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Gonzalez-Porras JR, Palomino D, Vaquero-Roncero LM, Bastida JM. Bleeding complications associated with pregnancy with primary immune thrombocytopenia: a meta-analysis. TH OPEN 2022; 6:e230-e237. [PMID: 36046200 PMCID: PMC9423940 DOI: 10.1055/a-1837-7581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction
Immune thrombocytopenia (ITP) during pregnancy has received little attention from researchers. Reliable information about the outcome of mothers and newborns is required to properly counsel women who are pregnant or planning to become pregnant. Our primary outcomes were the frequency and severity of maternal and neonatal bleeding events in the setting of ITP in pregnancy. Mode of delivery, neonatal thrombocytopenia, and maternal/infant mortality were secondary outcomes.
Material and Methods
We comprehensively reviewed the prospective studies that enrolled ≥20 pregnant women with primary ITP. Two reviewers, blinded to each other, searched Medline and Embase up to February 2021. Meta-analyses of the maternal and newborn outcomes were performed. Weighted proportions were estimated by a random-effects model.
Results
From an initial screening of 163 articles, 15 were included, encompassing 1,043 pregnancies. The weighted event rate for bleeding during pregnancy was 0.181 (95% confidence interval [CI], 0.048–0.494). Most of these were nonsevere cases. The weighted event rates were 0.053 (95% CI, 0.020–0.134) for severe postpartum hemorrhage, 0.014 (95% CI, 0.008–0.025) for intracerebral hemorrhage, and 0.122 (0.095–0.157) for severe thrombocytopenia events in neonates (platelet count <50,000/μL). There were no reliable predictors of severe neonatal thrombocytopenia. The incidence of neonatal mortality was 1.06%. There were no maternal deaths.
Conclusion
Primary ITP in pregnant women is rarely associated with poor outcomes.
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Effect of Thrombopoietin Receptor Agonist on Pregnant Mice. Pharmaceutics 2022; 14:pharmaceutics14030514. [PMID: 35335889 PMCID: PMC8951389 DOI: 10.3390/pharmaceutics14030514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RAs) are an effective treatment for refractory immune thrombocytopenia (ITP). However, the use of TPO-RAs is limited for ITP in pregnant women due to concerns about fetal toxicity. In this study, we examined the effects of romiplostim, one of the TPO-RAs, on pregnant mice. The mice were injected subcutaneously with romiplostim (1, 5, 10, 30, and 100 μg/kg) on gestational days (GD) 1, 8, and 15. We evaluated maternal and fetal platelet and megakaryocyte counts (MK), fetal weight at birth, placental morphology, and miscarriage rates. Romiplostim increased platelet and MK counts in pregnant mice at all doses and in fetuses at doses above 10 µg/kg. Fetal weight at birth was slightly reduced at a dose of 100 μg/kg, but there were no significant differences in placental weight, spiral artery wall thickness, placental growth factor signal changes, or the rate of resorption at that dosage. The dose of romiplostim used clinically for ITP patients (1–10 μg/kg) did not show any adverse effects on pregnant mice. Although the results of the present study are encouraging, until there are more conclusive data, the use of romiplostim should be evaluated individually in severe, life-threatening cases, and all relevant ethical aspects should be considered.
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Agarwal N, Mangla A. Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review. Ther Adv Hematol 2021; 12:20406207211001139. [PMID: 33796239 PMCID: PMC7983475 DOI: 10.1177/20406207211001139] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.
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Affiliation(s)
- Nikki Agarwal
- Division of Pediatric Hematology and Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ankit Mangla
- Division of Hematology and Oncology, Seidman Cancer Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Fernandez Y, Sharman MJ, Seth M. Pregnancy-associated immune-mediated hemolytic anemia in a dog. J Vet Emerg Crit Care (San Antonio) 2020; 30:308-311. [PMID: 32189467 DOI: 10.1111/vec.12951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/01/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the clinical presentation, diagnostic investigations, and outcome of a dog with pregnancy-associated immune-mediated hemolytic anemia. CASE SUMMARY A 6-year-old, pregnant Bichon Frise was presented due to lethargy, inappetence, and progressive regenerative anemia with spherocytosis. The dog had been recently receiving ranitidine and amoxicillin/clavulanate. An in-house saline agglutination test identified marked agglutination and a urinalysis identified hemoglobinuria. Thoracic and abdominal imaging, as well as infectious diseases testing, was unremarkable. The bitch started whelping shortly following hospitalization, and the anemia progressively resolved without any other intervention. Ranitidine and amoxicillin/clavulanate were re-introduced within the following 2 months but the anemia did not reoccur. In light of these findings, a diagnosis of pregnancy-associated immune-mediated hemolytic anemia was made. NEW OR UNIQUE INFORMATION PROVIDED Pregnancy-associated immune-mediated hemolytic anemia should be considered in female dogs that develop severe hemolytic anemia during pregnancy and may resolve spontaneously following parturition.
