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Refractory Immune Thrombocytopenic Purpura and Cytomegalovirus Infection: A Call for a Change in the Current Guidelines. Mediterr J Hematol Infect Dis 2016; 8:e2016010. [PMID: 26740871 PMCID: PMC4696470 DOI: 10.4084/mjhid.2016.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/11/2015] [Indexed: 11/21/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is characterized by a decreased platelet count caused by excess destruction of platelets and inadequate platelet production. In many cases, the etiology is not known, but the viral illness is thought to play a role in the development of some cases of ITP. The current (2011) American Society of Hematology ITP guidelines recommend initial diagnostic studies to include testing for HIV and Hepatitis C. The guidelines suggest that initial treatment consist of observation, therapy with corticosteroids, IVIG or anti D. Most cases respond to the standard therapy such that the steroids may be tapered and the platelet counts remain at a hemostatically safe level. Some patients with ITP are dependent on long-term steroid maintenance, and the thrombocytopenia persists with the tapering of the steroids. Recent case reports demonstrate that ITP related to cytomegalovirus (CMV) can persist in spite of standard therapy and that antiviral therapy may be indicated. Herein we report a case of a 26-year-old female with persistent ITP that resolved after the delivery of a CMV-infected infant and placenta. Furthermore, we review the current literature on CMV-associated ITP and propose that the current ITP guidelines be amended to include assessment for CMV, even in the absence of signs and symptoms, as part of the work-up for severe and refractory ITP, especially prior to undergoing an invasive procedure such as splenectomy.
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102
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Refractory Immunological Thrombocytopenia Purpura and Splenectomy in Pregnancy. Case Reports Immunol 2015; 2015:216362. [PMID: 26798527 PMCID: PMC4698536 DOI: 10.1155/2015/216362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/30/2015] [Accepted: 12/08/2015] [Indexed: 11/21/2022] Open
Abstract
Thrombocytopenia is defined as a platelet count of less than 100,000 platelets per microlitre (mcL). Thrombocytopenia develops in approximately 6-7% of women during pregnancy and at least 3% of these cases are caused by immunological platelet destruction. Herein, we present a pregnant woman who develops at the first trimester autoimmune thrombocytopenia purpura associated with positive antiphospholipid antibodies. The disease was refractory to pharmacological treatments but had a favourable response to splenectomy. The patient carried the pregnancy to term without complication and gave birth to a healthy baby girl.
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103
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Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:795-802. [PMID: 26634939 PMCID: PMC4678382 DOI: 10.3238/arztebl.2015.0795] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge. METHODS In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed. RESULTS Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease. CONCLUSION The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.
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Affiliation(s)
| | - Werner Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
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Abstract
Thrombocytopenia during pregnancy is quite common. Evaluation of blood counts of pregnant women has shown that thrombocytopenia is the second most common haematological problem in pregnancy, after anaemia. While mostly thrombocytopenia has no consequences for either the mother or the foetus, in some cases it is associated with substantial maternal and/or neonatal morbidity and mortality. It may result from a number of diverse aetiologies. Adequate knowledge of these causes will help the clinicians in making proper diagnosis and management of thrombocytopenia in pregnancy. The evaluation of thrombocytopenia is essential to rule out any systemic disorders that may affect pregnancy management as thrombocytopenia can present as an isolated finding or in combination with underlying conditions. In this concise review, we have provided the overview of thrombocytopenia diagnosed during pregnancy.
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Affiliation(s)
- A Palta
- a Department of Pathology , Government medical college and hospital , Chandigarh , India
| | - P Dhiman
- b Department of Clinical Hematology , Institute of liver and biliary sciences , New Delhi , India
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105
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Yan M, Malinowski AK, Shehata N. Thrombocytopenic syndromes in pregnancy. Obstet Med 2015; 9:15-20. [PMID: 27512485 DOI: 10.1177/1753495x15601937] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/29/2015] [Indexed: 11/16/2022] Open
Abstract
The physiological changes in pregnancy result in platelet counts that are lower than in nonpregnant women. Consequently, thrombocytopenia is a common finding occurring in 7-12% of pregnant women. Gestational thrombocytopenia, the most common cause of low platelet counts, tends to be mild in most women and does not affect maternal, fetal or neonatal outcomes. Gestational thrombocytopenia needs to be distinguished from other less common causes of isolated thrombocytopenia, such as immune thrombocytopenia, which affects approximately 3% of thrombocytopenic pregnant women and can lead to neonatal thrombocytopenia. Hypertensive disorders of pregnancy and thrombotic microangiopathies are both associated with thrombocytopenia. They share a considerable number of similar characteristics and are associated with significant maternal and neonatal morbidity and rarely mortality. Accurate identification of the aetiology of thrombocytopenia and appropriate management are integral to optimizing the pregnancy, delivery and neonatal outcomes of this population. Clinical cases are described to illustrate the various aetiologies of thrombocytopenia in pregnancy and their treatment.
