorwayTromsøNorway,Meir Medical CenterTel Aviv UniversityIsrael
| | - Dariusz Borowski
- Nicolaus Copernicus University in ToruńCollegium Medicum in Bydgoszcz, The Faculty of Health Sciences, Department of Perinatology, Gynacology and Gynecologic OncologyToruńPoland
| | - Bartosz Czuba
- Chair and Department of Gynecology and ObstetricsFaculty of Health Sciences in Katowice, Medical University of SilesiaPoland
| | | | - Stepan Feduniw
- Department of Reproductive HealthCenter of Postgraduate Medical EducationWarsawPoland
| | | | | | - Maria M. Gil
- Hospital Universitario de TorrejónSchool of Medicine. Universidad Francisco de VitoriaMadridSpain
| | - Sonia Hassan
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMichiganUSA,Office of Women's HealthIntegrative Biosciences Center, Wayne State UniversityDetroitMichiganUSA,Department of PhysiologyWayne State University School of MedicineDetroitMichiganUSA
| | | | - Arancha Martin‐Arias
- Hospital Universitario de TorrejónSchool of Medicine. Universidad Francisco de VitoriaMadridSpain
| | | | - Federico Prefumo
- Department of Clinical and Experimental SciencesUniversity of BresciaItaly
| | - Michał Rabijewski
- Department of Reproductive HealthCenter of Postgraduate Medical EducationWarsawPoland
| | - Laurent J. Salomon
- Médecine et Chirurgie FoetalesMaternité—Hôpital Universitaire Necker‐Enfants Malades, Assistance Publique—Hôpitaux de Paris (AP‐HP), Université de ParisFrance
| | - Heidi Tiller
- Women's Health and Perinatology Research GroupInstitute of Clinical medicine, UiT The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North NorwayTromsøNorway
| | - Stefan Verlohren
- Department of ObstetricsMedical School – Charité – University Medicine BerlinGermany
| | - Hian Yan Voon
- Maternal Fetal Medicine SpecialistSarawak General HospitalKuchingMalaysia
| | | | - Soon Leong Yong
- Department of Obstetrics & GynaecologyHospital Tengku Ampuan AfzanKuantanMalaysia
| | - Liona C. Poon
- Department of Obstetrics and Gynaecology Prince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR
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Ernstsen SL, Ahlen MT, Johansen T, Bertelsen EL, Kjeldsen-Kragh J, Tiller H. Antenatal intravenous immunoglobulins in pregnancies at risk of fetal and neonatal alloimmune thrombocytopenia: comparison of neonatal outcome in treated and nontreated pregnancies. Am J Obstet Gynecol 2022; 227:506.e1-506.e12. [PMID: 35500612 DOI: 10.1016/j.ajog.2022.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/01/2022] [Accepted: 04/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Maternal alloantibodies to human platelet antigen-1a can cause severe intracranial hemorrhage in a fetus or newborn. Although never evaluated in placebo-controlled clinical trials, most Western countries use off-label weekly administration of high-dosage intravenous immunoglobulin in all pregnant women with an obstetrical history of fetal and neonatal alloimmune thrombocytopenia. In Norway, antenatal intravenous immunoglobulin is only recommended in pregnancies wherein a previous child had intracranial hemorrhage (high-risk) and is generally not given in other human platelet antigen-1a alloimmunized pregnancies (low-risk). OBJECTIVE To compare the frequency of anti-human platelet antigen-1a-induced intracranial hemorrhage in pregnancies at risk treated with intravenous immunoglobulin vs pregnancies not receiving this treatment as a part of a different management program. STUDY DESIGN This was a retrospective comparative study where the neonatal outcomes of 71 untreated human platelet antigen-1a-alloimmunized pregnancies in Norway during a 20-year period was compared with 403 intravenous-immunoglobulin-treated pregnancies identified through a recent systematic review. We stratified analyses on the basis of whether the mothers belonged to high- or low-risk pregnancies. Therefore, only women who previously had a child with fetal and neonatal alloimmune thrombocytopenia were included. RESULTS Two neonates with brain bleeds were identified from 313 treated low-risk pregnancies (0.6%; 95% confidence interval, 0.2-2.3). There were no neonates born with intracranial hemorrhage of 64 nontreated, low-risk mothers (0.0%; 95% confidence interval, 0.0-5.7). Thus, no significant difference was observed in the neonatal outcome between immunoglobulin-treated and untreated low-risk pregnancies. Among high-risk mothers, 5 of 90 neonates from treated pregnancies were diagnosed with intracranial hemorrhage (5.6%; 95% confidence interval, 2.4-12.4) compared with 2 of 7 neonates from nontreated pregnancies (29%; 95% confidence interval, 8.2-64.1; P=.08). CONCLUSION The most reliable data hitherto for the evaluation of intravenous immunoglobulins treatment in low-risk pregnancies is shown herein. We did not find evidence that omitting antenatal intravenous immunoglobulin treatment in low-risk pregnancies increases the risk of neonatal intracranial hemorrhage.
