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Zheng XL. Novel mechanisms of action of emerging therapies of hereditary thrombotic thrombocytopenic purpura. Expert Rev Hematol 2024; 17:341-351. [PMID: 38752747 PMCID: PMC11209763 DOI: 10.1080/17474086.2024.2356763] [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: 03/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hereditary thrombotic thrombocytopenic purpura (hTTP) is caused by deficiency of plasma ADAMTS13 activity, resulting from ADAMTS13 mutations. ADAMTS13 cleaves ultra large von Willebrand factor (VWF), thus reducing its multimer sizes. Hereditary deficiency of plasma ADAMTS13 activity leads to the formation of excessive platelet-VWF aggregates in small arterioles and capillaries, resulting in hTTP. AREAS COVERED PubMed search from 1956 to 2024 using thrombotic thrombocytopenic purpura and therapy identified 3,675 articles. Only the articles relevant to the topic were selected for discussion, which focuses on pathophysiology, clinical presentations, and mechanisms of action of emerging therapeutics for hTTP. Current therapies include infusion of plasma, or coagulation factor VIII, or recombinant ADAMTS13. Emerging therapies include anti-VWF A1 aptamers or nanobody and gene therapies with adeno-associated viral vector or self-inactivated lentiviral vector or a sleeping beauty transposon system for a long-term expression of a functional ADAMTS13 enzyme. EXPERT OPINION Frequent plasma infusion remains to be the standard of care in most parts of the world, while recombinant ADAMTS13 has become the treatment of choice for hTTP in some of the Western countries. The success of gene therapies in preclinical models may hold a promise for future development of these novel approaches for a cure of hTTP.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine and Institute of Reproductive Medicine and Developmental Sciences, the University of Kansas Medical Center, Kansas City, Kansas 66160, USA
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2
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Martin JN, Tucker JM. Maternal morbidity and mortality in pregnant/postpartum women with suspected HELLP syndrome identifiable as probable thrombotic thrombocytopenic purpura or atypical hemolytic uremic syndrome by high LDH to AST ratio. Int J Gynaecol Obstet 2022; 159:870-874. [PMID: 35301713 DOI: 10.1002/ijgo.14177] [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: 05/05/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe findings in 8 women initially diagnosed as presumptive HELLP Syndrome, eventually confirmed as TTP/aHUS as distinguished by elevated calculated LDH:AST ratio > 22:1. METHODS All medicolegal files of patients evaluated between 1986 and 2015 with presumptive HELLP syndrome but later determined to have TTP/aHUS had LDH:AST ratios evaluated throughout care. RESULTS Fifty-eight pregnant/postpartum women presented with a diagnosis of presumptive HELLP syndrome. In the final analysis, 8 women had TTP/aHUS characterized by severe thrombocytopenia (<20 000/μl) at admission, rare epigastric pain, and the consistent demonstration of a very high calculated total LDH to AST ratio. This calculation greatly exceeded 22:1 with TTP/aHUS (mean = 32:1) versus 2:1 with HELLP and could be consistently demonstrated throughout care. Six of 8 women with TTP/aHUS died. CONCLUSION Correctly distinguishing between HELLP syndrome versus an imitator disorder continues to challenge obstetric specialists. This medicolegal data supplements prior findings supporting the concept of the LDH:AST ratio as a useful screening tool for clinicians to differentiate TTP/aHUS apart from HELLP syndrome in order to facilitate earlier hematology consultation, patient referral to tertiary care and emergent hemotherapy for these mothers.
