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Toughza J, Agadr A, Nejjari M, Ammari IA. [Diagnosis and management of severe neonatal thrombocytopenia due to maternal alloimmunization against fetal platelet antigens: case study and literature review]. Pan Afr Med J 2020; 37:382. [PMID: 33796195 PMCID: PMC7992410 DOI: 10.11604/pamj.2020.37.382.24325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/02/2020] [Indexed: 11/23/2022] Open
Abstract
Thrombocytopenia is a common hematologic disorder in the neonatal period. It can occur in neonates hospitalized in the Intensive Care Unit and in preterm infants. It is characterized by a platelet count of less than 150.000/mm3. In the context of immune thrombocytopenia, neonatal thrombocytopenia due to maternal alloimmunization (estimated at 1 per 1000 live births) is not a rare event but it is often undiagnosed in minor forms. This is caused by maternal immunization against fetal platelet antigens inherited from the father and lacking in the mother. Maternal IgG alloantibodies cross the placenta causing fetal platelet destruction. In severe thrombocytopenia, consequences can be severe, with intracranial bleeding occurring in 10-30% of patients. Diagnosis is essentially based on clinical examination and must be suspected by pediatricians.
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Affiliation(s)
- Jihane Toughza
- Department of Pediatrics, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Aomar Agadr
- Department of Pediatrics, Mohammed V, Rabat, Morocco
| | - Mouad Nejjari
- Department of Pediatrics, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Insaf Al Ammari
- Department of Pediatrics, Mohammed VI University of Health Sciences, Casablanca, Morocco
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Fetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT): Past, Present, and Future. Obstet Gynecol Surv 2008; 63:239-52. [DOI: 10.1097/ogx.0b013e31816412d3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kaplan C, Freedman J. Alloimmune Thrombocytopenia. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50815-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kaplan C. Foetal and neonatal alloimmune thrombocytopaenia. Orphanet J Rare Dis 2006; 1:39. [PMID: 17032445 PMCID: PMC1624806 DOI: 10.1186/1750-1172-1-39] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 10/10/2006] [Indexed: 12/03/2022] Open
Abstract
Foetal/neonatal alloimmune thrombocytopaenia (NAIT) results from maternal alloimmunisation against foetal platelet antigens inherited from the father and different from those present in the mother, and usually presents as a severe isolated thrombocytopaenia in otherwise healthy newborns. The incidence has been estimated at 1/800 to 1/1000 live births. NAIT has been considered to be the platelet counterpart of Rh Haemolytic Disease of the Newborn (RHD). Unlike RHD, NAIT can occur during a first pregnancy. The spectrum of the disease may range from sub-clinical moderate thrombocytopaenia to life-threatening bleeding in the neonatal period. Mildly affected infants may be asymptomatic. In those with severe thrombocytopaenia, the most common presentations are petechiae, purpura or cephalohaematoma at birth, associated with major risk of intracranial haemorrhage (up to 20% of reported cases), which leads to death or neurological sequelae. Alloimmune thrombocytopaenia is more often unexpected and is usually diagnosed after birth. Once suspected, the diagnosis is confirmed by demonstration of maternal antiplatelet alloantibodies directed against a paternal antigen inherited by the foetus/neonate. Post-natal management involves transfusion of platelets devoid of this antigen, and should not be delayed by biological confirmation of the diagnosis (once the diagnosis is suspected), especially in case of severe thrombocytopaenia. Prompt diagnosis and treatment are essential to reduce the chances of death and disability due to haemorrhage. Due to the high rate of recurrence and increased severity of the foetal thrombocytopaenia in successive pregnancies, antenatal therapy should be offered. However, management of high-risk pregnancies is still a matter of discussion.
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Affiliation(s)
- Cecile Kaplan
- Unité d'Immunologie Plaquettaire, Institut National de Transfusion Sanguine, 6 rue Alexandre Cabanel, 75015 Paris, France.
