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Kjeldsen-Kragh J, Bein G, Tiller H. Pregnant Women at Low Risk of Having a Child with Fetal and Neonatal Alloimmune Thrombocytopenia Do Not Require Treatment with Intravenous Immunoglobulin. J Clin Med 2023; 12:5492. [PMID: 37685558 PMCID: PMC10488101 DOI: 10.3390/jcm12175492] [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: 07/19/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare condition in which maternal alloantibodies to fetal platelets cause fetal thrombocytopenia that may lead to intracranial hemorrhage (ICH). Off-label intravenous immunoglobulin (IVIg) has for 30 years been the standard of care for pregnant women who previously have had a child with FNAIT. The efficacy of this treatment has never been tested in a placebo-controlled clinical trial. Although IVIg treatment may improve the neonatal outcome in women who previously have had a child with FNAIT-associated ICH, the question is whether IVIg is necessary for all immunized pregnant women at risk of having a child with FNAIT. The results from some recent publications suggest that antenatal IVIg treatment is not necessary for women who are (1) HPA-1a-immunized and HLA-DRB3*01:01-negative, (2) HPA-1a-immunized with a previous child with FNAIT but without ICH or (3) HPA-5b-immunized. If IVIg is not used for these categories of pregnant women, the amount of IVIg used in pregnant women with platelet antibodies would be reduced to less than ¼ of today's use. This is important because IVIg is a scarce resource, and the collection of plasma for the treatment of one pregnant woman is not only extremely expensive but also requires tremendous donor efforts.
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Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Akutgatan 8, 221 85 Lund, Sweden
- Department of Laboratory Medicine, University Hospital of North Norway, 9019 Tromsø, Norway
| | - Gregor Bein
- Institute for Clinical Immunology, Transfusion Medicine and Hemostasis, Justus-Liebig-University, 35392 Giessen, Germany;
- German Center for Feto-Maternal Incompatibility, University Hospital Giessen and Marburg, Campus Giessen, 35392 Giessen, Germany
| | - Heidi Tiller
- Department of Obstetrics and Gynecology, University Hospital of North Norway, 9019 Tromsø, Norway;
- Women’s Health and Perinatology Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, 9019 Tromsø, Norway
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2
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Stam W, Wachholz GE, de Pereda JM, Kapur R, van der Schoot E, Margadant C. Fetal and neonatal alloimmune thrombocytopenia: Current pathophysiological insights and perspectives for future diagnostics and treatment. Blood Rev 2022; 59:101038. [PMID: 36581513 DOI: 10.1016/j.blre.2022.101038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
FNAIT is a pregnancy-associated condition caused by maternal alloantibodies against paternally-inherited platelet antigens, most frequently HPA-1a on integrin β3. The clinical effects range from no symptoms to fatal intracranial hemorrhage, but underlying pathophysiological determinants are poorly understood. Accumulating evidence suggests that differential antibody-Fc-glycosylation, activation of complement/effector cells, and integrin function-blocking effects contribute to clinical outcome. Furthermore, some antibodies preferentially bind platelet integrin αIIbβ3, but others bind αvβ3 on endothelial cells and trophoblasts. Defects in endothelial cells and angiogenesis may therefore contribute to severe anti-HPA-1a associated FNAIT. Moreover, anti-HPA-1a antibodies may cause placental damage, leading to intrauterine growth restriction. We discuss current insights into diversity and actions of HPA-1a antibodies, gathered from clinical studies, in vitro studies, and mouse models. Assessment of all factors determining severity and progression of anti-HPA-1a-associated FNAIT may importantly improve risk stratification and potentially reveal novel treatment strategies, both for FNAIT and other immunohematological disorders.
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Affiliation(s)
- Wendy Stam
- Institute of Biology, Leiden University, Leiden, the Netherlands; Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.
| | | | - Jose Maria de Pereda
- Centro de Investigación del Cáncer and Instituto de Biología Molecular y Celular del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Salamanca, 37007 Salamanca, Spain.
| | - Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ellen van der Schoot
- Sanquin Research, Department of Experimental Immunohematology, Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Coert Margadant
- Institute of Biology, Leiden University, Leiden, the Netherlands; Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.
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3
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Barg A, Bonstein L. New Horizons in Fetal and Neonatal Alloimmune Thrombocytopenia. Semin Thromb Hemost 2022; 49:402-408. [PMID: 36368687 DOI: 10.1055/s-0042-1757900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractFetal and neonatal alloimmune thrombocytopenia (FNAIT) is a common cause of severe thrombocytopenia in newborns. Intracranial bleeding may lead to severe neurological sequelae and mortality. Current management of pregnancies at risk is suboptimal. Prenatal FNAIT diagnosis commonly requires invasive procedures and therapy is associated with a high treatment burden. The present review explores advances in the field and their potential contribution to modification of the diagnostic and therapeutic landscape. Topics addressed include the role of noninvasive prenatal testing using fetal cell free DNA, insights into novel and prospective therapeutic options achieved through the development of murine models of FNAIT as well as the forecast for the progress in pregnancy risk stratification through advancement in the investigation of biological characteristics of alloantibodies and their association with the risk of fetal bleeding.
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Affiliation(s)
- Assaf Barg
- National Hemophilia Center, Sheba Medical Center, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Lilach Bonstein
- Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
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4
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Gordana T, Koraljka G, Ruža G, Desiree CH, Ostojić SB, Branka GĆ. Severe intracranial haemorrhage in neonatal alloimmune thrombocytopenia due to antibodies against human platelet antigen 1b: Case report and literature review. Transfus Med 2022; 32:269-275. [PMID: 35730350 DOI: 10.1111/tme.12892] [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: 08/03/2021] [Revised: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 12/01/2022]
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is a rare life-threatening disorder, leading to severe thrombocytopenia and potentially bleeding, with intracranial haemorrhage (ICH) being the most serious complication. We report on a FNAIT case with fourth-degree ICH that arose due to antibodies against human platelet antigen (HPA)-1b. The male infant, born to an otherwise healthy mother, presented with severe signs of ICH soon after delivery. Since only moderate thrombocytopenia was noted and there were no active signs of bleeding, the infant did not receive intravenous immunoglobulins (IVIg) or platelet transfusion. Spontaneous recovery of platelets was noted on the eighth day of life, but permanent neurological impairment remained as a consequence of ICH. We report the results of HPA and human leukocyte antigen (HLA) antibodies in the mother's and the infant's sera, the family's HPA genotype and the mother's HLA genotype, and summarise previously described cases of FNAIT due to anti-HPA-1b antibodies in the literature. FNAIT with severe ICH due to anti-HPA-1b antibodies is rarely diagnosed. An association between HLA genes and sensitization to HPA-1b antibodies was not demonstrated. The severity of FNAIT and the occurrence of ICH is often difficult to predict. In this case, the infant presented with moderate thrombocytopenia and ICH, with subsequent permanent consequences.
