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Chiffré-Rakotoarivony D, Diaz-Cau I, Ranc A, Champiat MA, Rousseau F, Gournay-Garcia C, Théron A, Navarro R, Boulot P, Aguilar-Martinez P, Sauguet P, Biron-Andréani C. Bleeding risk in hemophilia A and B carriers: comparison of factor levels determined using chronometric and chromogenic assays. Blood Coagul Fibrinolysis 2024; 35:232-237. [PMID: 38700721 DOI: 10.1097/mbc.0000000000001305] [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: 05/06/2024]
Abstract
BACKGROUND Predicting the bleeding risk in hemophilia A and B carriers (HAC, HBC) is challenging. OBJECTIVE The objectives of this study were to describe the bleeding phenotype in HAC and HBC using the standardized Tosetto bleeding score (BS); to determine whether the BS correlates better with factor levels measured with a chromogenic assay than with factor levels measured with chronometric and thrombin generation assays; and to compare the results in HAC and HBC. METHODS This ambispective, noninterventional study included obligate and sporadic HAC and HBC followed at a hemophilia treatment center between 1995 and 2019. RESULTS AND CONCLUSION The median BS (3, range 0-21 vs. 3.5, range 0-15, P = ns, respectively) and the abnormal BS rate (35.6% vs. 38.2%, P = ns) were not significantly different in 104 HAC and 34 HBC (mean age: 38 years, 6-80 years). However, some differences were identified. The risk of factor deficiency was higher in HBC than HAC. Specifically, Factor VIII activity (FVIII):C/Factor IX activity (FIX):C level was low (<40 IU/dl) in 18.3% (chronometric assay) and 17.5% (chromogenic assay) of HAC and in 47% and 72.2% of HBC ( P < 0.001). Moreover, the FIX:C level thresholds of 39.5 IU/dl (chronometric assay) and of 33.5 IU/dl (chromogenic assay) were associated with very good sensitivity (92% and 100%, respectively) and specificity (80% for both) for bleeding risk prediction in HBC. Conversely, no FVIII:C level threshold could be identified for HAC, probably due to FVIII:C level variations throughout life.
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Affiliation(s)
- Delphine Chiffré-Rakotoarivony
- Hemophilia Treatment Centre, Department of Biological Hematology
- Department of Biological Hematology, Hematology Laboratory
| | | | - Alexandre Ranc
- Department of Biological Hematology, Hematology Laboratory
| | | | | | | | - Alexandre Théron
- Hemophilia Treatment Centre, Department of Biological Hematology
| | - Robert Navarro
- Hemophilia Treatment Centre, Department of Biological Hematology
| | - Pierre Boulot
- Department of Obstetrics and Gynecology, University Hospital, Montpellier, France
| | - Patricia Aguilar-Martinez
- Hemophilia Treatment Centre, Department of Biological Hematology
- Department of Biological Hematology, Hematology Laboratory
| | | | - Christine Biron-Andréani
- Hemophilia Treatment Centre, Department of Biological Hematology
- Department of Biological Hematology, Hematology Laboratory
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Puetz J, Hu B. Factor activity levels and bleeding scores in pediatric hemophilia carriers enrolled in the ATHNdataset. Pediatr Blood Cancer 2023; 70:e30644. [PMID: 37638815 DOI: 10.1002/pbc.30644] [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: 05/09/2023] [Revised: 06/22/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Multiple studies have now shown that a significant proportion of hemophilia carriers meet the criteria for having hemophilia and/or report abnormal bleeding. However, to date, investigations of hemophilia carriers have almost exclusively involved women over 18 years of age. Little is known about factor activity levels and bleeding scores in carriers during childhood. We queried a large deidentified database of subjects with bleeding disorders residing in the United States to determine factor activity levels and bleeding scores. PROCEDURES The ATHNdataset was queried for hemophilia carriers under 18 years of age. Collected information included demographics, factor activity levels, and bleeding scores. RESULTS Over 700 carriers in the pediatric age group were identified, of which 626 submitted factor activity levels. Nearly half had factor activity levels less than 40 IU/dL, thereby meeting criteria for having hemophilia. Of those reporting bleeding scores, only 13.5% reported an abnormal bleeding score for age. The proportion reporting abnormal bleeding scores was higher in those with factor levels less than 40 IU/dL (23%) than those greater than 40 IU/dL (9.7%). CONCLUSIONS The proportion of pediatric carriers with hemophilia was double of that previously reported for adults. Of those with hemophilia reporting a bleeding score, the majority (77%) did not report an abnormal bleeding score for age. However, nearly 10% of pediatric carriers not meeting criteria for having hemophilia reported abnormal bleeding scores for age. Similar results are reported in adults suggesting that factor activity levels may not be predictive of bleeding symptoms in carriers.
