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Giannubilo SR, Marzioni D, Tossetta G, Ciavattini A. HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy. Diagnostics (Basel) 2024; 14:352. [PMID: 38396391 PMCID: PMC10887663 DOI: 10.3390/diagnostics14040352] [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: 12/31/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024] Open
Abstract
Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.
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Affiliation(s)
| | - Daniela Marzioni
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Giovanni Tossetta
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Tronto 10/a, 60126 Ancona, Italy; (D.M.); (G.T.)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Polytechnic University of Marche, Via Corridoni 11, 60123 Ancona, Italy;
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Wei L, Liping Z, Suya K. Expression of insulin-like growth factor binding protein-3 in HELLP syndrome. BMC Pregnancy Childbirth 2023; 23:778. [PMID: 37950229 PMCID: PMC10637003 DOI: 10.1186/s12884-023-06074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE To investigate the expression of insulin-like growth factor binding protein-3(IGFBP-3) in HELLP syndrome and its possible role in the pathogenesis of this disease. METHODS 1) 87 subjects were enrolled, including 29 patients with HELLP syndrome, 29 patients with pre-eclampsia (PE), and 29 healthy gravidae as control. The levels of IGFBP-3, IGF-1, TGF-β1, and VEGF in maternal and umbilical blood of them were detected using ELISA. Correlation analysis was used to observe the correlation between IGFBP-3 and IGF-1/TGF-β1/VEGF in maternal and umbilical blood, as well as that between maternal serum IGFBP-3 and clinical diagnostic indicators of HELLP syndrome. 2) Human hepatic sinusoid endothelial cells (HLSEC) and human umbilical vein endothelial cells (HUVEC) were cultured with different concentrations of IGFBP-3. After 72 h of culture, cell apoptosis and the normal living cells rate were detected and compared. RESULTS 1) In both maternal and umbilical blood of HELLP group, levels of IGFBP-3 and TGF-β1 were higher than control and PE group, IGF-1was lower than control group, VEGF was lower than control and PE group. IGFBP-3 in maternal blood was correlated with IGF-1/TGF-β1/ VEGF, while IGFBP-3 in umbilical blood was linked to IGF-1/TGF-β1. In maternal blood, there was a negative correlation between PLT and IGFBP-3, and a positive correlation between ALT/AST/LDH and IGFBP-3. 2) After cultured with IGFBP-3, the total apoptosis rate of either HLSEC or HUVEC was considerably elevated, while the normal living rate was decreased. CONCLUSION The expression of IGFBP-3 is elevated in HELLP syndrome, which may subsequently promote cell apoptosis by affecting the expression and function of IGF-1, VEGF, and TGFβ1 in the IGF/PI3K/Akt, TGF-β1/Smad3, and VEGF/eNOS/NO pathways. IGFBP-3 aggravates inflammatory reactions of the vascular endothelium and liver under hypoxia, affects the normal function of cells, and plays a role in the pathogenesis of diseases.
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Affiliation(s)
- Li Wei
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China
| | - Zhou Liping
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China
| | - Kang Suya
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, No. 26, Daoqian Street, Suzhou, Jiangsu, China.
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A Life-Threating Postpartum Atypical Hemolytic-Uremic Syndrome with Multiorgan Involvement. J Clin Med 2022; 11:jcm11236957. [PMID: 36498532 PMCID: PMC9738905 DOI: 10.3390/jcm11236957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis.
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Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome With Severe Thrombocytopenia and Severe ADAMTS13 Activity Deficiency. Obstet Gynecol 2021; 137:873-876. [PMID: 33831917 DOI: 10.1097/aog.0000000000004345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Differentiating preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome from thrombotic thrombocytopenic purpura (TTP) can present a diagnostic dilemma. CASE We report the case of a 34-year-old woman, G1P0, with monochorionic diamniotic twins who presented with new-onset blurry vision, hypertension, and a platelet count of 4×109/L. After a multidisciplinary discussion, a diagnosis of atypical HELLP syndrome was made, despite overlapping features concerning for TTP. Her platelet count and ADAMTS13 activity testing showed appropriate recovery after delivery, without plasma exchange therapy, supporting the diagnosis of HELLP syndrome. CONCLUSION Hemolysis, elevated liver enzymes, and low platelet count syndrome may present with severe thrombocytopenia and severe ADAMTS13 activity deficiency in ranges otherwise known to be more common with TTP.