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Affiliation(s)
- Tomac Gordana
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Gojčeta Koraljka
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.,University of Applied Health Sciences, Zagreb, Croatia
| | - Grizelj Ruža
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Coen Herak Desiree
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sanja Baršić Ostojić
- Clinical Department for Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Golubić Ćepulić Branka
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Vitagliano M, Dunbar M, Dyck Holzinger S, Letourneau N, Dewey D, Oskoui M, Shevell M, Kirton A. Perinatal arterial ischemic stroke and periventricular venous infarction in infants with unilateral cerebral palsy. Dev Med Child Neurol 2022; 64:56-62. [PMID: 34374437 DOI: 10.1111/dmcn.15000] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/12/2023]
Abstract
AIM To explore clinical factors associated with perinatal arterial ischemic stroke (AIS) and periventricular venous infarction (PVI) in infants who develop unilateral cerebral palsy (CP). METHOD This was a case-control study. Data current to 2019 was extracted from the Canadian Cerebral Palsy Registry (CCPR). Cases were infants born at term with confirmed unilateral CP. Magnetic resonance images were stratified by expert review of reports as definitive perinatal stroke (AIS or PVI). Controls with common data elements were recruited from a population-based study in Alberta. Multivariable regression analyses were performed to estimate associations expressed as odds ratios with 95% confidence intervals. RESULTS Of 2093 cases from the CCPR, 662 had unilateral CP, of whom 299 (45%) had perinatal stroke: AIS 169 (57%) and PVI 130 (43%). Median age at diagnosis for AIS was 11.9 months (interquartile range: 6.2-25.7mo; range 0.17-104.1mo), and 58.6% were male. Median age at diagnosis for PVI was 25.3 months (interquartile range: 14.5-38mo, range 0.7-114.7mo) and 57.7% were male. Independent associations for both AIS and PVI on multivariable analysis were chorioamnionitis, illicit drug exposure, diabetes, gestational age, and maternal age. Variables associated with AIS alone were low Apgar score and prolonged rupture of membranes. Variables associated with PVI alone were small for gestational age and primigravida. INTERPRETATION Controlled analysis of disease-specific unilateral CP may offer unique perspectives on its pathophysiology. Acute intrapartum factors are mainly associated with AIS, while in utero factors are associated with PVI.
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Affiliation(s)
| | - Mary Dunbar
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Sasha Dyck Holzinger
- Canadian Cerebral Palsy Registry, Research Institute of McGill Health Center, Montreal, Quebec, Canada
| | - Nicole Letourneau
- Departments of Pediatrics, Psychiatry and Community Health Sciences, Faculty of Nursing and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah Dewey
- Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Maryam Oskoui
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Departments of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Departments of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Adam Kirton
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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6
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Luo H, Li D, Gao F, Hong P, Feng W. A meta-analysis of neonatal outcomes in pregnant women with immune thrombocytopenic purpura. J Obstet Gynaecol Res 2021; 47:2941-2953. [PMID: 34137128 DOI: 10.1111/jog.14890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/10/2021] [Accepted: 06/01/2021] [Indexed: 01/11/2023]
Abstract
AIM Thrombocytopenia is an autoimmune disorder characterized by reduced platelet counts. Neonatal thrombocytopenia incidence has been linked with immune thrombocytopenic purpura in mothers during pregnancy, possibly because antiplatelet antibodies can cross the placental barrier. To date, no study has attempted to evaluate the actual prevalence of neonatal thrombocytopenia in infants born to mothers with immune thrombocytopenic purpura. In this meta-analysis of the available literature, we attempt to fill this gap. We want to evaluate the overall prevalence of neonatal thrombocytopenia, its severity, and the incidence of hemorrhage in infants with thrombocytopenia born from mothers with immune thrombocytopenic purpura. METHODS Adhering to PRISMA guidelines, we systematically scanned four academic databases including EMBASE, CENTRAL, Scopus, and MEDLINE to identify relevant literature. We performed a meta-analysis to summarize thrombocytopenia incidence rate and severity in newborn infants of mothers with immune thrombocytopenic purpura. RESULTS We identified 21 eligible studies involving 1951 mothers and 1844 neonates. Meta-analysis showed high prevalence for neonatal thrombocytopenia (24%). Within these, severe cases were the most prevalent (41.2%), followed by moderate (37.7%) and mild (17.6%) cases. Hemorrhage was only reported in 4.1% of the observed neonatal thrombocytopenia cases. CONCLUSION This review provides preliminary evidence that neonatal thrombocytopenia incidence is high in infants born to mothers with immune thrombocytopenic purpura. This study further reports that the largest proportion of these cases are severe.
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Affiliation(s)
- Hongqiang Luo
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Dan Li
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Feidan Gao
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Pan Hong
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
| | - Weiying Feng
- Department of Hematology, The First Affiliated Hospital of Shaoxing University, Shaoxing People's Hospital, Shaoxing, China
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7
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Fetal/neonatal alloimmune thrombocytopenia: a systematic review of impact of HLA-DRB3*01:01 on fetal/neonatal outcome. Blood Adv 2021; 4:3368-3377. [PMID: 32717028 DOI: 10.1182/bloodadvances.2020002137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/09/2020] [Indexed: 01/06/2023] Open
Abstract
The most common, severe cases of fetal and neonatal alloimmune thrombocytopenia among whites are caused by antibodies against human platelet antigen 1a (HPA-1a). The aims of this systematic review and meta-analysis are to determine the association between maternal HLA-DRB3*01:01 and: (1) HPA-1a-alloimmunization and (2) neonatal outcome in children born of HPA-1a-immunized women. A systematic literature search identified 4 prospective and 8 retrospective studies. Data were combined across studies to estimate pooled odds ratios (ORs) and the associated 95% confidence intervals (CIs). The population represented by the prospective studies was more than 150 000. In the prospective studies, there were 64 severely thrombocytopenic newborns (platelet count <50 × 109/L) of whom 3 had intracranial hemorrhage. The mothers of all 64 children were HLA-DRB3*01:01+. The number of severely thrombocytopenic children born of HPA-1a-alloimmunized women in the retrospective studies was 214; 205 of whom were born of HLA-DRB3*01:01+ women. For HLA-DRB3*01:01- women, the OR (95% CI) for alloimmunization was 0.05 (0.00-0.60), and for severe neonatal thrombocytopenia 0.08 (0.02-0.37). This meta-analysis demonstrates that the risk of alloimmunization and of having a child with severe thrombocytopenia are both very low for HPA-1a- women who are HLA-DRB3*01:01-.
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8
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Sachs UJ, Bedei I, Wienzek-Lischka S, Cooper N, Ehrhardt H, Axt-Fliedner R, Bein G. Fetale und neonatale Alloimmunthrombozytopenie, Teil 1. TRANSFUSIONSMEDIZIN 2021. [DOI: 10.1055/a-1258-1238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDie fetale und neonatale Alloimmunthrombozytopenie (FNAIT) wird durch mütterliche Antikörper hervorgerufen, die gegen ein vom Vater ererbtes Blutgruppenmerkmal an fetalen Thrombozyten gerichtet sind. Teil 1 des Beitrags stellt die Ätiologie, die Pathogenese und die Diagnostik der FNAIT dar, während Teil 2 die Risikostratifizierung und Behandlung der FNAIT thematisiert 1.
