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Hajjar R, Hatoum I, Krounbi A, Chahine R, Jalloul R, Ramadan MK. Pregnancy in a woman with congenital F-VII deficiency: a brief review of recent literature and case report. Hematol Transfus Cell Ther 2023; 45:394-398. [PMID: 34565715 PMCID: PMC10499559 DOI: 10.1016/j.htct.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/10/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rima Hajjar
- American University in Beirut-Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon
| | - Inaam Hatoum
- Rafik Hariri University Hospital, Beirut, Lebanon
| | | | - Rabih Chahine
- American University in Beirut-Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon; Rafik Hariri University Hospital, Beirut, Lebanon
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2
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Maas DPMSM, Saes JL, Blijlevens NMA, Cnossen MH, den Exter PL, van der Heijden OWH, Kruis IC, Meijer K, Peters M, Schutgens REG, van Heerde WL, Nieuwenhuizen L, Schols SEM. High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study. J Thromb Haemost 2023; 21:499-512. [PMID: 36696205 DOI: 10.1016/j.jtha.2022.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/27/2022] [Accepted: 11/22/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. OBJECTIVE To describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. METHODS In the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient-reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). RESULTS A total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. CONCLUSION PPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.
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Affiliation(s)
- Dominique P M S M Maas
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Joline L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ilmar C Kruis
- Netherlands Hemophilia Society, Nijkerk, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Peters
- Department of Pediatric Hematology, Amsterdam University Medical Centers, Location Emma Children's Hospital, Amsterdam, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Department of Hematology, Maxima Medical Center, Eindhoven, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands.
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Shirzadi M, Radfar AH, Dehghani M. Recurrent miscarriage in a woman with congenital factor V deficiency: a case report. BMC Pregnancy Childbirth 2022; 22:915. [PMID: 36482349 PMCID: PMC9732993 DOI: 10.1186/s12884-022-05273-y] [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: 04/01/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Factor V deficiency is a rare bleeding disorder that can be either congenital or acquired. Factor V deficiency mostly present with mucosal bleeding. Coagulation factor V does not increase considerably during normal gestation. Since pregnancy can be threatened by blood clotting disorders, abnormal changes in coagulation factors level can pose challenges to pregnant women. CASE PRESENTATION We report a 40-year-old pregnant woman with prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy. Her past medical history included two unexplained abortions. Physical examination was unremarkable, but the blood test showed elevated PT and PTT with a considerable decrease in factor V activity, while other factors were within normal range. Subsequently, the patient was diagnosed with congenital factor V deficiency. After treatment with fresh frozen plasma, she underwent vaginal delivery and a baby with factor V deficiency was born. CONCLUSIONS This is the second report of recurrent miscarriage in congenital factor V deficiency patients. Clinicians should consider the possibility of factor V deficiency in women with a history of idiopathic miscarriage even in patients without any symptoms.
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Affiliation(s)
- Mohammad Shirzadi
- grid.411036.10000 0001 1498 685XDepartment of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Hossein Radfar
- grid.411036.10000 0001 1498 685XSchool of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Dehghani
- grid.411036.10000 0001 1498 685XSchool of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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4
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Abdul‐Kadir R, Gomez K. Reproductive health and hemostatic issues in women and girls with congenital factor VII deficiency: A systematic review. J Thromb Haemost 2022; 20:2758-2772. [PMID: 36073900 PMCID: PMC9828586 DOI: 10.1111/jth.15872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/30/2022] [Accepted: 09/06/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Congenital factor VII (FVII) deficiency is an inherited bleeding disorder, with heterogenous bleeding symptoms. Women with FVII deficiency face hemostatic challenges during menstruation, ovulation, and childbirth. This systematic review evaluated prevalence and management of bleeding symptoms associated with gynecological and obstetric issues in women with FVII deficiency. METHODS Databases (BIOSIS Previews, Current Contents Search, Embase, and MEDLINE) were searched for studies reporting FVII deficiency and gynecological or obstetric issues in women. Articles were screened using Joanna Briggs Institute checklists and relevant data extracted. RESULTS One hundred fourteen women were identified from 62 publications. Forty-six women had severe deficiency (FVII:C < 5% or <5 IU/dl). Heavy menstrual bleeding (HMB) was the most common bleeding symptom (n = 94; 82%); hospitalization and urgent medical/surgical interventions for acute HMB episodes were required in 16 women (14%). Seven women reported ovarian bleeding (6%); other bleeding symptoms varied. Patient management was inconsistent and included hemostatic and hormonal treatments. Only four women (7%) reporting vaginal bleeding during pregnancy. Postpartum hemorrhage (PPH) occurred following 12/45 deliveries (27%; 5 [42%] requiring blood transfusion) and was not necessarily prevented by prophylaxis (8 women). CONCLUSION Women with congenital FVII deficiency have an increased risk of HMB, ovarian bleeding, and PPH, impacting quality of life. Recognition of a bleeding disorder as the cause is often delayed. Management of bleeding complications is heterogeneous due to lack of treatment guidelines. Harmonizing severity classification of FVII deficiency may help standardize treatment strategies and development of specific guidelines for these women.
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Affiliation(s)
- Rezan Abdul‐Kadir
- Katharine Dormandy Haemophilia Centre and Department of Obstetrics & GynaecologyRoyal Free HospitalLondonUK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
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5
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Swaminathan N, Sharathkumar A, Dowlut-McElroy T. Reproductive Tract Bleeding in Adolescent and Young Adult Females with Inherited Bleeding Disorders: An Underappreciated Problem. J Pediatr Adolesc Gynecol 2022; 35:614-623. [PMID: 35830928 DOI: 10.1016/j.jpag.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.
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Affiliation(s)
- Neeraja Swaminathan
- Division of Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Anjali Sharathkumar
- Division of Pediatric Hematology Oncology, Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 1322 BT, 200 Hawkins Drive, Iowa City, IA 52242, United States.
