1
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Zhang B, Chu R, Huang C, Song X, Wang J, Li L, Xu Y, Ma Y. Progress in the Management of Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Review. J Womens Health (Larchmt) 2024; 33:98-104. [PMID: 37917919 DOI: 10.1089/jwh.2023.0164] [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] [Indexed: 11/04/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired complement-mediated hemolytic disease characterized by intravascular hemolysis, thrombosis, smooth muscle dystonia, and so on. Thrombosis is the principal cause of death in PNH patients. During the perinatal period, pregnant PNH patients have increased morbidity and mortality with a heightened risk of complications, including significant preterm birth. The management of pregnancy complicated by PNH is difficult. Therefore, early diagnosis, standardized treatment protocols, and improving perinatal outcomes are crucial. However, there is a lack of consensus on treating patients with PNH during pregnancy. This article reviews 32 studies of pregnancy affected by PNH, focusing on the clinical presentation, diagnosis, and treatment strategies of PNH, to provide guidance for obstetricians on how to handle pregnant patients with PNH, and to offer academic support for the management of PNH patients. We found that Eculizumab has become the primary choice for treating PNH, effectively controlling intravascular hemolysis and reducing the frequency of blood transfusions necessary to stabilize the condition, with no severe threat to the safety of the mother and fetus.
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Affiliation(s)
- Bei Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P.R. China
| | - Changzhen Huang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Xiao Song
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, P.R. China
| | - Jianye Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
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2
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Schaap CCM, Heubel-Moenen FCJI, Nur E, Bartels M, van der Heijden OWH, de Jonge E, Preijers FWMB, Blijlevens NMA, Langemeijer SMC. Nationwide study of eculizumab in paroxysmal nocturnal hemoglobinuria: Evaluation of treatment indications and outcomes. Eur J Haematol 2023; 110:648-658. [PMID: 36811247 DOI: 10.1111/ejh.13946] [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: 11/29/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
Eculizumab is an effective treatment for paroxysmal nocturnal hemoglobinuria (PNH). However, considering the risk of life-threatening meningococcal disease, life-long duration and costs, there are strict criteria for initiation of therapy. To evaluate the application and real-world effectiveness of eculizumab in the Netherlands, a multicenter retrospective cohort study was conducted: indications and treatment outcomes were collected for 105 Dutch PNH patients. In all patients, eculizumab was initiated conforming to indications as formulated in the Dutch PNH guideline. According to recently published response criteria, 23.4% of the patients had reached a complete hematological response, 53.2% a good or partial response, and 23.4% a minor response after 12 months of therapy. In the majority of patients the response remained stable during long-term follow-up. The degree and relevance of extravascular hemolysis significantly differed between response groups (p = 0.002). Improvements of EORTC-QLQc30 and FACIT-fatigue scores were observed, however patients reported lower scores than the general population. A detailed evaluation of 18 pregnancies during eculizumab showed no maternal or fetal deaths, and no thromboembolic events during pregnancy. This study demonstrates that the majority of patients benefit from eculizumab when adhering to the indications as formulated in the Dutch PNH guideline. However, novel therapies are needed to further improve real-world outcomes, such as hematological responses and quality of life.
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Affiliation(s)
- Charlotte C M Schaap
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erfan Nur
- Department of Clinical Hematology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Marije Bartels
- Pediatric Hematology Department, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Emiel de Jonge
- Department of Laboratory Medicine-Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank W M B Preijers
- Department of Laboratory Medicine-Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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3
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Risitano AM, Peffault de Latour R. How we('ll) treat paroxysmal nocturnal haemoglobinuria: diving into the future. Br J Haematol 2021; 196:288-303. [PMID: 34355382 PMCID: PMC9291300 DOI: 10.1111/bjh.17753] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by complement-mediated intravascular haemolysis, severe thrombophilia and bone marrow failure. While for patients with bone marrow failure the treatment follows that of immune-mediated aplastic anaemia, that of classic, haemolytic PNH is based on anti-complement medication. The anti-C5 monoclonal antibody eculizumab has revolutionized treatment, resulting in control of intravascular haemolysis and thromboembolic risk, with improved long-term survival. Novel strategies of complement inhibition are emerging. New anti-C5 agents reproduce the safety and efficacy of eculizumab, with improved patient convenience. Proximal complement inhibitors have been developed to address C3-mediated extra-vascular haemolysis and seem to improve haematological response.
