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Staicu A, Popa-Stanila R, Albu C, Chira A, Constantin R, Boitor-Borza D, Surcel M, Rotar IC, Cruciat G, Muresan D. Neonatal Hemochromatosis: Systematic Review of Prenatal Ultrasound Findings—Is There a Place for MRI in the Diagnostic Process? J Clin Med 2023; 12:jcm12072679. [PMID: 37048762 PMCID: PMC10094906 DOI: 10.3390/jcm12072679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Neonatal hemochromatosis (NH) is an uncommon, severe disorder that results in fetal loss or neonatal death due to liver failure. NH is currently regarded as the phenotypic expression of gestational alloimmune liver disease (GALD). The diagnosis of NH-GALD is rarely prenatally established. In addition to providing a systematic review of the prenatal features that are identifiable using ultrasound (US) and MRI, we suggest a prenatal diagnosis algorithm for use in suspected NH during the first affected pregnancy. From a total of 586 database entries identified in PubMed, Google Scholar, and ResearchGate, we selected 18 studies published from 1993 to 2021 that reported maternal medical and obstetric history, prenatal ultrasound findings, and postpartum outcomes. We investigated the ultrasound and MRI features of these studies, along with the outcome due to this condition. A total of 74 cases were identified. The main reported prenatal US finding was fetal growth restriction (FGR) (33%), followed by oligohydramnios (13%) and hydrops fetalis (13%), with 13% cases described as uneventful. Other rare prenatal findings were fetal anemia, ascites, and abnormal fetal liver and spleen. Most pregnancies ended with fetal/perinatal death or therapeutic interruption of pregnancy. Favorable evolution with treatment (ensanguine transfusion and intravenous immunoglobulin (IVIG)) was reported for only 7% of fetuses. Using T2-weighted MRI, fetal extrahepatic siderosis confirmed prenatally in two cases and postnatally in 11 cases. IVIG treatment throughout subsequent pregnancies was found to significantly improve fetal prognosis. MRI should be indicated in selected cases of oligohydramnios, fetal hydrops, fetal hepatomegaly, ascites, or unexplained FGR or anemia after ruling out all other more frequently encountered conditions. MRI can be used to detect iron overload in the liver and extrahepatic siderosis.
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Affiliation(s)
- Adelina Staicu
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Roxana Popa-Stanila
- Department of Radiology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, 400006 Cluj-Napoca, Romania
| | - Camelia Albu
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, 400006 Cluj-Napoca, Romania
- Department of Pathology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alexandra Chira
- Department of Internal Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Medical Clinic, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Roxana Constantin
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Dan Boitor-Borza
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Mihai Surcel
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Ioana Cristina Rotar
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Gheorghe Cruciat
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Daniel Muresan
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
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Ibuki T, Yamamoto K, Matsui K. The Fetus as a Research Subject. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:76-78. [PMID: 35258432 DOI: 10.1080/15265161.2022.2027556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Mugarab-Samedi V, Ryan MD, Awad EHA, Elsharkawy A. The Effect of Prenatal and Postnatal Treatment with Intravenous Immunoglobulin on Severity of Neonatal Hemochromatosis: The Tale of Two Brothers (Case Report). AJP Rep 2021; 11:e102-e104. [PMID: 34221693 PMCID: PMC8245207 DOI: 10.1055/s-0041-1731311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/21/2020] [Indexed: 10/30/2022] Open
Abstract
Background Neonatal hemochromatosis (NH) is a rare condition that was the main reason for liver transplantation in infants. With the realization that NH results from the fetal complement-mediated liver injury, intravenous immunoglobulins (IVIG) were successfully introduced for the treatment. Case Presentation We present two cases of NH from the same family to illustrate the role of antenatal treatment with IVIG in alleviation and possible prevention of this serious morbidity. Conclusion A prenatal treatment and early postnatal administration of IVIG are effective ways to manage NH that help to reduce the severity of the symptoms, prevent liver failure, and avoid the need for liver transplantation.