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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6
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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7
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Lithgow KV, Buchholz VCH, Ku E, Konschuh S, D'Aubeterre A, Sycuro LK. Protease activities of vaginal Porphyromonas species disrupt coagulation and extracellular matrix in the cervicovaginal niche. NPJ Biofilms Microbiomes 2022; 8:8. [PMID: 35190575 PMCID: PMC8861167 DOI: 10.1038/s41522-022-00270-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/14/2022] [Indexed: 12/14/2022] Open
Abstract
Porphyromonas asaccharolytica and Porphyromonas uenonis are common inhabitants of the vaginal microbiome, but their presence has been linked to adverse health outcomes for women, including bacterial vaginosis and preterm birth. However, little is known about the pathogenesis mechanisms of these bacteria. The related oral opportunistic pathogen, Porphyromonas gingivalis, is comparatively well-studied and known to secrete numerous extracellular matrix-targeting proteases. Among these are the gingipain family of cysteine proteases that drive periodontal disease progression and hematogenic transmission to the placenta. In this study, we demonstrate that vaginal Porphyromonas species secrete broad-acting proteases capable of freely diffusing within the cervicovaginal niche. These proteases degrade collagens that are enriched within the cervix (type I) and chorioamniotic membranes (type IV), as well as fibrinogen, which inhibits clot formation. Bioinformatic queries confirmed the absence of gingipain orthologs and identified five serine, cysteine, and metalloprotease candidates in each species. Inhibition assays revealed that each species' proteolytic activity can be partially attributed to a secreted metalloprotease with broad substrate specificity that is distantly related to the P. gingivalis endopeptidase PepO. This characterization of virulence activities in vaginal Porphyromonas species highlights their potential to alter the homeostasis of reproductive tissues and harm human pregnancy through clotting disruption, fetal membrane weakening, and premature cervical remodeling.
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Affiliation(s)
- Karen V Lithgow
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Vienna C H Buchholz
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Emily Ku
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Shaelen Konschuh
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Ana D'Aubeterre
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
- Department of Biological Sciences, University of Alberta, Edmonton, AB, Canada
| | - Laura K Sycuro
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada.
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- International Microbiome Centre, University of Calgary, Calgary, AB, Canada.
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8
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Langer M, Manire M, Clarkson M, Samhouri Y, Shah D, Bhagavatula R. Management of congenital dysfibrinogenemia in pregnancy: A challenging patient case. Res Pract Thromb Haemost 2021; 5:e12619. [PMID: 34816075 PMCID: PMC8595964 DOI: 10.1002/rth2.12619] [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: 07/15/2021] [Revised: 09/01/2021] [Accepted: 10/13/2021] [Indexed: 11/06/2022] Open
Abstract
Afibrinogenemia and congenital dysfibrinogenemia (CD) are rare conditions with limited information available for appropriate management. Previous case reports have demonstrated the safe and efficacious use of fibrinogen replacement therapy (FRT) as a therapeutic approach to prevent hemorrhage and fetal loss in pregnant women with CD. In this case report, we present a 28-year-old pregnant woman who sought testing for CD given her family history. She denied any current or previous bleeding symptoms. Laboratory testing confirmed the diagnosis of CD. She was treated with FRT and prophylactic anticoagulation starting in her third trimester. She had preterm labor that prompted an urgent cesarean section with FRT support. This case adds to the sparse literature about fibrinogen disorders in pregnancy, and highlights the benefits, safety, and tolerability of FRT and prophylactic anticoagulation in pregnant women with CD. Finally, it emphasizes the importance of a multidisciplinary team approach for an uneventful delivery.
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Affiliation(s)
- Megan Langer
- Division of Hematology and Cellular TherapyAllegheny Health Network Cancer InstitutePittsburghPennsylvaniaUSA
| | - Meredith Manire
- Department of Obstetrics and GynecologyWest Penn HospitalAllegheny Health NetworkPittsburghPennsylvaniaUSA
| | - Matthew Clarkson
- Department of PharmacyWest Penn HospitalAllegheny Health NetworkPittsburghPennsylvaniaUSA
| | - Yazan Samhouri
- Division of Hematology and Cellular TherapyAllegheny Health Network Cancer InstitutePittsburghPennsylvaniaUSA
| | - Deep Shah
- Division of Hematology and Cellular TherapyAllegheny Health Network Cancer InstitutePittsburghPennsylvaniaUSA
| | - Rama Bhagavatula
- Division of Hematology and Cellular TherapyAllegheny Health Network Cancer InstitutePittsburghPennsylvaniaUSA
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Naderi M, Mirzaei I, Yaghoubi S, Milani I, Cohan N. Postpartum Hemorrhage in Heterozygote Factor XIII Deficient Women Compared With Healthy Women. A Cross-Sectional Experience From Iran. Clin Appl Thromb Hemost 2021; 27:10760296211051714. [PMID: 34697946 PMCID: PMC8552392 DOI: 10.1177/10760296211051714] [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] [Indexed: 11/16/2022] Open
Abstract
Postpartum hemorrhage (PPH) is a major cause of maternal mortality, which is a common clinical manifestation in women with rare bleeding disorders. In this study, we compare PPH and its complications in heterozygote factor XIII (FXIII) deficient women with healthy women. In this cross sectional case study, 50 women with heterozygote FXIII deficiency and 50 healthy women are evaluated. Data were initially collected by interviewing the women who were receiving FXIII replacement therapy after their childbirths. Data were analysed using SPSS (Version 22) and a P-value of less than .05 was considered statistically significant. The mean age in the patient and control groups were 31.2 and 32.5 years respectively. The occurring rate of PPH in the patient group was significantly higher than the control group (34% vs 2%) (P-value <.0001). None of the confounding variables such as maternal age, gestational age, numbers, and types of delivery in women with PPH showed any significant differences between the control and patient groups. According to the results of this study, the risk of PPH (early and late), miscarriage, and menorrhagia in women who are heterozygous for FXIII deficiency is significantly higher than healthy women. However, the effect of other factors such as maternal age, gestational age, number, and type of delivery require further studies to delineate any confounding factors.
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Affiliation(s)
- Majid Naderi
- 48538Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ilia Mirzaei
- 48538Zahedan University of Medical Sciences, Zahedan, Iran
| | | | - Ida Milani
- 48538Zahedan University of Medical Sciences, Zahedan, Iran
| | - Nader Cohan
- Shiraz University of Medical Sciences, Shiraz, Iran
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10
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Yan J, Wu Y, Liao L, Xiang L, Qiu Y, Lin F. The β-chain mutation p.Trp433Stop impairs fibrinogen secretion: A novel nonsense mutation associated with hypofibrinogenemia. Int J Lab Hematol 2021; 43:1549-1556. [PMID: 34185392 DOI: 10.1111/ijlh.13632] [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: 12/08/2020] [Revised: 05/12/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congenital hypofibrinogenemia is characterized by proportional decreases in fibrinogen activity and immunoreactive fibrinogen levels. Here, we describe a new case with the bleeding risk identified in our hospital. METHODS The proband was cut and bled for 3 h. Coagulation testing, gene analysis, thrombelastogram, sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), in vitro plasmid construction, and functional analyses were performed to explore the pathogenic mechanism. RESULTS Coagulation testing of the male proband revealed low levels of fibrinogen detected by two methods (the Clauss method and the PT-derived method); his two sons had normal coagulation results. DNA sequencing of the proband revealed a heterozygous point mutation in exon 8 of the FGB gene causing Trp→Stop substitution and a polymorphic site (p.Leu92Phe). Human Trp433 was found to be highly conserved. SDS-PAGE showed that the fibrinogen level of the proband was markedly lower than that of healthy controls. Using high-performance liquid chromatography-mass spectrometry, a mutated Bβ chain was not detected in circulation. In vitro expression analyses indicated that the mutation affected the secretion of fibrinogen. The TEG results indicated that the proband had a prolonged K time, a lower CI value, and a lower angle value. CONCLUSION We report a new case with a novel nonsense mutation that resulted in hypofibrinogenemia. The results indicate that the nonsense mutation may cause misfolding of the D domain, which then affects the secretion of fibrinogen.