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Affiliation(s)
- Matthew Yan
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada
| | - Ann K Malinowski
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Nadine Shehata
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
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106
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Piatek CI, El-Hemaidi I, Feinstein DI, Liebman HA, Akhtari M. Management of immune-mediated cytopenias in pregnancy. Autoimmun Rev 2015; 14:806-11. [DOI: 10.1016/j.autrev.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/07/2015] [Indexed: 10/24/2022]
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Delmas Y, Helou S, Chabanier P, Ryman A, Pelluard F, Carles D, Boisseau P, Veyradier A, Horovitz J, Coppo P, Combe C. Incidence of obstetrical thrombotic thrombocytopenic purpura in a retrospective study within thrombocytopenic pregnant women. A difficult diagnosis and a treatable disease. BMC Pregnancy Childbirth 2015; 15:137. [PMID: 26081109 PMCID: PMC4469004 DOI: 10.1186/s12884-015-0557-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 05/15/2015] [Indexed: 02/06/2023] Open
Abstract
Background Thrombotic thrombocytopenic Purpura (TTP) defined as ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin type 1 domain 13) activity <10 % is a rare aetiology of thrombocytopenia during pregnancy, although the precise incidence is unknown. During pregnancy, the diagnosis of TTP is crucial as it has high feto-maternal morbidity-mortality and requires urgent plasma exchange. The purpose of this study was to assess the incidence of TTP retrospectively and to describe case presentations and follow-up. Methods A monocentric retrospective study (2008–2009) was conducted among pregnant women followed in a tertiary care obstetrical unit who experienced at least one episode of severe thrombocytopenia (platelets ≤75 G/L) during 2008 and 2009. In cases of uncertain aetiology of thrombocytopenia, ADAMTS-13 activity was assessed by the full length technique. Results Among 8,908 deliveries over the 2 year period, 79 women had a platelet count nadir ≤75 G/L. Eighteen had a known aetiology of thrombocytopenia and 11 were lost to follow-up. Among 50 remaining patients, ADAMTS-13 activity was undetectable (<5 %) in 4, consistent with the diagnosis of TTP. Platelet count spontaneously normalized in 3 patients after delivery. None presented focal cerebral involvement. Three of the four, who were primipara patients, had a sustained severe deficiency in the absence of anti-ADAMTS-13 antibodies, and ADAMTS-13 gene sequencing indicated a constitutive deficiency. The fourth, a multipara patient, had an acquired, auto-immune TTP. Placental pathology in the three primipara patients showed severe and non-specific ischemic lesions. Two patients lost their babies shortly after birth. In subsequent pregnancies in these two patients, prophylactic plasma infusion initiated early with increasing volume throughout pregnancy prevented TTP relapse, improved placental pathology, and led to normal delivery. Conclusions The prevalence of TTP among thrombocytopenic pregnant women is high, up to 5 % in a tertiary unit. Platelet count normalization after delivery does not eliminate TTP. Clinicians should be aware of TTP during pregnancy, and, even if assessed retrospectively, ADAMTS-13 assessment is of particular importance for identifying patients with congenital TTP. In these patients, preventive plasma infusion and/or exchange can dramatically improve foetal prognosis, resulting in successful childbirth.