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9
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Liu B, Shao Y, Fu R. Current research status of HLA in immune-related diseases. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:340-350. [PMID: 33657268 PMCID: PMC8127548 DOI: 10.1002/iid3.416] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 02/06/2023]
Abstract
Human leukocyte antigen (HLA), also known as human major histocompatibility complex (MHC), is encoded by the HLA gene complex, and is currently known to have the highest gene density and the most polymorphisms among human chromosomal areas. HLA is divided into class I antigens, class II antigens, and class III antigens according to distribution and function. Classical HLA class I antigens include HLA-A, HLA-B, and HLA-C; HLA class II antigens include HLA-DP, HLA-DQ, and HLA-DR; nonclassical HLA class I and II molecules include HLA-F, E, H, X, DN, DO, and DM; and others, such as complement, are class III antigens. HLA is closely related to the body's immune response, regulation, and surveillance and is of great significance in the study of autoimmune diseases, tumor immunity, organ transplantation, and reproductive immunity. HLA is an important research topic that bridges immunology and clinical diseases. With the development of research methods and technologies, there will be more discoveries and broader prospects.
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Affiliation(s)
- Bingnan Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Yuanyuan Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, PR China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, PR China
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10
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Zhang L, DeBoer C, Ellison-Barnes A, Berger J, Lawrence CE, Stewart RW, Pecker LH. Thrombocytopenia in a 7-day-old Male. Pediatr Rev 2021; 42:S10-S14. [PMID: 33386351 DOI: 10.1542/pir.2018-0301] [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: 11/24/2022]
Affiliation(s)
- Lindy Zhang
- Departments of Pediatric Hematology, .,Pediatric Oncology
| | | | | | - Jessica Berger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Courtney E Lawrence
- Departments of Pediatric Hematology.,Division of Transfusion Medicine, Department of Pathology, and
| | | | - Lydia H Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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11
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HLA-DRB3*01:01 exhibits a dose-dependent impact on HPA-1a antibody levels in HPA-1a-immunized women. Blood Adv 2020; 3:945-951. [PMID: 30923048 DOI: 10.1182/bloodadvances.2019032227] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/19/2019] [Indexed: 01/05/2023] Open
Abstract
HLA-DRB3*01:01 is a predisposing factor for human platelet antigen 1a (HPA-1a) immunization, which is responsible for most cases of fetal and neonatal alloimmune thrombocytopenia. The aim of this study was to investigate if the HLA-DRB3*01:01 allele imposes a dose-dependent effect on anti-HPA-1a levels and neonatal platelet counts. One hundred and thirty HPA-1a-immunized women were divided into 3 groups: HLA-DRB3*01:01 negative, HLA-DRB3*01:01 hemizygous or heterozygous, and HLA-DRB3*01:01 homozygous. The dose of the HLA-DRB3*01:01 allele was determined by sequencing exon 2 of the HLA-DRB3 gene followed by HLA-DRB3 and HLA-DRB1 typing of selected samples. Anti-HPA-1a levels at time of delivery and neonatal platelet counts were compared among groups. There was a significant dose-dependent effect of the HLA-DRB3*01:01 allele on anti-HPA-1a levels (global P value [P global] = .0032). Median (range) anti-HPA-1a levels were 1.5 IU/mL (0.0-19.0 IU/mL), 21.1 IU/mL (0.0-1967 IU/mL), and 43.7 IU/mL (1.0-980 IU/mL) in women with 0, 1, and 2 copies of the HLA-DRB3*01:01 allele, respectively. There was also a significant, but opposite, dose-dependent effect of the mother's HLA-DRB3*01:01 allele on the platelet count of the newborn (P global = .0155). Median (range) neonatal platelet counts were 241 × 109/L (59 × 109/L to 393 × 109/L), 107 × 109/L (4 × 109/L to 387 × 109/L) and 32 × 109/L (4 × 109/L to 352 × 109/L) for newborns of mothers with 0, 1, and 2 copies of the HLA-DRB3*01:01 allele, respectively. Thus, the HLA-DRB3*01:01 allele exhibits a dose-dependent impact on maternal anti-HPA-1a levels in HPA-1a-immunized women.
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12
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The effect of antenatal magnesium sulfate on intraventricular hemorrhage in premature infants: a systematic review and meta-analysis. Obstet Gynecol Sci 2020; 63:395-406. [PMID: 32689768 PMCID: PMC7393747 DOI: 10.5468/ogs.19210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/08/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis study was to determine the pooled estimate of the effect of antenatal magnesium sulfate (MgSO4) on intraventricular hemorrhage (IVH) in premature infants. METHODS Two review authors independently searched all randomized clinical trials from international databases, including Medline (PubMed), Web of Sciences, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Research Registers of ongoing trials (ClinicalTrials.gov), from January 1989 to August 2017. Two independent review authors were responsible for data collection. After extracting the necessary information from the evaluated articles, metaanalysis of the data was performed using Stata version 14. Also, sources of heterogeneity among studies were determined by Meta regression. RESULTS In this study, among 126 articles that were extracted from primary studies, 7 papers that evaluated the effect of MgSO4 on IVH were eligible for inclusion in the meta-analysis. The results of the meta-analysis showed that pooled relative risk (95% confidence interval [CI]) was 0.80 (95% CI, 0.63 to 1.03) for the effect of MgSO4 on IVH. CONCLUSION RESULTS of this study showed that although MgSO4 had a protective effect on IVH in premature infants, this effect was not statistically significant. Further studies are needed to determine the best dosage, timing, and gestational age to achieve the optimum effect of MgSO4 on IVH. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO) Identifier: CRD42019119610.
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13
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Shaw J, Blakemore JK, Moomjy M. Preimplantation genetic testing for a monogenic disorder can prevent live births affected by fetal and neonatal alloimmune thrombocytopenia. Pediatr Blood Cancer 2020; 67:e28239. [PMID: 32285999 DOI: 10.1002/pbc.28239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/04/2020] [Accepted: 02/15/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Jacquelyn Shaw
- Department of Obstetrics and Gynecology, New York University Langone Fertility Center, New York, New York
| | - Jennifer K Blakemore
- Department of Obstetrics and Gynecology, New York University Langone Fertility Center, New York, New York
| | - Maureen Moomjy
- Department of Obstetrics and Gynecology, New York University Langone Fertility Center, New York, New York
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14
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Lewin A, Al Khan S, Beaudin L, Meilleur L, Clarke G, Richard L. Report on the 19th International Society of Blood Transfusion Platelet Immunology Workshop 2018. Vox Sang 2020; 115:767-782. [PMID: 32468604 DOI: 10.1111/vox.12945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES The aims of the 19th International Society of Blood Transfusion Platelet Immunology Workshop were to compare the sensitivity and specificity of in-house and commercially available methods for the detection of alloantibodies against human platelet antigens. Survey regarding laboratory management of samples collected for the diagnosis of foetal neonatal alloimmune thrombocytopenia was also conducted. MATERIALS AND METHODS Twenty-nine laboratories from 17 countries were invited to participate. Seven serum or plasma samples for antibody identification and eight DNA samples for genotyping were sent to participating laboratories. Additionally, samples, critical reagents, materials and instructions for three exercises, one using a commercial kit (Pak Lx), one on platelet preparation for the detection of anti-HPA-3 antibodies and one for testing four anti-CD109 monoclonal antibodies for anti-HPA-15 antibody detection, were provided. RESULTS Anti-HPA-1a, anti-HPA-2b, anti-HPA-5b and anti-GPIV were detected by the majority of the 28 reporting laboratories using their respective in-house MAIPA assay and/or a commercially available assay. Conversely, very few laboratories correctly identified anti-HPA-3a and HPA-15b. DNA genotyping of HPA and HLA alleles was highly accurate, with just a few discrepancies relative to the expected results. The Pak Lx kit has proven reliable for detecting anti-HPA-1a, anti-HPA-5a and anti-HLA; however, it failed at identifying an anti-HPA-3a in a clinical sample. CONCLUSIONS Some anti-platelet alloantibodies are reliably and consistently detected, yet others remain difficult to detect. Genotyping of HPA and HLA alleles has proven to be highly accurate and robust. Future work should focus on optimizing the detection of anti-HPA-3 and anti-HPA-15 antibodies.