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Affiliation(s)
- John Puetz
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
| | - Brian Hu
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, American Thrombosis and Hemostasis Network, Rochester, New York, USA
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Livanou ME, Matsas A, Valsami S, Papadimitriou DT, Kontogiannis A, Christopoulos P. Clotting Factor Deficiencies as an Underlying Cause of Abnormal Uterine Bleeding in Women of Reproductive Age: A Literature Review. Life (Basel) 2023; 13:1321. [PMID: 37374104 DOI: 10.3390/life13061321] [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: 04/25/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Clotting Factor deficiencies are rare disorders with variations in clinical presentation and severity of symptoms ranging from asymptomatic to mild to life-threatening bleeding. Thus, they pose a diagnostic and therapeutic challenge, mainly for the primary health care providers, general practitioners, and gynecologists who are more likely to first encounter these patients. An additional diagnostic challenge arises from the variable laboratory presentations, as PT, PTT, and BT are not always affected. The morbidity is higher among women of reproductive age since Abnormal Uterine Bleeding-specifically Heavy Menstrual Bleeding-is one of the most prevalent manifestations of these disorders, and in some cases of severe deficiencies has led to life-threatening episodes of bleeding requiring blood transfusions or even immediate surgical intervention. Physician awareness is important as, in the case of some of these disorders-i.e., Factor XIII deficiency-prophylactic treatment is available and recommended. Although uncommon, the potential for rare bleeding disorders and for hemophilia carrier states should be considered in women with HMB, after more prevalent causes have been excluded. Currently, there is no consensus on the management of women in these instances and it is reliant on the physicians' knowledge.
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Affiliation(s)
- Maria Effrosyni Livanou
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Alkis Matsas
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Serena Valsami
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Dimitrios T Papadimitriou
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Athanasios Kontogiannis
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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Zhang W, Li K, Poon MC, Zhang X, Wu J, Zhao X, Zhou M, Wang X, Zhang M, Xu W, Yang L, Huang M, Jin C, Wang X, Zhang D, Chen L, Liu W, Zhang L, Xue F, Yang R. Women and girls with haemophilia: A retrospective cohort study in China. Haemophilia 2023; 29:578-590. [PMID: 36595620 DOI: 10.1111/hae.14740] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Women and girls with haemophilia (WGH) may have spontaneous/traumatic bleeding similar to that in males with haemophilia, and in addition excessive bleeding during menstruation and delivery. AIM To characterize WGH in China and provide guidance for better management. METHODS We retrospectively analysed the characteristics of WGH registered in the Haemophilia Treatment Center Collaborative Network of China (HTCCNC) Registry, including demographics, diagnosis and treatment, bleeding characteristics, obstetrical and gynaecological experiences, and surgical history. RESULTS A total of 61 females had confirmed haemophilia. Diagnosis and treatment were typically delayed, longer in mild haemophilia than in severe and moderate. The most frequently reported bleeding manifestations were haemarthrosis in severe and moderate patients, and cutaneous bleeding in mild patients. Among 45 postmenarcheal WGH, 21 (46.7%) had history of heavy menstrual bleeding, but only three received treatments. Prenatal diagnosis and management of perinatal haemorrhage were inadequate. Of 34 deliveries in 30 women, nine deliveries were complicated by postpartum haemorrhage, and 22 offspring carried mutations causing haemophilia. Forty-four surgical procedures were performed in 29 patients. Those procedures receiving preoperative coagulation factors coverage were significantly less likely to have excessive bleeding than those who did not (P = .003). CONCLUSION This is the first and largest study describing WGH in China. There are currently deficiencies in the identification, diagnosis, and management of these patients. Improving health insurance policies, establishing haemophilia centres, and multidisciplinary teams for bleeding and perinatal or perioperative management will help reduce morbidity and mortality.
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Affiliation(s)
- Wenhui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Kuixing Li
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Man-Chiu Poon
- Departments of Medicine, Paediatrics and Oncology, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Xinsheng Zhang
- Shandong Blood Center, Shandong Hemophilia Treatment Center, Jinan, China
| | - Jingsheng Wu
- The First Affiliated Hospital, Chinese University of Science and Technology, Hefei, China
| | - Xielan Zhao
- Xiangya Hospital, Central South University, Changsha, China
| | - Min Zhou
- Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Xuefeng Wang
- Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Mei Zhang
- The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weiqun Xu
- Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linhua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Meijuan Huang
- Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China
| | - Chenghao Jin
- Jiangxi Provincial People's Hospital, Department of Hematology, Nanchang, China
| | - Xiaomin Wang
- Xinjiang Uygur Autonomous Region People's Hospital, Urumchi, China
| | - Donglei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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Kendel NE, Zia A, Rosenbaum LE, Stanek JR, Haamid FW, Christian-Rancy M, O'Brien SH. Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders. J Pediatr Adolesc Gynecol 2022; 35:653-658. [PMID: 35820606 DOI: 10.1016/j.jpag.2022.07.003] [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: 02/10/2022] [Revised: 06/03/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs) DESIGN: Retrospective multicenter cohort study from February 2014 through February 2020 SETTING: Young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas PARTICIPANTS: Female patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placement INTERVENTIONS AND MAIN OUTCOME MEASURES: Rates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatment RESULTS: We identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently. CONCLUSIONS In this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.
