Maternal thrombocytopenia. Predicting neonatal thrombocytopenia with cordocentesis

OBJECTIVE

To evaluate the efficacy of cordocentesis for predicting fetal thrombocytopenia in the presence of maternal thrombocytopenia.

STUDY DESIGN

We studied platelet counts obtained by cordocentesis from 42 consecutive immune thrombocytopenia purpura patients. Platelet counts were obtained on 36 neonates, and the statistical analysis included only these infants. Presence of maternal antiplatelet antibodies, interval from fetal sampling to delivery, neonatal platelet counts and outcome were evaluated. Thrombocytopenia was defined as a platelet count < or = 150,000/microL, with < or = 50,000 microL considered severe.

RESULTS

No procedure-related complications occurred. A moderate correlation existed between fetal and neonatal platelet counts (r = .48, P = .003), unrelated to the interval between sampling and delivery. Eight of 36 fetuses had thrombocytopenia, and 4 were confirmed at delivery. Two neonates had thrombocytopenia at birth but not at cordocentesis. Two neonatal thrombocytopenia cases were severe. Neither was categorized as severe antenatally. The sensitivity, specificity, and positive and negative value for predicting severe neonatal thrombocytopenia were 0%, 100%, 0%, and 94%, respectively. Grade 1 intraventricular hemorrhages occurred in two neonates delivered at 35 weeks' with normal platelet counts.

CONCLUSION

Cordocentesis was not reliable in predicting severe neonatal thrombocytopenia; however, the high negative predictive value was reassuring. The clinical utility of the technique and the population in which it should be used remain to be defined.

Characteristic generated alterations of autoantibody patterns in idiopathic thrombocytopenic purpura

Using a Western blot technique that allows quantitative detection of antibody reactivities to a large number of antigens, serum IgG and IgM antibody repertoires were compared in a group of 19 patients with a diagnosis of idiopathic thrombocytopenic purpura (ITP) and respective healthy controls. The results show that, irrespective of the duration of thrombocytopenia, age of the patients, and type of therapy, all ITP donors share characteristic alterations of serum antibody reactivity patterns on homologous erythrocyte and liver antigens. Multiparametric analyses of the immunoreactivity data readily segregated the groups of ITP and healthy donors. Similar analyses also distinguished ITP sera from those of a group of patients with systemic lupus erythematosus (SLE). We conclude that ITP is an autoimmune disease associated with generalized alterations of antibody repertoires, that may be characteristic enough to allow for diagnosis.

[Autoimmune thrombopenic purpura. Clinical practices during diagnosis. A French survey and recommendations. French College of Hemotologists Evaluation Commission]

THE SURVEY: To better ascertain diagnostic and treatment strategies used by physicians for idiopathic thrombocytopenic purpura, a questionnaire was addressed to 298 French hematologists and pediatricians. One hundred and ten responses were analyzed.

DIAGNOSTIC APPROACH

Thrombocytopenia was determined on capillary blood samples by 50% of the physicians and platelet-associated antibody by 44%. Bone marrow aspirates were obtained more frequently in adults (85%) than in children (47%) and immune disorders were more often investigated in 95% of adults and in 68% of children.

THERAPEUTICS

Treatment threshold was lower in children (20.10(9)/l) than in adults (50.10(9)/l). Corticoidsteroids was the treatment of choice in adults (98%) and children received either IV immunoglobulins (61%) and/or corticosteroids (63%); higher doses were used in children (> or = 2 mg/kg versus 1 mg/kg) for shorter periods (> or = 2 weeks versus > 3 weeks). Treatment failure was evaluated earlier in children (< 10 days) than in adults (> 20 days).

RECOMMENDATIONS

1. Diagnosis. Based on repeatedly low platelet counts and verification that only platelets are involved. Clinical examination is normal excepting rare cases of severe hemorrhage. Search for antiplatelet antibodies is non-contributive 2. Treatment Short-term corticosteroids, both in children and adults. Intravenous gammaglobulins should be limited to cases with signs of severe hemorrhage. 3. Consult the complete guidelines for each individual clinical situation.