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Affiliation(s)
- James Nello Martin
- Department of Obstetrics and Gynecology, The Winfred L. Wiser Hospital for Women & Infants at the University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - James Martin Tucker
- Department of Obstetrics and Gynecology, The Winfred L. Wiser Hospital for Women & Infants at the University of Mississippi Medical Center, Jackson, Mississippi, USA
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Mohamed Jiffry MZ, Ahmed-khan MA, Carmona Pires F. Diagnostic dilemma in a patient presenting with thrombotic microangiopathy in the setting of pregnancy. Arch Clin Cases 2022; 9:24-28. [PMID: 35529093 PMCID: PMC9066583 DOI: 10.22551/2022.34.0901.10199] [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] [Indexed: 11/25/2022] Open
Abstract
We report a case of thrombotic microangiopathy in a postpartum female for which considerable diagnostic uncertainty existed initially regarding the etiology. This case highlights the limitations surrounding PLASMIC scoring criteria for the diagnosis of thrombotic thrombocytopenic purpura (TTP). A 32-year-old woman presented to maternofetal medicine in her third trimester of pregnancy at 32 weeks for a routine follow up and was subsequently found to have elevated blood pressures with proteinuria, and was diagnosed with pre-eclampsia. Worsening anemia and thrombocytopenia prompted a blood smear which showed schistocytes, concerning for a thrombotic microangiopathy. Creatinine was also elevated with normal liver enzymes being noted. A PLASMIC score of 4 placed her in the low-risk category for severe ADAMTS13 deficiency whilst she fulfilled criteria for partial HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome per Tennessee classification. Despite delivery, her symptoms persisted with subsequent ADAMTS13 assay confirming acquired TTP, subsequently requiring repeated plasmapheresis and rituximab to achieve disease control. Thrombotic microangiopathy remains a diagnostic challenge especially in the peripartum population, and scoring systems such as PLASMIC score and Tennessee classification may be of limited utility.
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Zhou L, Zhu Y, Jiang M, Su J, Liu X, Jiang Y, Mu H, Yin J, Yang L, Liu H, Pan W, Su M, Liu H. Pregnancy-associated thrombotic thrombocytopenic purpura complicated by Sjögren's syndrome and non-neutralising antibodies to ADAMTS13: a case report. BMC Pregnancy Childbirth 2021; 21:804. [PMID: 34861845 PMCID: PMC8641216 DOI: 10.1186/s12884-021-04167-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 09/30/2021] [Indexed: 12/17/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is a severe and life-threatening disease. Given its heterogeneous clinical presentation, the phenotype of TTP during pregnancy and its management have not been well documented. Case presentation We report here a 25-year-old woman, G1P0 at 36 weeks gestation, who developed severe thrombocytopenia and anemia. She was performed an emergent caesarean section 1 day after admission because of multiple organ failure. As ADAMTS 13 enzyme activity of the patient was 0% and antibodies were identified by enzyme-linked immunosorbent assay, she was diagnosed as acquired thrombotic thrombocytopenic purpura (aTTP). Furthermore, asymptomatic primary Sjögren’s syndrome was incidentally diagnosed on screening. After treatment with rituximab in addition to PEX and steroids, the activity of the ADAMTS 13 enzyme increased significantly from 0 to 100%. Conclusions To the best of our knowledge, this is the first case report of concomitant TTP and asymptomatic Sjögren’s syndrome in a pregnant woman. It highlights the association between pregnancy, autoimmune disease, and TTP. It also emphasizes the importance of an enzyme-linked immunosorbent assay in the diagnosis and rituximab in the treatment of patients with acquired TTP. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04167-9.
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Affiliation(s)
- Lu Zhou
- Hematology department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Yu Zhu
- Obstetrics and Gynecology Department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Miao Jiang
- Key Laboratory of Thrombosis & Hemostasis of Ministry of Health, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Su
- Key Laboratory of Thrombosis & Hemostasis of Ministry of Health, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, Key Laboratory of Gene Therapy of Blood Diseases, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yizhi Jiang
- Hematology department, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Hui Mu
- Hematology department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Jie Yin
- Key Laboratory of Thrombosis & Hemostasis of Ministry of Health, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Yang
- Hematology department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Haiyan Liu
- Hematology department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Weidong Pan
- Obstetrics and Gynecology Department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Min Su
- Obstetrics and Gynecology Department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China.
| | - Hong Liu
- Hematology department, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
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Zununi Vahed S, Rahbar Saadat Y, Ardalan M. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021; 138:104226. [PMID: 34252400 DOI: 10.1016/j.mvr.2021.104226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Pregnancy is a high-risk time for the development of different kinds of thrombotic microangiopathy (TMA). Three major syndromes including TTP (thrombotic thrombocytopenic purpura), PE/HELLP (preeclampsia/hemolysis, elevated liver function tests, low platelets), and aHUS (atypical hemolytic- uremic syndrome) should be sought in pregnancy-TMA. These severe disorders share multiple clinical features and overlaps and even the coexistence of more than one pathologic mechanism. Each of these disorders finally ends in endothelial damage and fibrin thrombi formation within the microcirculation that fragments RBCs (schystocytes), aggregates platelets, and creates ischemic injury in the targeted organs i.e.; kidney and brain. Although the mechanisms of these severe disorders have been revealed, pregnancy-related TMA still interfaces with diagnostic and therapeutic challenges. Here, we highlight the current knowledge of diagnosis and management of these complications during pregnancy.
