Severe intracranial hemorrhage in a newborn infant with transplacental transfer of an acquired factor VII:C inhibitor

Acquired Hemophilia A: A Rare, Acquired Coagulopathy in the Postpartum Setting

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity. Pregnancy-associated acquired hemophilia A (AHA) caused by autoantibodies against factor VIII can present with recurrent episodes of postpartum bleeding. Case 1  A 50-year-old G2P0112 presented with vaginal bleeding 22 days postcaesarean. She underwent dilation and curettage, hysterectomy, and interventional radiology (IR) embolization before AHA diagnosis. She was hospitalized for 32 days and received 23 units of blood product. She remains without relapse of AHA after 5 years. Case 2  A 48-year-old G3P1021 presented with vaginal bleeding 8 days postcaesarean. She underwent three surgeries and IR embolization before AHA diagnosis. She was hospitalized for 18 days and received 39 units of blood product. Prednisone and cyclophosphamide were continued after discharge. AHA is a rare cause of PPH. An isolated prolonged activated partial thromboplastin time (aPTT) should prompt further workup in postpartum patients with refractory bleeding. Rapid recognition of AHA can prevent significant morbidity related to hemorrhage, massive transfusion, and multiple surgeries.

Acquired Haemophilia A: A Review of What We Know

Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.

Successful management of acquired hemophilia A onset during pregnancy: A case report

Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies that inhibit coagulation factor VIII. Pregnancy could be associated with AHA in younger women. Because of its rarity, the optimal management for pregnancy-related AHA has not yet been established. Herein, we present the case of a 32-year-old woman with AHA diagnosed during pregnancy because of elevated activated partial prothrombin time, decreased factor VIII activity, and the presence of a factor VIII inhibitor. She was treated with immunosuppressive therapy consisting of corticosteroid and cyclosporine administration. Although complete remission could not be induced in the peripartum period, she gave birth safely by cesarean delivery in combination with prophylactic bypass hemostatic therapy. This work would provide helpful information to guide better recognition and treatment of pregnancy-related AHA cases.

Transplacental hemophilia A and prophylactic treatment with intravenous immunoglobulin and recombinant factor VIIa in the newborn period: a case report

Acquired hemophilia due to inhibitor antibodies to factor VIII (FVIII) is a very rare entity in neonatal period. Maternal IgG antibodies may cross the placenta and can cause life-threatening hemorrhages in newborns. Here, we represent a newborn who diagnosed as a transplacental acquired hemophilia A. A very high titer of inhibitor level (320 Nijmegen-Bethesda unit) was detected in plasma due to transplasental transfer in this case. According to the best of our knowledge the baby had the highest inhibitor level in neonatal period in the literature. Bleeding complications including intracranial hemorrhage secondary to this condition were reported before. Therefore, to prevent possible life complications, prophylactic recombinant FVIIa was administered in the presenting case and any bleeding event was not observed during follow-up. In conclusion, using prophylactic recombinant FVIIa in newborns is a safe choice for transplacental acquired hemophilia A.

Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review

BACKGROUND

About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting.

AIMS

This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies.

METHODS

Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases).

RESULTS

Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy.

CONCLUSION

This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.

Compartment syndrome of the forearm with life-threatening bleeding after fasciotomy as the presenting sign of postpartum acquired hemophilia A: a case report

: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies against clotting factor VIII. Although the cause of this disorder remains obscure, it is often linked to malignancies, drug administration, autoimmune diseases and pregnancy. In pregnancy-associated AHA, hemorrhagic symptoms usually present 1-4 months peripartum, however they may occur up to 1-year postpartum. Compartment syndrome of the forearm is also very uncommon complication of AHA but can have devastating consequences. We report a rare case of a compartment syndrome of the forearm in a 30-year-old woman 2.5 months postpartum as the presentation of pregnancy-associated AHA.

Acquired factor XI deficiency and therapeutic plasma exchange

Congenital factor XI (FXI) deficiency is associated with a variable bleeding phenotype. Recent reports have documented the use of therapeutic plasma exchange to rapidly and isovolumetrically increase FXI levels before invasive procedures in patients with congenital FXI deficiency. We report a case of acquired FXI deficiency in a pregnant woman with lupus. We proved that the inhibitor was an IgG, therefore potentially capable of crossing the placenta. While immune suppression eliminated detectable circulating inhibitor, the woman's FXI remained quite low. A multi-disciplinary team was formed and therapeutic plasma exchange with 100% plasma replacement was performed when the patient went into labor, to acutely raise her FXI level and remove any potential non-neutralizing inhibitor. The mother had a controllable level of bleeding during post-TPE cesarean section; the baby had no bleeding and the baby's FXI levels were not overtly abnormal. Therapeutic plasma exchange in acquired FXI deficiency (or other acquired hemophilias) can both acutely isovolumetrically raise factor levels and remove any circulating inhibitor.