Diagnosis and treatment of idiopathic thrombocytopenic purpura: recommendations of the American Society of Hematology. The American Society of Hematology ITP Practice Guideline Panel

To develop guidelines for the diagnosis and management of idiopathic thrombocytopenic purpura (ITP) and to document the extent to which those guidelines are based on either scientific evidence or opinion, the AMerican Society of Hematology established a panel composed of 13 hematologists with expertise in ITP, a clinical epidemiologist, and a practice guidelines methodologist. A comprehensive review was done of all published English-language studies that met explicit inclusion criteria and that evaluated the natural history of ITP or the effectiveness of testing and treatment options for ITP. The quality of each study was graded by two reviewers using formal methodologic rules. In subject areas for which data was inadequate, recommendations were based on opinion and were derived by using a formal screening procedure. Confidential questionnaires were used to survey the hematologists on the panel about the appropriateness of testing and treatment options in hundreds of clinical scenarios. Practice recommendations were derived from the mean appropriateness scores for each indication. Voting was kept confidential to give each panel member an equal voice and to limit biases introduced by group dynamics. The recommendations were peer reviewed by eight outside experts. This report focuses on data and on recommendations for adults with ITP. Little high-quality scientific evidence with which to assess the efficacy of diagnostic tests and treatments for ITP is available. The opinion of the panel was that most diagnostic tests are unnecessary in the routine work-ups of patients suspected of having ITP and that ITP accompanied by severe bleeding requires treatment with glucocorticoids, intravenous immunoglobin, and other measures. However, treatment and hospitalization is often unnecessary when patients have only mild or moderate thrombocytopenia or minimal bleeding. Special therapeutic measures are sometimes indicated in pregnant women with ITP.

Immunologic aspects in the pathogenesis and treatment of immune thrombocytopenic purpura in children

Immune thrombocytopenic purpura (ITP) is either a transient or a chronic bleeding disorder characterized by an unbalanced immune response due to inflammation (ie, infection, autoimmunity). There is new evidence arguing for an immune-mediated mechanism operative in ITP-increased HLA-DR expression, defects in cellular and humoral immunity, and specific autoantibody production. Moreover, different forms of ITP may be associated with specific alterations in the immune response. New immunosupportive modalities emphasize biologic interventions as a therapeutic strategy for autoimmune disorders. Practical guidelines for the diagnosis and treatment of ITP were recently established by the American Society of Hematology. These recommendations will substantially influence patient care and future research.

Autoimmune thrombocytopenia in adults: clinical experience

Diagnostic and treatment algorithms in autoimmune thrombocytopenia (AITP) are still somewhat controversial. We present our experience in the diagnosis and treatment of 39 AITP patients, hospitalized at our department between 1990 and 1995, and discuss alternative approaches. There were 10 male and 29 female patients, median age 47 (range 18-75) years. All patients had isolated thrombocytopenia and normal or increased number of megakaryocytes in bone marrow. Platelet count lower than 15 x 10(9)/L was found in 25 (64.1%) patients. Eighteen (54.5%) patients responded well to standard and two (6.1%) to high doses of steroids, whereas 18.2% of the patients responded well to other immunosuppressive therapy. Antiplatelet antibodies were found only in 4 (10.2%) patients. Our conclusion was that a half of adult AITP patients achieve satisfactory recovery on standard doses of steroids.