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Affiliation(s)
- Antonio Maria Risitano
- Department of Onco-Hematology, AORN San Giuseppe Moscati Avellino, Avellino, Italy.,Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.,Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands
| | - Régis Peffault de Latour
- Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands.,French Reference Centre for Aplastic Anaemia and Paroxysmal Nocturnal Haemoglobinuria, Assistance Publique - Hôpitaux de Paris, Saint-Louis Hospital, Paris, France.,Bone Marrow Transplant Unit, Université de Paris, Denis Diderot, Paris, France
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4
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Al-Dosari YM, Al-Zahrani H, Al-Mohareb F, Hashmi S. Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Case Series with Review of the Literature. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2021; 9:178-189. [PMID: 34084110 PMCID: PMC8152383 DOI: 10.4103/sjmms.sjmms_4_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 12/31/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder, and eculizumab and ravulizumab are its two approved therapies. Only few case series/reports have reported the outcomes of pregnancies in patients with PNH despite the increased risk of thrombosis. Similarly, there is limited knowledge regarding the effect of the approved treatments on conception and pregnancy outcomes. Here, we report the first series of pregnancies in PNH patients from the Middle Eastern region from our tertiary care hospital. Ten pregnancies in four females after diagnosis with PNH were identified. In terms of PNH management, only eculizumab was used, as the safety of ravulizumab use in pregnancies has not yet been established. In the antepartum period, the patients had variable symptoms that ranged from mild symptoms including epistaxis, tea-colored urine and vaginal bleeding to life-threatening vessel thrombosis. Further, red blood cell and platelet transfusions were required because of bleeding and hemolysis in four pregnancies. The pregnancy outcomes varied, but based on these, the safety of eculizumab use during pregnancy remained inconclusive. The postpartum period was complicated in one case by portal vein thrombosis and was managed accordingly. In conclusion, pregnant females with PNH are at an increased risk for complications due to PNH, and thus experienced hematologists and obstetricians should be involved jointly in their care.
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Affiliation(s)
- Yara Mohammad Al-Dosari
- Internal Medicine Department, Bahrain Defence Force Hospital and Royal Medical Services, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hazza Al-Zahrani
- Adult Hematology/Bone Marrow Transplantation Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Al-Mohareb
- Adult Hematology, HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shahrukh Hashmi
- Adult Hematology/Bone Marrow Transplantation Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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5
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Treatment of paroxysmal nocturnal hemoglobinuria in pregnancy with eculizumab: A case report. Case Rep Womens Health 2021; 30:e00294. [PMID: 33665137 PMCID: PMC7903290 DOI: 10.1016/j.crwh.2021.e00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 11/21/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disease caused by mutations in hematopoietic stem cells leading to pancytopenia and a predisposition for thromboembolic events. In pregnancy, these manifestations can be amplified, leading to increased neonatal and maternal morbidity and mortality. Although data are limited, eculizumab has emerged as a potential treatment of PNH in pregnancy. This report describes a case of a woman with PNH successfully treated with eculizumab during two pregnancies. Although during both pregnancies she experienced breakthrough hemolysis requiring intermittent blood transfusions, she had no thromboembolic events and had term vaginal births. Granted more research is needed, eculizumab may be an acceptable therapy for PNH in pregnancy.