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Affiliation(s)
| | - Michelle D Ryan
- Section of Neonatology, University of Calgary, Calgary, Alberta, Canada
| | | | - Adel Elsharkawy
- Section of Neonatology, University of Calgary, Calgary, Alberta, Canada
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Gamez J, Salvado M, Casellas M, Manrique S, Castillo F. Intravenous immunoglobulin as monotherapy for myasthenia gravis during pregnancy. J Neurol Sci 2017; 383:118-122. [PMID: 29246598 DOI: 10.1016/j.jns.2017.10.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/04/2017] [Accepted: 10/24/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Pregnant women with myasthenia gravis (MG) are at increased risk of complications and adverse outcomes, including the teratogenic effects of many drugs used to treat MG women of childbearing age. The effectiveness of intravenous immunoglobulins (IVIg) on other autoimmune mediated diseases has been extensively reported in recent years, although little is known about the role of IVIg in the treatment of MG during pregnancy. We designed this study to determine the effectiveness of IVIg as monotherapy during pregnancy for women with MG. MATERIAL AND METHODS Five pregnant MG patients (mean age at delivery 36.4years, SD 5.8, range 29.4-45.2) were studied in 2013-14. Their treatment was switched to monthly IVIg cycles 2months before the pregnancy. Follow-up included monthly neurological QMG throughout the pregnancy and postpartum, obstetrical monitoring during monthly visits in the first two trimesters of the pregnancy, fortnightly visits between week 32 and week 36, and weekly visits after 36weeks, and neonatal follow-up after delivery. RESULTS We observed no exacerbations during pregnancy, delivery or post-partum. The mean QMG score at baseline (before pregnancy) was 7.4 points in five women with generalized forms of MG. The maximum mean value reached during pregnancy was 8.6 points. The mean pregnancy duration was 38 w+5 d. No infant with transient neonatal myasthenia gravis. CONCLUSIONS These results suggest that monotherapy with IVIg during pregnancy in MG patients could be promising, although confirmation is required in studies with larger populations.
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Affiliation(s)
- Josep Gamez
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain.
| | - Maria Salvado
- Myasthenia Gravis Unit, Neurology Department, Vall d'Hebron University Hospital, VHIR, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, UAB, Barcelona, Spain
| | - Manel Casellas
- Myasthenia Gravis Unit, Obstetrics Department, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Susana Manrique
- Myasthenia Gravis Unit, Anesthetics Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Felix Castillo
- Myasthenia Gravis Unit, Neonatology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Shimono A, Imoto Y, Sakamoto H, Chiba Y, Matsumoto K, Kawauchi M, Kusaka T, Tanaka H, Hata T, Kushida Y, Ueno M. An immunohistochemical study of placental syncytiotrophoblasts in neonatal hemochromatosis. Placenta 2016; 48:49-55. [PMID: 27871472 DOI: 10.1016/j.placenta.2016.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/27/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Neonatal hemochromatosis (NH) is a rare neonatal disorder that results in liver cirrhosis with hemosiderin deposition in the liver and other organs, similarly to hereditary hemochromatosis. Excess iron is transferred from the mother to fetus through the placenta in NH. We examined the expression of iron metabolism-related substances in placental syncytiotrophoblasts (STB) by immunostaining to clarify how the transfer of iron through STB increases in NH. METHODS Immunostaining was performed using formalin-fixed, paraffin-embedded sections of placentae from three NH cases, four gestational age-matched controls, and, depending on the antibody examined, five to seven full-term controls. The reactivity of immunostaining was assessed by averages of scores assigned by 3 researchers. RESULTS On the microvillar surface of STB, the reactions of the antibodies against transferrin receptor 1 (TFR1), transferrin, ferritin, hepcidin, ferroportin, divalent metal transporter-1 (DMT1), hephaestin, and HFE were stronger in NH than in controls. In the cytoplasm, the reactions of antibodies against TFR1, transferrin, ferritin, hepcidin, DMT1, hephaestin, HFE, and ZIP 14 were stronger in NH than in gestational age-matched controls. Among these reactions, those of anti-TFR1 antibody on the surface of STB in NH was especially marked. DISCUSSION In the placenta of NH, increases in expressions of TFR1, transferrin, and ferritin of which those of TFR1 were especially marked, reflect increased iron influx from the mother to fetus. The hepcidin observed on the surface and in the cytoplasm of STB of NH is suggested to be from the mother, possibly to compensate for the decreased fetal liver-derived hepcidin.