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Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood 2021; 136:2103-2117. [PMID: 32808006 DOI: 10.1182/blood.2020005221] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.
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Mu J, Zhang J, Sunnassee A, Dong H. A case report of undiagnosed postpartum hemolytic uremic syndrome. Diagn Pathol 2015; 10:89. [PMID: 26152455 PMCID: PMC4495808 DOI: 10.1186/s13000-015-0278-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/16/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postpartum hemolytic uremic syndrome (PHUS) is a severe thrombotic microangiopathy (TMA) that is clinically characterized by hemolytic anemia, renal dysfunction, and low platelet levels after childbirth. Here, we report a rare case of unexpected death due to PHUS. CASE PRESENTATION A 23-year-old parturient had an uncomplicated cesarean section at 40 weeks gestation. The immediate postpartum course was uneventful. However, eight days post delivery, the patient developed severe nausea and vomiting followed by hematuria, spontaneous bruising, marked pallor, icteric sclera, and lethargy. Laboratory findings revealed that the patient had hemolytic anemia, thrombocytopenia, and acute renal failure. This patient died approximately 29 h after the onset of symptoms. Post-mortem examination confirmed that the patient had PHUS. CONCLUSIONS This paper addresses the need for a renal histological examination in addition to a thorough clinical history and appropriate laboratory tests for the rapid and accurate diagnosis of PHUS. Early detection and diagnosis can significantly improve the prognosis and optimize maternal outcomes.
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Affiliation(s)
- Jiao Mu
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, Hubei, 430030, PR China.
- Department of Phatology, Hebei North University, No. 11 Zuanshinan Road, Zhangjiakou, Hebei, 075000, PR China.
| | - Ji Zhang
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, Hubei, 430030, PR China.
| | - Ananda Sunnassee
- Ministry of Health and Quality of Life, Victoria Hospital, Quatre Bornes, Mauritius.
| | - Hongmei Dong
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan, Hubei, 430030, PR China.
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Delmas Y, Helou S, Chabanier P, Ryman A, Pelluard F, Carles D, Boisseau P, Veyradier A, Horovitz J, Coppo P, Combe C. Incidence of obstetrical thrombotic thrombocytopenic purpura in a retrospective study within thrombocytopenic pregnant women. A difficult diagnosis and a treatable disease. BMC Pregnancy Childbirth 2015; 15:137. [PMID: 26081109 PMCID: PMC4469004 DOI: 10.1186/s12884-015-0557-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 05/15/2015] [Indexed: 02/06/2023] Open
Abstract
Background Thrombotic thrombocytopenic Purpura (TTP) defined as ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin type 1 domain 13) activity <10 % is a rare aetiology of thrombocytopenia during pregnancy, although the precise incidence is unknown. During pregnancy, the diagnosis of TTP is crucial as it has high feto-maternal morbidity-mortality and requires urgent plasma exchange. The purpose of this study was to assess the incidence of TTP retrospectively and to describe case presentations and follow-up. Methods A monocentric retrospective study (2008–2009) was conducted among pregnant women followed in a tertiary care obstetrical unit who experienced at least one episode of severe thrombocytopenia (platelets ≤75 G/L) during 2008 and 2009. In cases of uncertain aetiology of thrombocytopenia, ADAMTS-13 activity was assessed by the full length technique. Results Among 8,908 deliveries over the 2 year period, 79 women had a platelet count nadir ≤75 G/L. Eighteen had a known aetiology of thrombocytopenia and 11 were lost to follow-up. Among 50 remaining patients, ADAMTS-13 activity was undetectable (<5 %) in 4, consistent with the diagnosis of TTP. Platelet count spontaneously normalized in 3 patients after delivery. None presented focal cerebral involvement. Three of the four, who were primipara patients, had a sustained severe deficiency in the absence of anti-ADAMTS-13 antibodies, and ADAMTS-13 gene sequencing indicated a constitutive deficiency. The fourth, a multipara patient, had an acquired, auto-immune TTP. Placental pathology in the three primipara patients showed severe and non-specific ischemic lesions. Two patients lost their babies shortly after birth. In subsequent pregnancies in these two patients, prophylactic plasma infusion initiated early with increasing volume throughout pregnancy prevented TTP relapse, improved placental pathology, and led to normal delivery. Conclusions The prevalence of TTP among thrombocytopenic pregnant women is high, up to 5 % in a tertiary unit. Platelet count normalization after delivery does not eliminate TTP. Clinicians should be aware of TTP during pregnancy, and, even if assessed retrospectively, ADAMTS-13 assessment is of particular importance for identifying patients with congenital TTP. In these patients, preventive plasma infusion and/or exchange can dramatically improve foetal prognosis, resulting in successful childbirth.
