Purpura thrombopénique immunologique et grossesse : état des connaissances actuelles et questions encore sans réponse

[Establishment and one-year evaluation of an internal medicine consultation in a maternity]

OBJECTIVE

In the obstetric medicine movement and in response to requests for appointments in internal medicine by obstetricians and midwives, we created an internal medicine consultation within the maternity ward of our General Hospital, and provide feedback after 1 year.

METHODS

This retrospective descriptive study took place at the Robert Ballanger Intercommunal Hospital Center in Aulnay-sous-Bois in Seine-Saint-Denis (France) between 3rd March 2016 and 9th March 2017, the first year of the internal medicine consultation, one afternoon every 15 days, in the maternity level 2b.

RESULTS

Out of 121 appointments, 93 consultations were conducted for 63 patients. The main reasons were: thromboembolism (n=2), placental vascular disease (n=14), anemia (n=9), HIV infection (n=8), fetal deaths in utero (n=6), thrombocytopenia (n=6) and autoimmune biological abnormalities (n=3). Although none etiology was found for 16 patients (including 11 seen for placental vascular disease), a diagnosis was made in 75% of cases with a suitable therapeutic attitude. The diagnoses were varied: antiphospholipid syndrom, hypertension, but also discovery of a primary biliary cirrhosis, of a veritable pregnancy-induced immune thrombocytopenia induced by the pregnancy and of a lymphoma-associated on anemia.

CONCLUSIONS

This consultation provides satisfaction in terms of interdisciplinary organization and collaboration. It appears useful to patients, leading to prevention advice, various diagnoses and sometimes long-term follow-up.

Severe immune thrombocytopenia in pregnancy treated with Eltrombopag - A case report

Immune thrombocytopenia (ITP) during pregnancy is an acquired autoimmune disease present in 1-2 of every 1000 pregnancies. Thrombopoietin (TPO)-mimetic drugs, such as eltrombopag, have been successfully used for treatment of ITP during pregnancy, but studies regarding its safety during gestation are lacking. A 33-year-old nulliparous woman with a history of chronic ITP, presented at the emergency department with petechiae, epistaxis, bruises, conjunctival effusions and a platelet count of 3×10⁹/L at 25 weeks gestation. Her pregnancy had been uneventful until then. She was unresponsive to a therapeutic escalade of corticosteroids, azathioprine and intravenous immunoglobulin (IV Ig) so, at 27 weeks, eltrombopag was initiated, and analytical and clinical improvement was achieved. Labor was induced at 37 weeks due to preeclampsia, culminating in a vacuum-assisted vaginal delivery. A healthy female newborn weighing 2400g was born. After delivery, both had normal platelet counts and remained clinically stable through follow-up.

Efficacy and safety of dapsone as second line therapy for adult immune thrombocytopenia: A retrospective study of 42 patients

Dapsone is recommended as a second line therapy in immune thrombocytopenia (ITP), but is underused because of its potential side effects. The medical charts of 42 ITP patients treated with dapsone (100 mg/day) were retrospectively reviewed in order to assess its efficacy and safety in daily clinical practice. The overall response rate was 54.8% (n = 22, with a complete response in 38.1%) with a median time to response of 29 days (24-41 days). Patients with complete response had shorter disease duration whereas no difference was observed between responders and non-responders regarding age, sex or previous treatments received. Importantly, after dapsone withdrawal, a sustained response was observed in 5 patients, representing 12% of the whole cohort. Twenty percent of patients (n = 8) relapsed on therapy after 8.1 (6.5-13.6) months. Side effects occurred in 31% (n = 13) of patients, and required dapsone withdrawal in 22% (n = 9) or dosage reduction in 10% (n = 4) of the cases. Side effects resolved in all but one case. Overall, these data support dapsone as an interesting second line therapy in ITP, with a good safety and efficacy profile at a low cost.

[Platelet transfusion role in neonatal immune thrombocytopenia]

Neonatal immune thrombocytopenia represent less than 5% of cases of early thrombocytopenia (early-onset<72hours post-delivery). As in adults, thrombocytopenia in neonates is defined as a platelet count less than 150G/L. They are either auto- or allo-immune. Thrombocytopenia resulting from transplacental passage of maternal antibodies directed to platelet membrane glycoproteins can be severe. The major complication of severe thrombocytopenia is bleeding and particularly intra-cranial haemorrhage and neurologic sequelea following. However, auto- and allo-immune thrombocytopenia have very different characteristics including the treatment management. In fact, this treatment is based on platelet transfusion associated or not to intravenous immunoglobulin administration. The purpose of this article is to remind platelet transfusion's place in neonatal immune thrombocytopenia in terms of recently published French guidelines and international practices.

Is there still a place for "old therapies" in the management of immune thrombocytopenia?

New molecules such as rituximab or thrombopoietin receptor agonists (romiplostim and eltrombopag) have changed the management of immune thrombocytopenia. Therefore, old drugs which are less expensive and with a well-known benefit/risk ratio are being underused. We aim to define the place of dapsone, danazol, hydroxychloroquine and vinca-alkaloids at the era of targeted therapy in immune thrombocytopenia. With a response rate around 30% to 50%, dapsone is an interesting second-line therapy to be used just after corticosteroids. Patients with positive antinuclear antibodies can benefit from hydroxychloroquine with a 50% response rate. Because of its side effects, mostly virilization, danazol will be preferentially used in the elderly. Vinca-alkaloids could be temporarily used in patients that do not respond to intravenous immunoglobulins or to limit their use to avoid shortage periods.