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6
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Patriquin CJ, Kiss T, Caplan S, Chin-Yee I, Grewal K, Grossman J, Larratt L, Marceau D, Nevill T, Sutherland DR, Wells RA, Leber B. How we treat paroxysmal nocturnal hemoglobinuria: A consensus statement of the Canadian PNH Network and review of the national registry. Eur J Haematol 2018; 102:36-52. [PMID: 30242915 DOI: 10.1111/ejh.13176] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 12/27/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disease characterized by intravascular hemolysis, thrombophilia, and marrow failure. Its phenotype is due to absent or reduced expression of GPI-linked complement regulators and subsequent sensitivity of hematopoietic cells to complement-mediated damage and lysis. Introduction of the terminal complement inhibitor eculizumab drastically improved outcomes in PNH patients; however, despite this improvement, there remain several challenges faced by PNH patients and physicians who care for them. One of the most important is increasing awareness of the heterogeneity with which patients can present, which can lead to significant delays in recognition. Data from the Canadian PNH Registry are presented to demonstrate the variety of presenting symptoms. In Canada, geography precludes consolidation of care to just a few centers, so management is distributed across academic hospitals, linked together as the Canadian PNH Network. The Network over the last several years has developed educational programs and clinical checklists and has worked to standardize access to diagnostics across the country. Herein, we address some of the common diagnostic and therapeutic challenges faced by PNH physicians and give our recommendations. Gaps in knowledge are also addressed, and where appropriate, consensus opinion is provided.
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Affiliation(s)
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Stephen Caplan
- Transfusion Services, Jewish General Hospital, Montreal, Quebec, Canada
| | - Ian Chin-Yee
- Divisions of Hematology and Pathology & Laboratory Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Kuljit Grewal
- Department of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Jennifer Grossman
- Division of Hematology and Hematological Malignancies, University of Calgary, Calgary, Alberta, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
| | - Daniele Marceau
- Division of Hematology and Oncology, Laval University, Quebec City, Quebec, Canada
| | - Tom Nevill
- Leukemia/BMT Program of British Columbia, BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Brian Leber
- Division of Hematology & Thromboembolism, McMaster University, Hamilton, Ontario, Canada
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7
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Lauritsch‐Hernandez LS, Kraehenmann F, Balabanov S, Kimmich N. Eculizumab application during pregnancy in a patient with paroxysmal nocturnal hemoglobinuria: A case report with review of the literature. Clin Case Rep 2018; 6:1582-1587. [PMID: 30147909 PMCID: PMC6099006 DOI: 10.1002/ccr3.1634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/19/2018] [Accepted: 05/19/2018] [Indexed: 01/20/2023] Open
Abstract
Eculizumab is highly effective in inhibiting complement activation and has successfully shown to prevent complications and to improve quality of life in patients with paroxysmal nocturnal hemoglobinuria (PNH). Its application during pregnancy showed favorable fetal and maternal outcome in the presented case and has proven to be effective without raising safety concerns.
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Affiliation(s)
| | | | - Stefan Balabanov
- Department of HematologyUniversity Hospital of ZurichZurichSwitzerland
| | - Nina Kimmich
- Department of ObstetricsUniversity Hospital of ZurichZurichSwitzerland
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8
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Sicre de Fontbrune F, Peffault de Latour R. Ten Years of Clinical Experience With Eculizumab in Patients With Paroxysmal Nocturnal Hemoglobinuria. Semin Hematol 2018; 55:124-129. [DOI: 10.1053/j.seminhematol.2018.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022]
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9
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Paroxysmal Nocturnal Hemoglobinuria in Pregnancy: A Dilemma in Treatment and Thromboprophylaxis. Case Rep Hematol 2017; 2017:7289126. [PMID: 29147590 PMCID: PMC5632866 DOI: 10.1155/2017/7289126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/23/2017] [Indexed: 12/31/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a hematologic disorder characterized by an acquired somatic mutation in the phosphatidylinositol glycan class A gene which leads to a higher risk for increased venous and arterial thrombosis. Current treatment for PNH includes eculizumab. Pregnant patients who have PNH have higher risk for thrombosis and hemorrhage with both pregnancy and their underlying PNH. Treatment frequently poses conundrum. The safety and efficacy of eculizumab during pregnancy and breast feeding have not been extensively studied and contraception has been recommended due to potential for teratogenicity. We present a case of a patient who was safely on both eculizumab and modest prophylactic anticoagulation for 6 weeks post-partum.