Rare bleeding disorders-old diseases in the era of novel options for therapy

Rare diseases are defined as life-threatening or chronically debilitating diseases with a prevalence of less than one per 2000 according to the European Union or one per 1250 according to the USA. Congenital rare bleeding disorders RBD are reported in most populations, with incidence varying from 1 in 5000 (Hemophilia A), 1:30,000 (Hemophilia B) to much rarer (1:500,000 for FVII deficiency, 1-3 million for Prothrombin or FXIII deficiency). Acquired Hemophilia A is also a rare bleeding disorder with estimated frequency of 1 in million. Most RBDs are inherited as autosomal recessive (AR); however, heterozygous carriers with varying degrees of corresponding factor deficiency may render an unpredictable propensity for bleeding. In patients with bleeding symptoms, laboratory assessment and especially molecular techniques currently enable accurate diagnosis and may provide tools for prenatal and family counseling. Currently hemostasis control is mainly based upon replacement of the missing coagulation factors (unless presence of inhibitors renders it impossible), however future gene therapy and disruptive, non-replacement alternatives may be promising for patients with RBD.

Acquired Hemophilia: A Case Report of 2 Patients With Acquired Factor VIII Inhibitor Treated With Rituximab Plus a Short Course of Steroid and Review of the Literature

Acquired hemophilia is an unusual disorder in which nonhemophiliac patients develop autoantibodies (inhibitor) against the factor VIII coagulation protein. Factor VIII inhibitor leads to life-threatening bleeding disorders classically described as new onset of diffuse bruising and prolonged partial thromboplastin time in elderly patients. Treatment is focused in the control of the acute bleeding episode and the long-term suppression of the autoantibody. Several immunosuppressive combinations have been described; however, these treatments are also associated with serious side effects that are difficult to tolerate, especially in older and debilitated patients. New treatment modalities explore the elimination of the autoantibody production by targeting B-cells with rituximab, an anti CD-20 monoclonal antibody that has shown success in a multitude of autoimmune processes. This report presents 2 patients successfully treated with rituximab and a short tapering course of steroids and focuses our discussion in the analysis of different treatment approaches available for these patients' population.

Ischemic Stroke in Confederation with Trivial Head Trauma

Minor head injuries in children are common, resulting in brain concussion, and these injuries mostly end up without complications. Usually head trauma results in hemorrhagic stroke. Here we present a case of ischemic stroke following a trivial head trauma. A 10-month-old girl presented with posttraumatic right sided hemiparesis with right sided facial palsy. MRI brain revealed an area of acute infarct in the left capsuloganglionic region. The child was initially managed conservatively, as the hematological parameters were normal, and was started on anticoagulant therapy. An improvement in the clinical condition was achieved in 12 hrs of treatment with gain in power and resolution of weakness in 10 days. The specific cause for hemiparesis in the child is not elicited; possibility of genetic and environmental factors can be attributable.

A case series of acquired haemophilia in a Malaysian hospital: unpredictably rare medical emergency

Acquired haemophilia (AH) is a rare bleeding disorder characterized by the presence of acquired inhibitors against Factor VIII causing disruption of coagulation cascade. It has no known genetic inheritance, and diagnosis remains a challenge. The peculiar presentations are later age of onset as acute pain in weight-bearing joints and spontaneous muscle haematoma with isolated prolonged activated partial thrombin time (APTT). Prevalence is 1 per million per year affecting both genders equally where blood product transfusion is seen in almost 87% of cases. The direct cause of AH is still unknown, and autoimmune dysregulation has been postulated, which predisposes to the development of the factor inhibitors. Being extremely rare, we are reporting two consecutive patients diagnosed by unusual bleeding episodes with isolated prolonged APTT due to Factor VIII inhibitors. AH deserves a special mention as high index of suspicion is required. More studies are required to provide better guidance in diagnosis and management of this condition.

Hemostatic assessment, treatment strategies, and hematology consultation in massive postpartum hemorrhage: results of a quantitative survey of obstetrician-gynecologists

Objective

To assess potential diagnostic and practice barriers to successful management of massive postpartum hemorrhage (PPH), emphasizing recognition and management of contributing coagulation disorders.

