1
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González-López TJ, Bárez A, Bernardo-Gutiérrez Á, Bernat S, Fernández-Fuertes F, Guinea de Castro JM, Jiménez-Bárcenas R, Jarque I. Real-life clinical practice in Spain in the setting of new drug availability for ITP treatment. A Delphi-based Spanish expert panel consensus. Platelets 2024; 35:2336104. [PMID: 38742687 DOI: 10.1080/09537104.2024.2336104] [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] [Received: 11/15/2023] [Accepted: 03/22/2024] [Indexed: 05/16/2024]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune hematological disorder. Despite this, diagnosis is still challenging due to clinical heterogeneity and the lack of a specific diagnostic test. New findings in the pathology and the availability of new drugs have led to the development of different guidelines worldwide. In the present study, the Delphi methodology has been used to get a consensus on the management of adult patients with ITP in Spain and to help in decision-making. The Delphi questionnaire has been designed by a scientific ad hoc committee and has been divided into 13 topics, with a total of 127 items, covering the maximum possible scenarios for the management of ITP. As a result of the study, a total consensus of 81% has been reached. It is concluded that this Delphi consensus provides practical recommendations on topics related to diagnosis and management of ITP patients to help doctors to improve outcomes. Some aspects remain unclear, without consensus among the experts. Thus, more advances are needed to optimize ITP management.
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Affiliation(s)
| | - Abelardo Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de La Plana, Villarreal, Spain
| | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | | | | | - Isidro Jarque
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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2
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Ezveci H, Doğru Ş, Akkuş F, Yaman FK, Ünal EG, Gezginç K. Perinatal outcomes in pregnant women with ITP: a single tertiary center experience. J Perinat Med 2024; 0:jpm-2024-0120. [PMID: 39033383 DOI: 10.1515/jpm-2024-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE In this study, we aimed to compare the maternal and neonatal outcomes in pregnant women diagnosed with idiopathic thrombocytopenic purpura (ITP) in our clinic between different platelet groups. METHODS This study was designed retrospectively. A total of 62 pregnant women with ITP were included in the study. Demographic and clinical data for all cases were evaluated. Perinatal outcomes were evaluated according to platelet counts. RESULTS The median age of the patients participating in the study was 27, and their ages ranged from 21 to 44. ITP was diagnosed before pregnancy in 32.3 % (n=20) of the patients and during pregnancy in 67.7 % (n=42). The average platelet counts of the patients during the first trimester and birth were 104.8/μL (15-168) and 84/μL (16-235), respectively. The average platelet count of newborns is 242/μL. The most common (74.2 %) ITP treatment method is the combination of steroids and IVIG. The platelet count of 80.6 % of newborns is above 151/μL. There was no statistical difference between the results of both mothers and fetuses when the groups were categorized according to maternal platelet levels. CONCLUSIONS In this study, no difference was observed in maternal and neonatal morbidity and mortality rates, despite the different platelet counts of patients with ITP. The cooperation of the hematology, gynecology, obstetrics, and neonatology departments is responsible for this.
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Affiliation(s)
- Huriye Ezveci
- Faculty of Medicine, Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU), Konya, Türkiye
| | - Şükran Doğru
- Faculty of Medicine, Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU), Konya, Türkiye
| | - Fatih Akkuş
- Faculty of Medicine, Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU), Konya, Türkiye
| | - Fikriye K Yaman
- Faculty of Medicine, Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU), Konya, Türkiye
| | - Emine G Ünal
- Faculty of Medicine, Gynecology, and Obstetrics, Necmettin Erbakan University (NEU), Konya, Türkiye
| | - Kazım Gezginç
- Faculty of Medicine, Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU), Konya, Türkiye
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3
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Aslan MT, İnce Z, Bilgin L, Kunt İşgüder Ç, Çoban A. Is it possible to predict morbidities in neonates born to mothers with immune thrombocytopenic purpura?: A retrospective cross-sectional study. Medicine (Baltimore) 2024; 103:e38587. [PMID: 38905433 PMCID: PMC11191858 DOI: 10.1097/md.0000000000038587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/23/2024] [Indexed: 06/23/2024] Open
Abstract
Immune thrombocytopenic purpura (ITP) comprises ~1% to 4% of thrombocytopenia cases during pregnancy. Factors predicting neonatal thrombocytopenia and associated morbidities due to maternal ITP are unclear. The present study aimed to assess the neonatal outcomes of pregnant women with ITP. Fifty-five pregnant women with ITP and their babies, born between January/2013 and April/2021, were retrospectively reviewed. Maternal and neonatal thrombocytopenia cases other than ITP were excluded from the study. Physical examination, blood count, and cranial/abdominal ultrasonography findings of the newborns were recorded. Neonatal thrombocytopenia was defined as a platelet count < 150 × 109/L. Relationship between neonatal thrombocytopenia and maternal factors was investigated. Thrombocytopenia was detected in 17/55 babies (30.9%), and 8/17 (47.1%) had symptoms of bleeding, all but one being mild bleeding. There was a significant correlation between neonatal platelet counts of < 100 × 109/L and maternal splenectomy history. Incidence of moderate and severe thrombocytopenia was higher (statistically insignificant) in neonates of mothers with ITP. No significant correlation was determined between maternal and neonatal platelet counts. There was a weak insignificant correlation between platelet counts of neonates of mothers with or without thrombocytopenia. A significant correlation was found between the presence of splenectomy before delivery in the mother and a platelet count of < 100 × 109/L in the neonate. Moderate and severe thrombocytopenia was higher in neonates of mothers diagnosed with ITP before pregnancy and needed treatment during pregnancy and/or delivery, but the difference was insignificant. Close follow-up of babies born to mothers with ITP after birth is crucial since there is no significant prediction criterion for developing neonatal thrombocytopenia and associated morbidities.