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Affiliation(s)
- Nicole E Kendel
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio.
| | - Ayesha Zia
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lucy E Rosenbaum
- Division of Internal Medicine/Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio; Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
| | - Fareeda W Haamid
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Myra Christian-Rancy
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
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Puetz J, Cheng D. Descriptive analysis of bleeding symptoms in haemophilia carriers enrolled in the ATHNdataset. Haemophilia 2021; 27:1045-1050. [PMID: 34587351 DOI: 10.1111/hae.14422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/27/2021] [Accepted: 09/16/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Several studies have reported that haemophilia carriers have a bleeding tendency independent of factor activity. However, investigations have been fraught with methodological concerns. The ATHNdataset houses the largest data set of haemophilia carriers in the world. We undertook an analysis of haemophilia carriers in this data set using methodologies that characterize bleeding symptoms in carriers. AIM Determine the proportion of haemophilia carriers who have a normal bleeding score (BLS) and factors that affect the BLS. METHODS The ATHNdataset was queried for haemophilia carriers with a documented BLS. Collected data included demographics, ISTH-BAT score, factor activity level, type of haemophilia (A or B), genotype and geographic residence. RESULTS Nine hundred twenty-two haemophilia carriers in the ATHNdataset reported a BLS. When adjusted for age, 74% reported a normal score. Logistic regression identified age, factor activity level, ethnicity and region of residence as risk factors for an abnormal score. CONCLUSIONS The majority of haemophilia carriers (74%) in the ATHNdataset had a normal BLS, including the majority (59%) with factor activity levels < 40 IU/dl. Conversely, 24% of haemophilia carriers with a factor activity level > 40 IU/dl reported an abnormal BLS. These results are consistent with previous studies of haemophilia carriers. Additional investigation is needed to determine why a majority of haemophilia carriers with low factor activity levels report normal BLSs while a significant minority of haemophilia carriers with normal activity levels report abnormal BLSs.
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Affiliation(s)
- John Puetz
- Department of Pediatrics, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Dunlei Cheng
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
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van Galen KPM, d’Oiron R, James P, Abdul‐Kadir R, Kouides PA, Kulkarni R, Mahlangu JN, Othman M, Peyvandi F, Rotellini D, Winikoff R, Sidonio RF. A new hemophilia carrier nomenclature to define hemophilia in women and girls: Communication from the SSC of the ISTH. J Thromb Haemost 2021; 19:1883-1887. [PMID: 34327828 PMCID: PMC8361713 DOI: 10.1111/jth.15397] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/21/2022]
Abstract
Hemophilia A and B predominantly attracts clinical attention in males due to X-linked inheritance, introducing a bias toward female carriers to be asymptomatic. This common misconception is contradicted by an increasing body of evidence with consistent reporting on an increased bleeding tendency in hemophilia carriers (HCs), including those with normal factor VIII/IX (FVIII/IX) levels. The term HC can hamper diagnosis, clinical care, and research. Therefore, a new nomenclature has been defined based on an open iterative process involving hemophilia experts, patients, and the International Society on Thrombosis and Haemostasis (ISTH) community. The resulting nomenclature accounts for personal bleeding history and baseline plasma FVIII/IX level. It distinguishes five clinically relevant HC categories: women/girls with mild, moderate, or severe hemophilia (FVIII/IX >0.05 and <0.40 IU/ml, 0.01-0.05 IU/ml, and <0.01 IU/ml, respectively), symptomatic and asymptomatic HC (FVIII/IX ≥0.40 IU/ml with and without a bleeding phenotype, respectively). This new nomenclature is aimed at improving diagnosis and management and applying uniform terminologies for clinical research.