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Affiliation(s)
- Antoine Lewin
- Medical Affairs and Innovation, Héma-Québec, Saint-Laurent, QC, Canada.,Obstetrics and Gynecology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Shadhiya Al Khan
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lynnette Beaudin
- Diagnostic Services, Canadian Blood Services, Edmonton, AB, Canada
| | - Lynne Meilleur
- Diagnostic Services, Canadian Blood Services, Edmonton, AB, Canada
| | - Gwen Clarke
- Diagnostic Services, Canadian Blood Services, Edmonton, AB, Canada.,Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Lucie Richard
- Medical Affairs and Innovation, Héma-Québec, Saint-Laurent, QC, Canada.,Stem Cell and Reference Laboratories, Héma-Québec, Saint-Laurent, QC, Canada
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15
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Ahlen MT, Heide G, Husebekk A, Skogen B, Kjeldsen-Kragh J, Stuge TB. The prevalence of HPA-1a alloimmunization and the potential risk of FNAIT depend on both the DRB3*01:01 allele and associated DR-DQ haplotypes. Scand J Immunol 2020; 92:e12890. [PMID: 32299122 DOI: 10.1111/sji.12890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023]
Abstract
Alloimmunization against human platelet antigen (HPA)-1a during pregnancy can cause foetal/neonatal alloimmune thrombocytopenia (FNAIT) and severe bleeding in the foetus or newborn and likely depends on several factors. HPA-1a alloimmunization is associated with DRB3*01:01, which is associated with several DR-DQ haplotypes. However, it is not known to what extent these haplotypes contribute to the prevalence of HPA-1a alloimmunization. HPA-1a-alloimmunized women, identified in a prospective study, and random donors were typed for selected DRB3, DRB4, DRB1, DQA1 and DQB1 alleles to determine allele and DR-DQ haplotype frequencies. DRB3*01:01 was carried by 94% HPA-1a-immunized women compared to 27% in the general population. In the first population, the DR3-DQ2 haplotype was overrepresented (P < .003). The prevalence of HPA-1a alloimmunization was estimated to be about twice as frequent with DR3-DQ2 compared to DR13-DQ6, together accounting for about 90% of DRB3*01:01-positive individuals. Further, we examined DQB1*02 and DRB4*01:01 alleles for their reported association with HPA-1a alloimmunization, in the context of DR-DQ haplotypes. Since ~ 80% of DQB1*02 alleles are linked to the DR3-DQ2 haplotype, the association might be coincidental. However, the DQB1*02:02-associated DR7-DQ2 haplotype was also overrepresented in alloimmunized women, suggesting a role for this allele or haplotype in HPA-1a alloimmunization. As DRB4*01:01 is predominantly associated with the DR7-DQ2 haplotype in HPA-1a-alloimmunized individuals, the reported association with FNAIT may be coincidental. Typing for DR-DQ haplotypes revealed important genetic associations with HPA-1a alloimmunization not evident from typing individual alleles, and the presence of different DRB3-associated DR-DQ haplotypes showed different prevalence of HPA-1a alloimmunization.
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Affiliation(s)
- Maria Therese Ahlen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Gøril Heide
- Immunology Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Husebekk
- Immunology Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bjørn Skogen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Immunology Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jens Kjeldsen-Kragh
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Lund, Sweden
| | - Tor B Stuge
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Immunology Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
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16
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Abstract
After vascular injury and exposure of subendothelial matrix proteins to the intravascular space, mediators of hemostasis are triggered and allow for clot formation and restoration of vascular integrity. Platelets are the mediators of primary hemostasis, creating a platelet plug and allowing for initial cessation of bleeding. Platelet disorders, qualitative and quantitative, may result in bleeding signs and symptoms, particularly mucocutaneous bleeding such as epistaxis, bruising, petechiae, and heavy menstrual bleeding. Increasing evidence suggests that platelets have functional capabilities beyond hemostasis, but this review focuses solely on platelet hemostatic properties. Herein, normal platelet function as well as the effects of abnormal function and thrombocytopenia are reviewed.
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Affiliation(s)
- Kristina M Haley
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
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17
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Blanco S, Vega LC, Carrizo LH, Culasso JM, Gallego SV. Fetal and neonatal alloimmune thrombocytopenia: a late or missed diagnosis disease in fetal and perinatal health-care settings. J Matern Fetal Neonatal Med 2020; 35:263-268. [PMID: 31973628 DOI: 10.1080/14767058.2020.1716713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Even though Fetal and Neonatal Alloimmune Thrombocytopenia (FNAIT) has been recognized as the main cause of primary hemorrhagic morbidity and mortality in fetuses and newborns, screening programs to detect pregnancies at risk have not yet been implemented in any country. Moreover, in spite of increased concerns about maternal, fetal and neonatal health care in general, this potentially lethal disease is still underdiagnosed. The aim of this report is to highlight the importance of considering FNAIT in fetal and perinatal health-care settings and show the usefulness of molecular tools in early diagnosis of this clinical entity.Methods: DNA was extracted from whole blood from parents and newborns; genotyping was performed by in house PCR using sequence-specific primers for typing Human Platelet Antigens (HPA)-1 to -6, -9, and -15, and with commercial HPA-TYPE (BAG HealthCare, Lich, Germany). Anti-HPA antibodies in the maternal serum were detected by the Monoclonal Antibody Solid Phase Platelet antibody Test (MASPAT). Chloroquine-treated platelets were used for the discrimination of platelet-specific antibodies from anti-HLA antibodies.Results: Patients 1 and 2 had severe thrombocytopenia due to incompatibility in HPA-1 and HPA-15, respectively. The third case was a thrombocytopenic neonate with severe bleeding complications other than ICH and in whom differential diagnosis between FNAIT and Von Willebrand congenital disease was necessary; incompatibility in HPA-15 was also demonstrated. Case 4 represents a missed diagnostic opportunity.Conclusion: This is the first report of FNAIT cases confirmed by molecular evidence and anti-HPA antibodies detection in Argentina. This report reinforces the relevance of early diagnosis of this clinical entity. Since the delay in FNAIT diagnosis could lead to severe consequences in the fetus and neonates, strategies to approach maternal, fetal, and perinatal health, as well as prevention policies aimed to reduce fetal and neonatal morbidity and mortality should focus on implementing programs to identify high-risk pregnancies and thus reduce thrombocytopenia-related complications in fetuses and newborns.