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Affiliation(s)
- Yordan Fernandez
- The Centre for Small Animal Studies, Animal Health Trust, Suffolk, UK
| | - Mellora J Sharman
- The Centre for Small Animal Studies, Animal Health Trust, Suffolk, UK
| | - Mayank Seth
- The Centre for Small Animal Studies, Animal Health Trust, Suffolk, UK
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Maroto A, Martinez-Diago C, Tio G, Sagues M, Borrell A, Bonmati A, Teixidor M, Adrados C, Torrent S, Alvarez E. Autoimmune hemolytic anemia in pregnancy: a challenge for maternal and fetal follow-up. J Matern Fetal Neonatal Med 2020; 35:996-998. [PMID: 32098549 DOI: 10.1080/14767058.2020.1732344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Autoimmune hemolytic anemia (AIHA) is a rare entity during pregnancy. The fetal risk is determined primarily by the ability of autoantibodies to cross the placental barrier. Currently, the establishment of a standardized antenatal care in cases with AIHA remains as a pending issue.Cases: Firstly, we describe a case of a 17-week pregnant woman that was diagnosed with cold agglutinin mediated (C3 and IgM) AIHA. Treatment was started with prednisone, showing initial improvement, but requiring intravenous gammaglobulins at 27 weeks. During the fetal follow-up, all studies showed normal results. In the third trimester, when there was a clinic and analytic maternal improvement, an unexpected fetal death occurred. Secondly, we present a case of a 30-week pregnant woman, diagnosed with warm antibody (IgG) AIHA. Despite the ability of IgG to cross the placental barrier, the serial measurements of the Middle Cerebral Artery (MCA) peak systolic velocity were always normal and childbirth occurred at term without any adverse perinatal outcome.Conclusion: During pregnancy, identification of the type antibodies in AIHA is crucial to estimate the potential maternal and fetal risks and to establish the follow-up. The interaction of the complement cascade with the coagulation cascade could be an explanation for a perinatal adverse outcome despite the inability of the IgM to cross the placental barrier.
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Affiliation(s)
- Anna Maroto
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | | | - Gisela Tio
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | | | - Ana Borrell
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | | | - Mireia Teixidor
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | - Cristina Adrados
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | - Sara Torrent
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
| | - Elena Alvarez
- Doctor Josep Trueta University Hospital of Girona, Girona, Spain
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Kopke MA, Pemberton S, Ruaux CG. Presumed immune-mediated haemolytic anaemia associated with pregnancy in a cat. JFMS Open Rep 2019; 5:2055116919841689. [PMID: 30992997 PMCID: PMC6449813 DOI: 10.1177/2055116919841689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Case summary A 7-year-old female entire Birman presented with acute-onset haemorrhagic
vulvar discharge. Moderate, normocytic, normochromic, non-/pre-regenerative
anaemia, along with a moderate mature neutrophilia, were seen on
haematology. Saline test for agglutination was positive. No haemotropic
mycoplasmas were identified. Serum biochemistry revealed severe
hyperbilirubinaemia. Retroviral testing was negative. Serology for
toxoplasmosis revealed a titre of 1:512. Abdominal ultrasound identified a
large uterus, containing at least three advanced-stage fetuses, two of which
failed to exhibit independent motion or cardiac activity. Ovariohysterectomy
was performed. Histology demonstrated mild, multifocal suppurative
placentitis, with Gram staining revealing no evidence of bacteria. Complete
resolution of the anaemia was seen within 1.5 months of
ovariohysterectomy. Relevance and novel information Immune-mediated haemolytic anaemia (IMHA) in association with pregnancy has
not been previously reported in cats. This case represents a potential novel
cause for IMHA in cats, which resolved following ovariohysterectomy.