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Affiliation(s)
- Mustafa Törehan Aslan
- Department of Pediatrics, Division of Neonatology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Zeynep İnce
- Department of Pediatrics, Division of Neonatology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Leyla Bilgin
- Department of Pediatrics, Division of Neonatology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Çiğdem Kunt İşgüder
- Department of Obstetrics and Gynecology, Division of Perinatology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
| | - Asuman Çoban
- Department of Pediatrics, Division of Neonatology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Türkiye
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4
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Lambert C, Maitland H, Ghanima W. Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP). Eur J Haematol 2024; 112:504-515. [PMID: 38088207 DOI: 10.1111/ejh.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 03/19/2024]
Abstract
Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.
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Affiliation(s)
- Catherine Lambert
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, Oslo University, Oslo, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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5
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Fogerty AE, Kuter DJ. How I treat thrombocytopenia in pregnancy. Blood 2024; 143:747-756. [PMID: 37992219 DOI: 10.1182/blood.2023020726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/12/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Thrombocytopenia is a common hematologic abnormality in pregnancy, encountered in ∼10% of pregnancies. There are many possible causes, ranging from benign conditions that do not require intervention to life-threatening disorders necessitating urgent recognition and treatment. Although thrombocytopenia may be an inherited condition or predate pregnancy, most commonly it is a new diagnosis. Identifying the responsible mechanism and predicting its course is made challenging by the tremendous overlap of clinical features and laboratory data between normal pregnancy and the many potential causes of thrombocytopenia. Multidisciplinary collaboration between hematology, obstetrics, and anesthesia and shared decision-making with the involved patient is encouraged to enhance diagnostic clarity and develop an optimized treatment regimen, with careful consideration of management of labor and delivery and the potential fetal impact of maternal thrombocytopenia and any proposed therapeutic intervention. In this review, we outline a diagnostic approach to pregnant patients with thrombocytopenia, highlighting the subtle differences in presentation, physical examination, clinical course, and laboratory abnormalities that can be applied to focus the differential. Four clinical scenarios are presented to highlight the pathophysiology and treatment of the most common causes of thrombocytopenia in pregnancy: gestational thrombocytopenia, preeclampsia, and immune thrombocytopenia.
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Affiliation(s)
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Boston, MA
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6
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Madkhali MA. Recent advances in the management of immune thrombocytopenic purpura (ITP): A comprehensive review. Medicine (Baltimore) 2024; 103:e36936. [PMID: 38241567 PMCID: PMC10798712 DOI: 10.1097/md.0000000000036936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024] Open
Abstract
Autoimmune disorders place a substantial burden on the healthcare system all over the world affecting almost 3% to 8% of the population. Immune thrombocytopenic purpura (ITP), also known as idiopathic thrombocytopenic purpura, is a blood disorder in which the body immune system destroys platelets, leading to low platelet counts in the blood (peripheral blood platelet count < 150 × 109/L). Although the pathophysiology of ITP is not fully understood, it is believed to result from a complex interplay between hereditary and environmental variables. Certain factors, such as a low platelet count, history of bleeding, and certain comorbidities can increase the risk of severe bleeding in patients with ITP. Corticosteroids, intravenous immunoglobulin (IVIG), immunosuppressants, rituximab, and thrombopoietin receptor agonists (TPO-RAs) are some of the advanced treatments for ITP. Although these therapies may be successful, they also carry the risk of negative effects. Recently, significant advancements have been made in the understanding and treatment of ITP. There is still much to learn about the disease, and new, more effective treatments are needed. This comprehensive review offers a comprehensive assessment of recent advancements in ITP management, with a focus on active research projects, novel therapeutic targets, new treatment modalities, and areas of uncertainty and unmet needs. According to research, it is crucial to develop individualized treatment plans for ITP patients based on their age, platelet count, risk of bleeding, and comorbidities. The article also looks at how future developments in gene editing, bispecific antibody therapies, and cellular therapy may completely change the treatment of ITP.
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Affiliation(s)
- Mohammed Ali Madkhali
- Department of Internal Medicine, Division of Hematology and Oncology, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
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7
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Gao Y, Wang X, Li X, Fang Y, Lv C, Chen D. Association between platelet counts and clinical outcomes in acute fatty liver of pregnancy: A retrospective cohort study. Int J Gynaecol Obstet 2024; 164:173-183. [PMID: 37427679 DOI: 10.1002/ijgo.14955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES To investigate whether platelet counts are associated with clinical outcomes in patients with acute fatty liver of pregnancy (AFLP). METHODS We retrospectively analyzed 140 patients with AFLP admitted to the Third Affiliated Hospital of Guangzhou Medical University between January 2010 and August 2022. In this cohort study, we used smooth curve fitting, Kaplan-Meier analysis, and multivariable logistic regression analysis to examine the independent relationship between platelet counts and 42-day postpartum mortality in AFLP. RESULTS There were 140 patients with AFLP, of which 15 died and 53 (37.86%) had thrombocytopenia. The overall 42-day postpartum maternal mortality was 10.7%. We observed a U-shaped relationship between the platelet counts and 42-day postpartum mortality. Two different slopes were observed below and above the inflection point at approximately 220 × 109 /L. After adjusting for some confounders, patients with thrombocytopenia (<100 × 109 /L) were found to have increased 42-day postpartum mortality compared with middle-tertile and highest-tertile patients. Patients with thrombocytopenia had a higher 42-day postpartum mortality, and higher proportions of intensive care unit admissions, postpartum hemorrhage, and multiple organ failure (P < 0.05). CONCLUSIONS A U-shaped association between platelet counts and 42-day postpartum mortality was observed in patients with AFLP. Thrombocytopenia is associated with poorer adverse clinical outcomes in women with AFLP.
