Treatment of intracranial and extracranial haemorrhages in a neonate with severe haemophilia B with recombinant factor IX infusion

A Practical Guide to the Management of the Fetus and Newborn With Hemophilia

Newborns with hemophilia are at risk of intracranial hemorrhage, extracranial hemorrhage, and other bleeding complications. The safe delivery of a healthy newborn with hemophilia is a complex process that can begin even before conception, and continues throughout pregnancy, birth, and the newborn period. This process involves the expectant parents and a wide variety of health-care professionals: genetic counselors, obstetricians, neonatologists, pediatricians, radiologists, adult and pediatric hematologists, and nurses with expertise in hemophilia. Because of this multidisciplinary complexity, the relative rarity of births of newborns with hemophilia, and the lack of high-quality evidence to inform decisions, there is considerable variation in practice in this area. We present a comprehensive multidisciplinary approach, from preconception counseling to discharge planning after birth, and describe available options for management decisions. We highlight a number of areas of important uncertainty and controversy, including the preferred mode of delivery, the appropriate use and timing of neuroimaging tests, and the appropriate use of clotting factor concentrates in the newborn period. While the approach presented here will aid clinicians in planning and providing care, further research is required to optimize the care of newborns with hemophilia.

Guideline on the management of haemophilia in the fetus and neonate

Evidence-based guidelines are presented for the management of haemophilia in the fetus and neonate. This includes information regarding the management of pregnancy and delivery as well as aspects of management during the early neonatal period. Specific issues regarding the mode of delivery and the risk of intra-cranial and extra-cranial haemorrhage are discussed.

Perinatal gene transfer to the liver

The liver acts as a host to many functions hence raising the possibility that any one may be compromised by a single gene defect. Inherited or de novo mutations in these genes may result in relatively mild diseases or be so devastating that death within the first weeks or months of life is inevitable. Some diseases can be managed using conventional medicines whereas others are, as yet, untreatable. In this review we consider the application of early intervention gene therapy in neonatal and fetal preclinical studies. We appraise the tools of this technology, including lentivirus, adenovirus and adeno-associated virus (AAV)-based vectors. We highlight the application of these for a range of diseases including hemophilia, urea cycle disorders such as ornithine transcarbamylase deficiency, organic acidemias, lysosomal storage diseases including mucopolysaccharidoses, glycogen storage diseases and bile metabolism. We conclude by assessing the advantages and disadvantages associated with fetal and neonatal liver gene transfer.

Outcome of Long-Term Prophylaxis After Cerebral Hemorrhage in a Patient With Severe Hemophilia B

Reports of intracerebral hemorrhage (ICH) in patients with hemophilia B are relatively rare. We describe the first clinical results of the use of a monoclonal antibody purified factor IX (FIX) concentrate (Mononine) after an ICH and the long-term outcome of prophylaxis with this product to prevent recurrences. A 44-year-old male with severe hemophilia B was referred to our department because of nausea, vomiting, left lower limb hemiplegia, and left arm paresis. Computed tomography (CT) revealed a right frontal intraparenchymal bleed. The patient was treated with replacement therapy with FIX for 40 days. Computed tomography scans performed on day 40 after the event showed complete disappearance of the cerebral hematoma from the parenchymal tissue. Subsequently, the patient received 25.6 IU/kg-1 of FIX twice a week. At the 48-month follow-up visit, no more major or minor bleeding events had occurred. Long-term prophylaxis after ICH is recommended.

Pharmacokinetics of protein C and antithrombin in the fetal lamb: a model to predict human neonatal replacement dosing

BACKGROUND

The preterm infant is at risk for consumptive coagulopathy and thrombosis due to late maturation of coagulation regulatory proteins. Replacement proteins are available, but neonatal pharmacokinetic data are lacking.

OBJECTIVE

The objective was to determine the pharmacokinetic properties of antithrombin (AT) and protein C (PC) in order to provide data for estimating doses in human infants.

METHODS

A catheterized ovine model was used to determine pharmacokinetic properties of AT and PC, including plasma recovery, volume of distribution (V(d)), clearance (Cl) and half-life (t((1/2))), in the fetal lamb relative to the ewe.

RESULTS

AT studies showed statistically significant differences between ewes and fetuses in recovery (p < 0.0001), V(d) (p = 0.0002) and Cl (p < 0.0001). The AT t((1/2)) was significantly shortened among fetuses (5.55 h, 95% CI: 4.01-7.08) compared to ewes (18.7 h, 95% CI: 11.6-25.8). PC recovery (p < 0.0001), V(d) (p < 0.0001) and Cl (p = 0.004) differed significantly between ewes and singleton fetuses as did the t((1/2)): 3.86 h (95% CI: 3.35-4.36) and 11.9 h (95% CI: 10.9-12.9) in the singletons and ewes, respectively. All PC parameters were significantly different for twins compared to ewes.

CONCLUSIONS

AT and PC show decreased recovery and t((1/2)) in the fetal lamb. These data can be used to estimate dosing for human neonates in comparison with human adult dosing recommendations.

Perinatal trauma and cerebral palsy

In this article "perinatal trauma" is restricted to injuries that are sustained by the infant during the labor and delivery primarily as a result of mechanical factors, with the understanding that even under optimal circumstances, the process of birth is traumatic. Mechanical insults to the perinatal brain may result in primarily a hypoxic or ischemic injury to the cerebral tissues; those conditions are not discussed in this article. Although there are multiple types of perinatal trauma, this article is restricted mainly to those types that impact upon the subsequent development of cerebral palsy, although when applicable, other adverse developmental outcomes are mentioned.

Unresolved issues in diagnosis and management of inherited bleeding disorders in the perinatal period: A White Paper of the Perinatal Task Force of the Medical and Scientific Advisory Council of the National Hemophilia Foundation, USA

Haemophilia and inherited bleeding disorders in newborns and their carrier mothers pose unique challenges. The pattern of bleeding and the causes and risk factors for bleeding are decidedly different than an older child or an adult with haemophilia/inherited bleeding disorder. This document outlines the needs for further research and education, summarizes the state of the art background information and provides guidance regarding research, education and access to care issues in this population.