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Affiliation(s)
- Sebastián Blanco
- Fundación Banco Central de Sangre, Córdoba, Argentina.,Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Laura C Vega
- Servicio de Hemoterapia e Inmunohematología, Hospital Materno-Provincial Dr. Raúl Felipe Lucini, Córdoba, Argentina
| | - Luis H Carrizo
- Fundación Banco Central de Sangre, Córdoba, Argentina.,Servicio de Hemoterapia e Inmunohematología, Hospital Materno-Provincial Dr. Raúl Felipe Lucini, Córdoba, Argentina.,Servicio de Hemoterapia, Clínica y Maternidad del Sol, Córdoba, Argentina
| | - Jorge M Culasso
- Servicio de Hemoterapia e Inmunohematología, Hospital Materno-Provincial Dr. Raúl Felipe Lucini, Córdoba, Argentina
| | - Sandra V Gallego
- Fundación Banco Central de Sangre, Córdoba, Argentina.,Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
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18
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Abstract
A diagnosis of fetal/neonatal alloimmune thrombocytopenia (FNAIT) is made if a platelet-specific antibody is detected in the mother and the fetus or newborn carries the cognate antigen. Some children will experience very low platelet counts or even intracranial hemorrhage with devastating consequences, whereas others are largely unaffected. At the moment, predictive tools to forecast the severity of FNAIT during pregnancy are not available and over- or under-treatment may put the mother or the fetus at risk. A number of potential modulators of FNAIT severity have been reported. Maternal immune responses differ in respect to the IgG subtype composition, the glycosylation pattern of the antibodies, their fine specificity, and their functional effects on platelets, the trophoblast, and endothelial cells. In addition, antibody levels are variable. The efficacy of IgG transfer and, on the fetal side, gender and inflammatory responses, were also investigated for their potential impact on FNAIT severity. These potential risk modulators are scrutinized for available experimental and clinical evidence. Antibody glycosylation and anti-endothelial activity are hot candidates which, most likely in conjunction with the antibody level, should be explored further as tools to stratify fetal risk.
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Affiliation(s)
- Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany; Center for Transfusion Medicine and Hemotherapy, University Hospital Giessen and Marburg, Marburg, Germany; German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, Giessen, Germany.
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19
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Kjeldsen-Kragh J, Ahlen MT. Foetal and neonatal alloimmune thrombocytopenia - The role of the HLA-DRB3*01:01 allele for HPA-1a-immunisation and foetal/neonatal outcome. Transfus Apher Sci 2019; 59:102707. [PMID: 31919011 DOI: 10.1016/j.transci.2019.102707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Foetal and neonatal alloimmune thrombocytopenia (FNAIT) is the platelet counterpart of haemolytic disease of the foetus and newborn. Among Caucasians, around 80 % of FNAIT cases and some of the most severe cases, are caused by alloantibodies against the human platelet antigen 1a (HPA-1a). For around 3 decades it has been known that almost all HPA-1a-immunised women are HLA-DRB3*01:01 positive. The HLA molecule encoded by the HLA-DRA/DRB3*01:01 genes seems to be of crucial importance for initiating the immune response against HPA-1a. The HLA-DRB3*01:01 carrier status is not only important as a risk factor for immunisation, but does also have a significant impact on foetal/neonatal outcome. The possible role of HLA-DRB3*01:01 typing as tool for risk stratification is discussed.
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Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway; University and Regional Laboratories Region Skåne, Lund, Sweden.
| | - Maria Therese Ahlen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
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20
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Baker JM, Shehata N, Bussel J, Murphy MF, Greinacher A, Bakchoul T, Massey E, Lieberman L, Landry D, Tanael S, Arnold DM, Baidya S, Bertrand G, Kjaer M, Kaplan C, Kjeldsen-Kragh J, Oepkes D, Savoia H, Ryan G, Hume H. Postnatal intervention for the treatment of FNAIT: a systematic review. J Perinatol 2019; 39:1329-1339. [PMID: 30971767 DOI: 10.1038/s41372-019-0360-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is associated with life-threatening bleeding. This systematic review of postnatal management of FNAIT examined transfusion of human platelet antigen (HPA) selected or unselected platelets, and/or IVIg on platelet increments, hemorrhage and mortality. STUDY DESIGN MEDLINE, EMBASE and Cochrane searches were conducted until 11 May 2018. RESULT Of 754 neonates, 382 received platelet transfusions (51%). HPA-selected platelets resulted in higher platelet increments and longer response times than HPA-unselected platelets. However, unselected platelets generally led to sufficient platelet increments to 30 × 109/L, a level above which intracranial hemorrhage or other life-threatening bleeding rarely occurred. Platelet increments were not improved with the addition of IVIg to platelet transfusion. CONCLUSION Overall, HPA-selected platelet transfusions were more effective than HPA-unselected platelets but unselected platelets were often effective enough to achieve clinical goals. Available studies do not clearly demonstrate a benefit for addition of IVIg to platelet transfusion.
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Affiliation(s)
- Jillian M Baker
- St. Michael's Hospital and The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Nadine Shehata
- Departments of Medicine and Obstetric Medicine, Mount Sinai Hospital, Toronto, Canada.,Center for Innovation, Canadian Blood Services, Toronto, Canada
| | | | - Michael F Murphy
- NHS Blood & Transplant, Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Tamam Bakchoul
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,University Hospital of Tuebingen, Tuebingen, Germany
| | - Edwin Massey
- Diagnostic and Therapeutic Services, NHS Blood and Transplant, Bristol, UK
| | - Lani Lieberman
- University Health Network, University of Toronto, Toronto, Canada
| | - Denise Landry
- Center for Innovation, Canadian Blood Services, Ottawa, Canada
| | - Susano Tanael
- Center for Innovation, Canadian Blood Services, Toronto, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, McMaster University and Canadian Blood Services, Hamilton, Canada
| | - Shoma Baidya
- Australian Red Cross Blood Service, Brisbane, QLD, Australia
| | - Gerald Bertrand
- BloodCenter of Brittany - (EFS) Établissement Français du Sang, Rennes, France
| | - Mette Kjaer
- Finnmark Hospital Trust, Hammerfest, Norway.,University Hospital of North Norway, Tromsø, Norway
| | - Cécile Kaplan
- Retired and formerly Institut National de la Transfusion Sanguine, Paris, France
| | - Jens Kjeldsen-Kragh
- University Hospital of North Norway, Tromsø, Norway.,University and Regional Laboratories Region Skåne, Lund, Sweden
| | - Dick Oepkes
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - Greg Ryan
- Mount Sinai Hospital, Toronto, Canada
| | - Heather Hume
- Division of Haematology/Oncology, CHU Sainte-Justine, University of Montreal, Montreal, Canada
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21
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Bertrand G, Blouin L, Boehlen F, Levine E, Minon JM, Winer N. Management of neonatal thrombocytopenia in a context of maternal antiplatelet alloimmunization: Expert opinion of the French-speaking working group. Arch Pediatr 2019; 26:191-197. [PMID: 30827773 DOI: 10.1016/j.arcped.2019.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/13/2018] [Accepted: 02/03/2019] [Indexed: 01/07/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a potentially devastating disease, seen in 1/800-1000 neonates. FNAIT is the most common cause of early-onset isolated severe neonatal thrombocytopenia in maternity wards. The most feared complication of this disorder is intracranial hemorrhage, leading to death or neurological sequelae. There is no systematic screening of at-risk pregnancies and FNAIT is often discovered when fetal or neonatal bleeding is observed. A working group on fetomaternal platelet alloimmunization was created in 2017, under the auspices on the French Group of Thrombosis and Hemostasis (GFHT). The first objective of this group was to survey clinical practices for treatment of thrombocytopenic neonates in a context of suspected or confirmed FNAIT.