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Affiliation(s)
- Yahsou Delmas
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Sébastien Helou
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Chabanier
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Anne Ryman
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Service d'Hémostase Spécialisée, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Fanny Pelluard
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Dominique Carles
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Boisseau
- Service de Génétique Médicale, Centre Hospitalier Universitaire de Nantes Hôtel Dieu, Nantes, France.
| | - Agnès Veyradier
- Service d'hématologie, Centre Hospitalier Universitaire de Lariboisière, Assistance Publique Hôpitaux de Paris, Université Paris 7 Denis Diderot, Paris, France. .,Centre de Référence des Microangiopathies Thrombotiques, Paris, France.
| | - Jacques Horovitz
- Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Paris, France. .,Service d'Hématologie Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, Paris, France. .,Université Pierre et Marie Curie (UPMC), Univ Paris 6, Paris, France.
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
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108
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Nishikawa A, Mimura K, Kanagawa T, Maeda T, Tomimatsu T, Kimura T. Thrombocytopenia associated with Mycoplasma
pneumonia during pregnancy: Case presentation and approach for differential diagnosis. J Obstet Gynaecol Res 2015; 41:1273-7. [DOI: 10.1111/jog.12713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/02/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Aiko Nishikawa
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Suita Osaka Japan
| | - Kazuya Mimura
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Suita Osaka Japan
| | - Takeshi Kanagawa
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Suita Osaka Japan
| | - Tetsuo Maeda
- Hematology and Oncology; Osaka University Graduate School of Medicine; Suita Osaka Japan
| | - Takuji Tomimatsu
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Suita Osaka Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Suita Osaka Japan
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109
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Rodger M, Sheppard D, Gándara E, Tinmouth A. Haematological problems in obstetrics. Best Pract Res Clin Obstet Gynaecol 2015; 29:671-84. [PMID: 25819750 DOI: 10.1016/j.bpobgyn.2015.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 02/02/2023]
Abstract
Physiologic changes occur during pregnancy, which influence normal haematologic values and impact the diagnosis and management of haematologic disease in pregnancy. Physiologic changes of pregnancy also commonly lead to mimicking symptoms of haematologic disease that may prompt investigations for haematologic disease. The toxicity and radiation associated with the diagnostic imaging and pharmacologic management of both benign and malignant haematological conditions during pregnancy present unique challenges. Strategies for diagnosis and treatment must weigh the benefits and risks to the mother while also taking foetal outcome into consideration. In this review, we highlight the common haematologic diseases encountered by obstetricians and try to provide guidance for the most prevalent diagnostic and therapeutic questions. At the other end of the spectrum, we also comment on less common but very challenging haematologic diseases in pregnancy that require multidisciplinary effort to arrive at difficult individual diagnostic and treatment decisions.
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Affiliation(s)
- Marc Rodger
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Dawn Sheppard
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Esteban Gándara
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Alan Tinmouth
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Canadian Blood Services, Ottawa, Canada.
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110
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Loustau V, Pourrat O, Mandelbrot L, Godeau B. Purpura thrombopénique immunologique et grossesse : état des connaissances actuelles et questions encore sans réponse. Rev Med Interne 2015; 36:167-72. [DOI: 10.1016/j.revmed.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/30/2014] [Indexed: 11/28/2022]
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112
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Triad of Idiopathic Thrombocytopenic Purpura, Preeclampsia, and HELLP Syndrome in a Parturient: A Rare Confrontation to the Anesthetist. Case Rep Anesthesiol 2014; 2014:139694. [PMID: 25548684 PMCID: PMC4274831 DOI: 10.1155/2014/139694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 11/24/2014] [Indexed: 11/21/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) with HELLP represents a rare complication that requires combined care of obstetrician, anesthesiologist, hematologist, and neonatologist. At 37-week gestation a 35-year-old parturient (G2A1P0) a known case of chronic ITP presented with severe pregnancy induced hypertension (PIH), thrombocytopenia, and elevated liver enzymes. We describe successful anesthetic management of this patient who was taken for emergency caesarean section.
