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Shima E, Go H, Maeda H, Ogasawara K, Imamura T, Sasaki M, Koh Y, Nollet KE, Ikeda K, Ohto H, Hosoya M. Down syndrome with neonatal alloimmune thrombocytopenia due to anti-HLA A31 and B61 antibodies. Int J Hematol 2021; 113:945-949. [PMID: 33569741 DOI: 10.1007/s12185-021-03092-z] [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: 09/15/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
Neonatal alloimmune thrombocytopenia (NAIT) arises from fetomaternal platelet incompatibility that results in transplacental passage of maternal antibodies mostly against fetal human platelet antigens (HPA), whereas NAIT due to anti-human leukocyte antigen (HLA) antibodies is extremely rare. Here, we report a case of Down syndrome (DS) with NAIT that was attributed to HLA antibodies. A boy with DS was delivered at 36 weeks' gestation. His platelet count declined to 13.0 × 109/L, suggestive of NAIT rather than other conditions, including transient abnormal myelopoiesis. Random platelet concentrates and intravenous immunoglobulin administration resolved the thrombocytopenia without clinical complications. Immunoserological investigations detected anti-HLA, but no anti-HPA antibodies in samples from the patient and the mother. HLA typing and cross-matching indicated that anti-HLA antibodies to paternal HLA A31 and B61, which had probably been induced during a prior pregnancy, led to NAIT in this case. Although it is a rare condition, healthcare providers should consider NAIT due to HLA antibodies and be vigilant for subsequent cases in DS.
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Affiliation(s)
- Eriko Shima
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Hayato Go
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Hajime Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
| | - Kei Ogasawara
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Takashi Imamura
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.,Department of Pediatrics, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Mutsumi Sasaki
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yangsook Koh
- Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Kenneth E Nollet
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kazuhiko Ikeda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Ohto
- Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
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2
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Reiher VS, Hönger G, Infanti L, Passweg JR, Hösli I, Frey BM, Gassner C, Meyer S, Buser AS, Holbro A, Schaub S. Human platelet antigen antibody induction in uncomplicated pregnancy is associated with HLA sensitization. Transfusion 2017; 57:1272-1279. [DOI: 10.1111/trf.14053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/15/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Affiliation(s)
| | - Gideon Hönger
- Transplantation Immunology and Nephrology, University Hospital Basel
| | - Laura Infanti
- Regional Blood Transfusion Service; Swiss Red Cross
- Division of Hematology; University Hospital Basel
| | | | - Irene Hösli
- Department for Obstetrics and Fetomaternal Medicine; University Hospital Basel; Basel Switzerland
| | - Beat M. Frey
- Regional Blood Transfusion Service; Swiss Red Cross Zürich Switzerland
| | - Christoph Gassner
- Regional Blood Transfusion Service; Swiss Red Cross Zürich Switzerland
| | - Stefan Meyer
- Regional Blood Transfusion Service; Swiss Red Cross Zürich Switzerland
| | - Andreas S. Buser
- Regional Blood Transfusion Service; Swiss Red Cross
- Division of Hematology; University Hospital Basel
| | - Andreas Holbro
- Regional Blood Transfusion Service; Swiss Red Cross
- Division of Hematology; University Hospital Basel
| | - Stefan Schaub
- Transplantation Immunology and Nephrology, University Hospital Basel
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3
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Skariah A, Sung N, Salazar Garcia MD, Wu L, Tikoo A, Gilman-Sachs A, Kwak-Kim J. Low-dose prednisone and immunoglobulin G treatment for woman at risk for neonatal alloimmune thrombocytopenia and T helper 1 immunity. Am J Reprod Immunol 2017; 77. [PMID: 28240400 DOI: 10.1111/aji.12649] [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: 12/23/2016] [Accepted: 01/17/2017] [Indexed: 01/08/2023] Open
Abstract
PROBLEM Fetal and neonatal alloimmune thrombocytopenia is an alloimmune disorder resulting from platelet opsonization by maternal antibodies that destroy fetal platelets. As there is no antenatal screening or immunization to prevent sensitization, selection of high-risk population or the prevention of antenatal sensitization is significantly limited. METHOD OF STUDY (i) A case report of ante- and postnatal management of a woman with paternal homozygosity for human platelet antigen-1(HPA) incompatibility. (ii) A retrospective case-control study of 11 confirmed FNAIT patients, 8 possible-FNAIT women, and 10 women with confirmed ITP. RESULT Antenatal screening, prevention of maternal sensitization by serial monitoring and immunosuppression with prednisone and intravenous immunoglobulin G (IVIG) infusion resulted in two successful pregnancies without sensitization. CONCLUSION Screening for couples at risk and prednisone and/or IVIG treatment is an option for women with paternal homozygosity for offending HPA antigen to prevent antenatal sensitization. HPA incompatibility is associated with increased Th1 immunity and NK cell cytotoxicity.
