1
|
Shen K, Chen T, Xiao M. MYH9-related inherited thrombocytopenia: the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches. Res Pract Thromb Haemost 2024; 8:102552. [PMID: 39309229 PMCID: PMC11415342 DOI: 10.1016/j.rpth.2024.102552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 09/25/2024] Open
Abstract
Inherited thrombocytopenias have been considered exceedingly rare for a long time, but recent advances have facilitated diagnosis and greatly enabled the discovery of new causative genes. MYH9-related disease (MYH9-RD) represents one of the most frequent forms of inherited thrombocytopenia, usually presenting with nonspecific clinical manifestations, which renders it difficult to establish an accurate diagnosis. MYH9-RD is an autosomal dominant-inherited thrombocytopenia caused by deleterious variants in the MYH9 gene encoding the heavy chain of nonmuscle myosin IIA. Patients with MYH9-RD usually present with thrombocytopenia and platelet macrocytosis at birth or in infancy, and most of them may develop one or more extrahematologic manifestations of progressive nephritis, sensorial hearing loss, presenile cataracts, and elevated liver enzymatic levels during childhood and adult life. Here, we have reviewed recent advances in the study of MYH9-RD, which aims to provide an updated and comprehensive summary of the current knowledge and improve our understanding of the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches of this rare disease. Importantly, our goal is to enable physicians to better understand this rare disease and highlight the critical role of genetic etiologic analysis in ensuring accurate diagnosis, clinical management, and genetic counseling while avoiding ineffective and potentially harmful therapies for MYH9-RD patients.
Collapse
Affiliation(s)
- Kefeng Shen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Chen
- Department of Ophthalmology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
2
|
Bavinck AP, Heerde WV, Schols SEM. Point-of-Care Testing in Patients with Hereditary Disorders of Primary Hemostasis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38950596 DOI: 10.1055/s-0044-1787976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Inherited disorders of primary hemostasis, such as von Willebrand disease and congenital platelet disorders, can cause extensive, typically mucocutaneous bleeding. Assays to diagnose and monitor these disorders, such as von Willebrand factor activity assays and light transmission aggregometry, are performed in specialized hemostasis laboratories but are commonly not available in local hospitals. Due to the complexity and relative scarcity of these conventional assays, point-of-care tests (POCT) might be an attractive alternative in patients with hereditary bleeding disorders. POCTs, such as thromboelastography, are increasingly used to assess hemostasis in patients with acquired hemostatic defects, aiding clinical decision-making in critical situations, such as during surgery or childbirth. In comparison, the use of these assays in patients with hereditary hemostasis defects remains relatively unexplored. This review aims to give an overview of point-of-care hemostasis tests in patients with hereditary disorders of primary hemostasis. A summary of the literature reporting on the performance of currently available and experimental POCTs in these disorders is given, and the potential utility of the assays in various use scenarios is discussed. Altogether, the studies included in this review reveal that several POCTs are capable of identifying and monitoring severe defects in the primary hemostasis, while a POCT that can reliably detect milder defects of primary hemostasis is currently lacking. A better understanding of the strengths and limitations of POCTs in assessing hereditary defects of primary hemostasis is needed, after which these tests may become available for clinical practice, potentially targeting a large group of patients with milder defects of primary hemostasis.
Collapse
Affiliation(s)
- Aernoud P Bavinck
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Waander van Heerde
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| |
Collapse
|
3
|
Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Pathophysiology, Clinical Manifestations and Diagnosis of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:204-219. [PMID: 38651450 PMCID: PMC11036214 DOI: 10.3390/hematolrep16020021] [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: 01/09/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/25/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in the platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and impaired central megakaryopoiesis and platelet production in the bone marrow. Here, we intend to contextualize the current knowledge on the pathophysiology, terminology, epidemiology, clinical manifestations, diagnosis, and prognosis of ITP from a historical perspective and the first references to the never-stopping garnering of knowledge about this entity. We highlight the necessity to better understand ITP in order to be able to provide ITP patients with personalized treatment options, improving disease prognosis and reducing the incidence or frequency of refractoriness.