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Baiochi E, Camano L, Bordin JO. [Evaluation of fetomaternal hemorrhage in postpartum patients with indication for administration of anti-D immunoglobulin]. CAD SAUDE PUBLICA 2005; 21:1357-65. [PMID: 16158140 DOI: 10.1590/s0102-311x2005000500007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study evaluated fetomaternal hemorrhage (FMH) in 343 postpartum patients who required prophylaxis of Rh alloimmunization with anti-D immunoglobulin. The rosette test was applied to screen for patients needing quantitative determination of fetal blood transferred from the maternal circulation, which was then measured by the Kleihauer-Betke test (K-B). The rosette test was positive in 22 cases (6.4%). In five of these cases, K-B did not show fetomaternal hemorrhage (a 1.45% false-positive rate for the rosette test), and in one case the test was inconclusive. There were 8 cases with FMH < 10 ml (2.3%), 6 cases with FMH from 10 to 30 ml (1.7%), and two cases with FMH > 30 ml (0.58%), requiring a supplementary dose of anti-D. The study concludes that following the rosette test, additional evaluation of FMH using a quantitative test was unnecessary in 93.6% of the cases.
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Affiliation(s)
- Eduardo Baiochi
- Departamento de Obstetrícia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Bussel JB, Zacharoulis S, Kramer K, McFarland JG, Pauliny J, Kaplan C. Clinical and diagnostic comparison of neonatal alloimmune thrombocytopenia to non-immune cases of thrombocytopenia. Pediatr Blood Cancer 2005; 45:176-83. [PMID: 15828027 DOI: 10.1002/pbc.20282] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Affected patients with neonatal alloimmune thrombocytopenia (AIT) are often severely thrombocytopenic and, if so, may suffer an intracranial hemorrhage (ICH). This study was undertaken to compare the outcome of cases of AIT to cases of neonatal thrombocytopenia shown not to be AIT and to identify clinical features that would facilitate the diagnosis. PROCEDURE Two hundred twenty two cases of neonatal thrombocytopenia for which serologic testing was obtained by the referring physician were accrued for this study from 11 testing laboratories. The relevant clinical information was pursued. RESULTS The mean birth platelet count in 110 neonates with AIT was 26,000/mm(3) x 10(9)/L and the rate of ICH was 11% (not all neonates had head sonos). Three criteria distinguished cases of AIT from other causes of neonatal thrombocytopenia (n = 56): (1) severe thrombocytopenia <50,000/mm(3) x 10(9)/L; (2) ICH associated with 1 or more of: a 1-min Apgar score >5, birthweight >2,200 g, grade >1, antenatal occurrence, or signs of bleeding, that is, petechiae, ecchymoses; and (3) no additional, non-hemorrhagic neonatal medical problems. CONCLUSIONS AIT is a unique type of neonatal thrombocytopenia with significant hemorrhagic consequences. Identification of AIT at the bedside should guide institution of appropriate treatment and lead to serologic testing for confirmation.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, The New York Hospital, Cornell University Medical Center, New York, New York 10021, USA.
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Carbonne B, Chéreau E, Larsen M, Kaplan C, Brossard Y. Concomitant fetal anemia and thrombocytopenia due to anti-D and anti-HPA1a alloimmunization. Prenat Diagn 2005; 25:1172-4. [PMID: 16315336 DOI: 10.1002/pd.1320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
BACKGROUND Neonatal haemochromatosis is a rare disease of gestation that results in severe fetal liver injury. We hypothesised an alloimmune aetiology for the disorder on the basis of its high recurrence rate in sibships. In this study, we assessed the effectiveness in preventing or changing the severity of recurrent neonatal haemochromatosis of administering during pregnancy high-dose intravenous immunoglobulin (IVIG) derived from pooled serum of multiple donors. METHODS Women whose most recent pregnancy ended in documented neonatal haemochromatosis were treated with IVIG, 1 g/kg bodyweight, weekly from the 18th week until the end of gestation in their subsequent pregnancy. The outcomes of treated pregnancies were compared with those of randomly selected previous affected pregnancies for each woman, which were used as historical controls. FINDINGS 15 women were treated through 16 pregnancies. All pregnancies progressed uneventfully and resulted in live babies with normal physical examinations and birthweights that were appropriate for gestational age. 12 babies had evidence of liver involvement with neonatal haemochromatosis: 11 had higher than normal concentrations of serum alpha-fetoprotein and ferritin or serum alpha-fetoprotein alone, including four with coagulopathy (international normalised ratio >1.5), and one had coagulopathy alone. All babies survived with medical or no treatment and were healthy at follow-up within the past 6 months. In analysis on a per-mother basis comparing outcomes of treated gestations with those of randomly selected previous affected gestations, gestational IVIG therapy was associated with better infant survival (15 good outcomes vs two in previous pregnancies; p=0.0009). INTERPRETATION Treatment with high-dose IVIG during gestation appears to have modified recurrent neonatal haemochromatosis so that it was not lethal to the fetus or neonate. These results further support an alloimmune mechanism for recurrent neonatal haemochromatosis.