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Affiliation(s)
- Yahsou Delmas
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Sébastien Helou
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Chabanier
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Anne Ryman
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Service d'Hémostase Spécialisée, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Fanny Pelluard
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Dominique Carles
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Boisseau
- Service de Génétique Médicale, Centre Hospitalier Universitaire de Nantes Hôtel Dieu, Nantes, France.
| | - Agnès Veyradier
- Service d'hématologie, Centre Hospitalier Universitaire de Lariboisière, Assistance Publique Hôpitaux de Paris, Université Paris 7 Denis Diderot, Paris, France. .,Centre de Référence des Microangiopathies Thrombotiques, Paris, France.
| | - Jacques Horovitz
- Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Paris, France. .,Service d'Hématologie Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, Paris, France. .,Université Pierre et Marie Curie (UPMC), Univ Paris 6, Paris, France.
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
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Pourrat O, Coudroy R, Pierre F. Differentiation between severe HELLP syndrome and thrombotic microangiopathy, thrombotic thrombocytopenic purpura and other imitators. Eur J Obstet Gynecol Reprod Biol 2015; 189:68-72. [PMID: 25879992 DOI: 10.1016/j.ejogrb.2015.03.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 01/13/2015] [Accepted: 03/17/2015] [Indexed: 12/31/2022]
Abstract
Pre-eclampsia complicated by severe HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome is a multi-organ disease, and can be difficult to differentiate from thrombotic microangiopathy (appearing as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome), acute fatty liver, systemic erythematous lupus, antiphospholipid syndrome and severe sepsis. Many papers have highlighted the risks of misdiagnosis resulting in severe consequences for maternal health, and this can be fatal when thrombotic thrombocytopenic purpura is misdiagnosed as severe HELLP syndrome. The aim of this paper is to propose relevant markers to differentiate pre-eclampsia complicated by severe HELLP syndrome from its imitators, even in the worrying situation of apparently indistinguishable conditions, and thereby assist clinical decision-making regarding whether or not to commence plasma exchange. Relevant identifiers to establish the most accurate diagnosis include the frequency of each disease and anamnestic data. Frank hemolysis, need for dialysis, neurological involvement and absence of disseminated intravascular coagulation are indicative of thrombotic microangiopathy. The definitive marker for thrombotic thrombocytopenic purpura is undetectable ADAMTS 13 activity.
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Affiliation(s)
- O Pourrat
- Obstetric Medicine Clinic, Intensive Care and Internal Medicine Unit, University of Poitiers, Jean Bernard Hospital, Poitiers Cedex, France.