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113
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Kutuk MS, Croisille L, Gorkem SB, Yilmaz E, Korkmaz L, Bierling P, Unal E. Fetal intracranial hemorrhage related to maternal autoimmune thrombocytopenic purpura. Childs Nerv Syst 2014; 30:2147-50. [PMID: 24952237 DOI: 10.1007/s00381-014-2473-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 06/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Maternal autoimmune thrombocytopenic purpura (AITP) can cause fetal intracranial hemorrhage. CASE REPORT A 19-year-old primigravida was referred to our institution for prenatally detected ventriculomegaly at 30th week of gestation. Her personal and family histories were unremarkable. Her platelet count was 54 × 109/L. Fetal neurosonography showed intraparenchymal hemorrhage. AITP was diagnosed in the mother and platelet count decreased at 34 × 109/L. Patient was treated with methylprednisolone and intravenous immunoglobulin. She delivered a 2,340-g infant at 37 weeks with elective cesarean section. The platelet count of the newborn was 181 × 109/L and coagulation tests were normal. No antiplatelet specific antibodies were detected in cord blood. Postnatal MRI evaluation confirmed grade IV intracranial hemorrhage. The newborn baby has suffered from mild spasticity and seizures. CONCLUSIONS Clinicians must be vigilant about the catastrophic fetal complications of maternal AITP; a close follow-up with a multidisciplinary cooperation between obstetricians, hematologists, and neonatologists must be warranted.
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Affiliation(s)
- Mehmet Serdar Kutuk
- Division of Perinatalogy, Faculty of Medicine, Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
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Fournet-Fayard A, Lebreton A, Ruivard M, Storme B, Godeau B, Bonnin M, Delabaere A, Gallot D. Prise en charge anténatale des patientes à risque d’hémorragie du post-partum (hors anomalies de l’insertion placentaire). ACTA ACUST UNITED AC 2014; 43:951-65. [DOI: 10.1016/j.jgyn.2014.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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115
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Matzdorff A, Eberl W, Giagounidis A, Imbach P, Pabinger I, Wörmann B. [Immune thrombocytopenia -- onkopedic guidelines update: recommendations of a joint working group of the DGHO, ÖGHO, SGH + SSH and GPOH]. Oncol Res Treat 2014; 37 Suppl 2:6-25. [PMID: 24613966 DOI: 10.1159/000356910] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Axel Matzdorff
- Klinik für Hämatologie und Onkologie, Caritasklinikum Saarbrücken St. Theresia, Saarbrücken, Deutschland
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116
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Anterior Ischemic Optic Neuropathy as a Manifestation of HELLP Syndrome. Case Rep Crit Care 2014; 2014:671976. [PMID: 25328716 PMCID: PMC4195348 DOI: 10.1155/2014/671976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/14/2014] [Accepted: 09/18/2014] [Indexed: 11/17/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a group of disorders characterized by occurrence of thrombi of fibrin and/or platelets with microvascular occlusion and organ ischemia especially the kidney and brain. Hemolysis with a microangiopathic blood smear, elevated liver enzymes, and low platelet count (HELLP syndrome) is a type of TMA peculiar to pregnancy and may be associated with neurological complications. Visual complications in HELLP are usually related to cortical blindness. We present the first case of HELLP associated with bilateral anterior ischemic optic neuropathy (AION) and blindness which resolved with plasma exchange.
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117
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Rescue therapy with romiplostim for refractory primary immune thrombocytopenia during pregnancy. Obstet Gynecol 2014; 124:481-483. [PMID: 25004319 DOI: 10.1097/aog.0000000000000371] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary immune thrombocytopenia is not a rare event during pregnancy, and it must be carefully managed to avoid hemorrhagic complications for the mother. After failure of first-line treatments, the teratogenicity and toxicity of other therapeutic agents limit the available options and treatment. CASES We describe the cases of two pregnant patients with corticosteroid-refractory immune thrombocytopenia who were successfully treated by romiplostim, a thrombopoietin receptor agonist, without any fetal or maternal complications. CONCLUSION Romiplostim may represent an important alternative treatment choice during pregnancy for immune thrombocytopenia cases refractory to first-line therapy, especially because of its speed of action and high efficacy. Nevertheless, further data are required to provide definitive evidence of its safety for newborns.