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Affiliation(s)
- Matthew A Kopke
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - Sarah Pemberton
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - Craig G Ruaux
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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Abstract
Importance Anemia is common in pregnancy, ranging from 5.4% in developed countries to more than 80% in developing countries. Anemia in pregnancy has been associated with prematurity, low birth weight, and adverse pregnancy outcomes. Objective This review uses clinical vignettes to illustrate the clinical presentations, approach to diagnosis, maternal and fetal implications, and treatment for the common etiologies of anemia in pregnancy. Evidence Acquisition Literature review. Results Normal physiological changes in pregnancy result in alterations of hematological parameters particularly in a reduction of hemoglobin (Hb) concentration. Consequently, the Hb used to define anemia in pregnancy is lower than in nonpregnant patients. As there is an increased requirement of iron in pregnancy, it is not unexpected that iron deficiency remains the most common cause of anemia and warrants a preemptive approach to prevent a further reduction in Hb. The syndromes associated with microangiopathic hemolytic anemia may pose a diagnostic challenge, as there are several potential etiologies that may be difficult to differentiate, and microangiopathic hemolytic anemia can be associated with significant maternal and fetal morbidity andmortality. Anemia secondary to sickle cell disease and autoimmune hemolytic anemiamerit special attention because there are risks secondary to red blood cell transfusion and risks to withholding transfusion. Conclusions Anemia in pregnancy is potentially associated with maternal and fetal adverse outcomes. Providing evidence-based care is essential to achieving the best pregnancy outcomes.
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Immune thrombocytopenia in pregnancy – a literature review. GINECOLOGIA.RO 2018. [DOI: 10.26416/gine.21.3.2018.1945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Roccatello D, Sciascia S, Baldovino S, Rossi D, Alpa M, Naretto C, Di Simone D, Simoncini M, Menegatti E. A 4-year observation in lupus nephritis patients treated with an intensified B-lymphocyte depletion without immunosuppressive maintenance treatment-Clinical response compared to literature and immunological re-assessment. Autoimmun Rev 2015; 14:1123-30. [PMID: 26244817 DOI: 10.1016/j.autrev.2015.07.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND B cells (BC) play a critical role in systemic lupus erythematosus (SLE). BC depletion therapy still remains an attractive option, despite the disappointing results of randomized controlled trials (RTCs). METHODS Twelve patients with SLE [3 males, mean age 43.8 yrs (25-55)] with severe multiorgan involvement all including kidney (3 patients with Class IV, 4 with Class III/V and 5 with Class V, according to the International Society of Nephrology/Renal Pathology Society glomerulonephritis classification), skin lesions [10], severe polyarthralgias with arthritis [10], polyserositis [2], and lymphadenopathy [5] have been prospectively treated with an intensified B cell depletion therapy (IBCDT) protocol due to their resistance or intolerance to previous therapy (six cases) or as a front line immunosuppressive treatment in 6 women with unsatisfactory therapeutic compliance or as a specific request of a short-time immunosuppression for gestational perspectives. PROTOCOL Rituximab (RTX) 375 mg/sm on days 1, 8, 15, 22, and 2 more doses after 1 and 2 months, associated with 2 IV administrations of 10mg/kg of cyclophosphamide and 3 methylprednisolone pulses (15mg/kg) followed by oral prednisone (0.8 mg/kg/day, rapidly tapered to 5mg/day by the end of the 3rd month after RTX). No further immunosuppressive maintenance therapy has been given. RESULTS Patients had been followed-up for a mean of 44.5 (24-93)months. Significant decreases (p<0.05) were found in the levels of ESR (baseline mean value: 55.0mm; 3 months: 36; end of follow-up: 13), anti-dsDNA antibodies (baseline: 185 U; 3 months: 107; end of follow-up: 15), and proteinuria (baseline: 4.9 g/24h; 3 months: 0.97; end of follow-up: 0.22). C4 values (baseline 11 mg/dl) significantly increased (p<0.05) after 3 months (22 mg/dl) and at the end of the follow-up (20mg/dl). Of the 12 patients, 9 (75%) have remained well after one cycle of IBCDT, with no flare (mean 51.6 months [25-93]). Three patients relapsed after 36, 41, and 72 months, respectively. Following re-treatment, they again showed complete remission over 18-48 months of observation. CONCLUSIONS A promising role of RTX in an intensified protocol of induction therapy can be envisaged in patients for whom avoiding immunosuppressive maintenance therapy and sparing steroids are particularly appealing. Moreover, our data confirm in one of the longest follow-up available, the opportunity to reconsider the regimens of BL depletion in the treatment of the most severe or refractory forms of SLE despite the disappointing results of RCTs.
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Affiliation(s)
- Dario Roccatello
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy; SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy.
| | - Savino Sciascia
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Simone Baldovino
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Daniela Rossi
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Mirella Alpa
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Carla Naretto
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Debora Di Simone
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Matteo Simoncini
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Elisa Menegatti
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
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