| | - R Coudroy
- Intensive Care and Internal Medicine Unit, University of Poitiers, Jean Bernard Hospital, Poitiers Cedex, France
| | - F Pierre
- Department of Gynaecology and Obstetrics, University of Poitiers, Jean Bernard Hospital, Poitiers Cedex, France
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Pourrat O, Coudroy R, Pierre F. ADAMTS13 deficiency in severe postpartum HELLP syndrome. Br J Haematol 2013; 163:409-10. [DOI: 10.1111/bjh.12494] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Rémi Coudroy
- Intensive Care and Internal Medicine Unit; University of Poitiers; Poitiers; France
| | - Fabrice Pierre
- Department of Gynaecology and Obstetrics; University of Poitiers; Poitiers; France
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Martínez-Blazquez A, de Capadocia-Rosell J, Cuesta-Montero P, Marín-Sánchez A. [Hemolysis, elevated liver enzymes and low platelet count in pregnancy: differential diagnosis]. ACTA ACUST UNITED AC 2013; 60:297-8. [PMID: 23582183 DOI: 10.1016/j.redar.2013.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 02/07/2013] [Accepted: 02/11/2013] [Indexed: 11/30/2022]
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13
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Milestones in the quest for best management of patients with HELLP syndrome (microangiopathic hemolytic anemia, hepatic dysfunction, thrombocytopenia). Int J Gynaecol Obstet 2013; 121:202-7. [DOI: 10.1016/j.ijgo.2013.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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Postpartum thrombotic microangiopathic syndrome. Transfus Apher Sci 2013; 48:51-7. [DOI: 10.1016/j.transci.2012.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 05/12/2012] [Indexed: 01/10/2023]
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Datta S, Opara E, Hanna L. Congenital thrombotic thrombocytopenia presenting with placental abruption. J OBSTET GYNAECOL 2012; 32:305-7. [PMID: 22369414 DOI: 10.3109/01443615.2011.649319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- S Datta
- Department of Obstetrics and Gynaecology, St Thomas's Hospital,Westminster, London, UK.
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Yamamoto T, Fujimura Y, Emoto Y, Kuriu Y, Iino M, Matoba R. Autopsy case of sudden maternal death from thrombotic thrombocytopenic purpura. J Obstet Gynaecol Res 2012; 39:351-4. [DOI: 10.1111/j.1447-0756.2012.01941.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Unexpected frequency of Upshaw-Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Blood 2012; 119:5888-97. [DOI: 10.1182/blood-2012-02-408914] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Abstract
Pregnancy may be complicated by a rare but life-threatening disease called thrombotic thrombocytopenic purpura (TTP). Most cases of TTP are due to an acquired autoimmune or hereditary (Upshaw-Schulman syndrome [USS]) severe deficiency of a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS13). In the present study, we performed a cross-sectional analysis of the national registry of the French Reference Center for Thrombotic Microangiopathies from 2000-2010 to identify all women who were pregnant at their initial TTP presentation. Among 592 adulthood-onset TTP patients with a severe ADAMTS13 deficiency, 42 patients with a pregnancy-onset TTP were included. Surprisingly, the proportion of USS patients (n = 10 of 42 patients [24%]; confidence interval, 13%-39%) with pregnancy-onset TTP was much higher than that in adulthood-onset TTP in general (less than 5%) and was mostly related to a cluster of ADAMTS13 variants. In the present study, subsequent pregnancies in USS patients not given prophylaxis were associated with very high TTP relapse and abortion rates, whereas prophylactic plasmatherapy was beneficial for both the mother and the baby. Pregnancy-onset TTP defines a specific subgroup of patients with a strong genetic background. This study was registered at www.clinicaltrials.gov as number NCT00426686 and at the Health Authority, French Ministry of Health, as number P051064.
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Keiser SD, Boyd KW, Rehberg JF, Elkins S, Owens MY, Sunesara I, Martin JN. A high LDH to AST ratio helps to differentiate pregnancy-associated thrombotic thrombocytopenic purpura (TTP) from HELLP syndrome. J Matern Fetal Neonatal Med 2011; 25:1059-63. [DOI: 10.3109/14767058.2011.619603] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mazzanti L, Cecati M, Vignini A, D'Eusanio S, Emanuelli M, Giannubilo SR, Saccucci F, Tranquilli AL. Placental expression of endothelial and inducible nitric oxide synthase and nitric oxide levels in patients with HELLP syndrome. Am J Obstet Gynecol 2011; 205:236.e1-7. [PMID: 21700268 DOI: 10.1016/j.ajog.2011.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Revised: 04/05/2011] [Accepted: 04/11/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine placental gene expression of endothelial and inducible nitric oxide synthases and measure nitric oxide levels in patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome. STUDY DESIGN Preterm placentas were obtained from 15 patients with hemolysis, elevated liver enzyme levels, and low platelet count syndrome and 30 controls matched for age, parity, and gestational age. mRNA levels were evaluated by real-time polymerase chain reaction, whereas nitric oxide and peroxynitrite production was measured by a commercially available kit. RESULTS Placental gene expression of inducible nitric oxide and endothelial nitric oxide synthases were significantly lower in the hemolysis, elevated liver enzyme levels, and low platelet count syndrome group than in controls, whereas nitric oxide and peroxynitrite production were significantly higher in hemolysis, elevated liver enzyme levels, and low platelet count syndrome compared with controls. CONCLUSION The reduced endothelial nitric oxide and inducible nitric oxide synthases gene expression in women with hemolysis, elevated liver enzyme levels, and low platelet count syndrome may indicate extreme placental dysfunction that is unable to compensate the endothelial derangement and the related hypertension. The higher nitric oxide formation found in hemolysis, elevated liver enzyme levels, and low platelet count syndrome placentas could be explained as a counteraction to the impaired fetoplacental perfusion, typical of the syndrome.