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Nedberg NH, Turowski G, Guz K, Przytuła E, Uhrynowska M, Roald B, Husebekk A, Sitras V, Nystad M, Dębska M, Brojer E, Tiller H. When platelet alloimmunization meets chronic intervillositis: A prospective histopathology study suggests increased severity of clinical outcome. Placenta 2021. [DOI: 10.1016/j.placenta.2021.07.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Nedberg NH, Turowski G, Guz K, Przytuła E, Uhrynowska M, Roald B, Husebekk A, Sitras V, Nystad M, Dębska M, Brojer E, Tiller H. Platelet alloimmunization is associated with low grade chronic histiocytic intervillositis - A new link to a rare placental lesion? Placenta 2021; 112:89-96. [PMID: 34329972 DOI: 10.1016/j.placenta.2021.07.291] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Maternal alloimmunization against human platelet antigen (HPA)-1a has been implied to mediate both reduced birth weight and chronic placental inflammation. Fetal growth restriction is associated with different types of chronic inflammation in the placenta, mainly chronic histiocytic intervillositis and chronic villitis. The aim of this prospective study was to do a systematic examination of placentas from HPA-1a alloimmunized pregnancies, with focus on the histopathological and immunohistochemical diagnosis of variants of chronic inflammation. MATERIAL AND METHODS In a Polish-Norwegian study, 48 placentas were examined. The histopathology of placentas from 27 HPA-1a immunized women was compared with 21 placentas from non-immunized HPA-1a negative women (controls). In the group of alloimmunized women, ten received antenatal intravenous immunoglobulin G (IVIg). Tissue sections from formalin fixed paraffin embedded placental tissue were stained with hematoxylin and eosin and microscopically examined with focus on various types of chronic placental inflammations. RESULTS Chronic histiocytic intervillositis was observed in 40.7% of placentas from HPA-1a alloimmunized pregnancies, compared to none in the control group (p = 0.001). Chronic villitis of unknown etiology was more frequently found in the alloimmunized group, however this difference was not statistically significant. Maternal administration of IVIg did not seem to protect against chronic inflammatory lesions. DISCUSSION Placentas with detectable maternal anti-HPA-1a antibodies are associated with highly increased risk of low-grade chronic histiocytic intervillositis.
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Affiliation(s)
- Nora Hersoug Nedberg
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
| | - Gitta Turowski
- Department of Pathology, Center for Perinatal and Pregnancy-Related Pathology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Katarzyna Guz
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Ewa Przytuła
- Department of Pathology, Centre of Medical Postgraduate Education, Warsaw, Poland
| | - Małgorzata Uhrynowska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Borghild Roald
- Department of Pathology, Center for Perinatal and Pregnancy-Related Pathology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Husebekk
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Vasilis Sitras
- Department of Fetal Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona Nystad
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Marzena Dębska
- Department of Obstetrics and Gynecology, Centre of Medical Postgraduate Education, Warsaw, Poland
| | - Ewa Brojer
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Heidi Tiller
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Dahl J, Skogen B, Kjaer M, Husebekk A, Kjeldsen-Kragh J, Tiller H. A combined effect of anti-HPA-1a and anti-HLA Class I in pregnancy? Transfusion 2020; 60:2121-2129. [PMID: 32608103 DOI: 10.1111/trf.15944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Maternal anti-human leukocyte antigen (HLA) Class I is commonly detected alongside anti-human platelet antigen (HPA)-1a in fetal and neonatal alloimmune thrombocytopenia (FNAIT). Little is known regarding whether the presence of anti-HLA Class I may exert an additive effect on the risk and severity of FNAIT. METHODS AND MATERIALS We reanalyzed samples originally collected as part of a large Norwegian screening study on FNAIT during 1995-2004. This study identified and managed 170 pregnancies where the mother was HPA-1a negative and had detectable anti-HPA-1a during pregnancy. Maternal samples from 166 of these pregnancies were rescreened for anti-HLA Class I, revealing 111 (67%) that were antibody positive. Various regression models were used to assess if and how maternal anti-HLA Class I influenced the neonatal platelet count. RESULTS AND CONCLUSIONS Unadjusted neonatal platelet counts and the frequency of neonatal thrombocytopenia was not significantly affected by the presence of anti-HLA Class I alongside anti-HPA-1a, but results from regression analyses revealed a possible increased risk when the mother was nulliparous. These results warrant further investigation.