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Affiliation(s)
- G Bertrand
- laboratoire HLA-HPA, Établissement français du sang (EFS) Bretagne, rue Pierre-Jean-Gineste, BP 91614, 35016 Rennes cedex, France.
| | - L Blouin
- Laboratoire d'immunologie et immunogénétique, EFS Nouvelle Aquitaine, CHU de Bordeaux, place Amélie-Léon, 33076 Bordeaux cedex, France
| | - F Boehlen
- Service d'angiologie et d'hémostase, hôpitaux universitaires de Genève, 4, rue Gabrielle-Perret-Gentil, 1211 Genève 14, Switzerland
| | - E Levine
- Service de néonatologie soins intensifs, hôpital universitaire de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France
| | - J-M Minon
- Unité d'hémostase et de transfusion, département de médecine de laboratoire, centre hospitalier régional de la Citadelle, boulevard du XXII(e)-de-Ligne, 4000 Liège, Belgium
| | - N Winer
- INRA, UMR 1280, département de gynécologie et d'obstétrique, physiologie des adaptations nutritionnelles, hôpital universitaire de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
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22
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Winkelhorst D, Oepkes D. Foetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2019; 58:15-27. [PMID: 30827816 DOI: 10.1016/j.bpobgyn.2019.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022]
Abstract
Foetal or neonatal thrombocytopenia results from alloimmunisation during pregnancy. Maternal alloantibodies can be formed following exposure to paternally derived human platelet antigens (HPAs) on foetal platelets, in case of incompatible HPA type. These alloantibodies are of the immunoglobulin G subclass and can therefore enter the foetal circulation through active placental transport mediated by the neonatal Fc-receptor. After entering the foetal circulation, these alloantibodies can cause destruction of foetal platelets and potentially damage other foetal cells containing the specific antigen. Subsequent clinical presentation in foetuses or neonates can vary widely, from an asymptomatic thrombocytopenia to a broad spectrum of bleeding complications. Most frequently encountered are minor skin haemorrhages, such as hematomas or petechiae, but also more devastating haemorrhages can occur. Of these, an intracranial haemorrhage is the most feared complication because of its high risk of life-long major neurological handicaps or perinatal death.
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Affiliation(s)
- Dian Winkelhorst
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
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23
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Åberg K, Norman M, Pettersson K, Järnbert-Pettersson H, Ekéus C. Protracted vacuum extraction and neonatal intracranial hemorrhage among infants born at term: a nationwide case-control study. Acta Obstet Gynecol Scand 2019; 98:523-532. [DOI: 10.1111/aogs.13519] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/16/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Katarina Åberg
- Department of Women′s and Children′s Health; Division of Reproductive Health; Karolinska Institutet; Stockholm Sweden
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Karin Pettersson
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Hans Järnbert-Pettersson
- Department of Clinical Science and Education; Södersjukhuset Hospital; Karolinska Institutet; Stockholm Sweden
| | - Cecilia Ekéus
- Department of Women′s and Children′s Health; Division of Reproductive Health; Karolinska Institutet; Stockholm Sweden
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24
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25
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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26
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Abstract
The aim of pediatric transfusions should be based on the concept of avoiding unnecessary transfusions without jeopardizing the patient safety and providing correct blood components when there are well founded indications to transfuse. Despite considerable efforts from transfusion services to increase transfusion safety, transfusions are still associated with preventable and unpreventable adverse effects that may, in the worst case, have severe and fatal consequences. Transfusions to pediatric patients constitute a small proportion of all transfusions but have higher incidence of adverse events compared to adults. Pediatric transfusions consist of intrauterine transfusions, top-up transfusions to neonates and young children, exchange transfusions in the management of hemolytic disease of newborn (HDN), in addition to sickle cell crisis, chronic transfusion therapy in thalassemia patients, massive transfusion in trauma, HLA- and HPA-compatible platelets in immunized patients and neonates with fetal neonatal alloimmune thrombocytopenia (FNAIT). Packed red cells (PRCs) and platelet (PLT) concentrates are the most utilized blood components and will be reviewed here.
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27
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Sachs UJ, Santoso S. Bleeding or no bleeding? Anti-endothelial alphaVbeta3 antibodies as a major cause of intracranial haemorrhage in fetal-neonatal alloimmune thrombocytopenia. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- U. J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University; Giessen Germany
- Center for Transfusion Medicine and Hemotherapy; University Hospital Giessen and Marburg; Marburg Germany
- German Center for Fetomaternal Incompatibility (DZFI); University Hospital Giessen and Marburg; Giessen Germany
| | - S. Santoso
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University; Giessen Germany
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28
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Kovanlikaya A, Tiwari P, Bussel JB. Imaging and management of fetuses and neonates with alloimmune thrombocytopenia. Pediatr Blood Cancer 2017; 64. [PMID: 28675682 DOI: 10.1002/pbc.26690] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/26/2017] [Accepted: 05/27/2017] [Indexed: 01/06/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the most common cause of severe neonatal thrombocytopenia and intracranial bleeding in term newborns. Intracranial hemorrhage (ICH) commonly results in death or severe, lasting neurologic disability. The timing of ICH is also important for management of the next affected pregnancy in cases of FNAIT. This manuscript reviews the advantages and disadvantages of the different radiologic methodologies to identify and characterize ICH. It discusses the limits of ultrasound and the advantages of magnetic resonance imaging allowing avoidance of the radiation associated with computed tomography (CT) scans.
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Affiliation(s)
- Arzu Kovanlikaya
- Division of Pediatric Radiology, Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Priyanka Tiwari
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - James B Bussel
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Medicine, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
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29
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Refsum E, Håkansson S, Mörtberg A, Wikman A, Westgren M. Intracranial hemorrhages in neonates born from 32 weeks of gestation-low frequency of associated fetal and neonatal alloimmune thrombocytopenia: a register-based study. Transfusion 2017; 58:223-231. [DOI: 10.1111/trf.14394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Erle Refsum
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics; Umeå University; Umeå Sweden
| | - Anette Mörtberg
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Agneta Wikman
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
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30
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Karnes JH, Shaffer CM, Cronin R, Bastarache L, Gaudieri S, James I, Pavlos R, Steiner H, Mosley JD, Mallal S, Denny JC, Phillips EJ, Roden DM. Influence of Human Leukocyte Antigen (HLA) Alleles and Killer Cell Immunoglobulin-Like Receptors (KIR) Types on Heparin-Induced Thrombocytopenia (HIT). Pharmacotherapy 2017; 37:1164-1171. [PMID: 28688202 PMCID: PMC5600645 DOI: 10.1002/phar.1983] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, life-threatening, immune-mediated reaction to heparin. Variation in human leukocyte antigen (HLA) genes is now used to prevent immune-mediated adverse drug reactions. Combinations of HLA alleles and killer cell immunoglobulin-like receptors (KIR) are associated with multiple autoimmune diseases and infections. The objective of this study is to evaluate the association of HLA alleles and KIR types, alone or in the presence of different HLA ligands, with HIT. HIT cases and heparin-exposed controls were identified in BioVU, an electronic health record coupled to a DNA biobank. HLA sequencing and KIR type imputation using Illumina OMNI-Quad data were performed. Odds ratios for HLA alleles and KIR types and HLA*KIR interactions using conditional logistic regressions were determined in the overall population and by race/ethnicity. Analysis was restricted to KIR types and HLA alleles with a frequency greater than 0.01. The p values for HLA and KIR association were corrected by using a false discovery rate q<0.05 and HLA*KIR interactions were considered significant at p<0.05. Sixty-five HIT cases and 350 matched controls were identified. No statistical differences in baseline characteristics were observed between cases and controls. The HLA-DRB3*01:01 allele was significantly associated with HIT in the overall population (odds ratio 2.81 [1.57-5.02], p=2.1×10-4 , q=0.02) and in individuals with European ancestry, independent of other alleles. No KIR types were associated with HIT, although a significant interaction was observed between KIR2DS5 and the HLA-C1 KIR binding group (p=0.03). The HLA-DRB3*01:01 allele was identified as a potential risk factor for HIT. This class II HLA gene and allele represent biologically plausible candidates for influencing HIT pathogenesis. We found limited evidence of the role of KIR types in HIT pathogenesis. Replication and further study of the HLA-DRB3*01:01 association is necessary.