Study design

A quantitative survey was conducted to assess practice patterns of US obstetrician-gynecologists in managing massive PPH, including assessment of coagulation.

Results

Nearly all (98%) of the 50 obstetrician-gynecologists participating in the survey reported having encountered at least one patient with “massive” PPH in the past 5 years. Approximately half (52%) reported having previously discovered an underlying bleeding disorder in a patient with PPH, with disseminated intravascular coagulation (88%, n=23/26) being identified more often than von Willebrand disease (73%, n=19/26). All reported having used methylergonovine and packed red blood cells in managing massive PPH, while 90% reported performing a hysterectomy. A drop in blood pressure and ongoing visible bleeding were the most commonly accepted indications for rechecking a “stat” complete blood count and coagulation studies, respectively, in patients with PPH; however, 4% of respondents reported that they would not routinely order coagulation studies. Forty-two percent reported having never consulted a hematologist for massive PPH.

Conclusion

The survey findings highlight potential areas for improved practice in managing massive PPH, including earlier and more consistent assessment, monitoring of coagulation studies, and consultation with a hematologist.

Acquired haemophilia A: a 2013 update

Acquired haemophilia A (AHA) is a rare but often severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). AHA occurs more frequently in the elderly and in association with several conditions, such as the post-partum period, malignancies, autoimmune diseases or drug exposure; however, approximately 50% of reported cases are apparently idiopathic. Beside the elimination of the underlying disorder, the therapeutic approach to AHA should be directed toward the control of acute bleed and the eradication of FVIII autoantibody production. In this narrative review, we summarise the current knowledge on the epidemiology, diagnosis and clinical features of AHA, focusing in particular on advances in the management of this challenging bleeding disorder.

Pediatric stroke: a review

Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.

Management of acquired haemophilia A

Acquired haemophilia A is an auto-immune disease caused by an inhibitory antibody to factor VIII. The pattern of bleeding varies but patients remain at risk of life threatening bleeding until the inhibitor has been eradicated. The cornerstones of management are; rapid and accurate diagnosis, control of bleeding, investigation for an underlying cause and eradication of the inhibitor by immunosuppression. Patients should always be managed jointly with a specialist centre even if they present without significant bleeding. Despite an extensive literature, few controlled data are available and treatment guidelines are based on expert opinion. To treat bleeds recombinant factor VIIa and activated prothrombin complex concentrate are equally efficacious but both are superior to factor VIII or desmopressin. Immunosuppression should be started as soon as the diagnosis is made. Commonly used regimens are steroids alone or combined with cytotoxic agents. Rituximab is being used more widely but current evidence does not suggest that it improves outcomes or reduces side effects.

Acquired hemophilia in pediatrics: a systematic review

Acquired hemophilia A is a rare but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies directed mostly against coagulation factor VIII. Acquired hemophilia is frequently associated with several underlying conditions such as malignancy, autoimmune disorders, drug reactions, and pregnancy, although the pathogenesis remains undetermined (idiopathic) in up to 50% of reported cases. The disorder occurs most commonly in the elderly and only rarely affects pediatric patients, who might however experience severe, and sometimes life-threatening, hemorrhage. The maternal transplacental transfer of the autoantibody to the neonate occurs very rarely and also in this circumstance it may be associated with clinically significant bleeding. The management of acute bleeding and the inhibitor eradication are the mainstay of the treatment. The outcome in pediatric patients seems more favorable than in adults because the inhibitors usually resolve more quickly and in a higher rate of patients. The epidemiology, diagnosis, clinical course, and management of this hemorrhagic disorder in children will be addressed in this systematic review.

Advances in the understanding of acquired haemophilia A: implications for clinical practice

Acquired haemophilia A is an auto-immune disease caused by an inhibitory antibody to factor VIII. Patients with an acquired factor VIII inhibitor are at risk of life- and limb-threatening bleeding until the inhibitor has been eradicated. Management relies on rapid and accurate diagnosis, control of bleeding episodes, investigation for a precipitating cause and eradication of the inhibitor by immunosuppression. Patients should always be managed jointly with a specialist centre even if they present without overt bleeding. Despite an extensive literature, few controlled data are available and management guidelines are predominantly based on case reports, retrospective cohorts and expert opinion. This paper reviews the current literature on incidence, pathogenesis, diagnosis, haemostatic therapy and inhibitor eradication strategies. Potential future developments are discussed.