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Affiliation(s)
- Laura Mazzanti
- Department of Biochemistry, Biology and Genetics, Università Politecnica Marche, Ancona, Italy
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Martin JN, Owens MY, Keiser SD, Parrish MR, Tam Tam KB, Brewer JM, Cushman JL, May WL. Standardized Mississippi Protocol Treatment of 190 Patients with HELLP Syndrome: Slowing Disease Progression and Preventing New Major Maternal Morbidity. Hypertens Pregnancy 2011; 31:79-90. [DOI: 10.3109/10641955.2010.525277] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Coppo P. Microangiopathie thrombotique en réanimation — Vers une classification physiopathologique pour des thérapeutiques ciblées. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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HE Y, CHEN Y, ZHAO Y, ZHANG Y, YANG W. Clinical study on five cases of thrombotic thrombocytopenic purpura complicating pregnancy. Aust N Z J Obstet Gynaecol 2010; 50:519-22. [DOI: 10.1111/j.1479-828x.2010.01222.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Vasko R, Koziolek M, Füzesi L, König F, Strutz F, Müller GA. Fulminant Plasmapheresis-refractory Thrombotic Microangiopathy Associated With Advanced Gastric Cancer. Ther Apher Dial 2010; 14:222-5. [DOI: 10.1111/j.1744-9987.2009.00710.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fakhouri F, Roumenina L, Provot F, Sallée M, Caillard S, Couzi L, Essig M, Ribes D, Dragon-Durey MA, Bridoux F, Rondeau E, Frémeaux-Bacchi V. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol 2010; 21:859-67. [PMID: 20203157 DOI: 10.1681/asn.2009070706] [Citation(s) in RCA: 278] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In contrast to pregnancy-associated thrombotic thrombocytopenic purpura, the pathogenesis and presentation of pregnancy-associated atypical hemolytic uremic syndrome (P-aHUS) remain ill-defined. We conducted a retrospective study to assess the presentation and outcomes of patients presenting with P-aHUS and the prevalence of alternative C3 convertase dysregulation. P-aHUS occurred in 21 of the 100 adult female patients with atypical HUS, with 79% presenting postpartum. We detected complement abnormalities in 18 of the 21 patients. The outcomes were poor: 62% reached ESRD by 1 month and 76% by last follow-up. The risk for P-aHUS was highest during a second pregnancy. Thirty-five women, 26 (74%) of whom had complement abnormalities, had at least one pregnancy before the onset of a non-pregnancy-related aHUS. Outcomes did not differ between patients with pregnancy-related and non-pregnancy-related aHUS. Mutations in the SCR19-20 domains of factor H were less frequent in P-aHUS patients compared with non-pregnancy-related aHUS. Pregnancies in female patients with complement abnormalities (n = 44) were complicated by fetal loss and preeclampsia in 4.8% and 7.7%, respectively. Better understanding of complement dysregulation in pregnancy complications is essential, especially to guide development of pharmacologic agents to modulate this system.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology and UMR 643, CHU de Nantes, Paris, France
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The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department: lessons from 4 tertiary hospitals. Am J Obstet Gynecol 2009; 200:381.e1-6. [PMID: 19110215 DOI: 10.1016/j.ajog.2008.10.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 09/04/2008] [Accepted: 10/07/2008] [Indexed: 01/06/2023]
Abstract
OBJECTIVE We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. STUDY DESIGN Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. RESULTS There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. CONCLUSION TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.