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Affiliation(s)
- Jie Yan
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yangyang Wu
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin Liao
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liqun Xiang
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yuling Qiu
- Department of Thalassemia Laboratory, Guangxi Medical University, Nanning, China
| | - Faquan Lin
- Department of Clinical Laboratory, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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11
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The association between coagulopathies such as thrombophilia or rare bleeding disorders with the development of gestational vascular complications. Blood Coagul Fibrinolysis 2021; 31:S25-S27. [PMID: 33351500 DOI: 10.1097/mbc.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The association between coagulopathies, more specifically thrombophilia, and the development of gestational vascular complications was established in the 1990s. Ever since, huge efforts have been invested into gaining a better understanding of the role played by clotting factors, both prothrombotic and hemorrhagic, in those complications, not least because hypertensive disorders and venous thromboembolism are among the most common causes of maternal mortality in the Western world.
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12
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Byrne B, Ryan K, Lavin M. Current Challenges in the Peripartum Management of Women with von Willebrand Disease. Semin Thromb Hemost 2021; 47:217-228. [PMID: 33636752 DOI: 10.1055/s-0041-1723797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For many women, pregnancy and childbirth represent their first major hemostatic challenges. Despite advancements in obstetric care, up to 2 to 5% of all deliveries are complicated by postpartum hemorrhage (PPH). To mitigate bleeding risk, physiological changes occur in pregnancy, including increases in plasma von Willebrand factor (VWF) and factor VIII levels. For women with von Willebrand disease (VWD), these physiological alterations are blunted or absent. As a result, women with VWD have a heightened risk of PPH, both primary (in the first 24 hours) and secondary (>24 hours to 6 to 12 weeks postpartum). Pregnancy and delivery management for women with VWD should therefore be carefully coordinated as part of a multidisciplinary team approach. In the absence of large-scale clinical trials, the management of women with VWD during pregnancy is guided by expert consensus guidelines. Clinical practices internationally are not uniform, and areas of considerable clinical uncertainty exist. Traditional peripartum plasma VWF thresholds for hemostatic cover and therapeutic targets are currently under scrutiny, as PPH is not eliminated in women with VWD who receive replacement therapy. The benefit and optimal duration of postpartum tranexamic acid have yet to be defined, and standardized methods of quantification of blood loss at the time of delivery are currently lacking. In this article, we review the evidence base to date and explore the current clinical challenges in the management of pregnant women with VWD.
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Affiliation(s)
- Bridgette Byrne
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin Ryan
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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13
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Casini A, Neerman-Arbez M, de Moerloose P. Heterogeneity of congenital afibrinogenemia, from epidemiology to clinical consequences and management. Blood Rev 2020; 48:100793. [PMID: 33419567 DOI: 10.1016/j.blre.2020.100793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/06/2020] [Accepted: 12/06/2020] [Indexed: 12/17/2022]
Abstract
Fibrinogen is a complex protein playing a major role in coagulation. Congenital afibrinogenemia, characterized by the complete absence of fibrinogen, is associated with major hemostatic defects. Even though the clinical course is unpredictable and can be completely different among patients, severe bleeding is the prominent symptom. Patients are also at increased risk of thrombosis and sometimes suffer from spontaneous spleen rupture, bone cysts and defective wound healing. Due to the relative rarity of afibrinogenemia, there are no evidence-based strategies for helping physicians in care of these patients. Fibrinogen supplementation is the keystone to prevent or treat bleeding events. In addition, fibrinogen, a pleiotropic protein with numerous physiological roles in immunity, angiogenesis and tissue repair, is involved in many diseases. Indeed, depletion of fibrinogen in animal models of infections, tumors and neurological diseases has an effect on the clinical course. The consequences for patients with afibrinogenemia still need to be investigated.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, 1 Rue Michel Servet, 1211 Geneva, Switzerland.
| | - Philippe de Moerloose
- Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
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14
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Wheeler AP, Hemingway C, Gailani D. The clinical management of factor XI deficiency in pregnant women. Expert Rev Hematol 2020; 13:719-729. [PMID: 32437625 DOI: 10.1080/17474086.2020.1772745] [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] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Factor XI (FXI) deficiency is associated with highly variable bleeding, including excessive gynecologic and obstetrical bleeding. Since approximately 20% of FXI-deficient women will experience pregnancy-related bleeding, careful planning and knowledge of appropriate hemostatic management is pivotal for their care. AREAS COVERED In this manuscript, authors present our current understanding of the role of FXI in hemostasis, the nature of the bleeding phenotype caused by its deficiency, and the impact of deficiency on obstetrical care. The authors searched PubMed with the terms, 'factor XI', 'factor XI deficiency', 'women', 'pregnancy', and 'obstetrics' to identify literature on these topics. Expectations of pregnancy-related complications in women with FXI deficiency, including antepartum, abortion-related, and postpartum bleeding, as well as bleeding associated with regional anesthesia are discussed. Recommendations for the care of these women are considered, including guidance for management of prophylactic care and acute bleeding. EXPERT COMMENTARY FXI deficiency results in a bleeding diathesis in some, but not all, patients, making treatment decisions and clinical management challenging. Currently available laboratory assays are not particularly useful for distinguishing patients with FXI deficiency who are prone to bleeding from those who are not. There is a need for alternative testing strategies to address this limitation.
