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Bakhsh E. Impact of Replacement Therapy on Pregnancy Outcomes in Hemophilia Carriers: A Historical Cohort Study in Saudi Arabia. Life (Basel) 2024; 14:623. [PMID: 38792643 PMCID: PMC11122275 DOI: 10.3390/life14050623] [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: 04/26/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
This retrospective cohort study evaluates the safety and efficacy of replacement therapy with regard to pregnancy outcomes in hemophilia carriers. Hemophilia carriers face elevated bleeding risks during pregnancy, necessitating meticulous management, including replacement therapy with clotting factors. This research examines the records of 64 pregnant hemophilia carriers at King Fahad Medical City, Riyadh, from January 2010 to December 2023, analyzing their demographic details, hemophilia type and severity, replacement therapy specifics, and pregnancy outcomes. The study found that 62.5% of the participants had hemophilia A, with 43.8% categorized as severe. Most subjects (87.5%) received recombinant factor VIII at a median dosage of 30 IU/kg weekly. Adverse pregnancy outcomes included gestational hypertension (15.6%), preterm labor (18.8%), and postpartum hemorrhage (12.5%). The cesarean section rate was 28.1%. Neonatal outcomes were generally favorable, with median birth weights at 3100 g and mean Apgar scores of 8.2 and 9.1 at 1 and 5 min, respectively. Logistic regression analysis revealed no significant association between adverse events and therapy type or dosage, though a trend towards significance was noted with once-weekly administration (p = 0.082). The study concludes that replacement therapy is a viable method for managing hemophilia in pregnant carriers, leading to generally favorable maternal and neonatal outcomes. However, it underscores the importance of individualized treatment plans and close monitoring to effectively manage the risks associated with hemophilia during pregnancy.
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Affiliation(s)
- Ebtisam Bakhsh
- Internal Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
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2
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Rodrigues-Martins D, Buchner G, Braga JS. Symptomatic haemophilia A: management during pregnancy and the postpartum period. BMJ Case Rep 2022; 15:e245474. [PMID: 34996767 PMCID: PMC8744121 DOI: 10.1136/bcr-2021-245474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/04/2022] Open
Abstract
As an X linked disorder, the presence of severe symptomatic haemophilia A is an extremely rare disorder in women. Therefore there are no high-level evidence-based guidelines when it comes to pregnancy. Although there have been advances in the fields of prenatal counselling and maternal-fetal care, the management of these gestations continues to embody a challenge for any medical team. We report the successful management of a pregnant woman with symptomatic haemophilia A, from pregnancy to the postpartum period. Our aim is to enhance knowledge on this topic, and further improve outcomes for these mothers and their offspring.
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Affiliation(s)
- Diana Rodrigues-Martins
- Department of Women and Reproductive Medicine, Centro Hospitalar Universitário do Porto EPE Centro Materno-Infantil do Norte Dr Albino Aroso, Porto, Portugal
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal
| | - Graça Buchner
- Department of Women and Reproductive Medicine, Centro Hospitalar Universitário do Porto EPE Centro Materno-Infantil do Norte Dr Albino Aroso, Porto, Portugal
| | - Jorge Sousa Braga
- Department of Women and Reproductive Medicine, Centro Hospitalar Universitário do Porto EPE Centro Materno-Infantil do Norte Dr Albino Aroso, Porto, Portugal
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How I manage pregnancy in carriers of hemophilia and patients with von Willebrand disease. Blood 2021; 136:2143-2150. [PMID: 32797211 DOI: 10.1182/blood.2019000964] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Women with inherited bleeding disorders, including carriers of hemophilia A and B, or with von Willebrand disease, have an increased risk of bleeding during pregnancy and delivery. The unborn child may also be affected by the bleeding disorder for which specific measures have to be considered. This requires a multidisciplinary approach, with a team that includes a hematologist, a pediatric hematologist, a clinical geneticist, an obstetrician-perinatologist, and an anesthesiologist. An optimal approach includes prepregnancy genetic counseling, prenatal diagnostic procedures, and a treatment plan for delivery for both the mother and child. Recent retrospective studies show that even if strict guidelines are followed, these women are still at risk of postpartum bleeding. This occurs even if coagulation factor levels are normalized, either due to the pregnancy-induced rise of factor levels or by infusion of coagulation factor concentrates at the time of delivery. In this article, we describe our current diagnostic and clinical management of pregnancy and delivery in women with inherited bleeding disorders. We also briefly discuss possible interventions to improve the outcome of current strategies by increasing target factor levels during and after delivery.