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Affiliation(s)
- Jesper Dahl
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bjørn Skogen
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mette Kjaer
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway.,Centre for Medicine, Clinical Research and Integrated Care, Finnmark Hospital Trust, Hammerfest, Norway
| | - Anne Husebekk
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jens Kjeldsen-Kragh
- Department of Laboratory Medicine Diagnostic Clinic, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories Region Skåne, Lund, Sweden
| | - Heidi Tiller
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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9
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Abstract
In Norway, the management strategy for fetal and neonatal alloimmune thrombocytopenia (FNAIT) has for more than two decades differed from most other countries. The focus of this paper is to describe and discuss the Norwegian FNAIT management program. We recommend antenatal IVIg to women who previously have had a child with FNAIT-induced ICH, and usually not to HPA-1a alloimmunized pregnant women where a previous child had FNAIT, but not ICH. When deciding management strategy, we use not only the obstetric history but also the antenatal anti-HPA-1a antibody level as a tool for risk stratification. The Norwegian National Unit for Platelet Immunology (NNUPI) at the University Hospital of North Norway in Tromsø provides diagnostic and consulting service for the clinicians and the blood banks all over the country, and serves as a national reference laboratory for FNAIT investigations.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.
| | - Maria Therese Ahlen
- Department of Laboratory Medicine, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Çiğdem Akalın Akkök
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Anne Husebekk
- Immunology Research Group, Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
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10
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Jensvoll H, Smeland MF, Tiller H, Holla ØL, Prescott TE, Vik A. A pregnant woman with pancytopenia. Tidsskr Nor Laegeforen 2019; 139:19-0022. [PMID: 31746163 DOI: 10.4045/tidsskr.19.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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11
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Nedberg NH, Turowski G, Guz K, Przytuła E, Uhrynowska M, Roald B, Eksteen M, Husebekk A, Dębska M, Brojer E, Tiller H. Chronic intervillositis linked to platelet alloimmunization – a new entry port to understanding a rare but important placental lesion. Placenta 2019. [DOI: 10.1016/j.placenta.2019.06.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Kjær M, Tiller H, Heide G, Kjeldsen-Kragh J, Skogen B, Husebekk A. Fetal exposure to maternal human platelet antigen-1a does not induce tolerance. An analytical observational study. PLoS One 2017; 12:e0182957. [PMID: 28837581 PMCID: PMC5570354 DOI: 10.1371/journal.pone.0182957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 07/27/2017] [Indexed: 11/19/2022] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a disease that may cause severe bleeding complications with risk of perinatal death or lifelong disability. The main cause of FNAIT is maternal antibodies against human platelet antigen (HPA)-1a. Both fetomaternal bleeding and transplacental trafficking of fetal cells during pregnancy could be the cause of alloimmunization. Persistence of fetal cells in the mother (fetal microchimerism) and maternal cells in the child (maternal microchimerism) are well-recognized phenomena. Thus, it could be envisaged that fetal exposure to the HPA-1a antigen could tolerize an HPA-1a negative female fetus and prevent production of anti-HPA-1a antibodies later in life if she becomes pregnant with an HPA-1a positive fetus. The objective of the current study was to assess if the risk of producing anti-HPA-1a antibodies and the severity of neonatal thrombocytopenia in HPA-1a negative women with HPA-1a positive mothers (i.e. the mother is HPA-1a/b), was lower than in HPA-1a negative women with HPA-1a negative mothers. HPA-1a negative women with HPA-1a antibodies, identified from a Norwegian screening study (1996-2004), where HPA-1 genotype of their mothers was available, were included in the study. The frequency of HPA-1a positive mothers to HPA-1a immunized daughters were compared to the calculated frequency in the general population. We did not find any difference in the frequency of HPA-1ab among mothers to daughters with HPA-1a antibodies as compared with the general population. Furthermore, acknowledging sample-size limitations, we neither found an association between the mothers' HPA type and their daughters' anti-HPA-1a antibody levels or any difference between the two groups of mothers (HPA-1ab vs HPA-1bb), with respect to frequency of thrombocytopenia in the children of their daughters with HPA-1a antibodies. Hence, there was no indication of tolerance against fetal HPA-1a antigen in HPA-1bb women who had been exposed to HPA-1a antigen during fetal development.
