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James AH. Management of pregnant women who have bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:229-236. [PMID: 38066866 PMCID: PMC10727034 DOI: 10.1182/hematology.2023000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management of bleeding disorders in pregnant women requires not only an understanding of bleeding disorders but also an understanding of when and how bleeding occurs in pregnancy. Bleeding does not occur during a normal pregnancy with a healthy placenta. Bleeding occurs during pregnancy when there is an interruption of the normal utero-placental interface, during miscarriage, during an ectopic pregnancy, or at the time of placental separation at the conclusion of pregnancy. Although mild platelet defects may be more prevalent, the most commonly diagnosed bleeding disorder among women is VWD. Other bleeding disorders are less common, but hemophilia carriers are unique in that they are at risk of bleeding themselves and of giving birth to an affected male infant. General guidance for maternal management of a woman who is moderately or severely affected includes obtaining coagulation factor levels at a minimum in the third trimester; planning for delivery at a center with hemostasis expertise; and anticipating the need for hemostatic agents. General guidance for fetal management includes pre-pregnancy counseling; the option of preimplantation genetic testing for hemophilia; delivery at a tertiary care center with pediatric hematology and newborn intensive care; consideration of cesarean delivery of a potentially severely affected infant; and avoidance of invasive procedures such as scalp electrodes and operative vaginal delivery in any potentially affected infant.
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Affiliation(s)
- Andra H. James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology; and Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC
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Hernandez MM, Buckley A, Mills A, Meislin R, Cromwell C, Bianco A, Strong N, Arinsburg S. Multidisciplinary management of a pregnancy complicated by Glanzmann thrombasthenia: A case report. Transfusion 2023; 63:2384-2391. [PMID: 37952246 DOI: 10.1111/trf.17594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Glanzmann thrombasthenia (GT) is a rare, autosomal recessive disorder of platelet glycoprotein IIb-IIIa receptors. Pregnant patients with GT are at increased risk of maternal and fetal bleeding. There is a paucity of literature on the peripartum management of patients. CASE DESCRIPTION We present the antepartum through the postpartum course of a patient with GT who was managed by a multidisciplinary approach that included communication across maternal-fetal medicine, hematology, transfusion medicine, and anesthesiology services. In addition to routine prepartum obstetric imaging and hematologic laboratory studies, we proactively monitored the patient for anti-platelet antibodies every 4-6 weeks to gauge the risk for neonatal alloimmune thrombocytopenia. Furthermore, we prioritized uterotonics, tranexamic acid, and transfusion of HLA-matched platelets to manage bleeding for mother and fetus intrapartum through the postpartum periods. CONCLUSION To date, there are limited guidelines for managing bleeding or preventing alloimmunization during pregnancy in patients with GT. Here, we present a complex case with aggressive management of bleeding prophylactically for the mother while serially monitoring both mother and fetus for peripartum bleeding risks and events. Moreover, future studies warrant continued evaluation of these approaches to mitigate increased bleeding risks in subsequent pregnancies.
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Affiliation(s)
- Matthew M Hernandez
- Department of Pathology, Molecular, and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ayisha Buckley
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Ariana Mills
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Rachel Meislin
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Caroline Cromwell
- Division of Hematology/Oncology, Department of Medicine, Icahn School of Medicine at Mount, New York, New York, USA
| | - Angela Bianco
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Noel Strong
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Suzanne Arinsburg
- Department of Pathology, Molecular, and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Bargehr C, Knöfler R, Streif W. Treatment of Inherited Platelet Disorders: Current Status and Future Options. Hamostaseologie 2023; 43:261-270. [PMID: 37611608 DOI: 10.1055/a-2080-6602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Inherited platelet disorders (IPDs) comprise a heterogeneous group of entities that manifest with variable bleeding tendencies. For successful treatment, the underlying platelet disorder, bleeding severity and location, age, and sex must be considered in the broader clinical context. Previous information from the AWMF S2K guideline #086-004 (www.awmf.org) is evaluated for validity and supplemented by information of new available and future treatment options and clinical scenarios that need specific measures. Special attention is given to the treatment of menorrhagia and risk management during pregnancy in women with IPDs. Established treatment options of IPDs include local hemostatic treatment, tranexamic acid, desmopressin, platelet concentrates, and recombinant activated factor VII. Hematopoietic stem cell therapy is a curative approach for selected patients. We also provide an outlook on promising new therapies. These include autologous hematopoietic stem cell gene therapy, artificial platelets and nanoparticles, and various other procoagulant treatments that are currently tested in clinical trials in the context of hemophilia.
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Affiliation(s)
- Caroline Bargehr
- Department of Paediatrics 1, Medical University of Innsbruck, Innsbruck, Austria
| | - Ralf Knöfler
- Department of Paediatric Haemostaseology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Werner Streif
- Department of Paediatrics 1, Medical University of Innsbruck, Innsbruck, Austria
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Barg A, Bonstein L. New Horizons in Fetal and Neonatal Alloimmune Thrombocytopenia. Semin Thromb Hemost 2022; 49:402-408. [PMID: 36368687 DOI: 10.1055/s-0042-1757900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractFetal and neonatal alloimmune thrombocytopenia (FNAIT) is a common cause of severe thrombocytopenia in newborns. Intracranial bleeding may lead to severe neurological sequelae and mortality. Current management of pregnancies at risk is suboptimal. Prenatal FNAIT diagnosis commonly requires invasive procedures and therapy is associated with a high treatment burden. The present review explores advances in the field and their potential contribution to modification of the diagnostic and therapeutic landscape. Topics addressed include the role of noninvasive prenatal testing using fetal cell free DNA, insights into novel and prospective therapeutic options achieved through the development of murine models of FNAIT as well as the forecast for the progress in pregnancy risk stratification through advancement in the investigation of biological characteristics of alloantibodies and their association with the risk of fetal bleeding.
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Affiliation(s)
- Assaf Barg
- National Hemophilia Center, Sheba Medical Center, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Lilach Bonstein
- Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
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How I manage pregnancy in women with Glanzmann thrombasthenia. Blood 2022; 139:2632-2641. [PMID: 35286390 DOI: 10.1182/blood.2021011595] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
Glanzmann thrombasthenia (GT) is a rare inherited platelet function disorder caused by a quantitative and/or qualitative defect of the αIIbβ3 integrin. Pregnancy and delivery is a recognized risk period for bleeding in women with GT. The newborn may also be affected by fetal and neonatal immune thrombocytopenia induced by the transplacental passage of maternal anti-αIIbβ3 antibodies, which can lead to severe hemorrhage and fetal loss. Pregnancy in GT women thus requires a multidisciplinary approach, including prepregnancy counseling, and a treatment plan for delivery for both the mother and child. In this article, we summarize the current knowledge on pregnancy in women with GT and describe how we manage this severe platelet disorder in our clinical practice.
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