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Affiliation(s)
- Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University , Nashville, TN, USA
| | - Celeste Hemingway
- Department of Obstetrics and Gynecology, Vanderbilt University , Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA
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Comparison of clinical phenotype with genetic and laboratory results in 31 patients with congenital dysfibrinogenemia in northern Slovakia. Int J Hematol 2020; 111:795-802. [PMID: 32166693 DOI: 10.1007/s12185-020-02842-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
Congenital dysfibrinogenemia (CD) is a rare disorder of hemostasis. The majority of cases are caused by heterozygous missense mutations in one of the three fibrinogen genes. Patients with CD may experience bleeding and thrombosis, but many are asymptomatic. To better describe the clinical, laboratory, and genotypic picture of CD, we evaluated 31 patients from seven unrelated families using standard coagulation tests and genetic analysis. The clinical phenotype consisted of bleeding in 13/31 (42%) patients; other patients (18/31; 58%) were asymptomatic. Among patients with bleeding, symptoms were mostly in single anatomical sites, with variable intensity of bleeding. Compared to results from a previous large systematic survey, our results showed a similar mean bleeding score, but a higher incidence of bleeding episodes without thrombotic complications. In the present study, we identified three known pathogenic point mutations in the FGA (c.95G > A, c.104G > A) and FGB (c.586C > T) genes. The variants of CD identified in this cross-sectional study were either asymptomatic or had bleeding manifestations and showed similar laboratory features, irrespective of genotype. Results from genetic and clinical studies will continue to yield valuable information on the structure and function of the fibrinogen molecule.
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Winikoff R, Scully MF, Robinson KS. Women and inherited bleeding disorders - A review with a focus on key challenges for 2019. Transfus Apher Sci 2019; 58:613-622. [PMID: 31582329 DOI: 10.1016/j.transci.2019.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The area of women and inherited bleeding disorders has undergone quick expansion in recent years. More patients are being identified and expertise to diagnose and manage these patients is now essential for practising physicians. Programs to help educate and empower patients and caregivers are now in place. Common inherited bleeding disorders affecting women include von Willebrand disease (VWD), inherited platelet disorders, and rare inherited bleeding disorders such as factor VII (FVII) deficiency and factor XI (FXI) deficiency. Specific clinical tools have been developed to help clinicians and patients screen for the presence of these bleeding disorders in both adult and pediatric populations. Affected women can experience heavy menstrual bleeding and resulting iron deficiency anemia, postpartum hemorrhage, and hemorrhagic ovarian cysts which need to be properly managed. Excessive bleeding can adversely affect quality of life in these women. Front line therapy for bleeding in mild cases focuses on the use of non-specific hemostatic agents such as DDAVP ®, tranexamic acid and hormonal agents but specific factor replacement and/or blood products may be required in more severe cases, in severe bleeding or as second line treatment when bleeding is not responsive to first line agents. Iron status should be optimised in these women especially in pregnancy and use of an electronic app can now help clinicians achieve this. These patients should ideally be managed by a multidisciplinary team whenever possible even remotely. Although clinical research has closed some knowledge gaps regarding the diagnosis and management of these women, there remains significant variation in practise and lack of evidence-based guidelines still exists in many spheres of clinical care in which caregivers must rely on expert opinion. Ongoing efforts in education and research will continue to improve care for these women and restore quality of life for them.
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Affiliation(s)
- R Winikoff
- Division of Hematology-Oncology, Sainte-Justine University Hospital Center, Montréal, QC, Canada
| | - M F Scully
- Department of Medicine, Memorial University of Newfoundland Medical School, NL, Canada.
| | - K S Robinson
- Division of Hematology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Department of Medicine, Halifax, NS, Canada.
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Abstract
Factor VII (FVII) deficiency is the most common of the Rare Inherited Coagulation Disorders. The inheritance is autosomal recessive but there is variable penetrance. Overall there is poor correlation between the FVII level and the bleeding phenotype. Heterozygotes may have significant bleeding and severe homozygotes, or compound heterozygotes can be asymptomatic. Typically, homozygotes have FVII levels <10% and heterozygotes have levels above that. In most cases bleeding is uncommon with FVII levels>10-20%. A personal and family history is essential to determine the bleeding risk and to plan for surgical and obstetrical prophylaxis. Severe bleeding complications including central nervous system bleeding, gastrointestinal system bleeding and bleeding into the joints occurs in 10-15% of FVII deficient patients. Mucocutaneous bleeding is a common symptom but 30% of patients are asymptomatic. Fifty to 69% of women have heavy menstrual bleeding. Due to the limited number of publications regarding this rare disorder there are no consensus guidelines. There is registry data which has led to the best recommendations for treatment of bleeding episodes, initiation of long-term prophylaxis in addition to surgical plus ante and peripartum prophylaxis. Recombinant FVII concentrate is the best replacement therapy and a review of treatment and prophylaxis dosing is discussed.
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Affiliation(s)
- K Sue Robinson
- Division of Hematology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Department of Medicine, Rm. 416, 4th Floor Bethune Bldg, 1276 South Park St., Halifax, NS, B3H 2Y9, Canada.
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18
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Shapiro A. The use of prophylaxis in the treatment of rare bleeding disorders. Thromb Res 2019; 196:590-602. [PMID: 31420204 DOI: 10.1016/j.thromres.2019.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
Abstract
Rare bleeding disorders (RBDs) are a heterogeneous group of coagulation factor deficiencies that include fibrinogen, prothrombin, α2-antiplasmin, plasminogen activator inhibitor-1, and factors II, V, V/VIII, VII, X, XI and XIII. The incidence varies based upon the disorder and typically ranges from 1 in 500,000 to 1 per million population. Symptoms vary with the disorder and residual level of the clotting factor, and can range from relatively minor such as epistaxis, to life threatening, such as intracranial hemorrhage. Rapid treatment of bleeding episodes in individuals with severe bleeding phenotypes is essential to preserve life or limb and to prevent long-term sequelae; therapeutic options depend on the deficiency and range from plasma-derived (eg, fresh frozen plasma, prothrombin complex concentrates, factor X concentrate) to highly purified and recombinant single factor concentrates. The rarity of these disorders limits the feasibility of conventional prospective clinical trials; instead, clinicians rely upon registries, published case reports/series and experience to guide treatment. In some disorders, long-term prophylactic therapy is administered in response to the bleeding phenotype in an individual patient or based on the known natural history and severity of the deficiency. Intermittent prophylaxis, surrounding surgery, pregnancy, labor, and menstruation may be required to prevent or control excessive bleeding. This review summarizes therapeutic options, guidelines, recommendations and observations from the published literature for long-term, surgical, gynecological, and obstetric prophylaxis in deficiencies of fibrinogen; prothrombin; factors II, V, V/VIII, VII, X, XI and XIII; combined vitamin-K dependent factors; α2-antiplasmin; and plasminogen activator inhibitor 1. Platelet disorders including Glanzmann's thrombasthenia and Bernard-Soulier syndrome are also addressed.