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Affiliation(s)
- Yuanmei Gao
- Pulmonary and Critical Care Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoli Wang
- Maternal and Child Office, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiangbin Li
- The Third Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Yuxin Fang
- The Third Clinical College, Guangzhou Medical University, Guangzhou, China
| | - Chengtian Lv
- Pulmonary and Critical Care Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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8
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Thakre R, Gharde P, Raghuwanshi M. Idiopathic Thrombocytopenic Purpura: Current Limitations and Management. Cureus 2023; 15:e49313. [PMID: 38143653 PMCID: PMC10748795 DOI: 10.7759/cureus.49313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenia, is a blood disorder characterized by a reduction in the number of platelets. A reduction in the number of platelets beyond the normal levels leads to several consequences. A severe reduction in blood platelet levels leads to a rash of purple spots on the skin, joints, etc. due to leakage in the small blood vessels, easy bruising, bleeding gums, intestinal bleeding, and hemorrhage. Suppose a case of ITP resolves in fewer than six months. In that case, it is an acute case of ITP. Still, if a case settles in more than six months, it is a case of ITP. The cause of a reduced platelet count can be increased peripheral destruction or impaired production; this is termed an autoimmune condition in which the body's immune system attacks platelets thinking it to be a foreign antigen. ITP in children occurs commonly following a previous viral attack. Even though evaluating patients' reports is useful for understanding and guiding the treatment, these estimates might not be regularly evaluated in clinical settings. First-line drugs in the treatment of ITP are corticosteroids, and long-term use of these drugs has several side effects, such as excessive increase in weight, mental health disturbances, and sleep disturbances; additional therapies to treat hemorrhage are usually momentary. As a result, it is essential to recognize the flaws in current procedures and adopt innovative measures for the management and minimization of difficulties.
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Affiliation(s)
- Rakshanda Thakre
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mohit Raghuwanshi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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9
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Mingot-Castellano ME, Canaro Hirnyk M, Sánchez-González B, Álvarez-Román MT, Bárez-García A, Bernardo-Gutiérrez Á, Bernat-Pablo S, Bolaños-Calderón E, Butta-Coll N, Caballero-Navarro G, Caparrós-Miranda IS, Entrena-Ureña L, Fernández-Fuertes LF, García-Frade LJ, Gómez del Castillo MDC, González-López TJ, Grande-García C, Guinea de Castro JM, Jarque-Ramos I, Jiménez-Bárcenas R, López-Ansoar E, Martínez-Carballeira D, Martínez-Robles V, Monteagudo-Montesinos E, Páramo-Fernández JA, Perera-Álvarez MDM, Soto-Ortega I, Valcárcel-Ferreiras D, Pascual-Izquierdo C. Recommendations for the Clinical Approach to Immune Thrombocytopenia: Spanish ITP Working Group (GEPTI). J Clin Med 2023; 12:6422. [PMID: 37892566 PMCID: PMC10607106 DOI: 10.3390/jcm12206422] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is a complex autoimmune disease whose hallmark is a deregulation of cellular and humoral immunity leading to increased destruction and reduced production of platelets. The heterogeneity of presentation and clinical course hampers personalized approaches for diagnosis and management. In 2021, the Spanish ITP Group (GEPTI) of the Spanish Society of Hematology and Hemotherapy (SEHH) updated a consensus document that had been launched in 2011. The updated guidelines have been the reference for the diagnosis and management of primary ITP in Spain ever since. Nevertheless, the emergence of new tools and strategies makes it advisable to review them again. For this reason, we have updated the main recommendations appropriately. Our aim is to provide a practical tool to facilitate the integral management of all aspects of primary ITP management.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, 41013 Sevilla, Spain
| | | | | | - María Teresa Álvarez-Román
- Hematology Department, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
| | | | - Ángel Bernardo-Gutiérrez
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - Silvia Bernat-Pablo
- Hematology Department, Hospital Universitario de la Plana, 12540 Villarreal, Spain;
| | | | - Nora Butta-Coll
- Hematology Department, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain;
| | | | | | - Laura Entrena-Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Luis Fernando Fernández-Fuertes
- Hematology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain;
| | - Luis Javier García-Frade
- Hematology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León, 47012 Valladolid, Spain;
| | | | | | | | | | - Isidro Jarque-Ramos
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Elsa López-Ansoar
- Hematology Department, Complejo Hospitalario Universitario de Vigo, 36312 Vigo, Spain;
| | | | | | | | | | - María del Mar Perera-Álvarez
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, 35010 Las Palmas de Gran Canaria, Spain;
| | - Inmaculada Soto-Ortega
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - David Valcárcel-Ferreiras
- Hematology Department, Vall d’Hebron Instituto de Oncología (VHIO), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Cristina Pascual-Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañón (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28007 Madrid, Spain;
- Spanish Immune Thrombocytopenia Group, 28040 Madrid, Spain
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10
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Affiliation(s)
- James B Bussel
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
| | - Ming Hou
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
| | - Douglas B Cines
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
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11
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Bank TC, Ma'ayeh M, Rood KM. Maternal Coagulation Disorders and Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:384-398. [PMID: 37130381 DOI: 10.1097/grf.0000000000000787] [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: 05/04/2023]
Abstract
Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.