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10
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Vasbien M, Minon JM. Paroxysmal nocturnal haemoglobinuria diagnosis in a woman after foetal loss. Int J Lab Hematol 2017; 39:e86-e89. [PMID: 28333408 DOI: 10.1111/ijlh.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Vasbien
- Thrombosis and Haemostasis Unit, Department of Laboratory Medicine, Centre Hospitalier Régional de Liège, Liege, Belgium
| | - J M Minon
- Thrombosis and Haemostasis Unit, Department of Laboratory Medicine, Centre Hospitalier Régional de Liège, Liege, Belgium
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11
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Two consecutive pregnancies in a patient with paroxysmal nocturnal haemoglobinuria treated with anticoagulant therapy at different doses. Blood Coagul Fibrinolysis 2016; 27:109-12. [PMID: 26258669 DOI: 10.1097/mbc.0000000000000386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is a rare acquired disorder of haematopoietic stem cells characterized by intravascular haemolysis, cytopenias and thrombophilia. Thrombophilia is the leading cause of mortality in patients with PNH. As the risk of thrombogenesis further increases during pregnancy and the postpartum period, an anticoagulant therapy is generally recommended for pregnant women with PNH. However, there are no standardized criteria for determining the appropriate dose of anticoagulant therapy. We describe the case of a PNH patient with who was managed with anticoagulant therapy at different doses during two consecutive pregnancies. A prophylactic dose of heparin was administered during her first pregnancy and a therapeutic dose, during her second pregnancy. Both pregnancies resulted in uncomplicated vaginal deliveries without thrombosis. Interestingly, not only D-dimer (as a thrombotic marker) but also lactate dehydrogenase (as a haemolytic marker) levels were lower during her second pregnancy when a therapeutic dose of heparin was used.
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12
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Servais A, Devillard N, Frémeaux-Bacchi V, Hummel A, Salomon L, Contin-Bordes C, Gomer H, Legendre C, Delmas Y. Atypical haemolytic uraemic syndrome and pregnancy: outcome with ongoing eculizumab. Nephrol Dial Transplant 2016; 31:2122-2130. [PMID: 27587606 DOI: 10.1093/ndt/gfw314] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A therapeutic strategy based on complement blockade by eculizumab is widely used to treat atypical haemolytic uraemic syndrome (aHUS). Recent data are available on the administration of eculizumab during pregnancy in patients treated for paroxysmal nocturnal haemoglobinuria but there are very few data for aHUS patients. METHODS We analysed the use of eculizumab for the treatment of aHUS during five pregnancies in three patients and studied an additional pregnancy without eculizumab. Obstetrical data and maternal and foetal complications during pregnancy, at delivery, and during the post-partum period were recorded. RESULTS The mean age at pregnancy was 28.5 (range 25-33) years. The mean serum creatinine before pregnancy was 189 (range 130-300) µmol/L and the mean eGFR was 32 (range 18-45) mL/min/1.73 m2. One patient who stopped eculizumab 3 weeks after conception had a termination due to a relapse of HUS at 12 weeks of gestation (WG) during a first pregnancy and an intrauterine death at 24 WG despite continuous eculizumab treatment during a second pregnancy. In the other four pregnancies, treatment stabilized clinical and laboratory markers until 29-34 WG, but did not prevent hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome in one patient or pre-eclampsia in two other patients. All babies were born preterm and two presented with growth retardation. The mean body weight was 1632.5 (range 1070-2500) g. The dose of eculizumab had to be increased during all pregnancies due to incomplete complement blockade. CONCLUSIONS Eculizumab therapy during pregnancy displayed no overt safety issues but did not appear to prevent HELLP syndrome or pre-eclampsia in these high-risk chronic kidney disease patients.