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Affiliation(s)
- Annie Skariah
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Nayoung Sung
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Maria D Salazar Garcia
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Li Wu
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Anjali Tikoo
- Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Alice Gilman-Sachs
- Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Joanne Kwak-Kim
- Reproductive Medicine, Department of Obstetrics and Gynecology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA.,Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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4
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Nakamura T, Nomura T, Kamohara T, Takahashi H, Hatanaka D, Kusakari M, Nakamura M, Kawabata K, Ohto H. DOWN'S SYNDROME WITH NEONATAL ALLOIMMUNE THROMBOCYTOPENIA DUE TO HLA-A2 ANTIBODY. Fukushima J Med Sci 2015; 61:149-54. [PMID: 26632192 DOI: 10.5387/fms.2015-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Anti-HLA antibodies reportedly exist in the one third of pregnant women. But few occurrences of neonatal alloimmune thrombocytopenia (NAIT) caused by anti-HLA antibodies have been reported. Here a male baby, who was admitted for low birth weight with Down syndrome (DS), was suffered from thrombocytopenia without transient myeloproliferative disorder (TMD). Positive reactions of HLA-specific antibodies were detected in maternal serum. Cross-matching tests between maternal serum and paternal platelets and lymphocytes were strongly positive. It is most conceivable that the previous pregnancy of the mother induced the production of anti-HLA-A2 antibody, which crossed the placenta and subsequently caused an NAIT in the case presented. This is the first case of DS with NAIT due to anti-HLA antibodies.
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5
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Curtis BR. Recent progress in understanding the pathogenesis of fetal and neonatal alloimmune thrombocytopenia. Br J Haematol 2015; 171:671-82. [PMID: 26344048 DOI: 10.1111/bjh.13639] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) occurs in c. 1 in 1000 births and is caused by maternal antibodies against human platelet alloantigens that bind incompatible fetal platelets and promote their clearance from the circulation. Affected infants can experience bleeding, bruising and, in severe cases, intracranial haemorrhage and even death. As maternal screening is not routinely performed, and first pregnancies can be affected, most cases are diagnosed at delivery of a first affected pregnancy. Unlike its erythrocyte counterpart, Haemolytic Disease of the Fetus and Newborn, there is no prophylactic treatment for FNAIT. This report will review recent advances made in understanding the pathogenesis of FNAIT: the platelet alloantigens involved, maternal exposure and sensitization to fetal platelet antigens, properties of platelet Immunoglobulin G antibodies, maternal-fetal antibody transport mechanisms and efforts to develop an effective FNAIT prophylaxis.
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Affiliation(s)
- Brian R Curtis
- Platelet & Neutrophil Immunology Laboratory and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
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6
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7
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Egbor M, Knott P, Bhide A. Red-cell and platelet alloimmunisation in pregnancy. Best Pract Res Clin Obstet Gynaecol 2012; 26:119-32. [DOI: 10.1016/j.bpobgyn.2011.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 09/20/2011] [Accepted: 10/11/2011] [Indexed: 10/14/2022]
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8
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Knight M, Pierce M, Allen D, Kurinczuk JJ, Spark P, Roberts DJ, Murphy MF. The incidence and outcomes of fetomaternal alloimmune thrombocytopenia: a UK national study using three data sources. Br J Haematol 2011; 152:460-8. [DOI: 10.1111/j.1365-2141.2010.08540.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Kamphuis MM, Paridaans N, Porcelijn L, De Haas M, van der Schoot CE, Brand A, Bonsel GJ, Oepkes D. Screening in pregnancy for fetal or neonatal alloimmune thrombocytopenia: systematic review. BJOG 2010; 117:1335-43. [DOI: 10.1111/j.1471-0528.2010.02657.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Althaus J, Blakemore KJ. Fetomaternal alloimmune thrombocytopenia: The questions that still remain. J Matern Fetal Neonatal Med 2009; 20:633-7. [PMID: 17701662 DOI: 10.1080/14767050701490517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetomaternal alloimmune thrombocytopenia (FMAIT) occurs when maternal antibodies are formed to fetal platelet antigens, leading to thrombocytopenia and hemorrhagic complications. The diagnosis is frequently made only after a major hemorrhagic event has occurred during a pregnancy. Identifying patients at risk remains difficult, and the optimal treatment regimen remains to be determined.