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Affiliation(s)
- Mette Kjær
- Laboratory Medicine, University Hospital North Norway, Tromsø, Norway
- Finnmark Hospital Trust, Hammerfest, Norway
- * E-mail:
| | - Heidi Tiller
- Immunology Research Group, Department of Medical Biology, UiT The Artic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital North Norway, Tromsø, Norway
| | - Gøril Heide
- Immunology Research Group, Department of Medical Biology, UiT The Artic University of Norway, Tromsø, Norway
| | - Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Skåne, Lund, Sweden
| | - Bjørn Skogen
- Laboratory Medicine, University Hospital North Norway, Tromsø, Norway
- Immunology Research Group, Department of Medical Biology, UiT The Artic University of Norway, Tromsø, Norway
| | - Anne Husebekk
- Immunology Research Group, Department of Medical Biology, UiT The Artic University of Norway, Tromsø, Norway
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Eksteen M, Heide G, Tiller H, Zhou Y, Nedberg NH, Martinez-Zubiaurre I, Husebekk A, Skogen BR, Stuge TB, Kjær M. Anti-human platelet antigen (HPA)-1a antibodies may affect trophoblast functions crucial for placental development: a laboratory study using an in vitro model. Reprod Biol Endocrinol 2017; 15:28. [PMID: 28427432 PMCID: PMC5399428 DOI: 10.1186/s12958-017-0245-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 04/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a bleeding disorder caused by maternal antibodies against paternal human platelet antigens (HPAs) on fetal platelets. Antibodies against HPA-1a are accountable for the majority of FNAIT cases. We have previously shown that high levels of maternal anti-HPA-1a antibodies are associated with clinically significant reduced birth weight in newborn boys. Chronic inflammatory placental lesions are associated with increased risk of reduced birth weight and have previously been reported in connection with FNAIT pregnancies. The HPA-1a epitope is located on integrin β3 that is associated with integrin αIIb (the fibrinogen receptor) on platelets and megakaryocytes. Integrin β3 is also associated with integrin αV forming the αVβ3 integrin heterodimer, the vitronectin receptor, which is expressed on various cell types, including trophoblast cells. It is therefore thinkable that maternal anti-HPA-1a antibodies present during early pregnancy may affect placenta function through binding to the HPA-1a antigen epitope on invasive throphoblasts. The aim of the study was to examine whether interaction of a human anti-HPA-1a monoclonal antibody (mAb) with HPA-1a on trophoblast cells affect adhesion, migration and invasion of extravillous trophoblast cells. METHODS An in vitro model with human anti-HPA-1a mAb, clone 26.4, and the first trimester extravillous trophoblast cell line HTR8/SVneo was employed. The xCELLigence system was utilized to assess the possible effect of anti-HPA-1a mAb on adhesion and migration of HTR8/SVneo cells. Specially designed chambers precoated with Matrigel were used to assess the effect on the invasive capacity of cells. RESULTS We found that human anti-HPA-1a mAb 26.4 partially inhibits adhesion and migratory capacity of HTR8/SVneo cells. CONCLUSIONS Our findings suggest that anti-HPA-1a antibodies may affect trophoblast functions crucial for normal placental development. Future studies including primary throphoblast cells and polyclonal anti-HPA-1a antibodies are needed to confirm these results.