Collapse
Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
| |
Collapse
|
4
|
Sarıdoğan E, Onat T, Arda Düz S, Tuncay G, Abdurahmanova N, Orujova L, Karaer A. Bernard-Soulier Syndrome from the Perspective of the Obstetrician: A Case Report with a Review of the Literature. Z Geburtshilfe Neonatol 2023. [PMID: 36889343 DOI: 10.1055/a-2024-0819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
OBJECTIVE Bernard-Soulier syndrome (BSS) is one of the rare inherited platelet disorders that is characterized by macrothrombocytopenia and adhesion abnormality due to the absence or malfunctioning of the membrane GPIb-IX-V complex. There is no high-quality evidence on obstetric management of BSS owing to its rarity. Here we report an uncomplicated delivery of an adolescent with BSS and review the literature on the topic of BSS and pregnancy. METHODS PUBMED, EMBASE, COCHRANE, and Google Scholar databases were searched up to April 2022 without language and year restriction using the terms "Bernard Soulier" and "Pregnancy". The primary objectives were to evaluate maternal and fetal outcomes. The secondary objectives were to analyze pregnancy complications, gestational age at delivery, mode of delivery, administered prophylaxis, treatment approaches, duration of postpartum hospitalization, and the postpartum requirement of blood and blood product. RESULTS The patient was a 19-year-old and 39-week pregnant woman who was diagnosed with BSS at the age of 10 by flow cytometry and genetic analysis. Single donor platelet transfusions and oral tranexamic acid were administered as prophylaxis at the peripartum period. She was delivered by cesarean section due to failure of labor. The postpartum period was uneventful for both mother and neonate. In the literature review, postpartum hemorrhage (PPH) was found in 52.9% (27/51) of deliveries. Late PPH occurred more frequently than early PPH (35.3 and 31.4%, respectively). 49% (25/51) of pregnancies had severe thrombocytopenia, and antepartum hemorrhage was observed in 11.8% (6/51) of those. The platelet count was in close relation to antenatal complications. 64.7% (33/51) of the patients were delivered via cesarean section. PPH and late PPH were found to be more common in those who delivered vaginally compared to those who delivered by caesarean section. It was observed that PPH was less common in women who were given prophylaxis in the peripartum period. CONCLUSION BSS is an inherited macro-thrombocytopathy that may cause adverse maternal and neonatal outcomes. The optimal mode and timing of delivery remain unclear. A multidisciplinary approach with prophylaxis at the peripartum period should be applied.
Collapse
Affiliation(s)
- Erdinç Sarıdoğan
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Taylan Onat
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Senem Arda Düz
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Görkem Tuncay
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Nuray Abdurahmanova
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Lumayat Orujova
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| | - Abdullah Karaer
- Obstetrics and Gynecology, Inonu University School of Medicine, Malatya, Turkey
| |
Collapse
|
5
|
Swaminathan N, Sharathkumar A, Dowlut-McElroy T. Reproductive Tract Bleeding in Adolescent and Young Adult Females with Inherited Bleeding Disorders: An Underappreciated Problem. J Pediatr Adolesc Gynecol 2022; 35:614-623. [PMID: 35830928 DOI: 10.1016/j.jpag.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.
Collapse
Affiliation(s)
- Neeraja Swaminathan
- Division of Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Anjali Sharathkumar
- Division of Pediatric Hematology Oncology, Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 1322 BT, 200 Hawkins Drive, Iowa City, IA 52242, United States.
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
6
|
Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
Collapse
Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
| |
Collapse
|
7
|
Abstract
The new techniques of genetic analysis have made it possible to identify many new forms of inherited thrombocytopenias (IT) and study large series of patients. In recent years, this has changed the view of IT, highlighting the fact that, in contrast to previous belief, most patients have a modest bleeding diathesis. On the other hand, it has become evident that some of the mutations responsible for platelet deficiency predispose the patient to serious, potentially life-threatening diseases. Today's vision of IT is, therefore, very different from that of the past and the therapeutic approach must take these changes into account while also making use of the new therapies that have become available in the meantime. This review, the first devoted entirely to IT therapy, discusses how to prevent bleeding in those patients who are exposed to this risk, how to treat it if it occurs, and how to manage the serious illnesses to which patients with IT may be predisposed.