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Affiliation(s)
- Janyne Althaus
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD 21287, USA.
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11
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Kjeldsen-Kragh J, Husebekk A, Killie MK, Skogen B. Is it time to include screening for neonatal alloimmune thrombocytopenia in the general antenatal health care programme? Transfus Apher Sci 2008; 38:183-8. [DOI: 10.1016/j.transci.2008.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Fetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT): Past, Present, and Future. Obstet Gynecol Surv 2008; 63:239-52. [DOI: 10.1097/ogx.0b013e31816412d3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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van den Akker ES, Oepkes D. Fetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2008; 22:3-14. [DOI: 10.1016/j.bpobgyn.2007.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Valentin N, Gagne K, Kerdudou N, Hallé L, Kaplan C, Killie MK, Skogen B, Muller JY, Bignon JD. The alloimmune response to the human platelet antigen-1a is not related to maternal-fetal killer immunoglobulinlike receptor/HLA-Cw combinations. Transfusion 2007; 47:2322-9. [PMID: 17714418 DOI: 10.1111/j.1537-2995.2007.01450.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Human platelet antigen (HPA)-1a fetomaternal alloimmune thrombocytopenia, responsible in the most severe cases for fetal or neonatal intracranial hemorrhages leading to death or survival with neurologic sequelae, was shown to be restricted to the human leukocyte antigen (HLA) Class II DRB3*0101-encoded molecule. Whereas more than 90 percent of alloimmunized mothers display the DRB3*0101 allele, the positive predictive value of the presence of DRB3*0101 is only 35 percent. Additional genetic risk factors may exist of which elucidation could improve the undertaking of incompatible pregnancies in at-risk families, encouraging an antenatal screening. Interactions of killer immunoglobulinlike receptors (KIRs) on maternal decidual NK cells with HLA-Cw molecules on fetal trophoblasts were reported as one of the mechanisms involved in the fetomaternal tolerance during pregnancy. STUDY DESIGN AND METHODS Genotyping was performed of 16 KIR genes in HPA-1a-negative/DRB3*0101-positive alloimmunized mothers and in HPA-1a-negative/DRB3*0101-positive nonimmunized mothers as well as HLA-Cw genotyping in thrombocytopenic children and their nonaffected siblings. RESULTS No particular KIR genes or KIR genotypes were observed in the alloimmunized or nonimmunized mothers. Distribution of HLA-Cw genes in affected infants and nonaffected siblings did not reveal any HLA-Cw specificity associated with triggering or modulation of the HPA-1a alloimmunization. No maternal KIR/fetal HLA-Cw combinations were demonstrated in association with a detrimental or a protective effect on the HPA-1a alloimmunization. CONCLUSION Maternal KIR/fetal HLA-Cw gene combinations that are involved in the fetomaternal tolerance do not appear to play a role in the HPA-1a alloimmunization.
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Affiliation(s)
- Nathalie Valentin
- Laboratoire d'Immunologie, Institut de Biologie, CHU Nantes, France.
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15
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Kjeldsen-Kragh J, Killie MK, Tomter G, Golebiowska E, Randen I, Hauge R, Aune B, Øian P, Dahl LB, Pirhonen J, Lindeman R, Husby H, Haugen G, Grønn M, Skogen B, Husebekk A. A screening and intervention program aimed to reduce mortality and serious morbidity associated with severe neonatal alloimmune thrombocytopenia. Blood 2007; 110:833-9. [PMID: 17429009 DOI: 10.1182/blood-2006-08-040121] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The study's objective was to identify HPA 1a-negative women and to offer them an intervention program aimed to reduce morbidity and mortality of neonatal alloimmune thrombocytopenia (NAIT). HPA 1 typing was performed in 100 448 pregnant women. The HPA 1a-negative women were screened for anti-HPA 1a. In immunized women, delivery was performed by Cesarean section 2 to 4 weeks prior to term, with platelets from HPA 1a-negative donors reserved for immediate transfusion if petechiae were present and/or if platelet count was less than 35 x 10(9)/L. Of the women screened, 2.1% were HPA 1a negative, and anti-HPA 1a was detected in 10.6% of these. One hundred seventy pregnancies were managed according to the intervention program, resulting in 161 HPA 1a-positive children. Of these, 55 had severe thrombocytopenia (< 50 x 10(9)/L), including 2 with intracranial hemorrhage (ICH). One woman with a twin pregnancy missed the follow-up and had one stillborn and one severely thrombocytopenic live child. In 15 previous prospective studies (136 814 women) there were 51 cases of severe NAIT (3 intrauterine deaths and 7 with ICH). Acknowledging the limitation of comparing with historic controls, implementation of our screening and intervention program seemed to reduce the number of cases of severe NAIT-related complications from 10 of 51 to 3 of 57.