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Affiliation(s)
- Aude Servais
- Department of Nephrology and Transplantation, Hôpital Necker-Enfants Malades, AP-HP, 149 rue de Sèvres, 75015 Paris, France.,Université Paris Descartes, Paris, France
| | | | - Véronique Frémeaux-Bacchi
- Cordeliers Research Center, INSERM UMRS 872, 75006 Paris, France.,Department of Immunology, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Aurélie Hummel
- Department of Nephrology and Transplantation, Hôpital Necker-Enfants Malades, AP-HP, 149 rue de Sèvres, 75015 Paris, France.,Université Paris Descartes, Paris, France
| | - Laurent Salomon
- Université Paris Descartes, Paris, France.,Department of Obstetrics, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Cécile Contin-Bordes
- Department of Immunology, CHU Bordeaux, CNRS-UMR 5164 Bordeaux University, Bordeaux, France
| | - Hélène Gomer
- Department of Obstetrics, CHU Bordeaux, Bordeaux, France
| | - Christophe Legendre
- Department of Nephrology and Transplantation, Hôpital Necker-Enfants Malades, AP-HP, 149 rue de Sèvres, 75015 Paris, France.,Université Paris Descartes, Paris, France
| | - Yahsou Delmas
- Department of Nephrology Transplantation-Dialysis, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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13
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Al-Ani F, Chin-Yee I, Lazo-Langner A. Eculizumab in the management of paroxysmal nocturnal hemoglobinuria: patient selection and special considerations. Ther Clin Risk Manag 2016; 12:1161-70. [PMID: 27536121 PMCID: PMC4975135 DOI: 10.2147/tcrm.s96720] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a nonmalignant clonal disorder resulting from somatic mutation in the PIG-A gene leading to a deficiency of the membrane-anchoring molecule glycosylphosphatidylinositol. The lack of expression of two glycosylphosphatidylinositol-anchored proteins involved in the regulation of the complement system renders PNH erythrocytes susceptible to complement-mediated lysis. Clinical manifestations include thromboembolic disease, chronic kidney injury, pulmonary hypertension, smooth muscle dysfunction, and chronic hemolysis. Until recently, treatment was mainly supportive with most patients suffering from significant morbidity and shortened survival compared to age-matched controls. The development of eculizumab, a humanized monoclonal antibody directed against the terminal complement protein C5, has resulted in dramatic improvements of survival and reduction in complications. In this paper, we review some special considerations pertaining to the use of eculizumab for PNH.
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Affiliation(s)
| | | | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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14
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Vaught AJ, Gavriilaki E, Hueppchen N, Blakemore K, Yuan X, Seifert SM, York S, Brodsky RA. Direct evidence of complement activation in HELLP syndrome: A link to atypical hemolytic uremic syndrome. Exp Hematol 2016; 44:390-8. [PMID: 26921648 DOI: 10.1016/j.exphem.2016.01.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 12/27/2022]
Abstract
HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a severe variant of pre-eclampsia whose pathogenesis remains unclear. Recent evidence and clinical similarities suggest a link to atypical hemolytic uremic syndrome, a disease of excessive activation of the alternative complement pathway effectively treated with a complement inhibitor, eculizumab. Therefore, we used a functional complement assay, the modified Ham test, to analyze sera of women with classic or atypical HELLP syndrome, pre-eclampsia with severe features, normal pregnancies, and healthy nonpregnant women. Sera were also evaluated using levels of the terminal product of complement activation (C5b-9). We tested the in vitro ability of eculizumab to inhibit complement activation in HELLP serum. Increased complement activation was observed in participants with classic or atypical HELLP compared with those with normal pregnancies and nonpregnant controls. Mixing HELLP serum with eculizumab-containing serum resulted in a significant decrease in cell killing compared with HELLP serum alone. We found that HELLP syndrome is associated with increased complement activation as assessed with the modified Ham test. This assay may aid in the diagnosis of HELLP syndrome and could confirm that its pathophysiology is related to that of atypical hemolytic uremic syndrome.
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Affiliation(s)
- Arthur J Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eleni Gavriilaki
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nancy Hueppchen
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karin Blakemore
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xuan Yuan
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara M Seifert
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah York
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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15
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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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16
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Management of pregnancy in paroxysmal nocturnal hemoglobinuria on long-term eculizumab. Blood Coagul Fibrinolysis 2016; 26:464-6. [PMID: 25688464 DOI: 10.1097/mbc.0000000000000248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pregnancy in women with paroxysmal nocturnal hemoglobinuria (PNH) is associated with increased maternal and fetal complications, to such an extent that PNH has for long been considered a relative contraindication for pregnancy. The most serious life-threatening complications are venous thromboembolic events, the risk of which is increased by the hypercoagulable state related to pregnancy. Eculizumab, a C5 complement inhibitor, has revolutionized the treatment of PNH. However, there are no published trials evaluating its use in pregnancy. Most recommendations are based on expert opinions and case reports. We report on the favorable outcome of a PNH patient who became pregnant while under eculizumab, suggesting that this drug can be given from conception to delivery.