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Affiliation(s)
- Mariana Eksteen
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Gøril Heide
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Heidi Tiller
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Yan Zhou
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San-Francisco, CA USA
| | - Nora Hersoug Nedberg
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Prophylix Pharma AS, Tromsø, Norway
| | - Inigo Martinez-Zubiaurre
- Bone and Joint research group, Department of Clinical Medicine, UiT- The Arctic University of Norway, Tromsø, Norway
| | - Anne Husebekk
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Bjørn R. Skogen
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Tor B. Stuge
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Mette Kjær
- Immunology research group, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
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Tiller H, Husebekk A, Ahlen MT, Stuge TB, Skogen B. Current perspectives on fetal and neonatal alloimmune thrombocytopenia - increasing clinical concerns and new treatment opportunities. Int J Womens Health 2017; 9:223-234. [PMID: 28458583 PMCID: PMC5402885 DOI: 10.2147/ijwh.s90753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Differences in platelet type between the fetus and the mother can lead to maternal immunization and destruction of the fetal platelets, a condition named fetal and neonatal alloimmune thrombocytopenia (FNAIT). FNAIT is reported to occur in ~1 per 1,000 live born neonates. The major risk is intracranial hemorrhage in the fetus or newborn, which is associated with severe neurological complications or death. Since no countries have yet implemented a screening program to detect pregnancies at risk, the diagnosis is typically established after the birth of a child with symptoms. Reports on broader clinical impact have increased clinical concern and awareness. Along with new treatment options for FNAIT, the debate around antenatal screening to detect pregnancies at risk of FNAIT has been revitalized.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Anne Husebekk
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | | | - Tor B Stuge
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Bjørn Skogen
- Department of Laboratory Medicine, Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
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15
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Kamphuis MM, Tiller H, van den Akker ES, Westgren M, Tiblad E, Oepkes D. Fetal and Neonatal Alloimmune Thrombocytopenia: Management and Outcome of a Large International Retrospective Cohort. Fetal Diagn Ther 2016; 41:251-257. [PMID: 27728915 DOI: 10.1159/000448753] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/14/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate the management and outcome of a large international cohort of cases of pregnancies complicated by fetal and neonatal alloimmune thrombocytopenia (FNAIT). METHODS This was an observational prospective and retrospective cohort study of all cases of FNAIT entered into the international multicentre No IntraCranial Haemorrhage (NOICH) registry during the period of 2001-2010. We evaluated human platelet antigen (HPA) specificity, the antenatal and postnatal interventions performed, and clinical outcome. RESULTS A total of 615 pregnancies complicated by FNAIT from 10 countries were included. Anti-HPA-1a was the most commonly implicated antibody. Antenatal treatment was administered in 273 pregnancies (44%), varying from intrauterine platelet transfusion to maternal administration of immunoglobulins, steroids, or a combination of those. Intracranial haemorrhage was diagnosed in 23 fetuses or neonates (3.7%). Overall perinatal mortality was 1.14% (n = 7). CONCLUSION This study presents the largest cohort of cases of FNAIT published. Our data show that antenatal treatment for FNAIT results in favourable perinatal outcome. Over time, in most centres, treatment for FNAIT changed from an invasive to a complete non-invasive procedure.
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Affiliation(s)
- Marije M Kamphuis
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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16
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Dahl J, Husebekk A, Acharya G, Flo K, Stuge T, Skogen B, Straume B, Tiller H. Maternal anti-HLA class I antibodies are associated with reduced birth weight in thrombocytopenic neonates. J Reprod Immunol 2016; 113:27-34. [DOI: 10.1016/j.jri.2015.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/16/2015] [Accepted: 10/19/2015] [Indexed: 01/19/2023]
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17
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Tiller H, Fedorcsak P, Skogen BR. Old tools revisited give hope - new treatment option for families with a history of severe FNAIT complications. Acta Obstet Gynecol Scand 2016; 95:486-7. [DOI: 10.1111/aogs.12842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Heidi Tiller
- Department of Obstetrics and Gynecology; University Hospital North Norway; Tromsø Norway
- Immunology Research Group; Department of Medical Biology; The Arctic University of Norway; Tromsø Norway
| | - Peter Fedorcsak
- Section for Reproductive Medicine; Department of Gynecology; Oslo University Hospital; Oslo Norway
| | - Bjørn R. Skogen
- Immunology Research Group; Department of Medical Biology; The Arctic University of Norway; Tromsø Norway
- Department of Laboratory Medicine; University Hospital North Norway; Tromsø Norway
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18
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Eksteen M, Tiller H, Averina M, Heide G, Kjaer M, Ghevaert C, Michaelsen TE, Ihle Ø, Husebekk A, Skogen B, Stuge TB. Characterization of a human platelet antigen-1a-specific monoclonal antibody derived from a B cell from a woman alloimmunized in pregnancy. J Immunol 2015; 194:5751-60. [PMID: 25972474 DOI: 10.4049/jimmunol.1401599] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 04/09/2015] [Indexed: 11/19/2022]
Abstract
Human platelet Ag (HPA)-1a, located on integrin β3, is the main target for alloantibodies responsible for fetal and neonatal alloimmune thrombocytopenia (FNAIT) in the white population. There are ongoing efforts to develop an Ab prophylaxis and therapy to prevent or treat FNAIT. In this study, an mAb specific for HPA-1a, named 26.4, was derived from an immortalized B cell from an alloimmunized woman who had an infant affected by FNAIT. It is the only HPA-1a-specific human mAb with naturally paired H and L chains. Specific binding of mAb 26.4, both native and recombinant forms, to platelets and to purified integrins αIIbβ3 (from platelets) and αVβ3 (from trophoblasts) from HPA-1a(+) donors was demonstrated by flow cytometry and surface plasmon resonance technology, respectively. No binding to HPA-1a(-) platelets or integrins was detected. Moreover, the Ab binds with higher affinity to integrin αVβ3 compared with a second HPA-1a-specific human mAb, B2G1. Further in vitro experimentation demonstrated that mAb 26.4 can opsonize HPA-1a(+) platelets for enhanced phagocytosis by monocytes, inhibit binding of maternal polyclonal anti-HPA-1a Abs, and weakly inhibit aggregation of HPA-1a-heterozygous platelets, the latter with no predicted clinical relevance. Thus, mAb 26.4 is highly specific for HPA-1a and could potentially be explored for use as a prophylactic or therapeutic reagent for FNAIT intervention and as a phenotyping reagent to identify women at risk for immunization.