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MESH Headings
- Adult
- Antigens, Human Platelet/blood
- Antigens, Human Platelet/immunology
- Blood Grouping and Crossmatching
- Blood Transfusion
- Cesarean Section
- Female
- Fetal Death/blood
- Fetal Death/immunology
- Fetal Death/prevention & control
- Follow-Up Studies
- Humans
- Immunization
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/prevention & control
- Integrin beta3
- Intracranial Hemorrhages/blood
- Intracranial Hemorrhages/immunology
- Intracranial Hemorrhages/mortality
- Intracranial Hemorrhages/prevention & control
- Male
- Neonatal Screening
- Platelet Count
- Pregnancy
- Stillbirth
- Thrombocytopenia/blood
- Thrombocytopenia/immunology
- Thrombocytopenia/mortality
- Thrombocytopenia/prevention & control
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16
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Paladini D, Maruotti GM, Sglavo G, Fratellanza G, Quarantelli M, Martinelli P. Massive fetal hemorrhage and fetomaternal alloimmune thrombocytopenia from human platelet antigen 5b incompatibility: an unusual association. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 29:471-4. [PMID: 17390327 DOI: 10.1002/uog.3987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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17
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Abstract
There have been considerable advances in the clinical and laboratory diagnosis of alloimmune thrombocytopenia (AIT), and its postnatal and antenatal management. The antenatal management of AIT has been particularly problematic, because severe haemorrhage occurs as early as 16 weeks gestation and there is no non-invasive investigation that reliably predicts the severity of AIT in utero. The strategies for antenatal treatment have included the use of serial platelet transfusions that, while effective, are invasive and associated with significant morbidity and mortality. Maternal therapy involving the administration of intravenous immunoglobulin and/or steroids is also effective and associated with fewer risks to the fetus. Significant recent progress has involved refinement of maternal treatment, stratifying it according to the likely severity of AIT based on the history in previous pregnancies. However, the ideal antenatal treatment, which is effective without causing significant side-effects to the mother or fetus, has yet to be determined, and further clinical trials are needed.
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Affiliation(s)
- Michael F Murphy
- National Blood Service, Department of Haematology, John Radcliffe Hospital, University of Oxford, Oxford, UK.
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18
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Kaplan C, Freedman J. Alloimmune Thrombocytopenia. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50815-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Turner ML, Bessos H, Fagge T, Harkness M, Rentoul F, Seymour J, Wilson D, Gray I, Ahya R, Cairns J, Urbaniak S. Prospective epidemiologic study of the outcome and cost-effectiveness of antenatal screening to detect neonatal alloimmune thrombocytopenia due to anti-HPA-1a. Transfusion 2006; 45:1945-56. [PMID: 16371049 DOI: 10.1111/j.1537-2995.2005.00645.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND To assess the value of antenatal screening to detect neonatal alloimmune thrombocytopenia (NAIT) due to anti-HPA-1a, a prospective study was carried out to quantify the potential clinical benefits and determine whether screening would be cost-effective. STUDY DESIGN AND METHODS An observational prospective controlled study was carried out on 26,506 pregnant women over 2 years. HPA-1a phenotyping was performed in the first trimester and women confirmed HPA-1a-negative were tested for anti-HPA-1a during pregnancy, at delivery, and 10 to 14 days after birth. Babies of HPA-1a-negative women were tested at delivery for thrombocytopenia and examined for signs of bleeding. Economic evaluation was undertaken on the basis of the data collected during the study. RESULTS Twenty-five of 318 women (7.9%) had anti-HPA-1a detected for the first time. Eight women (43 per 100,000) gave birth to babies with NAIT, and 5 (27 per 100,000) had severe thrombocytopenia. Three babies had mild signs of bleeding, and no cases of intracranial hemorrhage (ICH) or fetal loss were detected. It is estimated that it would cost 60,596 pounds (98,771 US dollars) to detect a case of severe NAIT, where anti-HPA-1a has been identified for the first time, and 1,151,323 pounds (1,876,656 US dollars) to prevent a case of ICH, assuming that detection allowed successful intervention. CONCLUSIONS Our data suggest that severe HPA-1a NAIT is underdiagnosed in the absence of routine antenatal screening. Serious bleeding complications and ICH, however, occur less frequently in first cases of NAIT than suspected from the literature, and the costs of screening and possible intervention must be balanced against the procedural risks.