Collapse
|
8
|
Arcudi S, Ronchi A, Capecchi M, Iurlaro E, Ossola MW, Mancini I, Schivardi G, Marconi AM, Podda GM, Artoni A. Assessment of post-partum haemorrhage risk among women with moderate thrombocytopenia. Br J Haematol 2022; 197:482-488. [PMID: 35266559 PMCID: PMC9314919 DOI: 10.1111/bjh.18098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/13/2022] [Accepted: 02/06/2022] [Indexed: 12/02/2022]
Abstract
It is unknown whether moderate thrombocytopenia represents a risk factor for post-partum haemorrhage (PPH). We assessed PPH risk among women with a platelet count of between 100 and 50 × 109 /l and stratified the risk for O/non-O blood group. We included consecutive women undergoing vaginal delivery or caesarean section with moderate thrombocytopenia. Women with >150 × 109 /l platelets at delivery were selected as controls and matched for age, type of birth and ethnicity. Odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated as risk estimates. A total of 94 thrombocytopenic women and 94 controls were included in the study. The rate of PPH was significantly higher in thrombocytopenic women than in controls (37% vs. 10%, p < 0.001); there was a higher risk of PPH in the thrombocytopenic group when compared to the control group (adjusted OR 4.7, 95% CI 2.1-10.8, p < 0.01) and this association was stronger in blood group O carriers (adjusted OR 11.0, 95% CI 2.4-49.6, p < 0.01). In conclusion, our study shows that a moderate thrombocytopenia is a risk factor for PPH, especially in blood group O carriers.
Collapse
Affiliation(s)
- Sara Arcudi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversità degli Studi di Milano, and Fondazione Luigi VillaMilanItaly
| | - Alice Ronchi
- Department of Obstetrics and GynecologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Marco Capecchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Biomedical Sciences for HealthUniversità degli Studi di MilanoMilanItaly
| | - Enrico Iurlaro
- Department of Obstetrics and GynecologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Manuela W. Ossola
- Department of Obstetrics and GynecologyFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Ilaria Mancini
- Department of Pathophysiology and TransplantationUniversità degli Studi di Milano, and Fondazione Luigi VillaMilanItaly
| | - Gabriella Schivardi
- Department of Obstetrics and GynecologyASST Santi Paolo e Carlo, Università degli Studi di MilanoMilanItaly
| | - Anna Maria Marconi
- Department of Obstetrics and GynecologyASST Santi Paolo e Carlo, Università degli Studi di MilanoMilanItaly
| | - Gian Marco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della SaluteUniversità degli Studi di MilanoMilanItaly
| | - Andrea Artoni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
| |
Collapse
|
9
|
Favier R, De Carne C, Elefant E, Rigouzzo A. A promising treatment to optimize delivery management in a pregnant woman with inherited thrombocytopenias: a new report of thrombopoietin receptor agonist administration. Int J Obstet Anesth 2022; 50:103541. [DOI: 10.1016/j.ijoa.2022.103541] [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: 11/08/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
|
10
|
Punt MC, Ruigrok ND, Bloemenkamp KWM, Uitslager N, Urbanus RT, Groot E, Kremer Hovinga ICL, Schutgens REG, van Galen KPM. Prevalence, burden and treatment effects of vaginal bleeding in women with (suspected) congenital platelet disorders throughout life: a cross-sectional study. Br J Haematol 2021; 196:215-223. [PMID: 34536019 PMCID: PMC9291839 DOI: 10.1111/bjh.17791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/08/2021] [Indexed: 02/06/2023]
Abstract
Congenital platelet disorders (CPDs) are rare bleeding disorders that are associated with mucocutaneous bleeds. However, data on vaginal bleeding in women with CPDs are scarce. A set of generic and bleeding‐specific questionnaires were used to evaluate the prevalence of vaginal bleeding, its impact on quality of life (QoL) and sexual functioning and the consequences for pregnancy, miscarriage and delivery in a cohort of women who were referred for diagnostic evaluation for CPDs. A total of 78 women included in the study were either diagnosed with a CPD (n = 35) or were clinically suspected of a CPD (n = 43). Heavy menstrual bleeding (HMB) was reported by a large proportion of women, which mainly started at menarche. In all, 76% of women received any kind of HMB treatment, often leading to surgical prodecures. HMB was shown to have a high impact on QoL, which improved upon treatment. Even though women reported that vaginal bleeding affects sexuality, this topic is not frequently discussed with physicians. Heavy blood loss frequently occurred after miscarriage/delivery, often requiring treatment. Women with (suspected) CPDs frequently encounter HMB, negatively impacting daily life and sexual functioning. Together with peripartum bleeding, these data highlight the burden of vaginal bleeding in CPDs and importance of adequate treatment.