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Walker JJA, Holm LP, Sarmiento ÓG, Caianiello R, Cortellini S, Walker DJ. Clinicopathological features of cutaneous and renal glomerular vasculopathy in 178 dogs. Vet Rec 2021; 189:e72. [PMID: 33829498 DOI: 10.1002/vetr.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND One hundred seventy-eight dogs with cutaneous and renal glomerular vasculopathy (CRGV) were evaluated to further the understanding of the natural course of CRGV. CRGV, a form of thrombotic microangiopathy, can cause skin lesions and potentially acute kidney injury (AKI) with a high mortality rate. METHODS Cases were submitted from multiple practices from 2012 until June 2019. Clinical histories and laboratory data were reviewed to describe the features of CRGV. RESULTS Most cases (91%) occurred between November and May. Fifteen dogs (8.4%) with CRGV were in contact with another dog that developed skin lesions +/- AKI. Limb lesions were present on 144 dogs (80.9%) at presentation. Median time from appearance of a lesion to AKI was 3 days (range -4-45 days). Neurological signs occurred in 33 dogs (18.6%) including at presentation in 2 (1.1%). Systemic signs were present in 13 dogs prior to a skin lesion (7.3%). Non-steroidal anti-inflammatory drugs were prescribed prior to AKI identification in 92 of 170 dogs (54.1%). Thrombocytopenia was present in 115 of 137 (83.9%) of dogs. CONCLUSION The timeframe over which AKI may develop is longer than previously reported, neurological signs can be identified at presentation or during hospitalisation, and thrombocytopenia is even more common than previously reported.
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Malinowski AK. Thrombotic microangiopathy in pregnancy: when you hear hoofbeats, consider the zebras? Br J Haematol 2020; 190:306-308. [PMID: 32342505 DOI: 10.1111/bjh.16694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Ann Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Torointo, Toronto, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
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Vinturache A, Popoola J, Watt-Coote I. The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. J Clin Med 2019; 8:jcm8091396. [PMID: 31500091 PMCID: PMC6780924 DOI: 10.3390/jcm8091396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (PR-AKI) is a heterogeneous disorder with multiple aetiologies that can occur at any time throughout pregnancy and the post-partum period. PR-AKI is an important obstetric complication that is associated with significant maternal and foetal morbidity and mortality. Although there has been an overall decline in the incidence of PR-AKI worldwide, a recent shift in the occurrence of this disease has been reported. Following improvements in obstetric care, PR-AKI incidence has been reduced in developing countries, whereas an increase in PR-AKI incidence has been reported in developed countries. Awareness of the physiological adaptations of the renal system is essential for the diagnosis and management of kidney impairment in pregnancy. In this review we scrutinize the factors that have contributed to the changing epidemiology of PR-AKI and discuss challenges in the diagnosis and management of acute kidney injury (AKI) in pregnancy from an obstetrics perspective. Thereafter we provide brief discussions on the diagnostic approach of certain PR-AKI aetiologies and summarize key therapeutic measures.
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Affiliation(s)
- Angela Vinturache
- Department of Obstetrics & Gynaecology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK.