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Swisher KK, Terrell DR, Vesely SK, Kremer Hovinga JA, Lämmle B, George JN. Clinical outcomes after platelet transfusions in patients with thrombotic thrombocytopenic purpura. Transfusion 2009; 49:873-87. [PMID: 19210323 DOI: 10.1111/j.1537-2995.2008.02082.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reports of deterioration and death after platelet (PLT) transfusions in patients with thrombotic thrombocytopenic purpura (TTP) have led to recommendations that they should not be given except for life-threatening hemorrhage. STUDY DESIGN AND METHODS Published reports of PLT transfusions in patients with TTP were systematically reviewed and data from the Oklahoma TTP-HUS Registry, an inception cohort of 382 consecutive patients, 1989 through 2007, were analyzed. RESULTS A systematic review identified 34 publications describing outcomes of patients with TTP after PLT transfusions: 9 articles attributed complications to PLT transfusions, 4 suggested that they may be safe, and 21 articles did not comment about a relation between PLT transfusions and outcomes. Fifty-four consecutive patients from the Oklahoma TTP-HUS Registry were prospectively analyzed. ADAMTS13 activity was less than 10 percent in 47 patients; also included were 7 patients whose activity was not measured but who may have been deficient. Thirty-three (61%) patients received PLT transfusions. The frequency of death was not different between the two groups (p = 0.971): 8 (24%) patients who received PLT transfusions died (thrombosis, 5; hemorrhage, 1; sepsis, 2) and 5 (24%) patients who did not receive PLT transfusions died (thrombosis, 4; hemorrhage, 1). The frequency of severe neurologic events was also not different (p = 0.190): 17 (52%) patients who received PLT transfusions (in 5 of these 17 patients, neurologic events only occurred before PLT transfusions) and 7 (33%) patients who did not receive PLT transfusions. CONCLUSION Evidence for harm from PLT transfusions in patients with TTP is uncertain.
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Affiliation(s)
- Karen K Swisher
- Hematology-Oncology Section, Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Kato R, Shinohara A, Sato J. ADAMTS13 deficiency, an important cause of thrombocytopenia during pregnancy. Int J Obstet Anesth 2009; 18:73-7. [DOI: 10.1016/j.ijoa.2008.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Revised: 07/28/2008] [Accepted: 07/29/2008] [Indexed: 11/30/2022]
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Beucher G, Simonet T, Dreyfus M. Prise en charge du HELLP syndrome. ACTA ACUST UNITED AC 2008; 36:1175-90. [DOI: 10.1016/j.gyobfe.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 08/09/2008] [Indexed: 11/26/2022]
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Martin JN, Bailey AP, Rehberg JF, Owens MT, Keiser SD, May WL. Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006. Am J Obstet Gynecol 2008; 199:98-104. [PMID: 18456236 DOI: 10.1016/j.ajog.2008.03.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 02/28/2008] [Accepted: 03/05/2008] [Indexed: 10/22/2022]
Abstract
A review of pregnancy-associated thrombotic thrombocytopenic purpura (TTP) in 166 pregnancies was undertaken using 92 English-language publications from 1955 to 2006. Initial and recurrent TTP presents most often in the second trimester (55.5%) after 1-2 days of signs/symptoms; postpartum TTP usually occurs following term delivery. TTP with preeclampsia (n = 28) exhibits 2-4 times higher aspartate aminotransferase (AST) values and lower total lactate dehydrogenase (LDH) to AST ratios (LDH to AST ratio = 13:1), compared with TTP without preeclampsia (LDH to AST ratio = 29:1). Maternal mortality is higher with initial TTP (26% vs 10.7%), especially with concurrent preeclampsia (44.4% vs 21.8%, P < .02). Although maternal mortality with TTP has substantially declined when plasma therapy is utilized, delay of diagnosis and therapy for initial TTP confounded by preeclampsia/hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome remains a significant maternal-perinatal threat. Rapid and readily available laboratory testing to quickly diagnose TTP and HELLP syndrome/preeclampsia is desperately needed to improve care.