Collapse
Affiliation(s)
- Marieke C Punt
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nienke D Ruigrok
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kitty W M Bloemenkamp
- Department of Gynaecology and Obstetrics, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Nanda Uitslager
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rolf T Urbanus
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Evelyn Groot
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Idske C L Kremer Hovinga
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Karin P M van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | |
Collapse
|
11
|
Zaninetti C, Wolff M, Greinacher A. Diagnosing Inherited Platelet Disorders: Modalities and Consequences. Hamostaseologie 2021; 41:475-488. [PMID: 34391210 DOI: 10.1055/a-1515-0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Inherited platelet disorders (IPDs) are a group of rare conditions featured by reduced circulating platelets and/or impaired platelet function causing variable bleeding tendency. Additional hematological or non hematological features, which can be congenital or acquired, distinctively mark the clinical picture of a subgroup of patients. Recognizing an IPD is challenging, and diagnostic delay or mistakes are frequent. Despite the increasing availability of next-generation sequencing, a careful phenotyping of suspected patients-concerning the general clinical features, platelet morphology, and function-is still demanded. The cornerstones of IPD diagnosis are clinical evaluation, laboratory characterization, and genetic testing. Achieving a diagnosis of IPD is desirable for several reasons, including the possibility of tailored therapeutic strategies and individual follow-up programs. However, detailed investigations can also open complex scenarios raising ethical issues in case of IPDs predisposing to hematological malignancies. This review offers an overview of IPD diagnostic workup, from the interview with the proband to the molecular confirmation of the suspected disorder. The main implications of an IPD diagnosis are also discussed.
Collapse
Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Martina Wolff
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
12
|
Gresele P, Falcinelli E, Bury L, Pecci A, Alessi MC, Borhany M, Heller PG, Santoro C, Cid AR, Orsini S, Fontana P, De Candia E, Podda G, Kannan M, Jurk K, Castaman G, Falaise C, Guglielmini G, Noris P. The ISTH bleeding assessment tool as predictor of bleeding events in inherited platelet disorders: Communication from the ISTH SSC Subcommittee on Platelet Physiology. J Thromb Haemost 2021; 19:1364-1371. [PMID: 33880867 DOI: 10.1111/jth.15263] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The ISTH Bleeding Assessment Tool (ISTH-BAT) has been validated for clinical screening of suspected von Willebrand disease (VWD) and for bleeding prediction. Recently it has been validated for subjects with inherited platelet disorders (IPD) (BAT-VAL study). OBJECTIVES To determine whether the ISTH-BAT bleeding score (BS) predicts subsequent bleeding events requiring treatment in IPD patients. METHODS Patients with IPD, type 1 VWD (VWD-1) and age- and sex-matched healthy controls enrolled in the BAT-VAL study were prospectively followed-up for 2 years and bleeding episodes requiring treatment were recorded. RESULTS Of the 1098 subjects initially enrolled, 955 were followed-up and 124 suffered hemorrhages during follow-up, 60% of whom had inherited platelet function disorders (IPFD). Total number of events was significantly higher in IPFD (n = 235) than VWD-1 (n = 52) or inherited thrombocytopenia (IT; n = 20). Events requiring transfusions were 66% in IPFD, 5.7% in VWD-1, and 3% in IT. Baseline BS was significantly higher in IPFD patients with a bleeding event at follow-up than in those without (p < .01) and the percentage of subjects suffering a bleeding event increased proportionally to baseline BS quartile. A significant association between the BS and the chance of suffering severe bleeding was found in the overall, IPFD, and VWD-1 populations. Similar results were obtained for the pediatric population. CONCLUSIONS Inherited platelet function disorder patients with high BS at enrollment are more likely to suffer from bleeding events requiring treatment at follow-up. Moreover, the higher the baseline BS quartile the greater the incidence of subsequent events, suggesting that independently from diagnosis a high BS is associated with a greater risk of subsequent hemorrhage.