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Affiliation(s)
- Tracy C Bank
- Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Marwan Ma'ayeh
- Department of Obstetrics & Gynecology, ChristianaCare, Newark, Delaware
| | - Kara M Rood
- Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Yang X, Xia Q, Wang J. Acute thrombocytopenia during cesarean section. Int J Obstet Anesth 2023; 53:103612. [PMID: 36396546 DOI: 10.1016/j.ijoa.2022.103612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/10/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
We report a case of a healthy 29-year-old parturient with a normal pre-operative platelet count who received combined spinal-epidural anesthesia for cesarean section, and who suffered the sudden intra-operative onset of severe thrombocytopenia (platelet count 3 × 109/L). This event was likely due to cefoxitin administered for the prophylaxis of surgical infection.
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Affiliation(s)
- X Yang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Xinshi District, Xinjiang Province, China
| | - Q Xia
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Xinshi District, Xinjiang Province, China
| | - J Wang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Xinshi District, Xinjiang Province, China.
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13
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Systemic lupus erythematosus-complicating immune thrombocytopenia: From pathogenesis to treatment. J Autoimmun 2022; 132:102887. [PMID: 36030136 DOI: 10.1016/j.jaut.2022.102887] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The heterogeneity of its clinical characteristics and therapeutic responses reflects a complex pathogenesis. A better understanding of its pathophysiological mechanisms and employing an optimal treatment regimen is therefore important to improve the response rate and prognosis, and avoid unwanted outcomes. Besides glucocorticoids, traditional immunosuppressants (i.e. cyclosporine, mycophenolate mofetil) and intravenous immunoglobulins, new therapies are emerging and promising for the treatment of intractable SLE-ITP, such as thrombopoietin receptor agonists (TPO-RAs), platelet desialylation inhibitors(i.e. oseltamivir), B-cell targeting therapy(i.e. rituximab, belimumab), neonatal Fc receptor(FcRn) inhibitor, spleen tyrosine kinase(Syk) inhibitor and Bruton tyrosine kinase(BTK) inhibitor et al., although more rigorous randomized controlled trials are needed to substantiate their efficacy. In this review, we update our current knowledge on the pathogenesis and treatment of SLE-ITP.
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14
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Chung YY, Heneghan MA. Autoimmune hepatitis in pregnancy: Pearls and pitfalls. Hepatology 2022; 76:502-517. [PMID: 35182079 DOI: 10.1002/hep.32410] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 12/13/2022]
Abstract
Autoimmune hepatitis (AIH) in pregnancy has many unique considerations. Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period. Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.
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Affiliation(s)
- Y Y Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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15
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Lewandowska M, Englert-Golon M, Krasiński Z, Jagodziński PP, Sajdak S. A Rare Case of HELLP Syndrome with Hematomas of Spleen and Liver, Eclampsia, Severe Hypertension and Prolonged Coagulopathy-A Case Report. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137681. [PMID: 35805359 PMCID: PMC9265485 DOI: 10.3390/ijerph19137681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 02/05/2023]
Abstract
The HELLP syndrome (hemolysis, liver damage and thrombocytopenia) is a rare (0.5−0.9%) but serious complication of pregnancy or puerperium associated with a higher risk of maternal and fetal mortality and morbidity. Liver and spleen hematomas rarely entangle (<2%) HELLP cases, but rupture of the hematomas presents an immediate threat to life. We present the history of a 35-year old pregnant woman (at the 31st week) admitted to our hospital due to the risk of premature delivery. On the first day, the patient did not report any complains, and the only abnormality was thrombocytopenia 106 G/L. However, within several hours, tests showed platelet levels of 40.0 G/L, LDH 2862.0 U/L and AST 2051.6 U/L, and the woman was diagnosed with severe HELLP syndrome, complicated by hematomas of the liver and spleen, seizures (eclampsia), severe arterial hypertension and coagulation disorders. The purpose of this article is to highlight the need for early investigation of the causes of thrombocytopenia and the differentiation of HELLP from other thrombotic microangiopathies (TMAs).
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Affiliation(s)
- Małgorzata Lewandowska
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznan, Poland;
- Division of Gynecological Surgery, University Hospital, 33 Polna Str., 60-535 Poznan, Poland
- Correspondence:
| | - Monika Englert-Golon
- Department of Gynaecology Obstetrics and Gynaecological Oncology, Division of Gynecological Surgery, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (M.E.-G.); (S.S.)
| | - Zbigniew Krasiński
- Department of Vascular, Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Paweł Piotr Jagodziński
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznan, Poland;
| | - Stefan Sajdak
- Department of Gynaecology Obstetrics and Gynaecological Oncology, Division of Gynecological Surgery, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (M.E.-G.); (S.S.)