Transplacental transfer of postpartum inhibitors to factor VIII

Acquired haemophilia due to antibodies directed against coagulation factor VIII is a well-recognized cause of severe haemorrhage in adults but an uncommon cause of bleeding in children. We present the cases of a mother with a life-threatening postpartum haemorrhage due to an autoantibody to factor VIII and her newborn who developed symptomatic bleeding after a minor surgical intervention as a result of transplacental transfer of the autoantibody. Both patients were treated with infusions of recombinant factor VIIa to control bleeding. The mother required immunosuppressive therapy to decrease inhibitor levels and the infant's levels decreased over time without specific treatment. We also provide a concise review of postpartum haemophilia and transplacental transmission of factor VIII autoantibodies to the neonate--a rare but potentially life-threatening complication of acquired haemophilia in women of childbearing age.

Treatment of acquired hemophilia A

Acquired hemophilia A (AH) is an autoimmune disease that leads to potentially severe bleeding. Management relies on rapid and accurate diagnosis, control of bleeding episodes and eradication of the inhibitor by immunosuppression. There is extensive literature about the disease but only few controlled data are available. This paper reviews the current literature on treatment strategies for hemostatic therapy and inhibitor eradication. Potential future developments are discussed.

Intrakranielle Blutung bei erworbener Hemmkörperhämophilie

Acquired hemophilia is a rare complication in autoimmune disorders and malignancies. It can result in bleedings into skin and muscle, whereas intracranial hemorrhage in adults has so far not been described. We report a patient with acute intracerebral hemorrhage due to acquired hemophilia with factor VIII inhibition. The patient was treated with recombinant factor VIIa and open hematoma evacuation followed by administration of cortisone and cyclophosphamide. After good initial recovery, intracerebral rebleeding occurred and the patient died from brainstem compression.

Postpartum acquired factor VIII inhibitors

The development of factor VIII autoantibodies is a rare but severe complication of pregnancy. Although the natural history of postpartum acquired hemophilia A is usually benign, with a high percentage of spontaneous remissions and a low mortality, its quick recognition is important to control bleeding episodes. Based on an analysis of the literature, this review presents the current knowledge on the pathogenesis, diagnosis, epidemiology, natural history, clinical manifestations, and therapeutic management of postpartum acquired hemophilia A.

Acquired hemophilia A

Acquired hemophilia A is a rare but severe autoimmune bleeding disorder, resulting from the presence of autoantibodies directed against clotting factor VIII. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. A prompt diagnosis and appropriate management enable effective control of this acquired hemorrhagic disorder: the aims of therapy are to terminate the acute bleeding episode and eliminate or reduce the inhibitor. The recent availability of bypassing agents, first activated prothrombin complex concentrates and then recombinant activated factor VII, has significantly reduced mortality during the acute phase of the disease in patients with high titer inhibitors. On another front, immunosuppressive therapy (corticosteroids and cytotoxic agents, alone or in various combinations) has resulted in long-term inhibitor suppression in up to 70% of the cases. Moreover, new therapeutic strategies (anti-CD20 monoclonal antibody and immune tolerance protocols) are very promising and may further improve the prognosis of acquired hemophilia A.

Acquired hemophilia A: a concise review

Acquired hemophilia A is a rare but severe autoimmune bleeding disorder. It is more frequent in the elderly and results from the presence of autoantibodies directed against clotting factor VIII. In this review, we briefly report on the present state of knowledge regarding acquired hemophilia A, analyzing its epidemiology, pathogenesis, diagnostic, and clinical features. We also describe the main characteristics of this disorder according to its association with different conditions and the most important advances in the treatment of bleeding episodes and the eradication of the autoantibody.

Arterial strokes in children

Pediatric stroke has received special attention in the recent literature. It is now recognized as an important cause of mortality and morbidity in pediatric population. Varied and poorly specific symptomatology as well as overlapping risk factors makes the diagnosis of stroke in childhood challenging. Therapy remains controversial. The use of anticoagulation and thrombolysis in the management of acute stroke in children has not been systematically studied. In this article, we discuss the natural history, investigation, and treatment of pediatric arterial hemorrhagic and ischemic strokes.

Acquired factor VIII inhibitors as a cause of primary post-partum haemorrhage

Acquired haemophilia was diagnosed following detailed investigation of a post-partum haemorrhage unresponsive to standard management. Circulating factor VIII inhibitors and low factor VIII levels were detected and intravenous DDAVP treatment lead to a resolution of symptoms. This case highlights the importance of haematological investigations in persisting post-partum haemorrhage.