Collapse
Affiliation(s)
- Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Emanuela Falcinelli
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marie-Christine Alessi
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Munira Borhany
- Department of Hematology, Haemostasis & Thrombosis at National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Paula G Heller
- Instituto de Investigaciones Médicas A. Lanari, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento Hematología Investigación, Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET, Universidad de Buenos Aires, Instituto de Investigaciones Médicas (IDIM, Buenos Aires, Argentina
| | - Cristina Santoro
- Hematology, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Sara Orsini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Pierre Fontana
- Geneva Platelet Group and Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Meganathan Kannan
- Division of Blood and Vascular Biology, Department of Life Sciences, School of Life Sciences, Central University of Tamil Nadu, Thiruvarur, India
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Céline Falaise
- Centre for CardioVascular and Nutrition Research (C2VN, INSERM 1263, INRA 1260, Marseille, France
| | - Giuseppe Guglielmini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
13
|
Zaninetti C, Thiele T. Anticoagulation in Patients with Platelet Disorders. Hamostaseologie 2021; 41:112-119. [PMID: 33860519 DOI: 10.1055/a-1344-7279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Platelet disorders comprise heterogeneous diseases featured by reduced platelet counts and/or impaired platelet function causing variable bleeding symptoms. Despite their bleeding diathesis, patients with platelet disorders can develop transient or permanent prothrombotic conditions that necessitate prophylactic or therapeutic anticoagulation. Anticoagulation in patients with platelet disorders is a matter of concern because the bleeding risk could add to the hemorrhagic risk related to the platelet defect. This review provides an overview on the evidence on anticoagulation in patients with acquired and inherited thrombocytopenia and/or platelet dysfunction. We summarize tools to evaluate and balance bleeding- and thrombotic risks and describe a practical approach on how to manage these patients if they have an indication for prophylactic or therapeutic anticoagulation.
Collapse
Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Thomas Thiele
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
14
|
Giordano G, Tiscia GL, Favuzzi G, Chinni E, Intrieri M, Mastroianno M, Di Meglio L, Margaglione M, Grandone E. The curious incident of a cavum velum interpositum cyst in twins of a mother carrying May-Hegglin anomaly: a case report and short literature review. BMC Pregnancy Childbirth 2020; 20:772. [PMID: 33308197 PMCID: PMC7731508 DOI: 10.1186/s12884-020-03437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background May-Hegglin anomaly is an autosomal dominant inherited condition, characterized by thrombocytopenia, giant platelets and Dohle-like bodies. Incidence is unknown and affected individuals can show from mild to moderate-severe haemorrhagic symptoms. The cyst of cavum veli interpositi (a virtual space filled with fluid within the third ventricle) is rarely reported in the foetal period. Furthermore, it is unclear whether isolated cavum veli interpositi cysts are a normal variant or developmental malformations. The simultaneous presence of these two anomalies was never described. Case presentation We describe a very rare case of a twin monochorionic pregnancy in a woman with the May-Hegglin anomaly, whose foetuses carried cavum veli interpositi cysts. Since childhood, our patient had shown macro-thrombocytopenia, deafness and bleeding (epistaxis and menorrhagia), but she was misdiagnosed until the age of 30 years when our Centre identified a de novo allelic variant in the gene MYH9 coding for the non-muscle myosin heavy chain IIa. Our patient bled neither during the pregnancy, nor in the peripartum period. Children are now eight-months-old and have never bled, although both inherited the MYH9 variant and have thrombocytopenia with giant platelets. Furthermore, none of them developed psychomotor disorders. Conclusions To the best of our knowledge, this is the sixth case of twin pregnancy in a woman carrying May-Hegglin anomaly and the first one with cavum veli interpositi cysts in the neonates. We speculate that MYH9 could have, at least in part, played a role in the development of both conditions, as this gene has a pleiotropic effect.