Diagnosis and treatment of idiopathic thrombocytopenic purpura. American Society of Hematology ITP Practice Guideline Panel

The American Society of Hematology established a panel to develop practice guidelines for the diagnosis and management of idiopathic thrombocytopenic purpura and to document the extent to which the recommendations are based on either scientific evidence or opinion. A comprehensive literature review found little high-quality scientific evidence to define the natural history of idiopathic thrombocytopenic purpura or to assess the efficacy of diagnostic tests and treatments for the disorder. Recommendations were therefore based on opinion, derived from a formal scoring procedure. In the panel's opinion, in most cases only a history, physical examination and complete blood cell count with examination of the peripheral blood smear are necessary in the routine work-up of patients with suspected idiopathic thrombocytopenic purpura. The panel suggests different treatment approaches in children and adults because of important differences in the behavior of the disease in the two patient groups. The panel recommends that idiopathic thrombocytopenic purpura accompanied by severe bleeding be treated with glucocorticoids, intravenous immunoglobulin and other measures, but that treatment and hospitalization are often unnecessary when patients have only mild to moderate thrombocytopenia or minimal bleeding. Idiopathic thrombocytopenic purpura in pregnant women and the risk of thrombocytopenia in their newborns pose specific problems for diagnosis and treatment.

[Autoimmune thrombocytopenia and pregnancy]

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder with its highest frequency in young women in the reproductive years. An antepartum diagnosis of maternal thrombocytopenia has become more common because platelet counts are now included with routine complete blood cell counts. Sometimes platelet autoantibodies facilitate increased platelet destruction by the reticuloendothelial system especially the spleen. These autoantibodies (IgG) can cross the placenta and place the fetus at risk for thrombocytopenia and, sometimes, serious bleeding problems such as intracranial hemorrhage can occur. The treatment is performed by corticosteroids (prednisone) or intravenous immune gammaglobulin. Four patients with thrombocytopenia during pregnancy underwent medical treatment (prednisone 1 mg/kg/die). The results were successful. In one case only we did not have a clinical response after corticosteroid therapy. There were no intracranial hemorrhages; however the risk for the patients and fetal or neonatal hemorrhage is much lower than thought. Corticosteroid treatment is the first choice, but sometimes it can give a clinical negative response.

Diagnosis, clinical course, and management of idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura is a common acquired bleeding disorder. However, the diagnosis is often uncertain because there are no specific tests that define idiopathic thrombocytopenic purpura, and management decisions are often difficult because there are no firm data to define the clinical course and to estimate the risks of major bleeding and death. Because the incidence of idiopathic thrombocytopenic purpura is greatest in young women, its occurrence during pregnancy is a frequent problem, with specific issues related to the anticipated route of delivery and the risks for neonatal thrombocytopenia. To address these unresolved issues, the American Society of Hematology established a panel to develop a practice guideline for idiopathic thrombocytopenic purpura. The data from this recently published document and its recommendations are summarized in this review.

[Immune thrombocytopenic purpura in children--controversy and consensus. How much investigation and treatment is meaningful?]

Immune thrombocytopenic purpura (ITP) is a postinfectious thrombocytopenia with a general tendency to bleed. The disease is often self-limiting in children, but the risk of intracranial haemorrhage has led to some controversy about indications and intensities of treatment. In nearly all cases of intracranial haemorrhage documented in the literature since 1970, the platelet count was 15 x 10(9)/l) or lower and was observed in less than 1% of the patients. In typical cases of acute ITP no extensive laboratory investigation is required. Indications for treatment depend more on clinical bleeding symptoms than on platelet count. Up to now there is no proven difference in efficacy between steroids and immunoglobulins. In 10-25% the disease becomes chronic, but spontaneous remission can occur after many years. Management of the chronic form has to be adjusted to the individual patient. Continuous steroid treatment for more than three weeks is contraindicated. Splenectomy should be avoided if at all possible because the risk of sepsis after splenectomy is comparable with the risk of life-threatening bleeding.