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Affiliation(s)
- Mariana Eksteen
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Heidi Tiller
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Maria Averina
- Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Gøril Heide
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway
| | - Mette Kjaer
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway; Prophylix Pharma AS, Forskningsparken, N-9294 Tromsø, Norway
| | - Cedric Ghevaert
- Department of Haematology, University of Cambridge, Cambridge CB2 0XY, United Kingdom; National Health Service Blood and Transplant, Cambridge Biomedical Campus, Cambridge CB2 0PT, United Kingdom
| | - Terje E Michaelsen
- The Norwegian Institute of Public Health, N-0403 Oslo, Norway; and School of Pharmacy, University of Oslo, N-0316 Oslo, Norway
| | - Øistein Ihle
- The Norwegian Institute of Public Health, N-0403 Oslo, Norway; and
| | - Anne Husebekk
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway
| | - Bjørn Skogen
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway; Department of Laboratory Medicine, Diagnostic Clinic, University Hospital of North Norway, N-9038 Tromsø, Norway; Prophylix Pharma AS, Forskningsparken, N-9294 Tromsø, Norway
| | - Tor B Stuge
- Immunology Research Group, Department of Medical Biology, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, N-9037 Tromsø, Norway;
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19
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Yougbaré I, Lang S, Yang H, Chen P, Zhao X, Tai WS, Zdravic D, Vadasz B, Li C, Piran S, Marshall A, Zhu G, Tiller H, Killie MK, Boyd S, Leong-Poi H, Wen XY, Skogen B, Adamson SL, Freedman J, Ni H. Maternal anti-platelet β3 integrins impair angiogenesis and cause intracranial hemorrhage. J Clin Invest 2015; 125:1545-56. [PMID: 25774504 DOI: 10.1172/jci77820] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 02/05/2015] [Indexed: 01/09/2023] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a life-threatening disease in which intracranial hemorrhage (ICH) is the major risk. Although thrombocytopenia, which is caused by maternal antibodies against β3 integrin and occasionally by maternal antibodies against other platelet antigens, such as glycoprotein GPIbα, has long been assumed to be the cause of bleeding, the mechanism of ICH has not been adequately explored. Utilizing murine models of FNAIT and a high-frequency ultrasound imaging system, we found that ICH only occurred in fetuses and neonates with anti-β3 integrin-mediated, but not anti-GPIbα-mediated, FNAIT, despite similar thrombocytopenia in both groups. Only anti-β3 integrin-mediated FNAIT reduced brain and retina vessel density, impaired angiogenic signaling, and increased endothelial cell apoptosis, all of which were abrogated by maternal administration of intravenous immunoglobulin (IVIG). ICH and impairment of retinal angiogenesis were further reproduced in neonates by injection of anti-β3 integrin, but not anti-GPIbα antisera. Utilizing cultured human endothelial cells, we found that cell proliferation, network formation, and AKT phosphorylation were inhibited only by murine anti-β3 integrin antisera and human anti-HPA-1a IgG purified from mothers with FNAIT children. Our data suggest that fetal hemostasis is distinct and that impairment of angiogenesis rather than thrombocytopenia likely causes FNAIT-associated ICH. Additionally, our results indicate that maternal IVIG therapy can effectively prevent this devastating disorder.
