An acquired coagulation defect in a woman

Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review

BACKGROUND

About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting.

AIMS

This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies.

METHODS

Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases).

RESULTS

Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy.

CONCLUSION

This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.

A CIRCULATING ANTICOAGULANT INHIBITING ANTIHAEMOPHILIC GLOBULIN

A circulating anticoagulant inhibiting antihaemophilic globulin (A.H.G.) is described in an otherwise healthy 70-year-old woman, and the therapeutic response to steroids is discussed. The nature and pathogenesis of the anticoagulant remain obscure, but its properties and behaviour do not support an autoimmune aetiology.

Pregnancy and antibody to factor VIII

A patient who had developed a factor VIII antibody three weeks after the birth of her first baby became pregnant for the second time 10 weeks later. The pregnancy was normal apart from extensive spontaneous bruising during the first two months. This bleeding tendency disappeared in the third month of gestation and the antibody became undetectable during the eighth month. It has not reappeared seven months later. An unexplained long bleeding time and low platelet count were noted during the last trimester. The literature on postpartum coagulation inhibitors is reviewed.