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Affiliation(s)
- Amy Shapiro
- Indiana Hemophilia & Thrombosis Center, 8326 Naab Rd., Indianapolis, IN 46260, USA.
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19
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Drzymalski DM, Elsayes AH, Ward KR, House M, Manica VS. Platelet transfusion as treatment for factor V deficiency in the parturient: a case report. Transfusion 2019; 59:2234-2237. [DOI: 10.1111/trf.15322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/20/2019] [Accepted: 03/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Dan M. Drzymalski
- Department of Anesthesiology and Perioperative MedicineTufts Medical Center Boston Massachusetts
- Tufts University School of Medicine Boston Massachusetts
| | - Ali H. Elsayes
- Department of Anesthesiology and Perioperative MedicineTufts Medical Center Boston Massachusetts
| | | | - Michael House
- Department of Anesthesiology and Perioperative MedicineTufts Medical Center Boston Massachusetts
| | - Virgil S. Manica
- Department of Anesthesiology and Perioperative MedicineTufts Medical Center Boston Massachusetts
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20
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Treatment of rare factor deficiencies other than hemophilia. Blood 2018; 133:415-424. [PMID: 30559262 DOI: 10.1182/blood-2018-06-820738] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/18/2018] [Indexed: 12/18/2022] Open
Abstract
The deficiency of fibrinogen, prothrombin, factor V (FV), FVII, FVIII, FIX, FX, FXI, and FXIII, called rare coagulation disorders (RCDs), may result in coagulopathies leading to spontaneous or posttrauma and postsurgery hemorrhages. RCDs are characterized by a wide variety of symptoms, from mild to severe, which can vary significantly from 1 disease to another and from 1 patient to another. The most typical symptoms of all RCDs are mucosal bleedings and bleeding at the time of invasive procedures, whereas other life-threatening symptoms such as central nervous system bleeding and hemarthroses are mostly present only in some deficiencies (afibrinogenemia, FX, and FXIII). At variance with hemophilia A and B and von Willebrand disease, RCDs are much less prevalent, ranging from 1 case in 500 000 to 1 in 2 million in the general population. Their clinical heterogeneity associated with the low number of patients has led to a delay in the development of appropriate therapies. Indeed, a similar heterogeneity can also be found in the treatment products available, ranging from the specific recombinant proteins to treat FVII- and FXIII-deficient patients to the complete absence of specific products to treat patients with FII or FV deficiencies, for whom prothrombin complex concentrates or fresh frozen plasma are, to date, the only option. The recent development of novel hemostatic approaches for hemophilia, such as the use of nonsubstitutive therapy as RNA interference, anti-tissue factor pathway inhibitor, and the gene therapy aimed at improving the patient's quality of life may also have an important role in the treatment of patients with RCDs in the future.
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21
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The impact of antenatal factor XIII levels on postpartum haemorrhage: a prospective observational study. Arch Gynecol Obstet 2018; 299:421-430. [DOI: 10.1007/s00404-018-4980-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/16/2018] [Indexed: 12/19/2022]
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Franchini M, Marano G, Pupella S, Vaglio S, Masiello F, Veropalumbo E, Piccinini V, Pati I, Catalano L, Liumbruno GM. Rare congenital bleeding disorders. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:331. [PMID: 30306070 DOI: 10.21037/atm.2018.08.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The rare congenital bleeding disorders are a heterogeneous group of diseases which include deficiencies of fibrinogen, prothrombin and factors V, V + VIII, VII, X, XI and XIII. They are usually transmitted as autosomal recessive disorders, and the prevalence of the severe forms ranges from one case in 500,000 for factor VII up to one in 2,000,000 for factor XIII in the general population. Patients with rare congenital bleeding disorders may have a broad spectrum of clinical symptoms, ranging from mucocutaneous bleeding to life-threatening haemorrhages, such as those occurring in the central nervous system. The treatment of these disorders is based principally on the replacement of the deficient factor using, when available, specific plasma-derived or recombinant products. The aim of this narrative review is to summarise current knowledge about these rare bleeding conditions.
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Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy.,Department of Haematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Vanessa Piccinini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Liviana Catalano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Abstract
: Severe form of haemophilia in women is an extremely rare condition. Owing to the rarity of the disease there are no precise recommendations concerning the optimal management of pregnancy and delivery in these patients. We are reporting the clinical course and management of a 30-year-old woman with a severe form of haemophilia A (factor VIII <1 IU/dl) during her first pregnancy and delivery. Antepartum, she was treated on demand by FVIII concentrate and she delivered at 37 weeks of gestation by cesarean section. In postpartal period an excellent control of bleeding was obtained by regularly administering FVIII concentrate for several days as well by concomitant use of tranexamic acid and oral contraceptive pills in the next 6 weeks.
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24
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Preeclampsia in a factor XI deficient woman: discussion about one case. Blood Coagul Fibrinolysis 2017; 28:423-424. [PMID: 28704253 DOI: 10.1097/mbc.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Napolitano M, Di Minno MND, Batorova A, Dolce A, Giansily-Blaizot M, Ingerslev J, Schved JF, Auerswald G, Kenet G, Karimi M, Shamsi T, Ruiz de Sáez A, Dolatkhah R, Chuansumrit A, Bertrand MA, Mariani G. Women with congenital factor VII deficiency: clinical phenotype and treatment options from two international studies. Haemophilia 2016; 22:752-9. [PMID: 27338009 DOI: 10.1111/hae.12978] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 12/01/2022]
Abstract
INTRODUCTION A paucity of data exists on the incidence, diagnosis and treatment of bleeding in women with inherited factor VII (FVII) deficiency. AIM Here we report results of a comprehensive analysis from two international registries of patients with inherited FVII deficiency, depicting the clinical picture of this disorder in women and describing any gender-related differences. METHODS A comprehensive analysis of two fully compatible, international registries of patients with inherited FVII deficiency (International Registry of Factor VII deficiency, IRF7; Seven Treatment Evaluation Registry, STER) was performed. RESULTS In our cohort (N = 449; 215 male, 234 female), the higher prevalence of mucocutaneous bleeds in females strongly predicted ensuing gynaecological bleeding (hazard ratio = 12.8, 95% CI 1.68-97.6, P = 0.014). Menorrhagia was the most prevalent type of bleeding (46.4% of patients), and was the presentation symptom in 12% of cases. Replacement therapies administered were also analysed. For surgical procedures (n = 50), a receiver operator characteristic analysis showed that the minimal first dose of rFVIIa to avoid postsurgical bleeding during the first 24 hours was 22 μg kg(-1) , and no less than two administrations. Prophylaxis was reported in 25 women with excellent or effective outcomes when performed with a total weekly rFVIIa dose of 90 μg kg(-1) (divided as three doses). CONCLUSION Women with FVII deficiency have a bleeding disorder mainly characterized by mucocutaneous bleeds, which predicts an increased risk of ensuing gynaecological bleeding. Systematic replacement therapy or long-term prophylaxis with rFVIIa may reduce the impact of menorrhagia on the reproductive system, iron loss and may avoid unnecessary hysterectomies.