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Affiliation(s)
- Marc L Turner
- Scottish National Blood Transfusion Service, Aberdeen & Edinburgh, United Kingdom
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20
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Kanhai HHH, van den Akker ESA, Walther FJ, Brand A. Intravenous Immunoglobulins without Initial and Follow-Up Cordocentesis in Alloimmune Fetal and Neonatal Thrombocytopenia at High Risk for Intracranial Hemorrhage. Fetal Diagn Ther 2005; 21:55-60. [PMID: 16354976 DOI: 10.1159/000089048] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 12/10/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report on a less invasive treatment strategy in alloimmune fetal and neonatal thrombocytopenia (FNAIT) at high risk for either in utero or neonatal intracranial hemorrhage (ICH). METHODS In 7 pregnancies, with a history of ICH in the older sibling, weekly intravenous immunoglobulin (IVIG) therapy to the mother (1 g/kg) without initial cordocentesis was started at a median gestational age of 16 weeks. RESULTS In 4 pregnancies cordocentesis was avoided. One predelivery cordocentesis with platelet transfusion was performed in 3 further cases. Although none of the cases had a platelet count of >50 x 10(9)/l at cordocentesis, predelivery or birth, no ICHs were observed. The neonatal periods of the infants were uncomplicated. CONCLUSION IVIG treatment alone might be considered in patients with both severe platelet alloimmunization and an increased risk for morbidity and mortality at cordocentesis.
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Affiliation(s)
- Humphrey H H Kanhai
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
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21
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Affiliation(s)
- Cynthia Gyamfi
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, The Mount Sinai Medical Center, New York, NY, USA.
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22
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Allen D, Rigsby P, Bessos H, Berry J, Wilson D, Ouwehand WH, Urbaniak S, Metcalfe P. Collaborative study to establish the first international standard for quantitation of anti-HPA-1a. Vox Sang 2005; 89:100-4. [PMID: 16101692 DOI: 10.1111/j.1423-0410.2005.00669.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES This report describes the production of a freeze-dried preparation of pooled human plasma, containing immunoglobulin G (IgG) antibodies against the human platelet antigen 1a (HPA-1a). The material, coded 03/152, is proposed as an International Standard containing 100 arbitrary units of anti-HPA-1a for use in quantitative assays to determine the anti-HPA-1a activity in clinical samples. MATERIALS AND METHODS Plasma samples containing potent anti-HPA-1a were pooled and freeze dried in 1-ml ampoules. In addition, three individual plasma samples were selected which had varying levels of anti-HPA-1a activity. The anti-HPA-1a activity of these three samples was determined by using a variety of quantitative assays with the proposed standard as a reference. RESULTS An international collaborative study, which was part of the 2004 ISBT Platelet Immunology Workshop, involved 39 laboratories in 24 countries and showed that the anti-HPA-1a activity in three test samples could be reliably determined by using the proposed standard. CONCLUSIONS Laboratories can use this standard to measure the anti-HPA-1a activity in patient's samples. Further studies are required to determine the relationship between anti-HPA-1a activity and clinical outcome in patients with neonatal alloimmune thrombocytopenia (NAIT).