[Investigation and treatment of immune thrombocytopenic purpura in children in Norway]

The treatment of immune thrombocytopenic purpura (ITP) in children has been debated for a long time. Some years ago the Norwegian paediatric haematology and oncology group proposed guidelines for investigation and therapy. In order to assess the present management of ITP in Norway, we sent a questionnaire to all paediatric departments. Answers from 22 departments could be analyzed. The estimated number of new ITP cases was 54, giving an incidence of 6.7 per 100,000 children. Most of the departments treat only a few patients (one to three patients a year). Investigation and treatment of ITP follows roughly the Norwegian guidelines. Disagreement exists about the indication for start of drug treatment (the lowest accepted platelet count differed from < 5 to 30 x 10(9)/l) and about choice of drug (1/2 prefer steroids, 2/3 immunoglobulins). There seems to be great interest for this topic among the Norwegian pediatricians. A prospective registration of all ITP cases in Norway has now been started.

Childhood thrombocytopenic purpura--review and a case report

Childhood idiopathic thrombocytopenic purpura is a rare condition seen in children. A case of a 10 year old female child is reported. Bleeding from the gingiva and petechiae on the tongue were observed. The blood picture was normocytic normochromic with neutrophilia and thrombocytopenia. Bone marrow study was suggestive of marrow changes in idiopathic thrombocytopenic purpura. Dental extractions were postponed. Recognition of the disease by the dental profession is stressed.

Prospective evaluation of the clinical usefulness of an antigen-specific assay (MAIPA) in idiopathic thrombocytopenic purpura and other immune thrombocytopenias

The diagnosis of idiopathic immune thrombocytopenia remains a clinical diagnosis based on the exclusion of other causes of immune and nonimmune thrombocytopenia. Measurement of platelet-associated Ig (PAIg), while sensitive, is nonspecific for the diagnosis of immune thrombocytopenia. Published experience of antigen capture assays (including monoclonal antibody immobilization of platelet antigens or MAIPA) suggest a high sensitivity and specificity (70% to 80%) in selected groups of patients. In a prospective evaluation of 158 patients with thrombocytopenia from all causes, we report a sensitivity of 51% and specificity of 80% for direct MAIPA assays. MAIPA was considerably better in discriminating immune from nonimmune thrombocytopenia than two assays of PAIgG. Antiplatelet antibodies detected by MAIPA were more frequently directed against the glycoprotein (GP) IIb/IIIa than the GP Ib/IX complex. Our experience suggests that MAIPA assays are useful in the laboratory assessment of thrombocytopenia, should be performed before therapy, and that some patients with 'nonimmune' thrombocytopenia may have genuine antiplatelet antibodies.

Canine idiopathic thrombocytopenic purpura

Canine idiopathic thrombocytopenic purpura (ITP) is a disease in which antibodies bound to the surface of platelets mediate premature platelet destruction by macrophages. ITP in dogs and chronic ITP in humans are analogous diseases. This article draws on information from the literature on ITP in dogs and in humans, and reviews the pathogenesis, diagnosis, and treatment of ITP in dogs.

Current controversies in the management of idiopathic thrombocytopenic purpura during childhood

Both acute and chronic ITP in children are generally benign conditions. Few patients develop serious complications or long-term sequelae. Therefore, most patients require little or no specific therapy. IVIG or high-dose steroids may benefit some patients who have evidence of clinical bleeding, and splenectomy may be of value in patients with chronic ITP whose lives are altered by low platelet counts or bleeding. It is difficult to predict which patients are at risk for the development of ICH, and severe hemorrhage is not always curtailed by prior or concomitant therapy. The decision to treat a child with ITP should be based on the entire clinical picture rather than on the platelet count alone.

Immune thrombocytopenic purpura in three patients with preexisting ulcerative colitis

Ulcerative colitis (UC) is associated with extraintestinal diseases in numerous target tissues. Associated immune-mediated hematological diseases, however, are rarely described. We report three Caucasian adult patients with UC and immune thrombocytopenic purpura (ITP). Platelet-associated antibodies (IgG) were positive in two patients, and bone marrow examinations in two patients revealed normal to increased megakaryocyte numbers. ITP was treated with corticosteroids in all patients. Two patients eventually received intravenous immune gamma-globulin, and one patient required surgical splenectomy. Of particular interest, UC preceded the onset of ITP in all patients (by from 1 to 19 yr). This suggests that ITP in these patients is causally associated with UC, possibly secondary to immunostimulation from lumenal antigens and altered immunoregulation.