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Affiliation(s)
- Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
- Sarver Heart Center, Tucson, AZ
| | - Christian M Shaffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert Cronin
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville
| | - Silvana Gaudieri
- School of Anatomy, Physiology and Human Biology, University of Western Australia, Nedlands, Western Australia, Australia
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Ian James
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Heidi Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Jonathan D Mosley
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Simon Mallal
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joshua C Denny
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville
| | - Elizabeth J Phillips
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Dan M Roden
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
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Chen L, Liu Z, Liu T, Ma X, Rao M, Wang Y, Sun B, Yin W, Zhang J, Yan B, Li X, Wang Q, Zhang L, Wen J, Liu F, Wang P, Wei Y, Huang Y, Wu J, Guo Y, Kang Y, Song X, Liu X, Zhang G, Xie T, Chen Y, Zeng X, Li Z. Neonatal alloimmune thrombocytopenia caused by anti-HPA antibodies in pregnant Chinese women: a study protocol for a multicentre, prospective cohort trial. BMC Pregnancy Childbirth 2017; 17:281. [PMID: 28859622 PMCID: PMC5579874 DOI: 10.1186/s12884-017-1453-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/15/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Neonatal alloimmune thrombocytopenia (NAIT), caused by maternal antibodies raised against alloantigens carried on foetal platelets, is a very common haematological abnormality in newborns worldwide. However, baseline data on NAIT in China are lacking. Therefore, this study seeks to explore the incidence of alloantibody against the human platelet antigen (HPA) in pregnant women and its associations with NAIT in China. METHODS A multicentre, prospective cohort study design will be used, and 55,497 pregnant women will be recruited for the first screening of the anti-HPA antibody at 12 to 28 weeks of gestational age. Subjects who are positive in the first screening for the anti-HPA antibody will be included in the exposure group. Re-tests of the antibody titre, antigen-specificity and genotyping of HPA and HLA will be conducted during admission. A ratio of 1:1 paired individuals with the same ethnicity and parity but testing negative for the anti-HPA antibody will be randomly selected to be included in the non-exposure group. NAIT will be diagnosed in the newborns on day one of the birth. The HPA of the neonates in the exposure group will also be genotyped by sequencing. Associations of maternal HLA with the occurrence of the anti-HPA antibody and correlation of the severity of NAIT with the titre of the anti-HPA antibody will be further analysed. DISCUSSION The study is expected to provide baseline data on NAIT in China. Besides, we hope to find out a population who expresses particular HLA molecules has significant higher risk of HPA alloimmunization in Chinese individuals. We also hope to find a Chinese-specific cut-off antibody titre for the prediction of the severity of NAIT and to provide a means to evaluate the necessity of antenatal treatment. TRIAL REGISTRATION ClinicalTrials.gov: NCT02934906 (date registered: 13.10.2016).
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Affiliation(s)
- Li Chen
- Department of Blood Transfusion, The Second Affiliated Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Zhiwei Liu
- Department of Blood Transfusion, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, People's Republic of China
| | - Tiemei Liu
- Department of Blood Transfusion, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xianjun Ma
- Department of Blood Transfusion, Qilu Hospital of Shangdong University, Jinan, China
| | - Meiying Rao
- Derpartment of Blood Transfusion, The Second Hospital of Nanchang University, Nanchang, China
| | - Yongjun Wang
- Department of Blood Transfusion, The Second Xiang Ya Hospital of Central South University, Changsha, China
| | - Bo Sun
- Department of Blood Transfusion, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wen Yin
- Department of Blood Transfusion, Xijing Hospital of Fourth Military Medical University, Xi'an, China
| | - Jun Zhang
- Department of Blood Transfusion, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Beizhan Yan
- Department of Blood Transfusion, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xiaojuan Li
- Department of Blood Transfusion, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Qiushi Wang
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lei Zhang
- Department of Blood Transfusion, Affiliated Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jun Wen
- Department of Blood Transfusion, The People's Hospital of Xinjiang Autonomous Region, Wulumuqi, China
| | - Fenghua Liu
- Department of Blood Transfusion, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Peng Wang
- Department of Blood Transfusion, Peking University First Hospital, Beijing, China
| | - Yaming Wei
- Department of Blood Transfusion, Guangzhou First People's Hospital, Guangzhou, China
| | - Yuanshuai Huang
- Department of Blood Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiang Wu
- Department of Blood Transfusion, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Guo
- Department of Blood Transfusion, The First Affiliated Hospital/School of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yinlan Kang
- Department of Blood Transfusion, MCH Hospital of Yinchuan City, Yinchuan, China
| | - Xiaochuan Song
- Department of Blood Transfusion, The First Hospital of Xinjiang Medical University, Wulumuqi, China
| | - Xiangfu Liu
- Department of Blood Transfusion, The Third Affiliated Hospital, SUNYAT-SEN University, Guangzhou, China
| | - Genling Zhang
- Department of Blood Transfusion, The Second Affiliated Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Tingting Xie
- Department of Blood Transfusion, The Second Affiliated Hospital, The Third Military Medical University, Chongqing, People's Republic of China
| | - Yonggeng Chen
- Department of Blood Transfusion, Guangzhou First People's Hospital, Guangzhou, China
| | - Xiaojing Zeng
- Department of Blood Transfusion, The Affiliated Hospital of Guizhou University, Guiyang, China.
| | - Zhongjun Li
- Department of Blood Transfusion, The Second Affiliated Hospital, The Third Military Medical University, Chongqing, People's Republic of China.