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Affiliation(s)
- M Napolitano
- Haematology Unit, Thrombosis and Hemostasis Reference Regional Center, University of Palermo, Palermo, Italy.
| | - M N D Di Minno
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - A Batorova
- The National Haemophilia Centre, Institute of Haematology and Blood Transfusion, School of Medicine of Comenius University, University Hospital, Bratislava, Slovakia
| | - A Dolce
- National Institute of Statistics, Palermo, Italy
| | | | - J Ingerslev
- Centre for Haemophilia & Thrombosis, University Hospital Skejby, Aarhus, Denmark
| | - J-F Schved
- Laboratory of Haematology, University Hospital, Montpellier, France
| | - G Auerswald
- Klinikum Bremen-Mitte, Prof.-Hess Kinderklinik, Bremen, Germany
| | - G Kenet
- National Hemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Karimi
- Haematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - T Shamsi
- National Institute of Blood Diseases & Bone Marrow Transplantation, Karachi, Pakistan
| | - A Ruiz de Sáez
- Centro Nacional de Hemophilia, Banco Municipal de Sangre, Caracas, Venezuela
| | - R Dolatkhah
- Haematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - A Chuansumrit
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lavee O, Kidson-Gerber G. Update on inherited disorders of haemostasis and pregnancy. Obstet Med 2016; 9:64-72. [PMID: 27512496 PMCID: PMC4950409 DOI: 10.1177/1753495x15624307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/30/2015] [Indexed: 12/18/2022] Open
Abstract
Inherited bleeding disorders have the potential to cause bleeding complications during pregnancy, childbirth and the postpartum period as well as effect fetal outcomes. There is an evolving understanding of the need for specialised and individualised care for affected women during these times. The aim for each patient is to estimate the risk to mother, fetus and neonate; to implement measures to minimise these risks; and to anticipate complications and develop contingencies for these scenarios. This includes accurate diagnosis, preconceptual care, prenatal diagnostic options, antenatal care, delivery and postpartum care as well as care of an affected neonate. An understanding of the physiologic haemostatic changes associated with pregnancy as well as the scope of defects, inheritance and management of inherited bleeding disorders is paramount when caring for these women. Collaborative and prospective management in conjunction with haematology services underpins the approach advocated. This review draws on the available literature, and outlines the principles of care for women with inherited bleeding disorders before, during and after pregnancy, as well as their babies, based on both available data and collective clinical experience.
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Affiliation(s)
- Orly Lavee
- Department of Haematology, South Eastern Sydney Local Health District, Prince of Wales Hospital, New South Wales, Australia
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30
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Miscarriage and recurrent miscarriage in patients with congenital factor V deficiency: a report of six cases in Iran. Int J Hematol 2016; 103:673-5. [DOI: 10.1007/s12185-016-1981-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 12/19/2022]
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Management of Labour and Delivery in a Patient With Acquired Factor VII Deficiency With Inhibitor: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:160-3. [PMID: 27032741 DOI: 10.1016/j.jogc.2015.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/02/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acquired factor VII (FVII) deficiency with inhibitor increases the risk of hemorrhage during pregnancy. However, there are no published reports guiding its management in the peripartum period. CASE A 24-year-old woman with inhibitory antibodies to FVII delivered at 34 weeks of gestation. The patient was administered recombinant factor VIIa (rFVIIa) and tranexamic acid. There were no bleeding-related complications; however, the FVII level was supratherapeutic. The patient returned during a second pregnancy. A reduced dose of rFVIIa was administered. The delivery was complicated by postpartum hemorrhage, which resolved with the addition of uterotonic agents. CONCLUSION Recombinant FVIIa and tranexamic acid offer an effective peripartum treatment in women with inhibitory antibody to FVII. Further research should delineate the optimal time of administration.
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A case of congenital prothrombin deficiency and idiopathic thrombocytopenic purpura in a pregnant female. Blood Coagul Fibrinolysis 2016; 28:100-101. [PMID: 26886363 DOI: 10.1097/mbc.0000000000000534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hereditary prothrombin deficiency is an autosomal recessive disorder with an estimated incidence of 1 in 2 million . Presentation of the disease is variable; however, it is usually associated with moderate to severe bleeding tendencies including muscle hematomas, hemarthrosis, intracranial, mucosal, and postoperative bleeding. Here we report a case of a 35-year-old pregnant woman with congenital hypoprothrombinemia and idiopathic thrombocytopenic purpura, review the literature, and discuss its epidemiology, presentation, diagnosis, and treatment.
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Behboudi-Gandevani S, Moghaddam-Banaem L, Shahbazi S, Ekhtesari F. Maternal rare inherited bleeding disorders and neonatal complications. J Obstet Gynaecol Res 2015; 42:172-7. [PMID: 26627666 DOI: 10.1111/jog.12884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 08/13/2015] [Accepted: 09/08/2015] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to examine the association between maternal inherited bleeding disorders and neonatal complications. MATERIAL AND METHODS This was a historical cohort study. The rare inherited bleeding disorders (RIBD) group consisted of a total of 100 women suffering from inherited bleeding disorders, aged 20-45 years who experienced pregnancy. In the healthy control group, 200 age- and body mass index-matched women were selected. Details of demographic and obstetric characteristics of the samples in both groups were collected using their medical records. RESULTS The mean ages of the women in the RIBD and healthy control groups were 32.6 (7.07) and 32.4 (7.3) years, respectively. No statistically significant differences were found in terms of age and other demographic characteristics of the women between the groups. The mean neonatal birthweight in the RIBD group was statistically lower than that in the healthy control group, 3018.2 (546.9) g vs. 3299.4 (456.8) g, respectively (P = 0.021). The prevalence of low birthweight in the RIBD group was statistically higher in comparison to that in the healthy control group (P = 0.041). After adjustment for potential confounders, it was found that maternal bleeding disorder had significant negative effects on birthweight in newborns (odds ratio, 1.05; 95% confidence interval, 1.01-3.43, P = 0.001). Those infants were statistically more likely to experience head bleeding, early hyperbilirubinemia and hospitalization than the healthy group (P = 0.001). CONCLUSIONS Maternal rare inherited bleeding disorders may have a devastating consequence for neonates.