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Affiliation(s)
- Peter F Whitington
- Department of Pediatrics, Feinberg School of Medicine of Northwestern University, 2300 Children's Plaza Box 57, Children's Memorial Hospital, Chicago, IL 60614, USA.
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Abstract
Neonatal hemochromatosis is a rare gestational condition in which iron accumulates in the fetal tissues in a distribution like that seen in hereditary hemochromatosis. Extensive liver damage is the dominant clinical feature, with late fetal loss or early neonatal death. NH recurs within sibships at a rate higher than that predicted for simple Mendelian autosomal-recessive inheritance, possibly suggesting the role of a maternal factor. Immunomodulation during pregnancy at risk appears to lessen the severity of disease.
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Affiliation(s)
- A S Knisely
- Institute of Liver Studies, King's College Hospital, London, UK
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Radder CM, Brand A, Kanhai HHH. Will it ever be possible to balance the risk of intracranial haemorrhage in fetal or neonatal alloimmune thrombocytopenia against the risk of treatment strategies to prevent it? Vox Sang 2003; 84:318-25. [PMID: 12757506 DOI: 10.1046/j.1423-0410.2003.00302.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Intracranial haemorrhage (ICH) of the fetus or newborn is a severe complication of fetal or neonatal alloimmune thrombocytopenia (FNAIT). In order to attain management decisions to prevent ICH, the risk of ICH in successive pregnancies with thrombocytopenia, with or without a history of ICH, must be established. MATERIALS AND METHODS We performed a search of medline for ICH cases in untreated FNAIT pregnancies. After exclusion of cases with confounding factors, 24 reports, describing 62 pregnancies of 27 mothers, were eligible. In addition, two mothers with five pregnancies were included from our own case records. Observational studies were examined to estimate the risk of ICH in subsequent FNAIT pregnancies without a history of ICH. Finally, medline was searched for complication rates in the treatment of FNAIT pregnancies. RESULTS In 52% of the ICH cases, a previous sibling suffered from ICH. The recurrence rate of ICH in the subsequent offspring of women with a history of FNAIT with ICH was 72%[confidence interval (CI): 46-98%] without inclusion of fetal deaths and 79% (CI: 61-97%) with inclusion of fetal deaths. In 48% of the ICH cases, the previous sibling had thrombocytopenia but not ICH. Population studies revealed an overall ICH risk in thrombocytopenic infants of 11% (CI: 0.8-23%) without inclusion of fetal deaths and 15% (CI: 1.5-19%) with inclusion of fetal deaths. Assuming occurrence in 48%, the risk of ICH in a subsequent pregnancy following a history of FNAIT without ICH, was estimated to be 7% (CI: 0.5-13%). Invasive treatment strategies carry a risk of 2.8% (CI: 1.2-4.4%) on complications. CONCLUSIONS The number of eligible publications on ICH in untreated FNAIT pregnancies is strikingly limited. The recurrence rate is high. As sufficient data on successive FNAIT cases without ICH are lacking, the occurrence of ICH in pregnancies with thrombocytopenia, but without ICH in a previous sibling, cannot be predicted. We estimate this risk to be 7%. This risk must be balanced against the risk of interventions in treatment strategies.
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Affiliation(s)
- C M Radder
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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Abstract
Neonatal alloimmune thrombocytopenia results from platelet-antigen incompatibility between mother and fetus, leading to antibody-mediated destruction of fetal platelets. With a prevalence of 1 in 1000 births, approximately 4000 infants born in the United States each year develop neonatal alloimmune thrombocytopenia. Ten to 20% of affected neonates develop intracranial hemorrhage, with 25 to 50% occurring prenatally. We report three infants who developed prenatal hemorrhage. One died in utero, and the other two had cerebral porencephaly and neurologic deficits. Infants with neonatal alloimmune thrombocytopenia have elevated risks of perinatal death and neurologic complications, including cerebral palsy, hypotonia, cortical blindness, developmental delay, seizures, and psychomotor retardation. We also report our retrospective review of the New England Medical Center neonatal intensive care unit between 1990 and 1999. Using current management guidelines, including treatment of the mother with a weekly infusion of high-dose (1-2 g/kg) intravenous immunoglobulin and/or corticosteroids, all eight infants with neonatal alloimmune thrombocytopenia did well.