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Affiliation(s)
- Aiko Shimono
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Yuko Imoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Haruhiko Sakamoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan.
| | - Yoichi Chiba
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Koichi Matsumoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Machi Kawauchi
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Hirokazu Tanaka
- Department of Perinatal Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Toshiyuki Hata
- Department of Perinatal Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Yoshio Kushida
- Division of Diagnostic Pathology, Kagawa University Hospital, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Masaki Ueno
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
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Okada N, Ihara Y, Urahashi T, Sanada Y, Yamada N, Hirata Y, Tashiro M, Katano T, Ushijima K, Otomo S, Takahashi H, Matsubara S, Mizuta K. Antenatal immunoglobulin for prevention of neonatal hemochromatosis. Pediatr Int 2016; 58:1059-1061. [PMID: 27507570 DOI: 10.1111/ped.13028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 04/13/2016] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Abstract
Neonatal hemochromatosis (NH) is a rare disease with a poor prognosis, particularly prior to 2008. Antenatal maternal high-dose immunoglobulin (Ig) is effective in preventing NH recurrence, but the adverse effects of this treatment have not been documented as yet. Here, we report on a patient who underwent high-dose Ig treatment to prevent NH recurrence. The patient was a 31-year-old pregnant Japanese woman. Her first child died of NH after receiving living donor liver transplantation. The patient received high-dose Ig treatment to prevent recurrence of NH from gestational weeks 16 to 35. During the treatment, platelet count gradually decreased, and cesarean section was required at 35 gestational weeks. The child did not develop liver failure. High-dose Ig prevented the recurrence of NH. Caution should be exercised due to possible adverse effects of this treatment.
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Affiliation(s)
- Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan.
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Naoya Yamada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yuta Hirata
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masahisa Tashiro
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Takumi Katano
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kentaro Ushijima
- Department of Pharmacy, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shinya Otomo
- Department of Clinical Pharmacy, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Transient neonatal liver disease after maternal antenatal intravenous Ig infusions in gestational alloimmune liver disease associated with neonatal haemochromatosis. J Pediatr Gastroenterol Nutr 2014; 59:629-35. [PMID: 25079484 DOI: 10.1097/mpg.0000000000000514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Neonatal haemochromatosis is a rare gestational disease that results in severe foetal liver disease with extrahepatic iron overload, sparing the reticuloendothelial system. Recurrence can be prevented with intravenous immunoglobulin (IVIG) infusions during pregnancy, supporting an alloimmune aetiology. The aim of the study was to assess the effect of antenatal treatment with IVIG infusion on the outcome of pregnancies in women with a history of documented neonatal haemochromatosis likely owing to gestational alloimmune disease and to analyse IVIG tolerance. METHODS From 2004 to 2012, 8 pregnant women were treated with IVIG at 1 g/kg body weight weekly from 18 weeks' gestation until birth in a prospective multicentre study. RESULTS All 8 neonates born to the treated women survived. Five developed mild neonatal liver disease with hepatomegaly (n = 1), hyperechogenic liver (n = 2), abnormal liver function tests (n = 1), raised serum ferritin (n = 3) and α-fetoprotein (n = 5) levels, or mild iron overload on liver magnetic resonance imaging (n = 1). Ferritin and α-fetoprotein levels normalised before 14 days and 2 months, respectively. A per-mother-basis analysis comparing outcomes of treated (n = 8) and untreated (n = 9) gestations showed a significant improvement in the survival of neonates with gestational IVIG therapy (survival 8/8 vs 0/9, P < 0.001). Adverse effects of IVIG infusion occurred in 5 mothers leading to discontinuation of treatment in 1 case. Preterm neonates born before 37 weeks' gestation had a decreased risk of neonatal liver disease (P = 0.04). CONCLUSIONS Antenatal treatment with IVIG infusion in women at risk for gestational alloimmune disease recurrence improves the outcome of pregnancies despite mild signs of transient neonatal liver disease.
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Agrawal S, Dhiman RK. Hepatobiliary quiz-9 (2014). J Clin Exp Hepatol 2014; 4:81-4. [PMID: 25755542 PMCID: PMC4188737 DOI: 10.1016/j.jceh.2014.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Abstract
Neonatal hemochromatosis is a clinical condition in which severe liver disease in the newborn is accompanied by extrahepatic siderosis. Gestational alloimmune liver disease (GALD) has been established as the cause of fetal liver injury resulting in nearly all cases of NH. In GALD, a women is exposed to a fetal antigen that she does not recognize as "self" and subsequently begins to produce IgG antibodies that are directed against fetal hepatocytes. These antibodies bind to fetal liver antigen and activate the terminal complement cascade resulting in hepatocyte injury and death. GALD can cause congenital cirrhosis or acute liver failure with and without iron overload and siderosis. Practitioners should consider GALD in cases of fetal demise, stillbirth, and neonatal acute liver failure. Identification of infants with GALD is important as treatment is available and effective for subsequent pregnancies.
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Affiliation(s)
- Amy G. Feldman
- Address for correspondence. Amy G. Feldman, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 57, Chicago, IL 60611-2605, United States. Tel.: +1 312 227 7600; fax: +1 312 227 9645.
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