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Emanuelli M, Sartini D, Rossi V, Corradetti A, Landi B, Vianna CR, Giannubilo S, Tranquilli AL. Alpha-hemoglobin-stabilizing protein (AHSP) in hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome, intrauterine growth restriction (IUGR) and fetal death. Cell Stress Chaperones 2008; 13:67-71. [PMID: 18347943 PMCID: PMC2666222 DOI: 10.1007/s12192-008-0009-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 08/04/2007] [Accepted: 08/08/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Alpha hemoglobin-stabilizing protein (AHSP) inhibits the production of reactive oxygen species in various cells, including erythrocytes. Reduced AHSP can mean reduced protection from stressors. Our objective was to investigate whether AHSP is involved in the response to stress in pregnancy. STUDY DESIGN Placentas were collected from normal term pregnancies (n = 10) and pregnancies complicated by HELLP (n = 10), intrauterine growth restriction (IUGR; n = 10) or fetal death (IUFD; n = 6). AHSP messenger RNA (mRNA) and protein were determined using real time quantitative polymerase chain reaction (PCR) and Western blot, respectively. All statistical analyses were performed by using the GraphPad Prism Software. Differences were considered significant at p < 0.05. RESULTS Placental AHSP mRNA level in HELLP (4.16E10(-4) +/- 1.77) and IUFD (4.19E10(-4) +/- 3.37) were significantly decreased compared with controls (28.47E10(-4) +/- 14.86; p < 0.01), whereas levels in the IUGR group (7.55E10(-4) +/- 6.4) showed a trend toward being lower but the difference did not reach statistical significance. Western blot analysis results indicate a no significant increase of ASHP protein in the HELLP syndrome group and a significant decrease in the IUFD group compared with controls. There was no significant difference between the IUGR and control groups. CONCLUSION ASHP mRNA expression in the placenta is decreased in complicated pregnancies, and it may be involved in the pathogenic mechanisms leading to the adverse pregnancy outcome.
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Affiliation(s)
- Monica Emanuelli
- Istituto di Biotecnologie Biochimiche, Università Politecnica Marche, 65 Via Ranieri, Ancona, Italy.
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Groot E, de Groot PG, Fijnheer R, Lenting PJ. The presence of active von Willebrand factor under various pathological conditions. Curr Opin Hematol 2007; 14:284-9. [PMID: 17414220 DOI: 10.1097/moh.0b013e3280dce531] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To highlight mechanisms that regulate the balance between latent and active von Willebrand factor (VWF), and describe pathological conditions leading to increased levels of active VWF. RECENT FINDINGS Levels of circulating active VWF are increased in von Willebrand disease type 2B, HELLP syndrome, malaria and antiphospholipid syndrome. SUMMARY Freshly secreted VWF consists of ultra-large multimers that interact spontaneously with platelets at the endothelial cell surface. Proteolysis of ultra-large VWF by a member of the disintegrin and metalloprotease with thrombospondin motif family (ADAMTS13) reduces both multimeric size and accessibility of platelet-adhesion sites. The resulting VWF molecules circulate as inactive multimers, which regain their platelet-adhesion capacity upon binding to the subendothelial matrix, in particular under conditions of high shear. Unfortunately, mechanisms responsible for suppression of circulating plasma levels of active VWF are hampered in a number of pathological conditions, leading to VWF-platelet aggregates associated with thrombotic complications or thrombocytopenia. A recently developed assay allowed us to monitor the presence of circulating active VWF and we found that several diseases are characterized by increased levels. Further analysis provided insight into mechanisms contributing to the presence of active VWF, which revealed that beta2-glycoprotein I may act as a natural regulator of VWF-platelet interactions.
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Affiliation(s)
- Evelyn Groot
- Laboratory for Thrombosis and Haemostasis, Department of Clinical Chemistry & Haematology, University Medical Center Utrecht, The Netherlands
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Abstract
There are several obstetric, medical, and surgical disorders that share many of the clinical and laboratory findings of patients with severe preeclampsia-hemolysis, elevated liver enzymes, and low platelets syndrome. Imitators of severe preeclampsia-hemolysis, elevated liver enzymes, and low platelets syndrome are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal mortality, and survivors may face long-term sequelae. Perinatal mortality and morbidity also remain high in many of these conditions. The pathophysiologic abnormalities in many of these disorders include thrombotic microangiopathy, thrombocytopenia, and hemolytic anemia. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and acute exacerbation of systemic lupus erythematosus. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. Consequently, there are no systematic reviews or randomized trials on these subjects. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndromes. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. For example, severe preeclampsia and acute fatty liver of pregnancy are treated by delivery, whereas it is possible to continue pregnancy in those with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and exacerbation of systemic lupus erythematosus. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies.
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Affiliation(s)
- Baha M Sibai
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA.
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