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Affiliation(s)
- U Sharif
- Division of Pediatric Neurology, The Floating Hospital for Children, New England Medical Center, Boston, MA 02111, USA
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Gaddipati S, Berkowitz RL, Lembet AA, Lapinski R, McFarland JG, Bussel JB. Initial fetal platelet counts predict the response to intravenous gammaglobulin therapy in fetuses that are affected by PLA1 incompatibility. Am J Obstet Gynecol 2001; 185:976-80. [PMID: 11641688 DOI: 10.1067/mob.2001.117668] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Fetal alloimmune thrombocytopenia is the result of maternal fetal platelet antigen incompatibility; intracranial hemorrhage is its most serious complication. Our previous studies have demonstrated an inability to accurately predict fetal platelet counts in this disorder. The goal of the present investigation was to identify factors that would predict the response of the fetal platelet count to therapy so that use of fetal blood sampling could be minimized. STUDY DESIGN Patients who were eligible for the study were all those who (1) had alloimmune thrombocytopenia secondary to Pl(A1) (HPA-1a, Zw(A)) platelet antigen incompatibility, (2) were treated with maternally administered intravenous immunoglobulin at 1 g/kg of body weight per week, with or without low dose steroids, and (3) had percutaneous fetal blood sampling before the initiation of therapy (first fetal blood sampling) and again 3 to 7 weeks afterwards (second fetal blood sampling). RESULTS In this retrospective review, 74 patients who were affected by alloimmune thrombocytopenia had a median platelet count of 21,000 per microliter at the first fetal blood sampling and 47,000 per microliter at the second fetal blood sampling, with a median increase in platelet count of 24,000 per microliter. Response to treatment was defined as either (1) an improvement in platelet count (the second fetal blood sampling greater than the first fetal blood sampling, and second fetal blood sampling > 20,000 per microliter) or (2) a minimal decline in platelet count (the first fetal blood sampling > or = 40,000 per microliter and the difference between the first and second fetal blood sampling < or = 10,000 per microliter). The first fetal blood sampling had prognostic value for the second fetal blood sampling (P = .0001), although the previous sibling birth platelet count and history of sibling intracranial hemorrhage did not predict the platelet count at the first or second fetal blood sampling or the change in platelet count between the samplings. When the patients were segregated to first fetal blood sampling of > 20,000 per microliter versus < or = 20,000 per microliter, the response rates for the 2 groups were 89% (33/37 patients) versus 51% (19/37 patients; P = .001). CONCLUSION In fetal alloimmune thrombocytopenia secondary to Pl(A1) platelet antigen incompatibility, fetuses with platelet counts > 20,000 per microliter at the initiation of therapy were predicted to maintain their platelet count at the second fetal blood sampling at > 20,000 per microliter. The characteristics of the previous sibling, as previously reported, did not predict the initial fetal blood sampling, the second fetal blood sampling, or the response to treatment.
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Affiliation(s)
- S Gaddipati
- Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Medical Center, New York, NY 10029, USA
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Abstract
The scale of the application of molecular biological techniques to modern medicine and research in the biological sciences is vast, and in many instances has captured widespread public appeal. The intention of this review is to summarise the impact of molecular techniques on Transfusion Medicine ranging from diagnostic testing (platelet, granulocyte and red cell genotyping; microbiological testing), stable gene integration into haematopoeitic stem cells (gene therapy), production of blood products in transgenic animals and cell lines, and the inhibition of gene expression using synthetic antisense oligodeoxynucleotides. All of these techniques involve the manipulation of genes, be it from the relatively simple examination of different alleles to the technically demanding ability to express mammalian genes in culture and other animals.
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Affiliation(s)
- N D Avent
- International Blood Group Reference Laboratory, Southmead, Bristol, UK.