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Affiliation(s)
- D Allen
- National Blood Service, Oxford, UK
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Allen DL, Samol J, Benjamin S, Verjee S, Tusold A, Murphy MF. Survey of the use and clinical effectiveness of HPA-1a/5b-negative platelet concentrates in proven or suspected platelet alloimmunization. Transfus Med 2004; 14:409-17. [PMID: 15569235 DOI: 10.1111/j.1365-3148.2004.00536.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The optimal treatment of neonatal alloimmune thrombocytopenia (NAIT) is the transfusion of compatible donor platelets. The National Blood Service in England has established panels of "accredited" donors negative for human platelet antigens HPA-1a and HPA-5b, the most commonly implicated alloantigens. We have retrospectively surveyed the frequency of use and clinical effectiveness of donations collected over a 13-month period from the Oxford accredited panel. Ninety-five per cent of hyperconcentrated platelets (HPCs) collected were issued, all for intrauterine transfusion to fetuses at risk of NAIT due to the presence of maternal platelet alloantibodies and previously affected siblings. Thirty-one per cent of paediatric platelet concentrates (PPCs) collected were issued, of which 57% were used for cases of suspected NAIT. Fifty-four per cent of adult therapeutic doses collected were issued; 5% of these were used in cases of suspected NAIT or proven post-transfusion purpura (PTP). Good increments were seen in most NAIT cases transfused with HPCs or PPCs, and a moderate increment in the one PTP case. We conclude that the establishment of accredited panels is justified and enables delivery of a clinically effective treatment for NAIT. Increased use and cost-effectiveness could be achieved by the delivery of an educational programme to neonatal unit clinical staff to increase the awareness and appropriate treatment of NAIT.
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Affiliation(s)
- D L Allen
- National Blood Service, John Radcliffe Hospital, Headington, Oxford OX3 9BQ, UK.
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Ohto H, Miura S, Ariga H, Ishii T, Fujimori K, Morita S. The natural history of maternal immunization against foetal platelet alloantigens. Transfus Med 2004; 14:399-408. [PMID: 15569234 DOI: 10.1111/j.1365-3148.2004.00535.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Foetomaternal alloimmune thrombocytopenia (FMAIT) occurs when maternal antibodies of an antigen-negative mother cause destruction of sensitized foetal platelets. In Caucasian populations, 6-12% of human platelet antigen (HPA)-1a-negative women develop anti-HPA-1a, and the incidence of clinically affected cases is estimated to be 10-20% of immunized women. This study was performed in order to elucidate the rate of maternal immunization, incidence of FMAIT and the likely outcome of the condition in Asians. Excluding two or more pregnancies during the period, serum samples from 24 630 pregnant women, mainly Japanese, were screened for antibodies against platelet alloantigens by means of mixed passive haemagglutination (MPHA) (Anti-HPA-MPHA, Olympus, Tokyo). Antibodies were detected in 0.91% (223/24 630) of the women's samples and the immunization rate was correlated with the number of pregnancies. Antibody specificity included anti-HPA-4b (49), anti-HPA-5a (three), anti-HPA-5b (168), anti-HPA-4b + 5b (one) and anti-Nak(a) (CD36) (two). No alloimmunization was observed within the HPA-1, HPA-2, HPA-3 or HPA-6 systems. Among HPA-4b- or HPA-5b-negative women, 24% or 14% estimated, respectively, had antibodies and 26% (10/38) or 10% (12/125) of neonates, respectively, born to these mothers developed thrombocytopenia. Two neonates born to mothers having anti-HPA-4b developed generalized purpura. No cases of intracranial bleeding or death due to FMAIT were recorded. Generalized purpura due to FMAIT occurs in one in 9359 (95% CI: 1 in 77 519-1 in 2591) pregnancies solely because of HPA-4b incompatibility.
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Affiliation(s)
- H Ohto
- Division of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Hikariga-oka, Fukushima City, Fukushima 960-1295, Japan.
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Radder CM, de Haan MJJ, Brand A, Stoelhorst GMSJ, Veen S, Kanhai HHH. Follow up of children after antenatal treatment for alloimmune thrombocytopenia. Early Hum Dev 2004; 80:65-76. [PMID: 15363839 DOI: 10.1016/j.earlhumdev.2004.05.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the long-term follow-up of surviving offspring after antenatal treatment for fetal or neonatal alloimmune thrombocytopenia (FNAIT). PATIENTS Fifty children at risk of FNAIT were antenatally treated with maternal intravenous immunoglobulins (IVIG) (n=11), IVIG with intrauterine platelet transfusions (IUPT) (n=26) or IUPT alone (n=9). In four cases (n=4), only fetal blood sampling (FBS) was performed. One child died in the neonatal period and one was lost to follow up. METHODS The remaining 48 children, aged 1.3-11.6 years (median 5.1 years), were given both general and neurological examinations and assessed on their development and susceptibility for infections or atopic constitution. In addition, immunoglobulin levels were measured in 17 infants, aged 5 years and older. RESULTS Intracranial hemorrhage (ICH) was not observed. The general health and neurodevelopmental outcome in the children was comparable to a normal Dutch population. Children not exposed to maternal IVIG treatment had significantly more infections and hearing problems than children exposed to IVIG treatment or the normal population. Immunoglobulin G, A and M levels were within the normal range, independent of treatment and severity of FNAIT. A high IgE level was more frequently seen in children exposed to IVIG, but did not result in clinical consequences such as allergy or atopy. CONCLUSIONS Antenatal treatment of children for FNAIT did not affect general health or neurodevelopmental outcome. In particular, exposure to IVIG in utero showed no adverse effect on the clinical outcome of these children.