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16
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Khanuja K, Levy AT, McLaren RA, Berghella V. Pre- and postpregnancy platelet counts: evaluating accuracy of gestational thrombocytopenia and immune thrombocytopenia purpura diagnoses. Am J Obstet Gynecol MFM 2022; 4:100606. [PMID: 35283346 DOI: 10.1016/j.ajogmf.2022.100606] [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: 01/18/2022] [Revised: 02/15/2022] [Accepted: 02/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given the overlapping clinical indicators and lack of diagnostic testing, misdiagnosis of immune thrombocytopenic purpura and gestational thrombocytopenia in pregnancy may be common. Current recommendations suggest utilizing platelet nadir during pregnancy to guide diagnosis. OBJECTIVE This study aimed to assess the accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses using pre- and postpregnancy platelet counts. STUDY DESIGN This was a retrospective cohort study of patients diagnosed with gestational thrombocytopenia and immune thrombocytopenic purpura from January 2017 to December 2019. Platelet counts were extracted from charts and evaluated at several time periods, namely prepregnancy (within 5 years), during pregnancy, and postpartum (>6 weeks to 5 years). A diagnosis of gestational thrombocytopenia was considered inaccurate if platelet counts were <150,000/µL pre- or postpregnancy with no other apparent causes or if the platelet nadir dropped below 100,000/µL during pregnancy. A diagnosis of immune thrombocytopenic purpura was deemed inaccurate if pre- or postpregnancy platelet counts were >150,000/µL. The primary outcome was accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses in patients. Secondary outcomes included mean platelet counts during pregnancy and difference in mean platelet counts for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia. Outcomes were summarized with descriptive statistics and compared using Student t tests. RESULTS A total of 116 patients met the inclusion criteria of which 111 (96%) and 5 (4%) had gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses, respectively. Platelet counts outside of pregnancy were available for 91 (82%) of the patients, and 66 (57%) had prepregnancy platelet counts available. Of the 91 patients, the diagnosis was considered accurate in 61 (67%) and 5 (100%) patients with gestational thrombocytopenia and immune thrombocytopenic purpura, respectively. Conversely, 30 of 35 (86%) patients with immune thrombocytopenic purpura were found to be inaccurately diagnosed with gestational thrombocytopenia after application of platelet thresholds. Among these 30 patients, 10 had a prepregnancy platelet count <150,000/µL, 12 had a postpartum platelet count <150,000/µL, 3 had a platelet count nadir <100,000/µL during pregnancy, and 7 met more than 1 criterion. Pre- and postpregnancy platelet counts and platelet count nadir differed significantly for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia (P<.001). CONCLUSION When pre- and postpregnancy platelet counts were checked, one-third of cases of gestational thrombocytopenia met the criteria for immune thrombocytopenic purpura and were thus incorrectly diagnosed during pregnancy. Prepregnancy platelet counts, available for most patients, should be considered when diagnosing gestational thrombocytopenia vs immune thrombocytopenic purpura.
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Affiliation(s)
- Kavisha Khanuja
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Khanuja)
| | - Ariel T Levy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Weill Cornell Medicine at New York Presbyterian Hospital, New York, NY (Dr Levy)
| | - Rodney A McLaren
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA (Drs McLaren and Berghella)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA (Drs McLaren and Berghella).
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17
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Su K, Cheng H, Jia Z, Yuan Y, Yang H, Gao Q, Jiang Z, Wen H, Jiang J. Predictors of refractory risk in systemic lupus erythematosus-related thrombocytopenia: a dual-centre retrospective study. Lupus Sci Med 2022; 9:9/1/e000677. [PMID: 35606019 PMCID: PMC9125766 DOI: 10.1136/lupus-2022-000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
Abstract
Objectives Based on clinical and laboratory indicators, this study aimed to establish a multiparametric nomogram to assess the risk of refractory cases of SLE-related thrombocytopenia (SLE-related TP) before systematic treatment. Methods From June 2012 to July 2021, a dual-centre retrospective cohort study of prospectively collected data of patients with SLE-related TP was conducted. The cohort data were divided into a developing set, internal validation set and external validation set. Refractory thrombocytopenia (RTP) was defined as failed to prednisone at 1 mg/kg per day with a platelet count cannot achieve or maintain higher than 50×109/L. In the developing set, a nomogram were established to predict RTP risk based on clinical characteristics and laboratory indicators by multivariable logistic regression, and its performance was assessed by receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA) and clinical impact curve (CIC). Results A total of 1778 patients with SLE were included, and 413 eligible patients were involved in the final analysis with 121 RTPs. The RTP risk assessment (RRA) model was composed of five significant risk variables: pregnancy, severity of TP, complement 3, anticardiolipin antibody-immunoglobulin G and autoimmune haemolytic anaemia. In three datasets, the AUCs were 0.887 (95% CI 0.830 to 0.945), 0.880 (95% CI 0.785 to 0.975) and 0.871 (95% CI 0.793 to 0.949), respectively. The calibration curve, DCA and CIC all showed good performance of the RRA model. Conclusion The RRA model demonstrated good capability for assessing the refractory risk in SLE-related TP, which may be helpful for early identification and intervention.