| | - Joyce Popoola
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
- Department of Nephrology and Transplantation, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
| | - Ingrid Watt-Coote
- Department of Obstetrics & Gynaecology, St. George's University Hospital NHS Foundation Trust, London SW17 0QT, UK
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Radhakrishnan ST, Ruban A, Uthayakumar AK, Cohen P, Levy J, Teare J. Haemolytic uraemic syndrome - a rare case report of bloody diarrhoea in adults. BMC Gastroenterol 2019; 19:156. [PMID: 31462210 PMCID: PMC6714094 DOI: 10.1186/s12876-019-1071-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Haemolytic uraemic syndrome is a rarely seen in adults often leading to critical illness. This case highlights how difficult it can be to establish a diagnosis and treat when a patient presents with bloody diarrhoea. CASE PRESENTATION A 17-year-old Iraqi man presented to the emergency department with abdominal pain and bloody diarrhoea. He was initially treated as acute appendicitis, undergoing an appendectomy but following a recurrence in his symptoms a colonoscopy was performed. A diagnosis of shiga toxin-producing Escherichia coli leading to HUS was suspected following histology obtained at colonoscopy and this was confirmed on antibody testing. Despite intravenous fluids and supportive therapy the patient's symptoms and condition deteriorated. He developed seizures and acute renal failure requiring intubation and plasma exchange in the intensive care setting. He eventually required treatment with ecluzimab therapy; a monoclonal antibody and subsequently made a full recovery. CONCLUSIONS Haemolytic uraemic syndrome is a triad of progressive renal failure, thrombocytopenia and haemolytic anaemia which is a condition rarely seen in adults. It is usually associated with an E. coli infection and supportive therapy remains the mainstay of treatment.
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Affiliation(s)
- Shiva Thambiah Radhakrishnan
- Department of Gastroenterology, Imperial College Healthcare NHS trust, St Marys Hospital, London, W2 1NY, England.
| | - Aruchuna Ruban
- Department of Surgery and Cancer, Imperial College London, W2 1NY, London, England
| | | | - Patrizia Cohen
- Imperial College Healthcare NHS trust, St Marys Hospital, London, W2 1NY, England
| | - Jeremy Levy
- Imperial College Healthcare NHS Trust, Hammersmith hospital, London, W12 0HS, England
| | - Julian Teare
- Department of Gastroenterology, Imperial College Healthcare NHS trust, St Marys Hospital, London, W2 1NY, England
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A potentially deadly influenza mimic. J Am Assoc Nurse Pract 2019; 32:344-348. [PMID: 31369452 DOI: 10.1097/jxx.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This case challenge presents a rare but potentially fatal condition initially mistaken for influenza. Prodromic manifestations are not uncommon at the time of diagnosis or in the preceding days in this idiopathic condition. Untreated, mortality rates are extremely high, but initiation of appropriate therapy has significantly improved survival. Pathophysiology, symptomatology, diagnostics, and treatment are detailed as the case study unfolds.
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Thrombotic microangiopathies during pregnancy: The obstetrical and neonatal perspective. Eur J Obstet Gynecol Reprod Biol 2019; 237:7-12. [DOI: 10.1016/j.ejogrb.2019.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 12/24/2022]
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Kang S, Zhou L, Wang X, Li Y, Wang Y. Effectiveness of high-dose glucocorticoids on hemolysis, elevating liver enzymes, and reducing platelets syndrome. J Int Med Res 2018; 47:738-747. [PMID: 30453812 PMCID: PMC6381480 DOI: 10.1177/0300060518809783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate the effectiveness of high-dose glucocorticoids on hemolysis, elevating liver enzymes, and reducing platelets (HELLP) syndrome. Methods A total of 151 patients with HELLP syndrome were analyzed and divided into two groups. Six subgroups of treatment and control groups were divided into three grades in accordance with the American Mississippi Diagnostic Criteria. Results There were no differences in general characteristics of the patients, primipara rate, minimum platelet recovery time, postpartum hemorrhage volume, postpartum hemorrhage rate, cumulative average of maternal damage, intensive care unit admission rate, perinatal mortality rate, and overall incidence rate of adverse outcomes in fetuses among the groups. The primipara rate in the control group of the third grade was significantly higher than that in the treatment group of the third grade. The treatment group of the second grade (88.7%) had a significantly higher preterm delivery rate than that in the control group of the second grade (66.7%). There were no differences in minimum hemoglobin, and maximum lactate dehydrogenase, alanine aminotransferase, and aspartate aminotransferase levels among the groups and subgroups. Conclusion High-dose glucocorticoids cannot significantly improve maternal and fetal prognoses and laboratory indices. However, our results might offer some clinical evidence for HELLP syndrome therapy.