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17
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Kelly RJ, Höchsmann B, Szer J, Kulasekararaj A, de Guibert S, Röth A, Weitz IC, Armstrong E, Risitano AM, Patriquin CJ, Terriou L, Muus P, Hill A, Turner MP, Schrezenmeier H, Peffault de Latour R. Eculizumab in Pregnant Patients with Paroxysmal Nocturnal Hemoglobinuria. N Engl J Med 2015; 373:1032-9. [PMID: 26352814 DOI: 10.1056/nejmoa1502950] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Eculizumab, a humanized monoclonal antibody against complement protein C5 that inhibits terminal complement activation, has been shown to prevent complications of paroxysmal nocturnal hemoglobinuria (PNH) and improve quality of life and overall survival, but data on the use of eculizumab in women during pregnancy are scarce. METHODS We designed a questionnaire to solicit data on pregnancies in women with PNH and sent it to the members of the International PNH Interest Group and to the physicians participating in the International PNH Registry. We assessed the safety and efficacy of eculizumab in pregnant patients with PNH by examining the birth and developmental records of the children born and adverse events in the mothers. RESULTS Of the 94 questionnaires that were sent out, 75 were returned, representing a response rate of 80%. Data on 75 pregnancies in 61 women with PNH were evaluated. There were no maternal deaths and three fetal deaths (4%). Six miscarriages (8%) occurred during the first trimester. Requirements for transfusion of red cells increased during pregnancy, from a mean of 0.14 units per month in the 6 months before pregnancy to 0.92 units per month during pregnancy. Platelet transfusions were given in 16 pregnancies. In 54% of pregnancies that progressed past the first trimester, the dose or the frequency of use of eculizumab had to be increased. Low-molecular-weight heparin was used in 88% of the pregnancies. Ten hemorrhagic events and 2 thrombotic events were documented; both thrombotic events occurred during the postpartum period. A total of 22 births (29%) were premature. Twenty cord-blood samples were examined for the presence of eculizumab; the drug was detected in 7 of the samples. A total of 25 babies were breast-fed, and in 10 of these cases, breast milk was examined for the presence of eculizumab; the drug was not detected in any of the 10 breast-milk samples. CONCLUSIONS Eculizumab provided benefit for women with PNH during pregnancy, as evidenced by a high rate of fetal survival and a low rate of maternal complications. (ClinicalTrials.gov number, NCT01374360.).
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Affiliation(s)
- Richard J Kelly
- From Department of Haematology, St. James's University Hospital, Leeds (R.J.K., A.H.), and Haematological Medicine, Kings College Hospital, London (A.K.) - both in the United Kingdom; University of Ulm and German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen, Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, Ulm (B.H., H.S.), and Department of Hematology, University Hospital of Essen, Essen (A.R.) - both in Germany; PNH Subcommittee of the Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden (B.H., A.K., A.M.R., L.T., H.S., R.P.L.), and Radboud University Medical Center, Nijmegen (P.M.) - both in the Netherlands; Department of Clinical Haematology, the Royal Melbourne Hospital and University of Melbourne, Parkville, VIC, Australia (J.S.); Department of Hematology, University Hospital, Rennes (S.G.), Clinical Immunology, Department of Internal Medicine, University Hospital of Lille, Lille (L.T.), and Assistance Publique-Hôpitaux de Paris, Service d'Hématologie-Greffe, Hôpital Saint-Louis, University Paris Diderot, Sorbonne Paris Cité, Centre de Référence Aplasie Médullaire-HPN, and Filière de Santé Maladie Rare Immuno-Hématologique (MARIH), Paris (R.P.L.) - all in France; Jane Anne Nohl Division of Hematology, Keck School of Medicine of University of Southern California, Los Angeles (I.C.W.); Department of Hematology, Helsinki University Central Hospital, Helsinki (E.A.); Hematology, Department of Clinical Medicine and Surgery, Federico II, University of Naples, Naples, Italy (A.M.R.); Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada (C.J.P.); and ICON Clinical Research, San Francisco (M.P.T.)