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Affiliation(s)
- Kaisheng Su
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China.,Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Hao Cheng
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Zhifang Jia
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yuan
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Huidan Yang
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Qi Gao
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhenyu Jiang
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Hongyan Wen
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Jing Jiang
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China .,Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
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18
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Park YH. Diagnosis and management of thrombocytopenia in pregnancy. Blood Res 2022; 57:79-85. [PMID: 35483931 PMCID: PMC9057658 DOI: 10.5045/br.2022.2022068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombocytopenia, defined as platelet count <150×109/L, is frequently observed by physicians during pregnancy, with an incidence of approximately 10% of all pregnancies. Most of the cases of thrombocytopenia in pregnancy are due to gestational thrombocytopenia, which does not confer an increased risk of maternal bleeding. However, because other causes can be associated with life-threatening events, such as severe bleeding, that can affect to maternal and fetal outcomes, differentiating other cause of thrombocytopenia, which includes preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, acute fatty liver of pregnancy, immune thrombocytopenia, hereditary thrombocytopenia, antiphospholipid syndrome, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome, is important. Understanding the mechanisms and recognition of symptoms and signs are important to decide an adequate line of investigation. In this review, the approach to diagnosis and the management of the thrombocytopenia commonly observed in pregnancy are presented.
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Affiliation(s)
- Young Hoon Park
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
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19
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Zhu XL, Feng R, Huang QS, Liang MY, Jiang M, Liu H, Liu Y, Yao HX, Zhang L, Qian SX, Yang TH, Zhang JY, Shen XL, Yang LH, Hu JD, Huang RW, Jiang ZX, Wang JW, Zhang HY, Xiao Z, Zhan SY, Liu HX, Wang XL, Chang YJ, Wang Y, Kong Y, Xu LP, Liu KY, Zhang XH, Yin CH, Li YY, Wang QF, Wang JL, Huang XJ, Zhang XH. Prednisone plus IVIg compared with prednisone or IVIg for immune thrombocytopenia in pregnancy: a national retrospective cohort study. Ther Adv Hematol 2022; 13:20406207221095226. [PMID: 35510211 PMCID: PMC9058461 DOI: 10.1177/20406207221095226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/16/2022] [Indexed: 01/05/2023] Open
Abstract
Background: The responses of intravenous immunoglobulin (IVIg) or corticosteroids as the initial treatment on pregnancy with ITP were unsatisfactory. This study aimed to assess the safety and effectiveness of prednisone plus IVIg versus prednisone or IVIg in pregnant patients with immune thrombocytopenia (ITP). Methods: Between 1 January 2010 and 31 December 2020, 970 pregnancies diagnosed with ITP at 19 collaborative centers in China were reviewed in this observational study. A total of 513 pregnancies (52.89%) received no intervention. Concerning the remaining pregnancies, 151 (33.04%) pregnancies received an initial treatment of prednisone plus IVIg, 105 (22.98%) pregnancies received IVIg alone, and 172 (37.64%) pregnancies only received prednisone. Results: Regarding the maternal response to the initial treatment, no differences were found among the three treatment groups (41.1% for prednisone plus IVIg, 33.1% for prednisone, and 38.1% for IVIg). However, a significant difference was observed in the time to response between the prednisone plus IVIg group (4.39 ± 2.54 days) and prednisone group (7.29 ± 5.01 days; p < 0.001), and between the IVIg group (6.71 ± 4.85 days) and prednisone group (p < 0.001). The median prednisone duration in the monotherapy group was 27 days (range, 8–195 days), whereas that in the combination group was 14 days (range, 6–85 days). No significant differences were found among these three treatment groups in neonatal outcomes, particularly concerning the neonatal platelet counts. The time to response in the combination treatment group was shorter than prednisone monotherapy. The duration of prednisone application in combination group was shorter than prednisone monotherapy. The combined therapy showed a lower predelivery platelet transfusion rate than IVIg alone. Conclusion: These findings suggest that prednisone plus IVIg may represent a potential combination therapy for pregnant patients with ITP.