Postpartum acquired haemophilia: clinical recognition and management

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32-year-old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laparotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA(R) therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Postpartum acquired hemophilia (factor VIII inhibitors): a case report and review of the literature

Pathologic inhibitors of blood coagulation as a cause of postpartum acquired hemostatic failure are rare. Since 1937, 96 cases of postpartum factor VIII (FVIII) inhibitors, including the current case, have been reported. Suspicion for the diagnosis of this condition is often low. We report a case of postpartum FVIII inhibitor formation in a 24-year-old woman who developed intermittent postpartum bleeding that resulted from the inhibitors she formed to FVIII. A unique form of therapy was used in treatment of her disorder. She did not respond to conventional surgical or medical management of her bleeding until Autoplex T (Baxter Healthcare, Glendale, CA), an activated prothrombin complex concentrate (aPCC) was used. The literature concerning acquired hemophilia is reviewed, and new therapeutic medical advances are emphasized.

Hemorrhagic problems in obstetrics, exclusive of disseminated intravascular coagulation

During pregnancy many physiologic changes occur that result in an increase in coagulation factors and a decrease in fibrinolytic activity. Because hemorrhage during pregnancy is a major cause of maternal morbidity, it is important to recognize and understand the pathophysiology of hereditary and acquired bleeding disorders. This article reviews von Willebrand's disease types 1, 2, and 3 and acquired hemophilia.

Obstetrical and gynaecological bleeding: a common presenting symptom

Excessive haemorrhage is one of the commonest symptom when women present to obstetricians and gynaecologists. In the majority of cases the cause is related to the primary obstetric and gynaecological pathology and is easily identified. However, less commonly, the bleeding is unexpected and due to an undiagnosed underlying coagulation defect, the commonest of which is von Willebrand (vWD) disease. Menorrhagia is a common, and may be the only, clinical manifestation of an inherited bleeding disorder. Screening 150 women with menorrhagia, vWD was diagnosed in 13% of patients and other hereditary haemorrhagic disorders in another 4%. Menorrhagia with onset at the menarche was predictive of an inherited bleeding disorder in 65% of vWD and 67% of FXI deficient patients. Therefore, testing for bleeding disorders should be considered in women with menorrhagia especially those with early onset and no obvious pelvic pathology. Childbirth and puerperium present a special risk for excessive haemorrhage. The risk of postpartum haemorrhage is very high in women with inherited bleeding disorders. In our centre, the incidence of primary and secondary postpartum haemorrhage was 22% and 11% in carriers of haemophilia 18.5% and 20% in vWD and 16% and 24% in FXI deficient women, respectively. Acquired haemophilia can be an unusual cause of severe and unexpected postpartum haemorrhage with a very high mortality rate. Unexplained postpartum and postoperative haemorrhage that does not respond to general measures should alert clinicians to the possibility of bleeding disorders as a causative factor. In addition, increased awareness among obstetricians and gynaecologists of these less common causes and close collaboration with the local haemophilia centre and availability of management guidelines are essential for optimal outcome.

Postpartum acquired factor VIII inhibitors: results of a survey

Postpartum factor VIII inhibitors are rare; thus, collecting clinical and treatment data may provide valuable information in guiding patient management. This paper reports the results of a survey of United States and Canadian hemophilia centers on 14 patients with postpartum acquired factor VIII inhibitors. Patients ranged in age from 23 to 40 years. Parity at diagnosis was most frequently the first gestation. Two patients were diagnosed prepartum, but two patients only up to one year postpartum. Initial inhibitor titers ranged from two to 550 Bethesda units (BU), and rose to five to 885 BU. The median duration of the inhibitor was 27 months, with two of the 14 inhibitors unresolved at the time of the survey. A total of 80 bleeding episodes occurred, five of which were life or limb threatening. Three patients received no blood products and were not hospitalized. Of those treated for hemostasis, activated prothrombin complex concentrates and porcine factor VIII were most often reported to be effective. For immunosuppression, all patients received steroids and most received additional treatment. Steroids were reported ineffective more frequently than cyclophosphamide. No adverse fetal events were noted and there was no maternal mortality. These results underline the clinical heterogeneity of the severity of postpartum factor VIII inhibitors, and provide treatment guidelines in the absence of prospective studies.