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Affiliation(s)
- Celine M Radder
- Department of Obstetrics, Leiden University Medical Center, H4-P, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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26
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Radder CM, Beekhuizen H, Kanhai HHH, Brand A. Effect of maternal anti-HPA-1a antibodies and polyclonal IVIG on the activation status of vascular endothelial cells. Clin Exp Immunol 2004; 137:216-22. [PMID: 15196265 PMCID: PMC1809094 DOI: 10.1111/j.1365-2249.2004.02496.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Maternal anti-HPA-1a antibodies can cause severe fetal and neonatal alloimmune thrombocytopenia (FNAIT), complicated by intracranial haemorrhage (ICH). Antenatal treatment with maternal intravenous immunoglobulin (IVIG) seems to protect against ICH even when thrombocytopenia persists. The aim of this study was to investigate if anti-HPA-1a antibodies and IVIG potentially affect vascular endothelial cells (ECs) in order to identify susceptibility for ICH. Human umbilical cord endothelial cells (HUVEC) were incubated with anti-HPA-1a antibodies with or without polyclonal IVIG and evaluated for EC activation. Maternal sera with anti-HPA-1a antibodies affected neither the EC expression of intracellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1) and tissue factor (TF) nor the release of van Willebrand factor (vWF) or interleukin (IL)-8 nor the integrity of ECs. Maternal sera obtained after IVIG treatment and polyclonal IVIG decrease constitutive and cytokine-induced ICAM-1 and VCAM-1 expression on ECs. The results show that maternal anti-HPA-1a antibodies cause no activation or damage of ECs in this model. The clinical relevance of the de-activating properties of IVIG on EC activation with respect to ICH deserves further investigation.
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Affiliation(s)
- C M Radder
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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Davoren A, Curtis BR, Aster RH, McFarland JG. Human platelet antigen-specific alloantibodies implicated in 1162 cases of neonatal alloimmune thrombocytopenia. Transfusion 2004; 44:1220-5. [PMID: 15265127 DOI: 10.1111/j.1537-2995.2004.04026.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonatal alloimmune thrombocytopenia (NATP) caused by fetomaternal mismatch for human platelet (PLT) alloantigens (HPAs) complicates approximately 1 in 1000 to 1 in 2000 pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage, and sometimes death of the fetus or neonate. As a national reference center for NATP investigations, our experience with this entity over a 12-year period was reviewed. STUDY DESIGN AND METHODS The laboratory records of all cases of suspected NATP referred for evaluation from January 1, 1990, to December 31, 2002, were analyzed. The spectrum of PLT alloantibody specificities identified was compared with an earlier reported series of serologically verified NATP cases. RESULTS HPA-specific alloantibodies were identified in 1162 (31%) of 3743 sera of mothers of infants with clinically suspected NATP. Maternal HPA-1a (PlA1) alloimmunization accounted for the majority (79%) of confirmed NATP cases, with HPA-5b (Bra), HPA-3a (Baka), and HPA-1b (PLA2) alloantibodies accounting for 9, 2, and 4 percent of cases, respectively. In addition, an increase in the number of cases in which multiple HPA-specific alloantibodies were present in maternal sera was observed during the study period. CONCLUSION Although, as with the earlier series, maternal HPA-1a alloimmunization was the dominant cause of NATP, the identification of an increasing number of cases due to alternative HPA polymorphisms suggests that investigation for HPA-1 incompatibility alone is no longer sufficient to fully evaluate clinically suspect NATP cases.
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Affiliation(s)
- Anne Davoren
- Blood Center of Southeastern Wisconsin, Milwaukee, Wisconsin 53201-2178, USA.