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Affiliation(s)
- Xiao-Lu Zhu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ru Feng
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Mei-Ying Liang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Ming Jiang
- Center of Hematologic Diseases, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, P.R. China
| | - Hui Liu
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Yi Liu
- Department of Hematology, Navy General Hospital, Beijing, P.R. China
| | - Hong-Xia Yao
- Department of Hematology, People’s Hospital of Hainan Province, Haikou, P.R. China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shen-Xian Qian
- Department of Hematology, First People’s Hospital of Hangzhou, Hangzhou, P.R. China
| | - Tong-Hua Yang
- Department of Hematology, First People’s Hospital of Yunnan Province, Kunming, P.R. China
| | - Jing-Yu Zhang
- Department of Hematology, Hebei Institute of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Xu-Liang Shen
- Department of Hematology, He Ping Central Hospital of the Changzhi Medical College, Changzhi, P.R. China
| | - Lin-Hua Yang
- Department of Hematology, Second Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, P.R. China
| | - Ren-Wei Huang
- Department of Hematology, Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China
| | - Zhong-Xing Jiang
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, P.R. China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, P.R. China
| | - Hong-Yu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhen Xiao
- Department of Hematology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, P.R. China
| | - Si-Yan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, P.R. China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xing-Lin Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yu Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yuan Kong
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Kai-Yan Liu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hong Zhang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Cheng-Hong Yin
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P.R. China
| | - Yue-Ying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Jian-Liu Wang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, P.R. China
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20
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Li J, Gao YH, Su J, Zhang L, Sun Y, Li ZY. Diagnostic Ideas and Management Strategies for Thrombocytopenia of Unknown Causes in Pregnancy. Front Surg 2022; 9:799826. [PMID: 35465428 PMCID: PMC9019731 DOI: 10.3389/fsurg.2022.799826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/21/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To summarize the clinical characteristics and treatment options together with the maternal and neonatal prognoses in women with different degrees of thrombocytopenia of unknown causes during pregnancy. Materials and Methods One hundred twenty-nine cases meeting the inclusion and exclusion criteria were retrospectively analyzed. Patients were divided into group A (50*109/L) and group B (50*109/L to 100*109/L) according to the lowest level of platelet count during pregnancy. Patients were divided into those found to have thrombocytopenia in the relatively early, middle, and late stages according to the detection period of maternal thrombocytopenia during pregnancy. Results There were 72 cases in group A, and 57 cases in group B. There existed statistically significant differences in terms of the proportion of primipara, the proportion with a history of thrombocytopenia, and the median length of pregnancy between the two groups (p < 0.05). The proportion of patients with severe thrombocytopenia as an indication for cesarean delivery was higher in group A than in group B (p < 0.05). More cases were detected at the relatively early stages of pregnancy in group A than in group B (p < 0.05). There was no difference in neonatal hemorrhage and events of thrombocytopenia between the two groups. Conclusion Patients with platelet counts below 50*109/L were mostly primipara with a history of thrombocytopenia, most often detected at a relatively early stage of pregnancy, and continued pregnancy might lead to aggravation of the disease. Combination therapy was required for patients with platelet counts below 30*109/L to maintain the platelet counts within a safe range. Cesarean delivery was selected to terminate the pregnancies, and platelet counts should be raised above 50*109/L before surgery. Close monitoring was required for those with platelet counts above 30*109/L. There was no direct correlation between the maternal and neonatal platelet counts.
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Shibata S, Misugi T, Nakane T, Hino M, Tachibana D. Use of Eltrombopag for the First Trimester Pregnancy Complicated with Refractory Idiopathic Thrombocytopenic Purpura: A Case Report and Literature Review. Cureus 2022; 14:e22505. [PMID: 35371812 PMCID: PMC8958988 DOI: 10.7759/cureus.22505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/05/2022] Open
Abstract
Severe idiopathic thrombocytopenic purpura (ITP) is thought to occur in approximately one in 10,000 pregnancies and refractoriness for conventional treatment is life-threatening. We herein describe a pregnant case of refractory ITP successfully treated with eltrombopag, orally medicated thrombopoietin receptor agonist (TPO-RA). The patient was diagnosed with ITP at the age of 22 and corticosteroid, immune globulin treatments, or splenectomy was invalid. Eltrombopag was administered at 25 mg/day and the platelet count was maintained at 50-80 × 109/L. At the age of 32, she discontinued the medication out of fear of the possible adverse events of TPO-RA. She became pregnant and visited our hospital at the gestational age of 9th week with the result of a platelet count at 18 × 109/L. Two weeks later, her platelet counts further decreased to 9 × 109/L, and eltrombopag administration was resumed with 12.5 mg/day after informed written consent. The platelet counts subsequently increased and were maintained between 30 and 90 × 109/L. At 34th gestational week, the dose of eltrombopag was increased to 25 mg/day in preparation for delivery and the count increased to 123 × 109/L by the 38th gestational week. A healthy female infant weighing 2370 g was vaginally delivered by induced labor. Maternal blood loss was 0.4 L at delivery, and the newborn’s platelet count was 173 × 109/L on the second day after birth and 174 × 109/L on the fifth day. The infant is neurologically and developmentally intact at 6 months of age. Regarding TPO-RA treatment for refractory ITP during pregnancy, only six pregnant cases including the present one treated with eltrombopag have been reported so far. This case is rare with reference to the use of eltrombopag for the first trimester and we increased the dose of eltrombopag at the gestational age of 34 in preparation for delivery and vaginal delivery was successful without platelet transfusion. Despite the very limited information on eltrombopag, its use might be a possible optional treatment for refractory ITP during pregnancy.
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22
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Scully M. How to evaluate and treat the spectrum of TMA syndromes in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:545-551. [PMID: 34889427 PMCID: PMC8791125 DOI: 10.1182/hematology.2021000290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Thrombotic microangiopathy (TMA) is the broad definition for thrombocytopenia, microangiopathic hemolytic anemia, and end-organ damage. Two important categories are thrombotic thrombocytopenic purpura (TTP) and complement-mediated hemolytic-uremic syndrome (CM-HUS). Pregnancy and the immediate postpartum period are associated with TMAs specific to pregnancy in rare situations. These include pregnancy-induced hypertension, preeclampsia, and hemolysis, elevated liver enzymes, and low platelets. TTP and CM-HUS may present in pregnancy. However, the diagnosis may not be immediately obvious as they share characteristics of pregnancy-related TMAs. Within this review, we discuss investigations, differential diagnosis of TMAs in pregnancy, and management. The importance is a risk of maternal mortality but also poor fetal outcomes in relation to TTP and CM-HUS. Treatment of these disorders at presentation in pregnancy is discussed to achieve remission and prolong fetal viability if possible. In subsequent pregnancies, a treatment pathway is presented that has been associated with successful maternal and fetal outcomes. Critical to this is a multidisciplinary approach involving obstetricians, the fetal medicine unit, and neonatologists.