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Gandhi J, C McLean K, Gernander K, E Holmes C. Pregnancy outcomes in female carriers of haemophilia B Leyden. Br J Haematol 2020; 190:e261-e264. [PMID: 32562495 DOI: 10.1111/bjh.16887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jinal Gandhi
- Larner College of Medicine at University of Vermont, Burlington, Vermont, USA
| | - Kelley C McLean
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine at University of Vermont, Burlington, Vermont, USA
| | - Kelly Gernander
- Department of Hematology and Oncology, Larner College of Medicine at University of Vermont, Burlington, Vermont, USA
| | - Chris E Holmes
- Department of Hematology and Oncology, Larner College of Medicine at University of Vermont, Burlington, Vermont, USA
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Kulkarni R, Presley RJ, Lusher JM, Shapiro AD, Gill JC, Manco-Johnson M, Koerper MA, Abshire TC, DiMichele D, Hoots WK, Mathew P, Nugent DJ, Geraghty S, Evatt BL, Soucie JM. Complications of haemophilia in babies (first two years of life): a report from the Centers for Disease Control and Prevention Universal Data Collection System. Haemophilia 2016; 23:207-214. [PMID: 27813214 DOI: 10.1111/hae.13081] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 12/11/2022]
Abstract
AIM To describe the prevalence and complications in babies ≤2 years with haemophilia. METHODS We used a standardized collection tool to obtain consented data on eligible babies aged ≤2 years with haemophilia enrolled in the Centers for Disease Control and Prevention Universal Data Collection System surveillance project at US Hemophilia Treatment Centers (HTCs). RESULTS Of 547 babies, 82% had haemophilia A, and 70% were diagnosed within one month of birth. Diagnosis was prompted by known maternal carrier status (40%), positive family history (23%), bleeding (35%) and unknown 2%; 81% bled during the first two years. The most common events were bleeding (circumcision, soft tissue, oral bleeding) and head injury. There were 46 episodes of intracranial haemorrhage (ICH) in 37 babies (7%): 18 spontaneous, 14 delivery related, 11 traumatic, 2 procedure related and 1 unknown cause. Of the 176 central venous access devices (CVADs) in 148 (27%) babies, there were 137 ports, 22 surgically inserted central catheters and 20 peripherally inserted central catheters. Ports had the lowest complication rates. Inhibitors occurred in 109 (20%) babies who experienced higher rates of ICH (14% vs. 5%; P = 0.002), CVAD placement (61% vs. 19%; P < 0.001) and CVAD complications (44% vs. 26%; P < 0.001). The most common replacement therapy was recombinant clotting factor concentrates. CONCLUSION Bleeding events in haemophilic babies ≤2 years were common; no detectable difference in the rates of ICH by the mode of delivery was noted. Neonatal factor exposure did not affect the inhibitor rates. Minor head trauma, soft tissue and oropharyngeal bleeding were the leading indications for treatment.