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Affiliation(s)
- Suya Kang
- Department of Obstetrics, Suzhou Affiliated Hospital of Nanjing Medical University, Suzhou Municipal Hospital, China
| | - Liping Zhou
- Department of Obstetrics, Suzhou Affiliated Hospital of Nanjing Medical University, Suzhou Municipal Hospital, China
| | - Xiaoyan Wang
- Department of Obstetrics, Suzhou Affiliated Hospital of Nanjing Medical University, Suzhou Municipal Hospital, China
| | - Yongmei Li
- Department of Obstetrics, Suzhou Affiliated Hospital of Nanjing Medical University, Suzhou Municipal Hospital, China
| | - Yun Wang
- Department of Obstetrics, Suzhou Affiliated Hospital of Nanjing Medical University, Suzhou Municipal Hospital, China
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Burwick RM, Rincon M, Beeraka SS, Gupta M, Feinberg BB. Evaluation of Hemolysis as a Severe Feature of Preeclampsia. Hypertension 2018; 72:460-465. [PMID: 29941517 DOI: 10.1161/hypertensionaha.118.11211] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 03/28/2018] [Accepted: 05/26/2018] [Indexed: 12/29/2022]
Abstract
Hemolysis predisposes to adverse pregnancy outcomes. Yet, there are limited data on hemolysis in hypertensive disorders of pregnancy other than hemolysis, elevated liver enzymes, and low platelet count syndrome. To evaluate the prevalence and impact of hemolysis in hypertensive disorders of pregnancy, we performed a retrospective cohort study at a single center (October 2013-May 2017), among women screened for hemolysis using lactate dehydrogenase (LDH) levels. We compared LDH levels by hypertensive disorder (chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia with severe features) and evaluated impact on adverse pregnancy outcomes. Data were analyzed by χ2 or t test, ANOVA, test of medians, and logistic regression. Among 8645 deliveries, 1188 (13.7%) had a hypertensive disorder. Of these, 812 (68.4%) had LDH measurement before delivery: chronic hypertension (n=152); gestational hypertension (n=209); preeclampsia (n=216); and preeclampsia with severe features (n=235). LDH ≥400 U/L (≥1.6× normal) was more common in preeclampsia with severe features compared with other hypertensive disorders of pregnancy (9.8% versus 2.3%; P<0.001); adjusted odds ratio 4.52 (95% confidence interval, 2.2-9.2; P<0.001). LDH ≥400 U/L was associated with adverse maternal outcomes (41.7% versus 15.3%; P<0.001), adjusted odds ratio 3.05 (95% confidence interval, 1.4-6.7; P=0.006), and adverse neonatal outcomes (eg, preterm birth 59.4% versus 22.5%; P<0.001). We find that elevated LDH levels are associated with adverse maternal and neonatal outcomes in hypertension and preeclampsia, independent of hemolysis, elevated liver enzymes, and low platelet count syndrome. Therefore, elevated LDH levels (≥1.6× normal or ≥400 U/L) may be considered a severe feature of preeclampsia.
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Affiliation(s)
- Richard M Burwick
- From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA (R.M.B., M.G.)
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland (M.R., S.S.B.)
| | - Sridivya S Beeraka
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland (M.R., S.S.B.)
| | - Megha Gupta
- From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA (R.M.B., M.G.)
| | - Bruce B Feinberg
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY (B.B.F.)
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Yıldız S, Demirkan F. What is the evidence for the role of therapeutic apheresis in the management of complement-associated thrombotic microangiopathies? Transfus Apher Sci 2018; 57:31-34. [PMID: 29506907 DOI: 10.1016/j.transci.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMAs) are disorders characterized by endothelial cell activation, microangiopathic hemolytic anemia, thrombocytopenia and organ failure of variable intensity. The pathophysiology of various types of TMAs have become an interesting field of study. Alternative complement system activation plays an important role in several pathophysiological conditions. Complement activation is also described in an increasing number of TMAs. Inherited defects in complement regulatory genes and acquired autoantibodies against complement regulatory proteins have been described. Atypical hemolytic uremic synrome (HUS) is caused by uncontrolled activation of the alternative complement system, now called complement-mediated TMAs. Recently, application of a monoclonal antibody that specifically binds to C5 became available to treat patients with complement-mediated TMAs. Eculizumab is a humanized monoclonal antibody that blocks complement C5 activation. Empiric therapeutic apheresis is also recommended in all forms of complement-mediated TMAs. The justification for therapeutic apheresis use in all forms of complement-mediated TMAs is that it can effectively remove the autoantibodies or mutated circulating complement regulators while replacing absent or defective complement regulators. Currently, therapeutic apheresis and eculizumab are the available treatment options for complement-mediated TMAs. In this paper, we review the evidence for the role of therapeutic apheresis in the management of complement-associated TMAs.