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del Rosario ML, Fox ER, Kickler TS, Kao KJ. Neonatal alloimmune thrombocytopenia associated with maternal anti-HLA antibody: a case report. J Pediatr Hematol Oncol 1998; 20:252-6. [PMID: 9628438 DOI: 10.1097/00043426-199805000-00012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Although neonatal alloimmune thrombocytopenia (NAIT) due to maternal sensitization to human platelet antigens is well described, the role of maternal anti-human lymphocyte antigen (HLA) antibodies in NAIT is not yet firmly established. PATIENT A 31-week-old girl born prematurely to a G2POA1 mother was noted to have thrombocytopenia which lasted 18 days without any evidence of infection. MATERIALS AND METHODS Platelet-associated IgG, anti-platelet antibody, and platelet PL(A1) antigen typing were determined using a commercial solid-phase red cell adherent test. Antibodies to platelet glycoproteins human platelet antigen (HPA) 1 to 5 were determined using a commercial ELISA. Anti-HLA antibodies were assayed using a standard lymphocytotoxicity test. Activities and IgG subclass of anti-HLA antibodies in plasma of the mother and other postpartum mothers were measured using purified HLA antigens in an enzyme linked immunoassay. RESULTS Both mother and infant were positive for HPA-1 (PL(A1)) antigens. The mother's HLA phenotype was A3, A31, B7, B27. The level of platelet-associated IgG was not increased on maternal platelets; however, increased platelet-associated IgG was detected on the infant's platelets. Antibodies to platelet glycoproteins HPA1 to 5 were not detectable in the maternal plasma. Maternal serum was positive for anti-HLA antibodies, which reacted to 23 of 27 panel cells. The presence of HLA antibodies was confirmed by enzyme-linked immunoassay. Of note, the maternal antibodies reacted positively to the infant's platelets and anti-IgG anti-HLA antibodies were detected in the serum sample from the infant collected at birth. When the activity and IgG subclass of the maternal anti-HLA antibodies were compared with those of other mothers known to have high anti-HLA antibody activity, no differences were noted. CONCLUSION This report documents a patient with neonatal thrombocytopenia induced by maternal IgG anti-HLA antibody. Neither activity nor IgG subclass could explain the occurrence of NAIT. The factors that contribute to NAIT induced by maternal anti-HLA antibodies remain to be identified.
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Affiliation(s)
- M L del Rosario
- Department of Pathology, University of Florida Health Science Center, Gainesville, USA
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Kaplan C, Murphy MF, Kroll H, Waters AH. Feto-maternal alloimmune thrombocytopenia: antenatal therapy with IvIgG and steroids--more questions than answers. European Working Group on FMAIT. Br J Haematol 1998; 100:62-5. [PMID: 9450792 DOI: 10.1046/j.1365-2141.1998.00533.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The optimal antenatal therapy for fetal thrombocytopenia has not been determined. We analysed 37 cases managed by maternal therapy and observed a successful outcome of maternal treatment in 26% of IvIgG cases and in 10% of steroid-treated cases. The significance of a plateau of the fetal platelet counts during pregnancy, 41% of IvIgG cases and 20%, of cases treated with steroids, is uncertain. It may indicate a stabilization of thrombocytopenia, hence a beneficial effect of therapy, or the natural course of the platelet count in a low-risk pregnancy. Overall outcome was unpredictable, but amongst the therapy failures there were proportionally more severely affected siblings. Further multicentre studies are necessary to establish the optimal antenatal management of high-risk pregnancies.
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Affiliation(s)
- C Kaplan
- Service d'Immunologie Plaquettaire, I.N.T.S. Paris, France
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Lavu EK, Nelson M, Popp HJ, Gibson J, Kronenberg H, Pearson H, Child A. Antenatal screening for HPA-1a by flow cytometry. Aust N Z J Obstet Gynaecol 1997; 37:180-3. [PMID: 9222463 DOI: 10.1111/j.1479-828x.1997.tb02249.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pregnant women who attended antenatal clinics at King George V Hospital, the Birth Centre or were referred by obstetricians from February 19 July, 1996 were screened for the platelet antigen HPA-1a by flow cytometry. Forty out of 2,300 (1.7%) were found to be negative for this antigen. Of the 28 women followed throughout their pregnancy, none developed antibody to HPA-1a. Platelet counts performed on samples from 17 babies born to 17 of these mothers were all normal. This study proves the simplicity and rapidity of flow cytometry for platelet antigen screening. The results were comparable with the Solid Phase Red Cell Adherence (SPRCA) method and with PCR. The lack of a plentiful supply of specific antibody and the rarity of fetomaternal alloimmune thrombocytopenia (FMAIT) argue against the introduction of routine screening for maternal HPA-1a status at the present time.
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Affiliation(s)
- E K Lavu
- Institute of Haematology, Royal Prince Alfred Hospital, New South Wales, Australia
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