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118
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Kasai J, Aoki S, Kamiya N, Hasegawa Y, Kurasawa K, Takahashi T, Hirahara F. Clinical features of gestational thrombocytopenia difficult to differentiate from immune thrombocytopenia diagnosed during pregnancy. J Obstet Gynaecol Res 2014; 41:44-9. [PMID: 25163390 DOI: 10.1111/jog.12496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/03/2014] [Indexed: 01/28/2023]
Abstract
AIM To investigate the clinical features of gestational thrombocytopenia (GT) difficult to differentiate from immune thrombocytopenia (ITP) during pregnancy. METHODS The January 2000-December 2012 hospital database was analyzed to identify women with ITP or GT (after excluding other possible causes of thrombocytopenia) among those first noted to have platelet counts of less than 100 000/μL during pregnancy. The maternal characteristics, platelet count fluctuations and pregnancy outcomes were compared between women with ITP and GT. RESULTS There were 23 pregnancies (22 women) with thrombocytopenia (GT, 13; ITP, 10). The GT group included five twin pregnancies (38.5%), whereas all pregnancies of the ITP group were singleton pregnancies, with significantly more twin pregnancies in the GT group (P = 0.046). Thrombocytopenia in the first trimester occurred in 70% (7/10) of ITP cases and 23.1% (3/13) of even GT cases. The nadir platelet count was less than 70 000/μL in 100% (10/10) of ITP cases and 30.8% (4/13) of GT cases (P < 0.001). Maternal treatment was required in 80% (8/10) of ITP cases, but in none of the GT cases. The pregnancy outcomes were favorable in both groups, and no case required fetal treatment. CONCLUSION Gestational thrombocytopenia with platelet counts of less than 10 0000/μL occurred more frequently in twin pregnancies. Although onset of thrombocytopenia in the first trimester and a platelet count of less than 70 000/μL is more common in ITP, these findings were not uncommon in GT. Differentiation between ITP and GT may be feasible only with post-partum changes in the platelet count.
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Affiliation(s)
- Junko Kasai
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Japan
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119
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Abstract
Thrombocytopenia is one of the most common hematologic disorders, characterized by an abnormally low number of platelets from multiple causes. The normal count of thrombocytes (platelets) is between 150,000 and 450,000 per microliter. The clinical expression of thrombocytopenia has broad variation from asymptomatic to life-threatening bleeding. Various syndromes and diseases are associated with thrombocytopenia. Thrombocytopenia is sometimes a first sign of hematologic malignancies, infectious diseases, thrombotic microangiopathies, and autoimmune disorders, and is also a common side effect of many medications. There are more than 200 diseases that include low number of platelets among their symptoms. A brief discussion of the most common etiologies and management of them is provided in this review.
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Affiliation(s)
- Marina Izak
- NY Presbyterian Hospital and Weill Cornell Medical College, Division of Pediatric Hematology Oncology525 East 68th Street, Payson Pavilion 695, New York, NY 10065USA
- Assaf Harofeh Medical Center, Beer YakovZerifin 70300Israel
| | - James B. Bussel
- NY Presbyterian Hospital and Weill Cornell Medical College, Division of Pediatric Hematology Oncology525 East 68th Street, Payson Pavilion 695, New York, NY 10065USA
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120
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Uğur Bilgin A, Karaselek MA, Çamlı K. Successful management of thrombotic thrombocytopenic purpura associated with pregnancy. Transfus Apher Sci 2014; 50:433-7. [DOI: 10.1016/j.transci.2014.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/20/2014] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
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121
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Bolten K, Salama A, Thomas A, Eucker J, Henrich W. Severe Case of Autoimmune Thrombocytopenia First Diagnosed in Pregnancy. Geburtshilfe Frauenheilkd 2014; 73:1252-1255. [PMID: 24771907 DOI: 10.1055/s-0033-1360149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/02/2013] [Accepted: 11/05/2013] [Indexed: 10/25/2022] Open
Abstract
We report on a 28-year old primigravida who presented in the second trimester with sudden onset of bleeding tendencies and thrombocytopenia of 2/nL during the first manifestation of autoimmune thrombocytopenia (ITP). Therapy with intravenous immunoglobulins (IVIG) and steroids was initiated but could not prevent renewed bleeding incidents and recurrent thrombocytopenia in the long term, thus premature delivery by Caesarean section in the 32 + 3 week of pregnancy could not be avoided. The bleeding complications could only be mastered by multiple thrombocyte transfusions. Because the ITP remained refractory to therapy in the postpartum period a thrombopoietin receptor agonist (TPO-RA) was administered. This led to an increase in the thrombocyte count which was later stabilised by prednisolone alone.