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MESH Headings
- Animals
- Antibody Specificity
- Antigens, Human Platelet/immunology
- Apoptosis
- Autoantigens/immunology
- Blood Platelets/immunology
- Brain/blood supply
- Brain/embryology
- Disease Models, Animal
- Female
- Fetal Blood/immunology
- Human Umbilical Vein Endothelial Cells
- Humans
- Immune Sera/toxicity
- Immunity, Maternally-Acquired
- Immunoglobulin G/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Integrin beta3/genetics
- Integrin beta3/immunology
- Intracranial Hemorrhages/embryology
- Intracranial Hemorrhages/etiology
- Intracranial Hemorrhages/immunology
- Intracranial Hemorrhages/physiopathology
- Male
- Maternal-Fetal Exchange
- Mice
- Mice, Knockout
- Neovascularization, Pathologic/etiology
- Neovascularization, Physiologic/immunology
- Platelet Glycoprotein GPIb-IX Complex/genetics
- Platelet Glycoprotein GPIb-IX Complex/immunology
- Pregnancy
- Proto-Oncogene Proteins c-akt/physiology
- Retinal Vessels/embryology
- Retinal Vessels/pathology
- Thrombocytopenia, Neonatal Alloimmune/embryology
- Thrombocytopenia, Neonatal Alloimmune/immunology
- Thrombocytopenia, Neonatal Alloimmune/prevention & control
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Tiller H, Husebekk A, Skogen B, Kjeldsen-Kragh J, Kjaer M. True risk of fetal/neonatal alloimmune thrombocytopenia in subsequent pregnancies: a prospective observational follow-up study. BJOG 2015; 123:738-44. [DOI: 10.1111/1471-0528.13343] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2015] [Indexed: 11/27/2022]
Affiliation(s)
- H Tiller
- Department of Obstetrics and Gynaecology; University Hospital North Norway; Tromsø Norway
- Immunology Research Group; Department of Medical Biology; The Artic University of Norway; Tromsø Norway
| | - A Husebekk
- Immunology Research Group; Department of Medical Biology; The Artic University of Norway; Tromsø Norway
| | - B Skogen
- Immunology Research Group; Department of Medical Biology; The Artic University of Norway; Tromsø Norway
- Department of Laboratory Medicine; University Hospital North Norway; Tromsø Norway
| | - J Kjeldsen-Kragh
- Clinical Immunology and Transfusion Medicine; University and Regional Laboratories Region Skåne; Lund Sweden
| | - M Kjaer
- Immunology Research Group; Department of Medical Biology; The Artic University of Norway; Tromsø Norway
- Department of Laboratory Medicine; University Hospital North Norway; Tromsø Norway
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21
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Killie M, Tiller H, Flodmark O, Skogen B, Husebekk A, Kjeldsen-Kragh J. Screening of pregnant women to reduce fetal and neonatal alloimmune thrombocytopenia (FNAIT). Z Geburtshilfe Neonatol 2013. [DOI: 10.1055/s-0033-1361260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Tiller H, Kamphuis MM, Flodmark O, Papadogiannakis N, David AL, Sainio S, Koskinen S, Javela K, Wikman AT, Kekomaki R, Kanhai HHH, Oepkes D, Husebekk A, Westgren M. Fetal intracranial haemorrhages caused by fetal and neonatal alloimmune thrombocytopenia: an observational cohort study of 43 cases from an international multicentre registry. BMJ Open 2013; 3:bmjopen-2012-002490. [PMID: 23524102 PMCID: PMC3612794 DOI: 10.1136/bmjopen-2012-002490] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterise pregnancies where the fetus or neonate was diagnosed with fetal and neonatal alloimmune thrombocytopenia (FNAIT) and suffered from intracranial haemorrhage (ICH), with special focus on time of bleeding onset. DESIGN Observational cohort study of all recorded cases of ICH caused by FNAIT from the international No IntraCranial Haemorrhage (NOICH) registry during the period 2001-2010. SETTING 13 tertiary referral centres from nine countries across the world. PARTICIPANTS 37 mothers and 43 children of FNAIT pregnancies complicated by fetal or neonatal ICH identified from the NOICH registry was included if FNAIT diagnosis and ICH was confirmed. PRIMARY AND SECONDARY OUTCOME MEASURES Gestational age at onset of ICH, type of ICH and clinical outcome of ICH were the primary outcome measures. General maternal and neonatal characteristics of pregnancies complicated by fetal/neonatal ICH were secondary outcome measures. RESULTS From a total of 592 FNAIT cases in the registry, 43 confirmed cases of ICH due to FNAIT were included in the study. The majority of bleedings (23/43, 54%) occurred before 28 gestational weeks and often affected the first born child (27/43, 63%). One-third (35%) of the children died within 4 days after delivery. 23 (53%) children survived with severe neurological disabilities and only 5 (12%) were alive and well at time of discharge. Antenatal treatment was not given in most (91%) cases of fetal/neonatal ICH. CONCLUSIONS ICH caused by FNAIT often occurs during second trimester and the clinical outcome is poor. In order to prevent ICH caused by FNAIT, at-risk pregnancies must be identified and prevention and/or interventions should start early in the second trimester.