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28
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Rousseau J, Goldman M, David M. HPA-5b (Bra
) neonatal alloimmune thrombocytopenia in Quebec: incidence and clinical outcome in 31 cases. Transfusion 2004; 44:844-8. [PMID: 15157249 DOI: 10.1111/j.1537-2995.2004.03304.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical detection of neonatal allo-immune thrombocytopenia (NAITP) is often less than the incidence predicted in prospective studies. The aims of this study were to calculate the observed and expected incidence of NAITP in Quebec, Canada, and to evaluate the clinical outcome of infants with anti-HPA-5b NAITP. STUDY DESIGN AND METHODS Records from 1998 to 2002 of the only PLT serology laboratory for the province of Quebec were reviewed, as were hospital charts of all HPA-5 cases. The number of expected NAITP cases was estimated with known alloantigen gene frequencies. RESULTS Ninety cases of NAITP were identified. The clinical detection rate was 1 in 4100, with 9 to 30 percent of expected HPA-1a and 11 to 23 percent of expected HPA-5b NAITP cases detected. Seventy-eight percent of cases of HPA-5b NAITP were asymptomatic. Sixty-three percent of all deliveries but 94 percent of HPA-5b cases occurred in hospitals performing cord blood PLT counts. CONCLUSION The NAITP detection rate was 25 to 50 percent of the rate reported in prospective trials. The less severe clinical presentation of NAITP owing to HPA-5b was confirmed. The frequent routine determination of cord blood PLT counts may explain increased detection of asymptomatic NAITP involving anti-HPA-5b.
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Radder CM, Brand A, Kanhai HHH. Will it ever be possible to balance the risk of intracranial haemorrhage in fetal or neonatal alloimmune thrombocytopenia against the risk of treatment strategies to prevent it? Vox Sang 2003; 84:318-25. [PMID: 12757506 DOI: 10.1046/j.1423-0410.2003.00302.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Intracranial haemorrhage (ICH) of the fetus or newborn is a severe complication of fetal or neonatal alloimmune thrombocytopenia (FNAIT). In order to attain management decisions to prevent ICH, the risk of ICH in successive pregnancies with thrombocytopenia, with or without a history of ICH, must be established. MATERIALS AND METHODS We performed a search of medline for ICH cases in untreated FNAIT pregnancies. After exclusion of cases with confounding factors, 24 reports, describing 62 pregnancies of 27 mothers, were eligible. In addition, two mothers with five pregnancies were included from our own case records. Observational studies were examined to estimate the risk of ICH in subsequent FNAIT pregnancies without a history of ICH. Finally, medline was searched for complication rates in the treatment of FNAIT pregnancies. RESULTS In 52% of the ICH cases, a previous sibling suffered from ICH. The recurrence rate of ICH in the subsequent offspring of women with a history of FNAIT with ICH was 72%[confidence interval (CI): 46-98%] without inclusion of fetal deaths and 79% (CI: 61-97%) with inclusion of fetal deaths. In 48% of the ICH cases, the previous sibling had thrombocytopenia but not ICH. Population studies revealed an overall ICH risk in thrombocytopenic infants of 11% (CI: 0.8-23%) without inclusion of fetal deaths and 15% (CI: 1.5-19%) with inclusion of fetal deaths. Assuming occurrence in 48%, the risk of ICH in a subsequent pregnancy following a history of FNAIT without ICH, was estimated to be 7% (CI: 0.5-13%). Invasive treatment strategies carry a risk of 2.8% (CI: 1.2-4.4%) on complications. CONCLUSIONS The number of eligible publications on ICH in untreated FNAIT pregnancies is strikingly limited. The recurrence rate is high. As sufficient data on successive FNAIT cases without ICH are lacking, the occurrence of ICH in pregnancies with thrombocytopenia, but without ICH in a previous sibling, cannot be predicted. We estimate this risk to be 7%. This risk must be balanced against the risk of interventions in treatment strategies.
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Affiliation(s)
- C M Radder
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands.
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30
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Ahya R, Drayton M. Fetomaternal alloimmune thrombocytopenia. Vox Sang 2003; 84:338. [PMID: 12757513 DOI: 10.1046/j.1423-0410.2003.00307_4.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: 11/20/2022]
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31
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Current awareness in prenatal diagnosis. Prenat Diagn 2003; 23:179-85. [PMID: 12622104 DOI: 10.1002/pd.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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