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Affiliation(s)
- K Bolten
- Klinik für Geburtsmedizin CCM, Charité, Berlin
| | - A Salama
- Institut für Transfusionsmedizin, Charité, Berlin
| | - A Thomas
- Klinik für Geburtsmedizin CCM, Charité, Berlin
| | - J Eucker
- Medizinische Klinik mit Schwerpunkt Onkologie und Hämatologie CCM, Charité, Berlin
| | - W Henrich
- Klinik für Geburtsmedizin CCM, Charité, Berlin
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122
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Smock KJ, Perkins SL. Thrombocytopenia: an update. Int J Lab Hematol 2014; 36:269-78. [DOI: 10.1111/ijlh.12214] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 02/14/2014] [Indexed: 12/26/2022]
Affiliation(s)
- K. J. Smock
- Department of Pathology; University of Utah Health Sciences Center and ARUP Laboratories; Salt Lake City UT USA
| | - S. L. Perkins
- Department of Pathology; University of Utah Health Sciences Center and ARUP Laboratories; Salt Lake City UT USA
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123
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Sui WG, Tan QP, Yan Q, Yang M, Ou ML, Xue W, Chen JJ, Zou TX, Cao CH, Sun YF, Cui ZZ, Dai Y. Genome-wide analysis of DNA 5-hmC in peripheral blood of uremia by hMeDIP-chip. Ren Fail 2014; 36:937-45. [PMID: 24697287 DOI: 10.3109/0886022x.2014.900406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment of uremia is now dominated by dialysis; in some cases, patients are treated with dialysis for decades, but overall outcomes are disappointing. A number of studies have confirmed the relevance of several experimental insights to the pathogenesis of uremia, but the specific biomarkers of uremia have not been fully elucidated. To date, our knowledge about the alterations in DNA 5-hydroxymethylcytosine (5-hmC) in uremia is unclear, to investigate the role of DNA 5-hmC in the onset of uremia, we performed hMeDIP-chip between the uremia patients and the normal controls from the experiment to identify differentially expressed 5-hmC in uremia-associated samples. METHODS Extract genomic DNA, using hMeDIP-chip technology of Active Motif companies for the analysis of genome-wide DNA 5-hmC, and quantitative real-time PCR confirmation to identify differentially expressed 5-hmC level in uremia-associated samples. RESULTS There were 1875 genes in gene Promoter, which displayed significant 5-hmC differences in uremia patients compared with normal controls. Among these genes, 960 genes displayed increased 5-hmC and 915 genes decreased 5-hmC. 4063 genes in CpG Islands displayed significant 5-hmC differences in uremia patients compared with normal controls. Among these genes, 1780 genes displayed increased 5-hmC and 2283 genes decreased 5-hmC. Three positive genes, HMGCR, THBD, and STAT3 were confirmed by quantitative real-time PCR. CONCLUSION Our studies indicate the significant alterations of 5-hmC. There is a correlation of gene modification 5-hmC in uremia patients. Such novel findings show the significance of 5-hmC as a potential biomarker or promising target for epigenetic-based uremia therapies.