Collapse
Affiliation(s)
- Giulio Giordano
- Hematology Clinic-Internal Medicine Dept. "A. Cardarelli" Hospital, Campobasso, Italy
| | - Giovanni L Tiscia
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | - Giovanni Favuzzi
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | - Elena Chinni
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | - Mariano Intrieri
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Mario Mastroianno
- Scientific Direction, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | | | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy. .,Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| |
Collapse
|
15
|
Pecci A, Balduini CL. Inherited thrombocytopenias: an updated guide for clinicians. Blood Rev 2020; 48:100784. [PMID: 33317862 DOI: 10.1016/j.blre.2020.100784] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/05/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
The great advances in the knowledge of inherited thrombocytopenias (ITs) made since the turn of the century have significantly changed our view of these conditions. To date, ITs encompass 45 disorders with different degrees of complexity of the clinical picture and very wide variability in the prognosis. They include forms characterized by thrombocytopenia alone, forms that present with other congenital defects, and conditions that predispose to acquire additional diseases over the course of life. In this review, we recapitulate the clinical features of ITs with emphasis on the forms predisposing to additional diseases. We then discuss the key issues for a rational approach to the diagnosis of ITs in clinical practice. Finally, we aim to provide an updated and comprehensive guide to the treatment of ITs, including the management of hemostatic challenges, the treatment of severe forms, and the approach to the manifestations that add to thrombocytopenia.
Collapse
Affiliation(s)
- Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy.
| | | |
Collapse
|
16
|
Punt MC, Ruigrok ND, Bloemenkamp KWM, Schutgens REG, Kremer Hovinga ICL, van Galen KPM. Obstetrical bleeding in women with MYH9-related disease-A systematic review. Haemophilia 2020; 27:e278-e283. [PMID: 32997874 DOI: 10.1111/hae.14147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 07/23/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Marieke C Punt
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nienke D Ruigrok
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kitty W M Bloemenkamp
- Division Woman and Baby, Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Idske C L Kremer Hovinga
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karin P M van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
17
|
Lazaro E, Houssin C, Sentilhes L, Blouin L, Fiore M. Successful management of a pregnant woman with severe ANKRD26-related thrombocytopenia and anti-HPA-5b alloimmunization. Platelets 2020; 31:827-829. [PMID: 31607198 DOI: 10.1080/09537104.2019.1678116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Estibaliz Lazaro
- Service de médecine interne et maladies infectieuses, Centre Hospitalier Universitaire de Bordeaux, Hôpital Haut-Lévêque , Pessac, France
| | - Clémence Houssin
- Service de gynécologie-obstétrique, Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin , Bordeaux, France
| | - Loic Sentilhes
- Service de gynécologie-obstétrique, Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin , Bordeaux, France
| | - Laura Blouin
- Service d'Immunologie et Immunogénétique, Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Établissement Français du Sang , Bordeaux, France
| | - Mathieu Fiore
- Service d'Hématologie Biologique, Centre de Référence des Pathologies Plaquettaires, Centre Hospitalier Universitaire de Bordeaux, Hôpital Haut-Lévêque , Pessac, France
| |
Collapse
|
18
|
Paciullo F, Bury L, Noris P, Falcinelli E, Melazzini F, Orsini S, Zaninetti C, Abdul-Kadir R, Obeng-Tuudah D, Heller PG, Glembotsky AC, Fabris F, Rivera J, Lozano ML, Butta N, Favier R, Cid AR, Fouassier M, Podda GM, Santoro C, Grandone E, Henskens Y, Nurden P, Zieger B, Cuker A, Devreese K, Tosetto A, De Candia E, Dupuis A, Miyazaki K, Othman M, Gresele P. Antithrombotic prophylaxis for surgery-associated venous thromboembolism risk in patients with inherited platelet disorders. The SPATA-DVT Study. Haematologica 2020; 105:1948-1956. [PMID: 31558677 PMCID: PMC7327644 DOI: 10.3324/haematol.2019.227876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/25/2019] [Indexed: 12/11/2022] Open
Abstract
Major surgery is associated with an increased risk of venous thromboembolism (VTE), thus the application of mechanical or pharmacologic prophylaxis is recommended. The incidence of VTE in patients with inherited platelet disorders (IPD) undergoing surgical procedures is unknown and no information on the current use and safety of thromboprophylaxis, particularly of low-molecular-weight-heparin in these patients is available. Here we explored the approach to thromboprophylaxis and thrombotic outcomes in IPD patients undergoing surgery at VTE-risk participating in the multicenter SPATA study. We evaluated 210 surgical procedures carried out in 155 patients with well-defined forms of IPD (VTE-risk: 31% high, 28.6% intermediate, 25.2% low, 15.2% very low). The use of thromboprophylaxis was low (23.3% of procedures), with higher prevalence in orthopedic and gynecological surgeries, and was related to VTE-risk. The most frequently employed thromboprophylaxis was mechanical and appeared to be effective, as no patients developed thrombosis, including patients belonging to the highest VTE-risk classes. Low-molecular-weight-heparin use was low (10.5%) and it did not influence the incidence of post-surgical bleeding or of antihemorrhagic prohemostatic interventions use. Two thromboembolic events were registered, both occurring after high VTE-risk procedures in patients who did not receive thromboprophylaxis (4.7%). Our findings suggest that VTE incidence is low in patients with IPD undergoing surgery at VTE-risk and that it is predicted by the Caprini score. Mechanical thromboprophylaxis may be of benefit in patients with IPD undergoing invasive procedures at VTE-risk and low-molecular-weight-heparin should be considered for major surgery.