The thrombocytopenic purpuras. Recognition and management

Idiopathic thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP), are distinct entities. ITP is a relatively common autoimmune disorder typically manifesting with isolated thrombocytopenia. The acute form, more common in children, is a self-limiting, often post-viral disease. Therapy, if indicated, usually consists of a brief course of steroids or intravenous IgG. Chronic ITP, more common in adults, rarely remits spontaneously. Most patients respond initially to steroids, but generally the disease relapses when steroids are tapered. Splenectomy offers a 70% chance of cure. A variety of treatment options exist for patients not responding to splenectomy. The treating physician must choose the most effective and least toxic treatment for the individual patient. TTP is a rare, often life-threatening, multisystem disease of unknown aetiology. Its hallmark is widespread occlusion of the microcirculation by platelet aggregates. The clinical symptoms usually respond dramatically to plasma exchange therapy. Steroids, antiplatelet agents and vincristine may also be useful. Splenectomy should be considered in patients with multiple relapses. More specific therapy awaits a fuller understanding of the pathogenesis of this disease.

Systemic lupus erythematosus presenting with thrombocytopenia. Report of a child with positive anticardiolipin antibodies

We report a case of systemic lupus erythematosus initially presenting with thrombocytopenia and diagnosed as immune thrombocytopenic purpura. The patient subsequently developed lymphadenopathy, arthritis and cardiac involvement along with anticardiolipin antibodies. We would like to emphasize the fact that these autoantibodies have a role in the pathogenesis of thrombocyte destruction, and that patients with immune thrombocytopenic purpura should be followed for signs of systemic lupus erythematosus.

Antiplatelet antibody testing in thrombocytopenic pregnant women

OBJECTIVE

The purpose of the study was to attempt to distinguish pregnant women with gestational thrombocytopenia from those with idiopathic immune thrombocytopenia by eight different platelet antibody assays.

STUDY DESIGN

Sera from pregnant women with presumed gestational thrombocytopenia (n = 160) and idiopathic immune thrombocytopenia (n=90) were prospectively tested for indirect and platelet-associated immunoglobulins G and M and complement C3, as well as for serotonin release. After the results were analyzed, a subset of patients were subsequently analyzed for circulating antiplatelet antibody directed against platelet membrane glycoprotein GPIIb/IIIa.

RESULTS

Indirect immunoglobulin G was significantly greater in the 85 women with idiopathic immune thrombocytopenia than in the 129 women with gestational thrombocytopenia (p<0.001). Platelet-associated immunoglobulin G was elevated in the majority of women, both those with gestational thrombocytopenia and those with idiopathic immune thrombocytopenia. There were also no statistically significant difference in the values for platelet-associated C3 or indirect immunoglobulin M and C3. Levels of platelet-associated immunoglobulin M showed a tendency to be higher in women with gestational thrombocytopenia (p=0.04), as did the values in the serotonin release assay (p=0.06).

CONCLUSION

Our data demonstrate that patients with gestational thrombocytopenia had surprisingly high levels of platelet-associated immunoglobulin despite mild thrombocytopenia. Comparison of a relatively large number of patients with idiopathic immune thrombocytopenia and gestational thrombocytopenia indicates that women with idiopathic immune thrombocytopenia cannot be distinguished from those with gestational thrombocytopenia by means of one or more of the prototypic platelet antiglobulin tests currently in use. Our preliminary data with glycoprotein-specific assays indicate that they may be more useful.