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18
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Eculizumab treatment during pregnancy does not affect the complement system activity of the newborn. Immunobiology 2015; 220:452-9. [DOI: 10.1016/j.imbio.2014.11.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/18/2022]
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19
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DeZern AE, Brodsky RA. Paroxysmal nocturnal hemoglobinuria: a complement-mediated hemolytic anemia. Hematol Oncol Clin North Am 2015; 29:479-94. [PMID: 26043387 DOI: 10.1016/j.hoc.2015.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria is manifests with a chronic hemolytic anemia from uncontrolled complement activation, a propensity for thrombosis and marrow failure. The hemolysis is largely mediated by the alternative pathway of complement. Clinical manifestations result from the lack of specific cell surface proteins, CD55 and CD59, on PNH cells. Complement inhibition by eculizumab leads to dramatic clinical improvement. While this therapeutic approach is effective, there is residual complement activity resulting from specific clinical scenarios as well as from upstream complement components that can account for suboptimal responses in some patients. Complement inhibition strategies are an area of active research.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, Department of Oncology, The Bunting and Blaustein Cancer Research Building, 1650 Orleans Street, Room 3M87, Baltimore, MD 21287-0013, USA.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 1025, Baltimore, MD 21205, USA
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20
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Wong EKS, Kavanagh D. Anticomplement C5 therapy with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Transl Res 2015; 165:306-20. [PMID: 25468487 DOI: 10.1016/j.trsl.2014.10.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 10/15/2014] [Accepted: 10/16/2014] [Indexed: 12/28/2022]
Abstract
The complement inhibitor eculizumab is a humanized monoclonal antibody against C5. It was developed to specifically target cleavage of C5 thus preventing release of C5a and activation of the terminal pathway. Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are 2 diseases with distinctly different underlying molecular mechanisms. In PNH, progeny of hematopoietic stem cells that harbor somatic mutations lead to a population of peripheral blood cells that are deficient in complement regulators resulting in hemolysis and thrombosis. In aHUS, germline mutations in complement proteins or their regulators fail to protect the glomerular endothelium from complement activation resulting in thrombotic microangiopathy and renal failure. Critical to the development of either disease is activation of the terminal complement pathway. Understanding this step has led to the study of eculizumab as a treatment for these diseases. In clinical trials, eculizumab is proven to be effective and safe in PNH and aHUS.
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Affiliation(s)
- Edwin K S Wong
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom.
| | - David Kavanagh
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
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21
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Morita Y, Nishimura JI, Shimada T, Tanaka H, Serizawa K, Taniguchi Y, Tsuritani M, Kanakura Y, Matsumura I. Successful anticoagulant therapy for two pregnant PNH patients, and prospects for the eculizumab era. Int J Hematol 2013; 97:491-7. [DOI: 10.1007/s12185-013-1302-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
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22
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Keating GM, Lyseng-Williamson KA, McKeage K. Eculizumab: A Guide to its Use in Paroxysmal Nocturnal Hemoglobinuria. BioDrugs 2012; 26:125-30. [DOI: 10.2165/11208420-000000000-00000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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23
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Mohanty BD, De Castro CM. Too many clots for comfort. Am J Med 2012; 125:243-5. [PMID: 22340919 DOI: 10.1016/j.amjmed.2011.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 09/12/2011] [Accepted: 09/14/2011] [Indexed: 11/28/2022]
Affiliation(s)
- Bibhu D Mohanty
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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24
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Berencsi III G. Fetal and Neonatal Illnesses Caused or Influenced by Maternal Transplacental IgG and/or Therapeutic Antibodies Applied During Pregnancy. MATERNAL FETAL TRANSMISSION OF HUMAN VIRUSES AND THEIR INFLUENCE ON TUMORIGENESIS 2012. [PMCID: PMC7121401 DOI: 10.1007/978-94-007-4216-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The human fetus is protected by the mother’s antibodies. At the end of the pregnancy, the concentration of maternal antibodies is higher in the cord blood, than in the maternal circulation. Simultaneously, the immune system of the fetus begins to work and from the second trimester, fetal IgM is produced by the fetal immune system specific to microorganisms and antigens passing the maternal-fetal barrier. The same time the fetal immune system has to cope and develop tolerance and TREG cells to the maternal microchimeric cells, latent virus-carrier maternal cells and microorganisms transported through the maternal-fetal barrier. The maternal phenotypic inheritance may hide risks for the newborn, too. Antibody mediated enhancement results in dengue shock syndrome in the first 8 month of age of the baby. A series of pathologic maternal antibodies may elicit neonatal illnesses upon birth usually recovering during the first months of the life of the offspring. Certain antibodies, however, may impair the fetal or neonatal tissues or organs resulting prolonged recovery or initiating prolonged pathological processes of the children. The importance of maternal anti-idiotypic antibodies are believed to prime the fetal immune system with epitopes of etiologic agents infected the mother during her whole life before pregnancy and delivery. The chemotherapeutical and biological substances used for the therapy of the mother will be transcytosed into the fetal body during the last two trimesters of pregnancy. The long series of the therapeutic monoclonal antibodies and conjugates has not been tested systematically yet. The available data are summarised in this chapter. The innate immunity plays an important role in fetal defence. The concentration of interferon is relative high in the placenta. This is probably one reason, why the therapeutic interferon treatment of the mother does not impair the fetal development.