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Affiliation(s)
- Marie Scully
- Correspondence Marie Scully, Department of Haematology, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UC BRC, 250 Euston Rd, London NW1 2PG, UK; e-mail:
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Practical considerations for the management of immune thrombocytopenic purpura. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2021; 14:350-354. [PMID: 34691269 PMCID: PMC8522252 DOI: 10.1007/s12254-021-00771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/04/2021] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenic purpura (ITP) is a rare hematological disorder with an autoimmune-mediated, often dramatic reduction of platelets in peripheral blood. Thrombocytopenia results from a reduced life span of thrombocytes and an additionally decreased production in bone marrow. For decades, the first-line therapy for ITP has been corticosteroids. As significant thrombocytopenic bleedings occur, the use of additional medication may be needed. Recent updates on therapy guidelines recommend the shortest possible use of corticosteroids. Thrombopoietin-receptor agonists are often used second line. Today splenectomy, which was previously recommended after unsuccessful first-line therapy, is usually considered much later. Patients who do not respond even after multiple lines of therapy continue to pose a major challenge. New drugs for ITP treatment are now available after steroid failure and will be discussed. This review gives a short summary on actual therapy guidelines taking into account newly available therapy options. In addition, comparisons between selected published data and experience at our department are made.
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Patel P, Balanchivadze N. Hematologic Findings in Pregnancy: A Guide for the Internist. Cureus 2021; 13:e15149. [PMID: 34164247 PMCID: PMC8214837 DOI: 10.7759/cureus.15149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 12/25/2022] Open
Abstract
Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.
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Affiliation(s)
- Pooja Patel
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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Malinowski AK, Othman M. Obstetric neuraxial anaesthesia in the setting of immune thrombocytopenia and low platelet counts: call to participate in an international registry. Br J Anaesth 2021; 127:e12-e13. [PMID: 33926714 DOI: 10.1016/j.bja.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ann Kinga Malinowski
- Department of Obstetrics & Gynaecology, Division of Maternal-Fetal Medicine, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada; Department of Obstetrics & Gynaecology, University of Toronto, ON, Canada.
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada; School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
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Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol 2021; 14:553-568. [PMID: 33724124 DOI: 10.1080/17512433.2021.1903315] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP. AREA COVERED This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'. EXPERT OPINION We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.
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Affiliation(s)
- Rajeev Sandal
- Dept of Clinical Hematology, IGMC, Shimla, Himachal Pradesh, India
| | - Kundan Mishra
- Department of Internal Medicine (Adult Clinical Hematology Division), Postgraduate Institute of Medical Education and Research, Chandigarh (Union Territory), India
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ahmad Daniyal Siddiqui
- Division of Hematology and Oncology, Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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Subtil SFC, Mendes JMB, Areia ALFDA, Moura JPAS. Update on Thrombocytopenia in Pregnancy. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2020; 42:834-840. [PMID: 33348401 PMCID: PMC10309201 DOI: 10.1055/s-0040-1721350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Thrombocytopenia, defined as platelet count < 150,000 mm3, is frequently diagnosed by obstetricians since this parameter is included in routine surveillance during pregnancy, with an incidence of between 7 and 12%. Therefore, decisions regarding subsequent examination and management are primordial. While most of the cases are due to physiological changes, as gestational thrombocytopenia, other causes can be related to severe conditions that can lead to fetal or maternal death. Differentiating these conditions might be challenging: they can be pregnancy-specific (pre-eclampsia/HELLP syndrome [hemolysis, elevated liver enzymes, low platelets]), or not (immune thrombocytopenia purpura, thrombotic thrombocytopenic purpura or hemolytic uremic syndrome). Understanding the mechanisms and recognition of symptoms and signs is essential to decide an adequate line of investigation. The severity of thrombocytopenia, its etiology and gestational age dictates different treatment regimens.
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Leng Q, Wang W, Wang Y, Wu L. Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review. J Clin Pharm Ther 2020; 46:532-538. [PMID: 33277725 DOI: 10.1111/jcpt.13321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Severe thrombocytopenia associated with systemic lupus erythematosus (SLE) in pregnancy is infrequent. Its occurrence can lead to serious adverse pregnancy consequences and perinatal complications. The thrombopoietin (TPO) analogue eltrombopag has been successfully used in the treatment of autoimmune thrombocytopenia, but its safety and efficacy in severe thrombocytopenia during pregnancy remain unclear. CASE SUMMARY We report a 33-year-old woman with SLE at 29 + 3 weeks gestational age who developed severe thrombocytopenia with complaints of epistaxis, gum bleeding and haematuresis. Most conventional treatments including glucocorticoids, intravenous immunoglobulin (IVIG) and cyclosporine did not elevate her platelets, but eltrombopag worked well and her platelet count gradually recovered, allowing her to deliver a healthy baby at 36 + 3 weeks gestational age. WHAT IS NEW AND CONCLUSION This suggests that eltrombopag in combination with glucocorticoids has a good safety and efficacy profile in pregnant patients with SLE complicated by severe thrombocytopenia.
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Affiliation(s)
- Qianru Leng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Wei Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
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