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Affiliation(s)
- Heidi Tiller
- Department of Obstetrics and Gynaecology, University Hospital North Norway, Tromsø, Norway
| | - Marije M Kamphuis
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Olof Flodmark
- Neuroradiologiska kliniken, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Nikos Papadogiannakis
- Department of Laboratory Medicine, Division of Pathology, Section of Perinatal Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anna L David
- Obstetrics and Maternal Foetal Medicine, Institute for Women's Health, University College, London, UK
| | | | | | - Kaija Javela
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - Agneta Taune Wikman
- Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Humphrey H H Kanhai
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Husebekk
- Institute of Medical Biology, University of Tromsø, Tromsø, Norway
| | - Magnus Westgren
- Department of Obstetrics and Gynaecology, Division of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Tiller H, Killie MK, Chen P, Eksteen M, Husebekk A, Skogen B, Kjeldsen-Kragh J, Ni H. Toward a prophylaxis against fetal and neonatal alloimmune thrombocytopenia: induction of antibody-mediated immune suppression and prevention of severe clinical complications in a murine model. Transfusion 2012; 52:1446-57. [DOI: 10.1111/j.1537-2995.2011.03480.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Skogen B, Killie MK, Kjeldsen-Kragh J, Ahlen MT, Tiller H, Stuge TB, Husebekk A. Reconsidering fetal and neonatal alloimmune thrombocytopenia with a focus on screening and prevention. Expert Rev Hematol 2011; 3:559-66. [PMID: 21083473 DOI: 10.1586/ehm.10.49] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Uncertainty regarding the pathophysiology of fetal and neonatal alloimmune thrombocytopenia (FNAIT) has hampered the decision regarding how to identify, follow-up and treat the women and children with this potentially serious condition. Since knowledge of the condition is derived mainly from retrospective studies, understanding of the natural history of this condition remains incomplete. General screening programs for FNAIT have still not been introduced, mainly because of a lack of reliable risk factors and effective treatment. Now, several prospective screening studies involving up to 100,000 pregnant women have been published and the results have changed the understanding of the pathophysiology of FNAIT and, thereby, the approach toward diagnostics, prevention and treatment in a more appropriate way.
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Affiliation(s)
- Bjørn Skogen
- Laboratory Medicine, University Hospital of North Norway, N-9038 Tromsø, Norway.
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Tiller H, Killie MK, Skogen B, Øian P, Husebekk A. Neonatal alloimmune thrombocytopenia in Norway: poor detection rate with nonscreening versus a general screening programme. BJOG 2009; 116:594-8. [DOI: 10.1111/j.1471-0528.2008.02068.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tiller H. [Critical spotlight on Norwegian screening study]. Tidsskr Nor Laegeforen 2008; 128:1982-1984. [PMID: 18787577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Affiliation(s)
- Heidi Tiller
- Avdeling for immunologi og transfusjonsmedisin, Universitetssykehuset Nord-Norge, 9038 Tromsø.
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Peters W, Ritter J, Tiller H, Valdes O, Renner U, Fountain M, Beck E. Growth, ageing and death of a photoautotrophic plant cell culture. Planta 2000; 210:478-487. [PMID: 10750906 DOI: 10.1007/pl00008155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Batch cultures of photoautotrophic cell suspensions of Chenopodium rubrum L., growing in an inorganic medium on CO2 under a daily balanced light-dark regime of 16: 8 h could be maintained for approximately 100 d without subcultivation. The long-lived cultures showed an initial cell division phase of 4 weeks, followed by a stationary phase of another 4 weeks, after which ageing and progressive cell death reduced the number of living cells and the cultures usually expired after another 3-4 weeks. These developmental phases of the cell culture were characterised with respect to photosynthetic performance, dark respiration, content of phytohormones and capacity of cell division. Cell division of the majority of the cells finished in the G1- or G0-phase of the cell cycle, caused by a pronounced decline in the endogenous levels of auxin and cytokinins. Supply of these growth factors to resting cells resulted in resumption of cytokinesis, at least by some of the cells. However, responsiveness to the phytohormones declined during the stationary phase, and subcultivation was no longer possible beyond day 60 when the phases of ageing and death commenced. Ageing was characterised by a further decline in the photosynthetic capacity of the cells, by a climacteric enhancement of dark respiration, but also by a slight increase in the level of IAA and cytokinins concomitant with a decrease in ethylene. Similarities and differences between the development of batch-cultured photoautotrophic cells of C. rubrum and that of a leaf are discussed with respect to using the cell culture as a model for a leaf.
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Affiliation(s)
- W Peters
- Lehrstuhl Pflanzenphysiologie, Universität Bayreuth, Germany
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