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Lee CC, Lin JJ, Lin KL, Lim WH, Hsu KH, Hsu JF, Fu RH, Chiang MC, Chu SM, Lien R. Clinical Manifestations, Outcomes, and Etiologies of Perinatal Stroke in Taiwan: Comparisons between Ischemic, and Hemorrhagic Stroke Based on 10-year Experience in A Single Institute. Pediatr Neonatol 2017; 58:270-277. [PMID: 28087259 DOI: 10.1016/j.pedneo.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/02/2016] [Accepted: 07/08/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Perinatal stroke is a common cause of established neurological sequelae. Although several risk factors have been identified, many questions regarding causes and clinical outcomes remain unanswered. This study investigated the clinical manifestations and outcomes of perinatal stroke and identified its etiologies in Taiwan. METHODS We searched the reports of head magnetic resonance imaging and computed tomography performed between January 2003 and December 2012. The medical records of enrolled infants with perinatal stroke were also reviewed. RESULTS Thirty infants with perinatal stroke were identified; 10 infants had perinatal arterial ischemic stroke (PAIS) and 20 had perinatal hemorrhagic stroke (PHS). Neonatal seizure was the most common manifestation and presented in 40% of infants with PAIS and 50% of infants with PHS. All survivors with PAIS and 77% of the surviving infants with PHS developed neurological sequelae. Acute seizure manifestation was associated with poststroke epilepsy in infants with PHS but not in infants with PAIS (86% vs. 0%, p=0.005). PAIS was mostly caused by dysfunctional hemostasis (20%) and embolism (20%), whereas PHS was mostly attributable to birth asphyxia (30%). CONCLUSION Perinatal stroke is associated with high mortality and morbidity rates in infants. Clinically, it can be difficult to distinguish PAIS and PHS. One should keep a high level of suspicion, especially for PHS, if infants develop unexplained seizure, cyanosis, conscious change, anemia, and/or thrombocytopenia. A systematic diagnostic approach is helpful in identifying the etiologies of perinatal stroke.
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Affiliation(s)
- Chien-Chung Lee
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Wai-Ho Lim
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC.
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Tiller H, Husebekk A, Ahlen MT, Stuge TB, Skogen B. Current perspectives on fetal and neonatal alloimmune thrombocytopenia - increasing clinical concerns and new treatment opportunities. Int J Womens Health 2017; 9:223-234. [PMID: 28458583 PMCID: PMC5402885 DOI: 10.2147/ijwh.s90753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Differences in platelet type between the fetus and the mother can lead to maternal immunization and destruction of the fetal platelets, a condition named fetal and neonatal alloimmune thrombocytopenia (FNAIT). FNAIT is reported to occur in ~1 per 1,000 live born neonates. The major risk is intracranial hemorrhage in the fetus or newborn, which is associated with severe neurological complications or death. Since no countries have yet implemented a screening program to detect pregnancies at risk, the diagnosis is typically established after the birth of a child with symptoms. Reports on broader clinical impact have increased clinical concern and awareness. Along with new treatment options for FNAIT, the debate around antenatal screening to detect pregnancies at risk of FNAIT has been revitalized.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Anne Husebekk
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | | | - Tor B Stuge
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Bjørn Skogen
- Department of Laboratory Medicine, Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
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Wienzek-Lischka S, König IR, Papenkort EM, Hackstein H, Santoso S, Sachs UJ, Bein G. HLA-DRB3*01:01 is a predictor of immunization against human platelet antigen-1a but not of the severity of fetal and neonatal alloimmune thrombocytopenia. Transfusion 2016; 57:533-540. [PMID: 28019029 DOI: 10.1111/trf.13950] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/06/2016] [Accepted: 10/28/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Most cases of fetal and neonatal alloimmune thrombocytopenia (FNAIT) are caused by maternal alloantibodies against human platelet antigen-1a (HPA-1a). Alloimmunization mainly occurs in HPA-1a-negative mothers who are carriers of the HLA-DRB3*01:01 allele. Recently, it has been reported that the combined presence of HLA-DRB3*01:01 and HLA-DRB4*01:01P was associated with severity of FNAIT. We tested this hypothesis by analyzing a large cohort of cases and controls. STUDY DESIGN AND METHODS In total, 101 mothers with a history of FNAIT caused by anti-HPA-1a were investigated. HLA-DRB1, -DRB3, -DRB4, and -DRB5 genotypes were determined by Luminex technology. Haplotype frequencies were compared between cases and 100 controls. The platelet (PLT) counts of neonates and the incidence of intracranial hemorrhage (ICH) were compared between subgroups defined by genotype. RESULTS Of the HPA-1a-immunized mothers, 98% (99/101) carried at least one copy of HLA-DRB3*01:01. Carriage of HLA-DRB3*01:01 was significantly associated with immune response to HPA-1a (odds ratio, 92.3; 95% confidence interval, 26.9-317.1; p = 1.34 × 10-12 ). No association between HLA-DRB3*01:01 and HLA-DRB4*01:01P alone or in combination with the PLT count of the newborns or the incidence of ICH was detected. CONCLUSION In contrast to HLA-DRB4*01:01P, the inheritance of HLA-DRB3*01:01 is strongly associated with the propensity for mounting a humoral immune response against fetal HPA-1a antigen. Neither a homozygous nor a compound heterozygous gene dose predicts the severity of the disease. Testing for the presence of HLA-DRB3*01:01 might be very useful in counseling women at risk of FNAIT due to anti-HPA-1a.
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Affiliation(s)
- Sandra Wienzek-Lischka
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany.,German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, Giessen, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Eva-Maria Papenkort
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany
| | - Holger Hackstein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany
| | - Sentot Santoso
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany
| | - Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany.,German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, Giessen, Germany
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany.,German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, Giessen, Germany
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Sainio S, Javela K, Tuimala J, Haimila K. Maternal HLA genotyping is not useful for predicting severity of fetal and neonatal alloimmune thrombocytopenia. Br J Haematol 2016; 176:111-117. [PMID: 27748520 DOI: 10.1111/bjh.14385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/11/2016] [Indexed: 11/29/2022]
Abstract
Lack of reliable laboratory parameters is the main challenge in the management of fetal and neonatal alloimmune thrombocytopenia (FNAIT). Despite the long-known association between the HLA-DRB3*01:01 allele and human platelet antigen 1a (HPA-1a) alloimmunisation, maternal human leucocyte antigen (HLA) typing has been of little clinical value. Recently, other DRB3 allele variants have been suggested to predict the severity of FNAIT. In this nationwide population-based retrospective cohort study, we performed extensive HLA typing of 96 women, accounting for 87% of our cohort of 110 families with confirmed or possible HPA-1a-immunisation. The HLA type was compared with anti-HPA-1a levels, severity of neonatal disease and responsiveness to maternally administrated intravenous gammaglobulin (IVIG). HLA haplotypes were constructed to investigate further HLA associations. Despite significantly lower anti-HPA-1a levels in DRB3*01:01-negative women, the carrier status of this particular allele could not be used to confirm or rule out FNAIT in the absence of detectable antibodies. In the haplotype analysis, the DRB3*01:01 allele was the actual factor associated with FNAIT. No other HLA allele was shown to be of additional value as a predictor of severe FNAIT or non-responsiveness to IVIG treatment. Thus, HLA genotyping was not found useful in differentiating high- and low-risk pregnancies or in guiding antenatal treatment in affected families.
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Affiliation(s)
- Susanna Sainio
- Platelet Immunology Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Kaija Javela
- Platelet Immunology Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Jarno Tuimala
- Platelet Immunology Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Katri Haimila
- Platelet Immunology Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
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Bussel JB. What do we know about intracranial hemorrhage in fetal and neonatal alloimmune thrombocytopenia? Transfusion 2016; 56:17-8. [PMID: 26756707 DOI: 10.1111/trf.13412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022]
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