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Affiliation(s)
- Samira Behboudi-Gandevani
- Reproductive Endocrine Research Center, Research Institute of Endocrine Science, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Lida Moghaddam-Banaem
- Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Shirin Shahbazi
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Ekhtesari
- Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Dysfibrinogenemia in a patient undergoing artificial abortion after misdiagnosis and review of the literature. Clin Chim Acta 2015; 447:86-9. [DOI: 10.1016/j.cca.2015.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 05/31/2015] [Accepted: 06/02/2015] [Indexed: 12/14/2022]
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Casini A, Neerman-Arbez M, Ariëns RA, de Moerloose P. Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management. J Thromb Haemost 2015; 13:909-19. [PMID: 25816717 DOI: 10.1111/jth.12916] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Indexed: 12/14/2022]
Abstract
Congenital dysfibrinogenemia is a qualitative congenital fibrinogen disorder characterized by normal antigen levels of a dysfunctional fibrinogen. The diagnosis is usually based on discrepancies between fibrinogen activity and antigen levels, but could require more specialized techniques for the assessment of fibrinogen function, owing to some limitations in routine assays. Molecular abnormalities, which are frequently heterozygous missense mutations localized in exon 2 of FGA and exon 8 of FGG, lead to defects in one or more phases of fibrinogen to fibrin conversion, fibrin network formation, and other important functions of fibrinogen. The clinical phenotype is highly heterogeneous, from no manifestations to bleeding and/or thrombotic events. Asymptomatic propositi and relatives with the predisposing genotype are at risk of developing adverse outcomes during the natural course of the disease. Correlations between genotype and phenotype have not yet been clearly established, with the exception of some abnormal fibrinogens that severely increase the risk of thrombosis. Functional analysis of polymerization and fibrinolysis, structural studies of the fibrin network and the viscoelastic properties of fibrin clot could help to predict the phenotype of congenital dysfibrinogenemia, but have not yet been evaluated in detail. The management is essentially based on personal and family history; however, even individuals who are still asymptomatic and without a family history should be carefully assessed and monitored. Particular situations, such as pregnancy, delivery, and surgery, require a multidisciplinary approach.
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Affiliation(s)
- A Casini
- Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - R A Ariëns
- Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine and Multidisciplinary Cardiovascular Research Centre, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - P de Moerloose
- Angiology and Hemostasis Division, University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Fournet-Fayard A, Lebreton A, Ruivard M, Storme B, Godeau B, Bonnin M, Delabaere A, Gallot D. Prise en charge anténatale des patientes à risque d’hémorragie du post-partum (hors anomalies de l’insertion placentaire). ACTA ACUST UNITED AC 2014; 43:951-65. [DOI: 10.1016/j.jgyn.2014.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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38
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Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, Mainwaring J, Mathias M, O'Connell N. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors' Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol 2014; 167:304-26. [PMID: 25100430 DOI: 10.1111/bjh.13058] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
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39
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Successful Pregnancy in a Patient with Combined Deficiency of Factor V and Factor VIII. Case Rep Obstet Gynecol 2014; 2014:343717. [PMID: 24883216 PMCID: PMC4026874 DOI: 10.1155/2014/343717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 01/08/2014] [Indexed: 11/29/2022] Open
Abstract
Inherited combined factor V and factor VIII deficiency (F5F8D) is autosomal recessive transmission disorder. Epistaxis, postsurgical bleeding, and menorrhagia are the most common symptoms. The risk of miscarriage and placental abruption is consequent. We report a case of successful pregnancy in a patient with F5F8D. 20-year-old woman, born of consanguineous parents, third gestate, first parity, two miscarriages, admitted for child birth of a spontaneous pregnancy estimated at 38 weeks and was diagnosed with F5F8D. At admission, patient was hemodynamically stable, with good obstetric conditions. The biologic results showed low levels of PT (52%), factor V (7%), and factor VIII (5%), and the activated partial thromboplastin time was prolonged (68,6%). Parturient was admitted in intensive care unit, maternal and fetal monitoring was performed. Fresh frozen plasma (FFP) and factor VIII concentrates were perfused at the induction of labor. Analgesia used fentanyl titration. The delivery gave birth to a newborn male, with Apgar 10/10 and 3000 g. The puerperium was simple without any important bleeding. Laboratory tests for the newborn were acceptable. Little literature is available on this subject and there are no guidelines available concerning pregnancy; we chose to prescribe a combination of factor VIII concentrate and FFP in pre-, per- and postpartum. The same protocol was successfully used in a patient before dental extraction and prostatectomy. Vaginal delivery is possible, as our case. Management by multidisciplinary team is recommended.
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Vaida S, Al-Mondhiry H, Bezinover D, Welsh L, Ural S, Janicki P. Peripartum anesthetic management of a parturient with inherited factor v deficiency. A & A CASE REPORTS 2013; 1:86-88. [PMID: 25612185 DOI: 10.1097/acc.0b013e31829ec0b7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Inherited Factor V deficiency is a rare bleeding disorder. We describe the genetic analysis and anesthetic management of a parturient with severe Factor V deficiency who presented in spontaneous labor. Good hemostatic conditions were obtained with prophylactic fresh frozen plasma administration of 10 mL/kg. Detailed genetic analysis by next-generation sequencing identified several relevant mutations in the coding part of the Factor V (F5) gene in our patient, her parents, and the newborn.