[Chronic immune thrombocytopenic purpura in pregnancy--a case report]

The authors present a young woman with chronic immune thrombocytopenic purpura during pregnancy. This association is the commonest cause of thrombycitopenia in the first three months of pregnancy. There is a bigger number of spontaneous abortions and more frequent bleeding in such patients, during delivery, in mothers and babies too. The number of mothers platelets and the level of circulating IgG antibodies associated to the mothers platelets are not reliable indicators of the fetus platelets number. Only reliable way for determination of the fetus platelets number is percutaneous umbilical cord blood sampling. Five days before delivery the fetus platelets number have been determinated by this method, and it was 260 x 10(9)/l. Mother was prepared for delivery with high doses of prednisone of 1 mg/kg body weight. Her platelets number was 128 x 10(9)/l on the day of delivery. Delivery has been performed by vaginaly route without complications. Healthy female baby was born.

[Autoimmune thrombocytopenia and pregnancy]

Autoimmune thrombocytopenic purpura PTA, occurs more commonly in women during the reproductive years. Consequently, physicians frequently must manage pregnant patients with PTA. The management of the mother is simplified because an important measure of platelet count, is readily available. However the management of the fetus is more difficult because no definitive maternal treatment to prevent fetal thrombocytopenia has been successful. The performance of percutaneous umbilical blood sampling or fetal scalp sampling allow the determination of fetal platelet before delivery. If a fetal thrombocytopenia of less than 50,000 mm3 is detected, cesarean section is indicated to avoid intracranial hemorrhage in the fetus.

Idiopathic thrombocytopenic purpura (ITP) in Ethiopian children: clinical findings and response to therapy

This retrospective study provides information on the clinical findings and response to therapy in Ethiopian children with idiopathic thrombocytopenic purpura. Forty-nine cases of idiopathic thrombocytopenic purpura admitted to the teaching hospital, Ethio-Swedish Children's Hospital (ESCH) in Addis Abeba, Ethiopia between January 1982 and December 1993 were studied. Among these were 31 females and 18 males with a female to male ratio of 1.9:1. The age range was three to 12 years with a mean of seven years. The commonest presenting clinical features were petechiae, epistaxis, gingival and gastro-intestinal bleeding. Twenty-nine patients were treated with prednisolone, out of whom, 27 attained absolute remission. Twenty patients were observed and managed conservatively and attained spontaneous remission. One child went on to develop chronic idiopathic thrombocytopenic purpura and underwent splenectomy after immunosuppressive treatment failure, while another child is still being followed up with recurrent episodes of thrombocytopenia and epistaxis. No mortality was noted in the review of these series of patients.

Idiopathic thrombocytopaenic purpura presenting as post-partum haemorrhage

We describe a patient with idiopathic (immune) thrombocytopaenic purpura who presented with postpartum haemorrhage. The patient did not have any external manifestations of idiopathic thrombocytopaenic purpura on admission but the diagnosis was suspected after examination of the baby.

Tuberculosis presenting as immune thrombocytopenic purpura

Various haematological abnormalities commonly occur in active tuberculosis (TB). However, thrombocytopenia is rare and immune thrombocytopenic purpura (ITP) is mentioned only in few case reports. We found that of 846 cases with active TB, 9 (1%) presented with ITP as the only abnormality. Three out of these 9 cases had disseminated miliary TB, 3 an abdominal abscess or lymphadenitis, and 3 pulmonary TB; none had palpable splenomegaly. All patients had purpura and the platelet count varied between 4 and 21 x 10(9)/l, and the bone marrow showed increased megakaryocytes. All tuberculous patients showed initially a poor platelet count response to steroid therapy. The platelet count returned to normal 2-6 weeks after oral prednisone combined with antituberculous drugs.