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Affiliation(s)
- Karin P. M. van Galen
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Roseline d’Oiron
- Centre de Référence de l’Hémophilie et des Maladies Hémorragiques ConstitutionnellesAPHP Paris Saclay ‐ Hôpital Bicêtre and Inserm U 1176Le Kremlin BicêtreFrance
| | - Paula James
- Department of MedicineQueen’s UniversityKingstonOntarioCanada
| | - Rezan Abdul‐Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis UnitThe Royal Free Foundation Hospital and Institute for Women’s HealthUniversity College LondonLondonUK
| | - Peter A. Kouides
- University of RochesterRochesterNew YorkUSA
- The Mary M. Gooley Hemophilia CenterRochesterNew YorkUSA
| | | | - Johnny N. Mahlangu
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Maha Othman
- School of MedicineQueen’s University, and School of Baccalaureate NursingSt. Lawrence CollegeKingstonOntarioCanada
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
| | | | - Rochelle Winikoff
- Department of PediatricService of HematologySainte‐Justine HospitalMontrealQuebecCanada
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Evaluation of bleeding symptoms and laboratory parameters related to bleeding in sisters of patients with hemophilia A and B. Transfus Apher Sci 2021; 60:103044. [PMID: 33390328 DOI: 10.1016/j.transci.2020.103044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Our purpose was to determine the bleeding risk of obligate and potential carriers, highlight the prophylactic applications before interventions for families and physicians. METHOD Forty-six sisters who had at least one family member with hemophilia A or B were included. Laboratory parameters were tested.Bleeding tendency interrogated by a detailed questionnaire.The results were compared with 43 healthy female controls. RESULTS Mean factor activity levels were significantly lower in sisters than control subjects (p = 0,004). Bleeding score was higher in sisters than controls (p = 0.001). Prolonged bleeding after minor injury was significantly higher in the sisters than control subjects (p = 0.008). Requiring further treatment due to prolonged bleeding after tooth extraction was significantly higher in sisters (p = 0.001). Sisters had postpartum hemorrhage lasting longer than 6 weeks than controls (p = 0.025). Menstrual period lasted longer in the sisters than controls (p < 0.001). Spontaneous epistaxis, oral and gingival bleeding were more frequently observed in sisters whose factor activity levels were 60 % or below (p = 0.014 and p = 0.047, respectively). There was no statistically significant difference between the severity of hemophilia in the affected family member and the factor levels in the sisters (p = 0.398).Spontaneous epistaxis has found to be significantly associated with the hemophilia severity in the family (p = 0.004). CONCLUSION Clotting factor levels were found to be lower in the sisters and associated with spontaneous epistaxis, oral and gingival bleeding.Also, regardless of clotting factor levels, sisters significantly experienced more bleeding problems.Our study demonstrated the importance of taking precautions for prolonged bleeding in cases where medical interventions are inevitable in these patients.
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d'Oiron R, O'Brien S, James AH. Women and girls with haemophilia: Lessons learned. Haemophilia 2020; 27 Suppl 3:75-81. [PMID: 32985086 DOI: 10.1111/hae.14094] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022]
Abstract
Severe and moderate factor VIII (FVIII) or IX (FIX) deficiencies in female carriers of haemophilia are rarely observed, but mild deficiency is quite frequent, although insufficiently recognized and registered. The confusion between the genetic diagnosis of the carriership, mainly assessed at adult age and the diagnosis of the bleeding disorder for those who have low factor levels often prevents early diagnosis of a potential bleeding risk. The factor levels in obligate or potential carriers of haemophilia can be assessed during childhood, possibly apart from genetic assays. The absence of early recognition of the bleeding disorder precludes the anticipation of menarche and the prevention of potential heavy menstrual bleeding to heavy menstrual bleeding. Standardized bleeding assessment tools (BAT) have demonstrated that women and girls with haemophilia (WGWH) have increased bleeding scores as compared to the general female population, however weakly correlating with factor levels. More recent evidence has highlighted that hemarthroses affect 4% to 19% of carriers and that some of them could experience sub-clinical joint bleeding. Desmopressin for women with FVIII deficiency and abnormal ISTH-BAT scores had a significantly lower FVIII response to DDAVP compared to those with normal bleeding scores, which could at least partially explain more postsurgical bleeding. Management of delivery of haemophilia carriers requires attention to the risks of maternal bleeding, the risks of foetal bleeding, preconception and prenatal care, strategies to reduce maternal bleeding, choice of mode of delivery to reduce foetal/neonatal bleeding, and postpartum care. Either prior to pregnancy, or during early pregnancy, a plan should be developed that addresses the needs of both the mother and her unborn baby. If the unborn baby is a male proven to be or potentially affected by moderate or severe form of haemophilia, there is a risk of severe foetal bleeding, so a planned caesarean delivery may be preferred. If the unborn baby is a carrier, or potentially affected carrier, there is still the risk of non-severe bleeding so invasive foetal procedures and operative vaginal delivery (forceps or vacuum) should be avoided. Further studies based on large cohorts will help the community to favour earlier diagnosis, increase knowledge on WGWH and promote better care.
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Affiliation(s)
- Roseline d'Oiron
- Centre de Référence de l'Hémophilie, Hôpital Bicêtre APHP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,HITh, UMR_S1176, INSERM, Hôpital Bicêtre APHP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sarah O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.,Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC, USA
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