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Affiliation(s)
- R Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI, USA
| | - R J Presley
- Division of Blood Disorders Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J M Lusher
- Department of Pediatric Hematology, Children's Hospital of Michigan Wayne State Medical Center, Detroit, MI, USA
| | - A D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - J C Gill
- Comprehensive Center for Bleeding Disorders, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - M Manco-Johnson
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - T C Abshire
- Blood Center of Wisconsin, Milwaukee, WI, USA
| | - D DiMichele
- Division of Blood Diseases and Resources, Bethesda, MD, USA
| | - W K Hoots
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - P Mathew
- Department of Pediatric Hematology/Oncology, University of New Mexico, Albuquerque, NM, USA
| | - D J Nugent
- Center for Inherited Blood Disorders, Children's Hospital of Orange County, Orange, CA, USA
| | - S Geraghty
- University of Colorado Denver, Aurora, CO, USA
| | - B L Evatt
- Division of Blood Disorders Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J M Soucie
- Division of Blood Disorders Centers for Disease Control and Prevention, Atlanta, GA, USA
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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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Palomo Bravo Á, Núñez R, Gutiérrez Pimentel MJ, Nieto MDM, Cos C, Pérez R. Haemophilia neonates: mode of delivery and perinatal complications. Haemophilia 2016; 22:e225-8. [PMID: 27029855 DOI: 10.1111/hae.12910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2016] [Indexed: 12/01/2022]
Affiliation(s)
| | - R Núñez
- Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - M D M Nieto
- Hospital Universitario Médico-Quirúrgico, Jaén, Spain
| | - C Cos
- Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - R Pérez
- Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Witmer CM. Low mortality from intracranial haemorrhage in paediatric patients with haemophilia. Haemophilia 2015; 21:e359-63. [DOI: 10.1111/hae.12716] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2015] [Indexed: 11/30/2022]
Affiliation(s)
- C. M. Witmer
- Division of Hematology; Departments of Pediatrics; Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
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Economou M, Banov L, Ljung R. Perinatal aspects of haemophilia. Eur J Haematol 2015; 76:21-5. [PMID: 24957104 DOI: 10.1111/ejh.12371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2014] [Indexed: 11/29/2022]
Abstract
Haemophilia is an X-linked recessive genetic disease of haemostasis. Women carriers may present with a bleeding tendency similar to milder forms of the disease. Haemophilic newborns present risk factors and patterns of bleeding that are challenging. Identification of carriers and genetic counselling before conception is considered optimal to help decide on available conception options and during pregnancy to help minimise bleeding risks for both carrier mother and affected baby. Preimplantation genetic diagnosis is attractive to many couples at risk of having a child with haemophilia and relevant technology is becoming more available although it has both practical and ethical limitations. Pregnancy in carriers should be managed by a multidisciplinary team in a comprehensive treatment centre. The optimal mode of delivery for carriers expecting a baby known to have or being at risk of haemophilia is an issue of great debate. The general consensus among authors is avoidance of instrumental delivery, foetal scalp electrodes and blood sampling in pregnancies at risk of carrying an affected foetus, as well as early recourse to Caesarean section as guided by obstetric indications. Intracranial haemorrhage, although infrequent, is one the most devastating types of bleeding in haemophilic newborns and can occur regardless of the mode of delivery or the severity of haemophilia. Early screening is proposed for all infants with severe or moderate haemophilia who have had traumatic delivery and/or have evidence of extracranial haemorrhage. Women with postpartum haemorrhage should have a bleeding work-up.
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Affiliation(s)
- Marina Economou
- 1st Pediatric Department, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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[Carriers of haemophilia: Experience of a French university hospital]. ACTA ACUST UNITED AC 2014; 44:565-76. [PMID: 25263159 DOI: 10.1016/j.jgyn.2014.08.009] [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: 04/11/2014] [Revised: 07/23/2014] [Accepted: 08/28/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To report the management of carriers of haemophilia in a French university hospital and assess different issues of these patients. PATIENTS AND METHODS Retrospective study of the carriers of haemophilia who consulted at the university hospital of Montpellier, France, between 1995 and 2011. Information were obtained from medical records and from a questionnaire sent to carriers. We recorded data about biological characteristics, bleeding tendency and management of pregnancies. RESULTS Sixty-four carriers of haemophilia A or B were included. Their median FVIII or FIX level was 52 % (range, 15-137 %). Menstrual bleeding lasted more than 7 days in 31 % of carriers. A total of 142 pregnancies started in 54 carriers, and 101 resulted in live births with 26 boys with haemophilia. Sixty-two prenatal diagnoses carried out, 15 have terminated their pregnancy because of a hemophiliac male fetus. Seventy-six percent of deliveries were vaginal delivery and 49 % took place in a level-3 maternity. There were 10.8 % and 8.5 % primary and secondary post-partum hemorrhage, respectively. CONCLUSION The risk of bleeding among carriers of haemophilia is associated with their antihemophilic factor level. To improve the management of carriers, a multidisciplinary and standardized medical record, with a specific questionnaire to evaluate bleedings, could be considered. A regional register that lists all carriers, regardless of their antihemophilic factor level, would also be useful.