Detection of platelet-bound and serum platelet-bindable antibodies for diagnosis of idiopathic thrombocytopenic purpura in dogs

The sensitivity and specificity of 2 antibody tests for diagnosis of idiopathic thrombocytopenic purpura (ITP) in dogs were investigated prospectively. An ELISA to detect antibodies bound to the surface of platelets from affected dogs (direct test) was performed in 34 dogs with a clinical diagnosis of ITP and in 21 dogs with thrombocytopenia attributable to other causes. An ELISA to detect platelet-bindable antibodies in serum from affected dogs (indirect test) was performed in 32 dogs with ITP and in 15 dogs with other causes of thrombocytopenia. The direct test was positive in 32 of 34 dogs with ITP (sensitivity, 94%) and negative in 13 of 21 dogs with other causes of thrombocytopenia (specificity, 62%). Positive direct test results were obtained in 2 dogs with systemic lupus erythematosus, and in 1 dog each with concurrent Ehrlichia canis and Babesia canis infections, dirofilariasis, myelodysplasia, disseminated intravascular coagulation (of unknown cause), and thrombocytopenia subsequent to administration of trimethoprim/sulfadiazine, as well as in 1 dog with thrombocytopenia 14 days after a whole blood transfusion. The indirect test had positive results in 11 of 32 dogs with ITP (sensitivity, 34%) and negative results in 12 of 15 dogs with other causes of thrombocytopenia (specificity, 80%). Positive indirect test results were obtained in 1 dog each with systemic lupus erythematosus, concurrent E canis and B canis infections, and thrombocytopenia subsequent to administration of trimethoprim/sulfadiazine. Detection of platelet-bound antibodies was more sensitive than detection of serum-platelet bindable antibodies in confirming a diagnosis of ITP in dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Kabuki make-up syndrome associated with chronic idiopathic thrombocytopenic purpura

Although susceptibility to infections in Kabuki make-up syndrome (KMS) has frequently been reported, there have been few immunological studies. We describe a 14 year old girl with KMS exhibiting chronic idiopathic thrombocytopenic purpura (chronic ITP), including immunological studies. Corticosteroid therapy was not effective therefore splenectomy was performed. The patient's platelet count increased transiently. Immunological studies revealed normal T cell functions and low serum immunoglobulin A (IgA) levels. Because of the abnormalities of B cell functions in chronic ITP and low serum IgA levels in our patient, we speculate that there may be some abnormalities of humoral immunity in KMS.

Platelet disorders in pregnancy: implications for mother and fetus

Platelet disorders in pregnancy are not uncommon. Most often, obstetricians are faced with a patient with undiagnosed thrombocytopenia and have the responsibility of deciding if the condition is ITP, gestational thrombocytopenia, or a process related to pre-eclampsia. Correct diagnosis is important because ITP can be associated with fetal thrombocytopenia, making route of delivery important. In alloimmune thrombocytopenia, the mother develops antibodies to a specific platelet antigen present on the fetal platelet but absent on her own. Severe AIT can cause intracranial hemorrhage and have disastrous consequences for the fetus and neonate. In preliminary studies antenatal intravenous gamma globulin therapy has shown promise in preventing the development of intracranial hemorrhage and ameliorating fetal thrombocytopenia. Essential thrombocythemia with a platelet count of greater than 600 x 10(9) platelet/L can occur in pregnancy; therapy consists of antiplatelet aggregating agents such as aspirin, and plateletpheresis. Platelet function disorders can be acquired or inherited. Acquired platelet dysfunction disorders are usually caused by drugs such as aspirin or indomethacin, or by a systemic disease. Hereditary disorders of platelet function can be diagnosed in utero, but cordocentesis may represent an unacceptably high risk. For prenatal diagnosis, other methods, such as chorionic villus sampling or amniocentesis, should be investigated as an alternative to the potentially high risk of cordocentesis.

Autoimmune thrombocytopenic purpura complicating lymphoproliferative disorders

Thrombocytopenia in patients with lymphoproliferative disorders is usually multifactorial. In some patients, peripheral destruction of platelets by platelet autoantibodies may account in part for the thrombocytopenia. However, the diagnosis of autoimmune thrombocytopenic purpura in this group of patients can be difficult due to the splenomegaly and compromised bone marrows in some of these patients. The development of autoimmune thrombocytopenic purpura in these patients does not affect the eventual outcome of the underlying lymphoproliferative disorders. Unfortunately the current available therapy for this condition is unsatisfactory. Other innovative treatment modalities are therefore much needed.