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Affiliation(s)
- György Berencsi III
- , Division of Virology, National Center for Epidemiology, Gyáli Street 2-6, Budapest, 1096 Hungary
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26
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Complement activation: a critical mediator of adverse fetal outcomes in placental malaria? Trends Parasitol 2011; 27:294-9. [DOI: 10.1016/j.pt.2011.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/17/2011] [Accepted: 02/22/2011] [Indexed: 11/19/2022]
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27
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de Guibert S, Peffault de Latour R, Varoqueaux N, Labussière H, Rio B, Jaulmes D, Eveillard JR, Dulucq S, Stoppa AM, Bouscary D, Girodon F, Bonnotte B, Laskri D, Socié G, Lamy T. Paroxysmal nocturnal hemoglobinuria and pregnancy before the eculizumab era: the French experience. Haematologica 2011; 96:1276-83. [PMID: 21606169 DOI: 10.3324/haematol.2010.037531] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Pregnancy in women with paroxysmal nocturnal hemoglobinuria is rare, with few reports on maternal and fetal mortality rates. DESIGN AND METHODS A specific questionnaire designed to solicit data on pregnancies in women with paroxysmal nocturnal hemoglobinuria was sent to all members of the French Society of Hematology in January 2008. RESULTS We identified 27 pregnancies in 22 women at 10 French Society of Hematology centers between 1978 and 2008. The median age was 21.5 years at diagnosis of paroxysmal nocturnal hemoglobinuria and 27 years at pregnancy. None of these women had received eculizumab during their pregnancy. Maternal complications, consisting mostly of cytopenias requiring transfusions, occurred in 95% of cases. Two cases of severe aplastic anemia (de novo in one case and relapse in the other) were recorded. No thrombotic events occurred during pregnancy, whereas 4 postpartum thromboses (16%) were recorded, 2 of which were fatal (maternal mortality rate 8%). Most patients received antithrombotic prophylaxis during pregnancy and postpartum (n=16; 64%). Delivery was preterm in 29% of cases, and birth weight was less than 3 kg in 53% of cases. Fetal mortality rate was 4%. CONCLUSIONS Pregnancy during paroxysmal nocturnal hemoglobinuria is associated with increased maternal and fetal mortality rates (8% and 4%, respectively, in this series). Maternal mortality is related to postpartum thromboses. Prophylactic anticoagulation is recommended during pregnancy and for six weeks postpartum.
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Affiliation(s)
- Sophie de Guibert
- Hématologie Clinique, Centre Hospitalier Pontchaillou, Rennes, France
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28
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Clinical management of paroxysmal nocturnal haemoglobinuria in pregnancy: three case reports. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 9:99-103. [PMID: 21084002 DOI: 10.2450/2010.0024-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 08/02/2010] [Indexed: 01/09/2023]
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29
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Marasca R, Coluccio V, Santachiara R, Leonardi G, Torelli G, Notaro R, Luzzatto L. correspondence: Pregnancy in PNH: another eculizumab baby. Br J Haematol 2010; 150:707-8. [DOI: 10.1111/j.1365-2141.2010.08258.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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