Fetal and Neonatal Thrombophilia

Neonatal Cerebral Venous Thrombosis following Maternal SARS-CoV-2 Infection in Pregnancy

A possible consequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is the development of an exacerbated thrombophilic status, and cerebral venous thrombosis (CVT) is a rare but possible complication of SARS-CoV-2 infection reported both in adults and in children. The present case report describes the clinical course of a term neonate showing extended CVT of unclear origin, whose mother had developed SARS-CoV-2 infection during the third trimester of pregnancy. We speculate that the prothrombotic status induced by maternal SARS-CoV-2 infection may have played a pathophysiological role in the development of such severe neonatal complication. Further investigations are required to confirm such hypothesis.

Thrombosis in the Neonatal Intensive Care Unit

Neonates have the highest risk for pathologic thrombosis among pediatric patients. A combination of genetic and acquired risk factors significantly contributes to this risk, with the most important risk factor being the use of central venous catheters. Proper imaging is critical for confirming the diagnosis. Despite a significant number of these events being life- and limb-threatening, there is limited evidence on what the appropriate management strategy should be. Evaluation and treatment of any neonate with a clinically significant thrombosis should occur at a tertiary referral center that has proper support.

Management of neonatal thrombosis

Neonates have one of the highest risks for thromboembolism among pediatric patients. This risk is attributable to a combination of multiple genetic and acquired risk factors. Despite a significant number of these events being either life threatening or limb threatening, there is limited evidence on appropriate management strategy. Most of what is recommended is based on uncontrolled studies, case series, or expert opinion. This review begins with a discussion of the neonatal hemostatic system, focusing on the common sites and imaging modalities for the detection of neonatal thrombosis. Perinatal and postnatal risk factors are presented and management options discussed.

Etiology and treatment of perinatal stroke; a role for prothrombotic coagulation factors?

The detection rate of perinatal stroke is rising due to improved neuroradiological imaging techniques, increased survival of neonates with severe underlying diseases and an increased awareness of the diagnosis by pediatricians. Its pathogenesis is multifactorial and includes a large variety of maternal and neonatal risk factors as well as prothrombotic coagulation factors. Although the relative risk of prothrombotic coagulation factors is still unknown, testing is recommended to design large studies in the near future. This article is an overview of studies of prothrombotic risk factors in both neonatal arterial ischemic stroke and cerebral sinovenous thrombosis. Although prothrombotic coagulation factors are present in more than half of the cases, we conclude that they most likely play a minor role in the pathogenesis of perinatal stroke. Current therapeutic guidelines focusing on thrombosis are based on expert opinion and recommend low molecular weight or unfractionated heparin for cardioembolic arterial ischemic stroke, antiplatelet or anticoagulant therapy for recurrent arterial ischemic stroke, and low molecular weight heparin or unfractionated heparin for sinovenous thrombosis without hemorrhage and/or when extension of the thrombotic process occurs.

The evaluation and management of postnatal thromboses

In the pediatric population, neonates have the highest risk for thromboembolism (TE), most likely due to the frequent use of intravascular catheters. This increased risk is attributed to multiple risk factors. Randomized clinical trials dealing with management of postnatal thromboses do not exist, thus, opinions differ regarding optimal diagnostic and therapeutic interventions. This review begins with an actual case study illustrating the complexity and severity of these types of cases, and then evaluates the neonatal hemostatic system with discussion of the common sites of postnatal thrombosis, perinatal and prothrombotic risk factors, and potential treatment options. A proposed step-wise evaluation of neonates with symptomatic postnatal thromboses will be suggested, as well as future research and registry directions. Owing to the complexity of ischemic perinatal stroke, this topic will not be reviewed.

The evaluation and management of neonatal coagulation disorders

Neonatal hemostatic abnormalities can present diagnostic and therapeutic challenges to the physician. Developmental deficiencies and/or increases of certain coagulation proteins, coupled with acquired or genetic risk factors, can result in a hemorrhagic or thromboembolic emergency. The timely diagnosis of a congenital hemorrhagic or thrombotic disorder can avoid significant long-term sequelae. However, due to the lack of randomized clinical trials addressing the management of neonatal coagulation disorders, treatment strategies are usually empiric and not evidence-based. In this chapter, we will review the neonatal hemostatic system and will discuss the most common types of hemorrhagic and thrombotic disorders. Congenital and acquired risk factors for hemorrhagic and thromboembolic disorders will be presented, as well as current treatment options. Finally, suggested evaluations for neonates with either hemorrhagic or thromboembolic problems will be reviewed.

Ischemic perinatal stroke: challenge and opportunities

The second highest risk group for developing a cerebral stroke is the perinatal period, generally defined as 20 weeks of gestation through 28th postnatal day of age. In this commentary, a brief overview of ischemic perinatal strokes is presented. Ischemic perinatal stroke (IPS) occurs at a rate of 1 : 2300 to 1 : 5000 births, accounting for 30% of children with hemiplegic cerebral palsy (CP). Thus, IPS is the most common known cause for CP [1-3]. Although they occur frequently, much remains to be studied about perinatal strokes in general and the ischemic variety in particular.

Frühkindliche Schlaganfälle - Studie zur klinischen Validität des ET 6-6

Zusammenfassung: Hintergrund: Untersucht werden soll die Einsatzmöglichkeit des ET 6-6 (Entwicklungstest 6 Monate bis 6 Jahre) zur Einschätzung von Entwicklungsdefiziten bei frühkindlichem Schlaganfall. Material und Methoden: 32 Kinder mit frühkindlichem Schlaganfall wurden im Alter zwischen 36 bis 72 Monaten mit dem ET 6-6 untersucht. Die Ergebnisse werden mit den Leistungen einer altersparallelisierten Kontrollgruppe aus der Normierungsstichprobe verglichen. Anschließend erfolgt ein deskriptiver Leistungsvergleich nach Lokalisation der zerebralen Schädigung. Ergebnisse: Im Gesamtgruppenvergleich zeigt die Untersuchungsgruppe in fast allen Entwicklungsdimensionen signifikant niedrigere Leistungen als die Kontrollgruppe. Die gefundenen Leistungsdiskrepanzen werden durch den Einbezug der Lokalisation des Schlaganfalles spezifiziert; nach Schlaganfällen im Bereich der A. cerebri media linksseitig zeigen sich die deutlichsten Entwicklungsrisiken. Diskussion: Der Einsatz des ET 6-6 zeigt sich als Überblicksverfahren geeignet, um gravierende Entwicklungsdefizite oder Entwicklungsrisiken in verschiedenen Dimensionen bei frühkindlichem Schlaganfall aufzuzeigen.