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Fink S, Kunzmann S, Andres O, Eyrich M, Wiegering V. Haemophilia in extreme immature preterm infants: increased risk for intracranial haemorrhage? J Matern Fetal Neonatal Med 2013; 27:621-4. [PMID: 23865671 DOI: 10.3109/14767058.2013.825600] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Haemophiliacs and extremely premature infants are both at an increased risk for intracranial haemorrhage; both conditions might be further elevating the risk. We report a case of a very immature preterm-infant of 26 gestational weeks (birth weight 635 g) with severe haemophilia A. Furthermore, we provide an overview of the published literature on this subject matter. Until now, deficiency of factor VIII or IX as a potential risk factor for ICH in preterm infants remains controversial. However, prophylactic substitution of factor VIII or IX in preterm infants with haemophilia may minimize the risk of bleeding complications and neurologic sequelae.
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Affiliation(s)
- Susanne Fink
- University of Würzburg, Paediatric Intensive Care and Neonatology Unit, Children's Hospital , Germany and
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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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Diagnosis and treatment of intracranial hemorrhage in children with hemophilia. Blood Coagul Fibrinolysis 2013; 24:23-7. [DOI: 10.1097/mbc.0b013e32835975d6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Abstract
For the past 5 decades, the care for hemophilia patients has improved significantly to the point that a newborn with hemophilia living in a developed nation can expect to have a normal lifespan and a high quality of life. Despite this, there are several new challenges that the hemophilia community will face in the coming years. First, the hemophilia community will soon be challenged with adopting a variety of new agents into clinical practice. Second, the normalization of patients' lives as a result of improved treatment has led to new problem areas, including obese/overweight hemophiliacs and osteoporosis. In addition, although mortality rates are similar to those of the healthy population, morbidities such as hemophilic arthropathy still occur. Third, the cost of care continues to rise, both due to the development of expensive new therapies and to the costs of managing problems such as obesity and osteoporosis. Finally, most patients in the world with hemophilia receive little to no care and although this is an enormous challenge, it must be confronted. This review discusses some new challenges facing developing nations and their care for hemophilia patients. In summary, in hemophilia in the coming few years, several new challenges will need to be confronted.
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Management of pregnancy and delivery in women with inherited bleeding disorders. Semin Fetal Neonatal Med 2011; 16:311-7. [PMID: 21852211 DOI: 10.1016/j.siny.2011.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Women with inherited bleeding disorders present a wide spectrum of clinical symptoms that vary from mild or moderate bleeding tendency to severe episodes. Monthly haemostatic changes affect these women during menstruation and ovulation. These events may be associated with significant bleeding and pain leading to the limitations in conducting daily activities and adverse effect on quality of life. Likewise, pregnancy and delivery are critical times for affected women. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. In particular, recurrent miscarriage was observed in women with type 3 von Willebrand disease, afibrinogenaemia and severe factor XIII deficiency, and an optimal therapeutic plan is required during their pregnancy. Precautions must be taken at delivery in these women, since they could be at risk of bleeding. The lack of adequate information makes it very difficult to prepare evidence-based guidelines for the prevention of bleedings in affected women and their treatment. A multidisciplinary team of obstetricians, haematologists and paediatricians is required with a good knowledge of these disorders and an awareness of the potential maternal neonatal complications.
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Altisent C, Martorell M, Vidal F, Sánchez MA, Parra R. The optimal mode of delivery for the haemophilia carrier expecting an affected infant: further considerations. Haemophilia 2011; 17:818-9. [PMID: 21371199 DOI: 10.1111/j.1365-2516.2011.02505.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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