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Affiliation(s)
- Sonia Vaida
- From the Department of Anaesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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41
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Baumann Kreuziger LM, Morton CT, Reding MT. Is prophylaxis required for delivery in women with factor VII deficiency? Haemophilia 2013; 19:827-32. [PMID: 23607277 PMCID: PMC3769463 DOI: 10.1111/hae.12167] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2013] [Indexed: 12/11/2022]
Abstract
Factor VII (fVII) deficiency is a rare congenital bleeding disorder in which fVII activity level and bleeding tendency do not completely correlate. Pregnancy and delivery present a significant haemostatic challenge to women with fVII deficiency. Treatment with recombinant factor VIIa (rfVIIa) carries a thrombotic risk and the literature is not clear whether prophylaxis is necessary prior to delivery. The aim of this study was to define management, haemorrhagic and thrombotic complications of pregnant women with fVII deficiency through a systematic review. Medical databases (PubMed, MEDLINE, CINAHL, Academic Search Premier, Cochrane Library, Web of Science and Scopus) were searched using "factor VII deficiency" and "pregnancy" or "surgery." Overall 34 articles, four abstracts, and three institutional cases were reviewed. Literature from 1953 to 2011 reported 94 live births from 62 women with fVII deficiency. The median fVII activity was 5.5%. Haemostatic prophylaxis was used in 32% of deliveries. Without prophylaxis, 40 vaginal deliveries and 16 caesarean sections were completed. The odds of receiving prophylaxis were 2.9 times higher in women undergoing caesarean section compared to vaginal delivery. Post-partum haemorrhage occurred in 10% of deliveries with prophylaxis and 13% of deliveries without prophylaxis. The fVII level did not significantly differ between women who did and did not receive prophylaxis. We present the only systematic review of the management of pregnancy in fVII deficient women. No difference in post-partum haemorrhage was seen in deliveries with and without prophylaxis. Therefore, we recommend that rfVIIa be available in the case of haemorrhage or surgical intervention, but not as mandatory prophylaxis.
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Affiliation(s)
- Lisa M. Baumann Kreuziger
- University of Minnesota, Division of Hematology, Oncology, and Transplantation, Mayo Mail Code 480, 420 Delaware St. S.E., Minneapolis, MN, USA 55455
| | - Colleen T. Morton
- Regions Hospital, Department of Hematology and Oncology, 640 Jackson Street, St. Paul, MN 55101
| | - Mark T. Reding
- University of Minnesota, Division of Hematology, Oncology, and Transplantation, Mayo Mail Code 480, 420 Delaware St. S.E., Minneapolis, MN, USA 55455
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Hoffmann C, Falzone E, Mihai A, Gitz L, Itzhar-Baikian N, Martel-Jacob S, Mercier F. Combined factor V and VIII deficiency and pregnancy – Need for an early protocol-based multidisciplinary management. ACTA ACUST UNITED AC 2013; 32:e163-5. [DOI: 10.1016/j.annfar.2013.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/20/2013] [Indexed: 12/20/2022]
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Kakade A, Panchanadikar T, Kulkarni Y. Rare case of combined factor V and factor X deficiency in pregnancy: presenting as secondary postpartum haemorrhage in first pregnancy and successful outcome in second pregnancy. Obstet Med 2013; 6:134-135. [PMID: 27708707 DOI: 10.1258/om.2012.110094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Isolated factor V and factor X deficiency is a very rare condition affecting 1 in 500,000-1,000,000 persons worldwide. We present a rare first reported case of combined deficiency of factor V and factor X where the patient developed secondary postpartum haemorrhage in first pregnancy, after which she was diagnosed to have this rare disorder and her subsequent pregnancy was then successfully managed.
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Affiliation(s)
- Aniket Kakade
- Bharati Vidyapeeth University Medical College, Bharati Hospital & Research Center, Department of Obsetrics and Gynaecology , Pune, Maharashtra , India
| | - Tushar Panchanadikar
- Bharati Vidyapeeth University Medical College, Bharati Hospital & Research Center, Department of Obsetrics and Gynaecology , Pune, Maharashtra , India
| | - Yashwant Kulkarni
- Bharati Vidyapeeth University Medical College, Bharati Hospital & Research Center, Department of Obsetrics and Gynaecology , Pune, Maharashtra , India
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Cutler J, Chappell LC, Kyle P, Madan B. Third trimester amniocentesis for diagnosis of inherited bleeding disorders prior to delivery. Haemophilia 2013; 19:904-7. [DOI: 10.1111/hae.12247] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2013] [Indexed: 11/29/2022]
Affiliation(s)
- J. Cutler
- Molecular Haemostasis and Thrombosis Laboratory; GSTS Pathology; London UK
| | - L. C. Chappell
- Women's Health Academic Centre; King's College London and King's Health Partners; London UK
| | - P. Kyle
- Fetal Medicine Unit; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - B. Madan
- The Centre for Haemostasis and Thrombosis; Guy's and St Thomas' NHS Foundation Trust; London UK
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45
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Younesi MR, Aligoudarzi SL. Successful delivery in patients with severe congenital factor V deficiency: a study of five homozygous patients. Haemophilia 2013; 19:e318-20. [DOI: 10.1111/hae.12210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2013] [Indexed: 11/26/2022]
Affiliation(s)
- M. R. Younesi
- Hematology Department; Allied Medical School; Tehran University of Medical Sciences; Tehran; Iran
| | - S. L. Aligoudarzi
- Hematology Laboratory; Hematology Oncology Ward; Shariati Hospital; Tehran; Iran
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Sharma V, Khalid A, Cohen AJ. Management of pregnancy in a patient with severe hemophilia type a. AJP Rep 2013; 3:29-32. [PMID: 23943706 PMCID: PMC3699150 DOI: 10.1055/s-0032-1331376] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 08/10/2012] [Indexed: 11/21/2022] Open
Abstract
Hemophilia type A is a rare inherited bleeding disorder with a diversity of clinical manifestations ranging from persistent bleeding after minor trauma, spontaneous deep muscle or joint hemorrhage, to intracranial hemorrhage. As an X-linked disorder, hemophilia is rare in females and therefore there is little experience with pregnancy and no standardized guidelines to prevent bleeding antepartum, at delivery, and postpartum. We report the clinical course and management of a woman with severe hemophilia A who on two occasions had uncomplicated pregnancies and vaginal deliveries at term utilizing bolus recombinant factor VIII concentrate.
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Affiliation(s)
- Vipra Sharma
- Department of Hematology Oncology, Newark Beth Israel Medical Center, Newark, New Jersey
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48
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Bonhomme F, Schved JF, Giansily-Blaizot M, Samama CM, de Moerloose P. Déficits rares de la coagulation et gestes invasifs. ACTA ACUST UNITED AC 2013; 32:198-205. [DOI: 10.1016/j.annfar.2013.01.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/21/2013] [Indexed: 12/20/2022]
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49
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50
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Combined factor V and VIII deficiency and pregnancy. Int J Hematol 2012; 96:786-8. [DOI: 10.1007/s12185-012-1201-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 09/28/2012] [Accepted: 10/01/2012] [Indexed: 12/19/2022]
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