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Affiliation(s)
- Serkan Yıldız
- Dokuz Eylul University, Division of Nephrology, Department of Internal Medicine, Izmir, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Division of Hematology, Department of Internal Medicine, 35340, Inciralti, Izmir, Turkey.
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Gupta M, Feinberg BB, Burwick RM. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens 2018; 12:29-34. [PMID: 29674195 DOI: 10.1016/j.preghy.2018.02.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/08/2018] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.
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Affiliation(s)
- M Gupta
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - B B Feinberg
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - R M Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Farklı Trombositopeni Sebeplerinin Klinik ve Laboratuvar Bulguları. JOURNAL OF CONTEMPORARY MEDICINE 2017. [DOI: 10.16899/gopctd.360762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Patient Blood Management in the Intensive Care Unit. Transfus Med Rev 2017; 31:264-271. [DOI: 10.1016/j.tmrv.2017.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 01/28/2023]
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Abstract
Extracellular histones promote platelet aggregation and thrombosis; this is followed by induction of coagulation disorder, which results in exhaustion of coagulation factors. Complement component 5 (C5) is known to be associated with platelet aggregation and coagulation system activation. To date, the pathological mechanism underlying liver injury has remained unclear. Here, we investigated whether C5 promotes liver injury associated with histone-induced lethal thrombosis. C5-sufficient and C5-deficient mice received single tail vein injections of purified, unfractionated histones obtained from calf thymus (45–75 μg/g). Subsequently, the mice were monitored for survival for up to 72 h. Based on the survival data, the 45 μg/g dose was used for analysis of blood cell count, liver function, blood coagulation ability, and promotion of platelet aggregation and platelet/leukocyte aggregate (PLA) production by extracellular histones. C5-deficient mice were protected from lethal thrombosis and had milder thrombocytopenia, consumptive coagulopathy, and liver injury with embolism and lower PLA production than C5-sufficient mice. These results indicate that C5 is associated with coagulation disorders, PLA production, and embolism-induced liver injury. In conclusion, C5 promotes liver injury associated with histone-induced lethal thrombosis.
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Chang J, Arani K, Chew S, Frosch MP, Gonzalez RG, Maza N, Romero JM. Susceptibility Etching on MRI in Patients with Microangiopathy. J Neuroimaging 2016; 27:43-49. [PMID: 27539492 DOI: 10.1111/jon.12384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/11/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We detected a novel imaging sign, which consists of a specific imaging pattern of diffuse susceptibility effect, delineating the cortical-subcortical junction on high-resolution susceptibility-weighted images (SWIs). We describe magnetic resonance imaging findings in 10 patients with "susceptibility etching" and possible association with their abnormal coagulation profile. MATERIALS/METHODS A retrospective case series study with a search for cases that demonstrated susceptibility effect at the cortical-subcortical junction on SWI sequences was performed. The patients' respective coagulation profiles including prothrombin time, partial thromboplastin time, fibrinogen, D-dimer values, and platelet counts were reviewed. In addition, clinical history and neurological deficits were recorded. RESULTS We identified 10 patients with the "susceptibility etching" pattern at the cortical-subcortical junction. All patients were acutely ill and had a significantly elevated D-dimer (4,309 mcg/L to >10,000 mcg/L) with variably reduced platelet count. Two patients had reduced fibrinogen and 5 patients had prolonged international normalized ratio. Of the 10 patients, 4 died during hospitalization, within a few days of imaging. Pathology of 1 patient at autopsy demonstrated findings suggestive of a microvascular thrombotic or embolic event without overt parenchymal microhemorrhage. CONCLUSION In this preliminary case series, we describe patients with "susceptibility etching" on SWI who were also found to have profound coagulation impairment. While other comorbities may also contribute to this novel sign, we suggest that a possible etiology may be secondary to microvascular in situ formation of fine thrombi and/or emboli lodged into an area of vascular caliber reduction and maybe related to thrombotic microangiopathy.