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Affiliation(s)
- Wei-Guo Sui
- Guangxi Key Laboratory of Metabolic Diseases Research, Central Laboratory of Guilin 181st Hospital , Guilin , China
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124
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Kawaguchi K, Matsubara K, Takafuta T, Shinzato I, Tanaka Y, Iwata A, Nigami H, Takeuchi Y, Fukaya T. Factors predictive of neonatal thrombocytopenia in pregnant women with immune thrombocytopenia. Int J Hematol 2014; 99:570-6. [DOI: 10.1007/s12185-014-1562-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/21/2014] [Accepted: 02/23/2014] [Indexed: 10/25/2022]
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125
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Abstract
In this issue of Blood, Jiang et al use the Oklahoma Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome (TTP-HUS) Registry to demonstrate that in women with a previous history of TTP, associated with severe ADAMTS13 deficiency, the frequency of TTP recurrence is low and pregnancy outcomes are positive.1
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126
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Abstract
Pregnancy induces a number of physiologic changes that affect the hematologic indices, either directly or indirectly. Recognizing and treating hematologic disorders that occur during pregnancy is difficult owing to the paucity of evidence available to guide consultants. This review discusses specifically the diagnosis and management of benign hematologic disorders occurring during pregnancy. Anemia secondary to iron deficiency is the most frequent hematologic complication and is easily treated with oral iron formulations; however, care must be taken not to miss other causes of anemia, such as sickle cell disease. Thrombocytopenia is also a common reason for consulting the hematologist, and distinguishing gestational thrombocytopenia from immune thrombocytopenia (ITP), preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), or thrombotic thrombocytopenic purpura (TTP) is essential since the treatment differs widely. Occasionally the management of mother and infant involves the expeditious recognition of neonatal alloimmune thrombocytopenia (NAIT), a condition that is responsible for severe life-threatening bleeding of the newborn. Additionally, inherited and acquired bleeding disorders affect pregnant women disproportionately and often require careful monitoring of coagulation parameters to prevent bleeding in the puerperium. Finally, venous thromboembolism (VTE) during pregnancy is still largely responsible for mortality during pregnancy, and the diagnosis, treatment options and guidelines for prevention of VTE during pregnancy are explored.
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Affiliation(s)
- Danielle M Townsley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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127
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Martínez-Blázquez A, de Capadocia-Rosell J, Cuesta-Montero P, Marín-Sánchez A. [Reply to the article "Hemolysis, elevated liver enzymes and low platelet count in pregnancy: differential diagnosis"]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:167-168. [PMID: 24199915 DOI: 10.1016/j.redar.2013.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/17/2013] [Indexed: 06/02/2023]
Affiliation(s)
- A Martínez-Blázquez
- Servicio de Anestesiología y Reanimación, Hospital General de Villarrobledo, Villarrobledo, Albacete, España
| | - J de Capadocia-Rosell
- Servicio de Anestesiología y Reanimación, Hospital General de Villarrobledo, Villarrobledo, Albacete, España.
| | - P Cuesta-Montero
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - A Marín-Sánchez
- Servicio de Hematología, Complejo Hospitalario Universitario de Albacete, Albacete, España
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128
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Sanchis Martín R, Catalá Bauset JC, Sanchez Campos H. [Haemolysis, elevated liver enzymes and low platelet count in pregnancy: differential diagnosis]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:165-166. [PMID: 24360739 DOI: 10.1016/j.redar.2013.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 07/29/2013] [Accepted: 08/05/2013] [Indexed: 06/03/2023]
Affiliation(s)
- R Sanchis Martín
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J C Catalá Bauset
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - H Sanchez Campos
- Servicio de Hematología, Consorcio Hospital General Universitario de Valencia, Valencia, España
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129
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HELLP syndrome and its relation with the antiphospholipid syndrome. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12:114-8. [PMID: 24333078 DOI: 10.2450/2013.0154-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 06/26/2013] [Indexed: 01/10/2023]
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130
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Smith D, Stevens J, Quinn J, Cavenagh J, Ingram W, Yong K. Myeloma presenting during pregnancy. Hematol Oncol 2013; 32:52-5. [DOI: 10.1002/hon.2088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/09/2013] [Accepted: 06/24/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Dean Smith
- Clinical Haematology; University College Hospital; London UK
| | | | - John Quinn
- Haematology; Beaumont Hospital; Dublin Ireland
| | | | - Wendy Ingram
- Haematology; University Hospital of Wales; Cardiff Wales UK
| | - Kwee Yong
- Clinical Haematology; University College Hospital; London UK
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131
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Acharya A, Santos J, Linde B, Anis K. Acute kidney injury in pregnancy-current status. Adv Chronic Kidney Dis 2013; 20:215-22. [PMID: 23928385 DOI: 10.1053/j.ackd.2013.02.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/07/2013] [Accepted: 02/08/2013] [Indexed: 12/17/2022]
Abstract
Pregnancy-related acute kidney injury (PR-AKI) causes significant maternal and fetal morbidity and mortality. Management of PR-AKI warrants a thorough understanding of the physiologic adaptations in the kidney and the urinary tract. Categorization of etiologies of PR-AKI is similar to that of acute kidney injury (AKI) in the nonpregnant population. The causes differ between developed and developing countries, with thrombotic microangiopathies (TMAs) being common in the former and septic abortion and puerperal sepsis in the latter. The incidence of PR-AKI is reported to be on a decline, but there is no consensus on the exact definition of the condition. The physiologic changes in pregnancy make diagnosis of PR-AKI difficult. Newer biomarkers are being studied extensively but are not yet available for clinical use. Early and accurate diagnosis is necessary to improve maternal and fetal outcomes. Timely identification of "at-risk" individuals and treatment of underlying conditions such as sepsis, preeclampsia, and TMAs remain the cornerstone of management. Questions regarding renal replacement therapy such as modality, optimal prescription, and timing of initiation in PR-AKI remain unclear. There is a need to systematically explore these variables to improve care of women with PR-AKI.