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Affiliation(s)
- Jennifer Chang
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keerthi Arani
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sheena Chew
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matthew P Frosch
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R Gilberto Gonzalez
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Noor Maza
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Javier M Romero
- Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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19
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Cicchetti A, Berrino A, Casini M, Codella P, Facco G, Fiore A, Marano G, Marchetti M, Midolo E, Minacori R, Refolo P, Romano F, Ruggeri M, Sacchini D, Spagnolo AG, Urbina I, Vaglio S, Grazzini G, Liumbruno GM. Health Technology Assessment of pathogen reduction technologies applied to plasma for clinical use. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:287-386. [PMID: 27403740 PMCID: PMC4942318 DOI: 10.2450/2016.0065-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.
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Affiliation(s)
- Americo Cicchetti
- Postgraduate School of Health Economics and Management (Altems), Catholic University of the Sacred Heart, Rome, Italy
| | - Alexandra Berrino
- Health Technology Assessment Unit of “Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Marina Casini
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Paola Codella
- Postgraduate School of Health Economics and Management (Altems), Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppina Facco
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Alessandra Fiore
- Postgraduate School of Health Economics and Management (Altems), Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Marco Marchetti
- Health Technology Assessment Unit of “Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Emanuela Midolo
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberta Minacori
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Pietro Refolo
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Federica Romano
- Postgraduate School of Health Economics and Management (Altems), Catholic University of the Sacred Heart, Rome, Italy
| | - Matteo Ruggeri
- Postgraduate School of Health Economics and Management (Altems), Catholic University of the Sacred Heart, Rome, Italy
| | - Dario Sacchini
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio G. Spagnolo
- Institute of Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Irene Urbina
- Health Technology Assessment Unit of “Gemelli” Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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20
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Haram K, Mortensen JH, Mastrolia SA, Erez O. Disseminated intravascular coagulation in the HELLP syndrome: how much do we really know? J Matern Fetal Neonatal Med 2016; 30:779-788. [PMID: 27181089 DOI: 10.1080/14767058.2016.1189897] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The rate of disseminated intravascular coagulation (DIC) during pregnancy varies among nations from 0.03% to 0.35%. The existing reports suggest dissimilarity in the underlying mechanisms leading to DIC during gestation. While in developing countries preeclampsia and the HELLP syndrome are prevalent causes of DIC, the leading causes in the developed countries are placental abruption and postpartum hemorrhage. In different cohort studies, DIC is reported in about 12-14% of women with preeclampsia. Nevertheless, it has been suggested that in most cases these women also had a HELLP syndrome and that the occurrence of DIC in women who had only preeclampsia without manifestations of the HELLP syndrome is rare. The aims of this review are to: (1) highlight the mechanisms leading to DIC; (2) describe the changes in the coagulation system during this complication; and; (3) discuss the diagnostic tool and treatment modalities of DIC, in women who develop a HELLP syndrome.