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González-Mesa E, Narbona I, Blasco M, Cohen I. Unfavorable course in pregnancy-associated thrombotic thrombocytopenic purpura necessitating a perimortem Cesarean section: a case report. J Med Case Rep 2013; 7:119. [PMID: 23628258 PMCID: PMC3656795 DOI: 10.1186/1752-1947-7-119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 04/04/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura is a type of occlusive thrombotic microangiopathy that is not specific to pregnancy but occurs with an increased frequency during it. Prognosis of thrombotic thrombocytopenic purpura greatly depends on early diagnosis and treatment. As delivery does not generally cause resolution of thrombotic thrombocytopenic purpura, pregnancy termination is not initially considered, especially under 34 weeks, although it may be required under some conditions such as preeclampsia. Plasma therapy, including plasmapheresis, and steroids are used for treatment. In the event of an unfavorable course leading to cardiopulmonary arrest, effectiveness of cardiopulmonary resuscitation measures greatly depends on an early start of such measures. In pregnant patients, not only rapid implementation of these measures is required, but a decision should also be taken about the convenience of fetal delivery through a perimortem Cesarean section. CASE PRESENTATION We report the case of thrombotic thrombocytopenic purpura in a 30-year-old primigravida white woman in week 28 of pregnancy that had a rapidly deteriorating course leading to cardiopulmonary arrest and an emergency perimortem Cesarean section resulting in fetal survival but maternal death. The patient was asymptomatic at admission and such an unfavorable evolution was initially unexpected. Analytical findings were treated with fresh frozen plasma and methylprednisolone but they did not improve. Plasmapheresis was considered but cardiac arrest rapidly ensued. CONCLUSIONS Despite the low prevalence of thrombotic thrombocytopenic purpura, the finding in a pregnant woman of the triad consisting of anemia, thrombocytopenia, and neurological changes should guide clinical diagnosis, and should prompt measurement of the metalloprotease ADAMTS-13 in order to rule out or confirm diagnosis of thrombotic thrombocytopenic purpura and evaluate the best therapeutic option. If cardiopulmonary arrest occurs in a woman with a gestational age of more than 24 weeks, a perimortem Cesarean section is advised if the patient has not recovered her pulse after the first four minutes.
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Affiliation(s)
- Ernesto González-Mesa
- Obstetrics and Gynecology Department, Obstetrics and Gynecology Research Group. IBIMA, University Carlos Haya Hospital, Arroyo de Los Angeles Avenue, Málaga, 29011, Spain
| | - Isidoro Narbona
- Obstetrics and Gynecology Department, Obstetrics and Gynecology Research Group. IBIMA, University Carlos Haya Hospital, Arroyo de Los Angeles Avenue, Málaga, 29011, Spain
| | - Marta Blasco
- Obstetrics and Gynecology Department, Obstetrics and Gynecology Research Group. IBIMA, University Carlos Haya Hospital, Arroyo de Los Angeles Avenue, Málaga, 29011, Spain
| | - Isaac Cohen
- Obstetrics and Gynecology Department, Obstetrics and Gynecology Research Group. IBIMA, University Carlos Haya Hospital, Arroyo de Los Angeles Avenue, Málaga, 29011, Spain
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