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Affiliation(s)
- Kjell Haram
- a Department of Obstetrics and Gynecology , Haukeland University Hospital , Bergen , Norway
| | - Jan Helge Mortensen
- b Department of Public Health and Primary Health Care , University of Bergen , Bergen , Norway
| | - Salvatore Andrea Mastrolia
- c Department of Obstetrics and Gynecology , Azienda Ospedaliera Universitaria Policlinico di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy , and.,d Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Offer Erez
- d Department of Obstetrics and Gynecology , Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev , Beer Sheva , Israel
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21
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Miyasaka N, Miura O, Kawaguchi T, Arima N, Morishita E, Usuki K, Morita Y, Nishiwaki K, Ninomiya H, Gotoh A, Imashuku S, Urabe A, Shichishima T, Nishimura JI, Kanakura Y. Pregnancy outcomes of patients with paroxysmal nocturnal hemoglobinuria treated with eculizumab: a Japanese experience and updated review. Int J Hematol 2016; 103:703-12. [PMID: 26857155 DOI: 10.1007/s12185-016-1946-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 12/16/2022]
Abstract
Pregnancy with paroxysmal nocturnal hemoglobinuria (PNH) is associated with significant risk of complications, such as life-threatening thrombosis. Recently, eculizumab has come into clinical use and revolutionized the treatment of PNH. However, clinical information regarding eculizumab use for PNH during pregnancy is limited. The present report describes pregnancies with PNH treated with eculizumab that were registered with the Japan PNH study group and reviews the literature. In case 1, the patient received eculizumab throughout pregnancy and delivered a healthy neonate at term, although breakthrough hemolysis occurred at 20 weeks of gestation. In case 2, the patient discontinued eculizumab before pregnancy and developed preeclampsia at 27 weeks of gestation. She received eculizumab and delivered a preterm, but healthy, neonate by cesarean section. In case 3, the patient received eculizumab from 18 weeks of gestation and delivered a healthy neonate at term without any complications. Reports of 11 pregnant women treated with eculizumab were identified in the literature. Of 14 pregnancies, including our own cases, breakthrough hemolysis and preeclampsia occurred in five and two cases, respectively. There were no thrombotic complications, maternal or neonatal deaths, or fetal structural abnormalities. Thus, eculizumab appears to be safe and effective for managing PNH during pregnancy.
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Affiliation(s)
- Naoyuki Miyasaka
- Department of Pediatrics, Perinatal and Maternal Medicine, Graduate School of Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan.
| | - Osamu Miura
- Department of Hematology, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Tatsuya Kawaguchi
- Departments of Hematology and Infectious Diseases, Kumamoto University Hospital, Kumamoto, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Nobuyoshi Arima
- Department of Hematology, Medical Research Institute Kitano Hospital, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Yasuyoshi Morita
- Division of Hematology and Rheumatology, Department of Internal Medicine, Kinki University Faculty of Medicine, Osaka-Sayama, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Kaichi Nishiwaki
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Haruhiko Ninomiya
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Akihiko Gotoh
- Division of Hematology, First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Shinsaku Imashuku
- Division of Hematology, Takasago-Seibu Hospital, Takasago, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Akio Urabe
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Tsutomu Shichishima
- Department of Cardiology and Hematology, Fukushima Medical University, Fukushima, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
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22
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Williams LA, Marques MB. Pathology Consultation on the Diagnosis and Treatment of Thrombotic Microangiopathies (TMAs). Am J Clin Pathol 2016; 145:158-65. [PMID: 27124904 DOI: 10.1093/ajcp/aqv086] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Pathologists specializing in transfusion medicine, apheresis medicine, and/or coagulation are often consulted by clinicians to reach a diagnosis for patients with thrombotic microangiopathy (TMA), so that disease-specific, often life-saving therapy can be initiated as promptly as possible. METHODS This article describes how to proceed when treating a patient with TMA. The differential diagnosis is broad and potentially very challenging. Thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), and typical hemolytic uremic syndrome (HUS) are three such TMAs that require timely diagnosis and treatment. RESULTS TTP is treated with daily therapeutic plasma exchange (TPE) and commonly with adjunctive immunosuppressive therapy, while aHUS may initially be managed with TPE but is best controlled with eculizumab once a presumptive diagnosis is made. TPE has no proven role in typical HUS, which is most commonly treated with supportive measures only. CONCLUSIONS Prompt and accurate diagnosis of TMA subtypes optimizes treatment and improves patient outcomes.
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Affiliation(s)
- Lance A Williams
- From the Department of Pathology, University of Alabama at Birmingham
| | - Marisa B Marques
- From the Department of Pathology, University of Alabama at Birmingham
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23
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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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24
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Clinical-Pathological Conference Series from the Medical University of Graz Case No 155: 26-year-old woman in third trimester of pregnancy with epigastric pain and thrombocytopenia. Wien Klin Wochenschr 2015; 127:707-14. [PMID: 26248584 DOI: 10.1007/s00508-015-0829-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
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