Collapse
Affiliation(s)
- Francesco Paciullo
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Federica Melazzini
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Carlo Zaninetti
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
- PhD program in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Rezan Abdul-Kadir
- Haemophilia Centre and Haemostasis Unit, The Royal Free Foundation Hospital and University College London, London, UK
| | - Deborah Obeng-Tuudah
- Haemophilia Centre and Haemostasis Unit, The Royal Free Foundation Hospital and University College London, London, UK
| | - Paula G Heller
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Buenos Aires,
Argentina
- CONICET, Universidad de Buenos Aires, Instituto de Investigaciones Médicas -IDIM-, Buenos Aires, Argentina
| | - Ana C Glembotsky
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Buenos Aires,
Argentina
- CONICET, Universidad de Buenos Aires, Instituto de Investigaciones Médicas -IDIM-, Buenos Aires, Argentina
| | - Fabrizio Fabris
- Clinica Medica 1 - Medicina Interna CLOPD, Dipartimento Assistenziale Integrato di Medicina, Azienda-Ospedale Università di Padova, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Jose Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Maria Luisa Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Nora Butta
- Unidad de Hematología, Hospital Universitario La Paz-IDIPaz, Madrid, Spain
| | - Remi Favier
- Assistance Publique-Hôpitaux de Paris, Armand Trousseau Children's Hospital, French Reference Centre for Inherited Platelet Disorders, Paris, France
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Marc Fouassier
- Consultations d'Hémostase - CRTH, CHU de Nantes, Nantes, France
| | - Gian Marco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Cristina Santoro
- Hematology, Department of Translational and Precision Medicine, La Sapienza University of Rome, Rome, Italy
| | - Elvira Grandone
- Unità di Ricerca in Aterosclerosi e Trombosi, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, The Russian Federation
| | - Yvonne Henskens
- Hematological Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paquita Nurden
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katrien Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | | | - Erica De Candia
- Hemostasis and Thrombosis Unit, Insitute of Internal Medicine, Policlinico Agostino Gemelli Foundation, IRCCS, Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Arnaud Dupuis
- Université de Strasbourg, Institut National de la Santé et de la Recherche Médicale, Etablissement Français du Sang Grand Est, Unité Mixte de Recherche-S 1255, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - Koji Miyazaki
- Department of Transfusion and Cell Transplantation Kitasato University School of Medicine, Sagamihara, Japan
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| |
Collapse
|
19
|
Nurden AT, Nurden P. Inherited thrombocytopenias: history, advances and perspectives. Haematologica 2020; 105:2004-2019. [PMID: 32527953 PMCID: PMC7395261 DOI: 10.3324/haematol.2019.233197] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/11/2022] Open
Abstract
Over the last 100 years the role of platelets in hemostatic events and their production by megakaryocytes have gradually been defined. Progressively, thrombocytopenia was recognized as a cause of bleeding, first through an acquired immune disorder; then, since 1948, when Bernard-Soulier syndrome was first described, inherited thrombocytopenia became a fascinating example of Mendelian disease. The platelet count is often severely decreased and platelet size variable; associated platelet function defects frequently aggravate bleeding. Macrothrombocytopenia with variable proportions of enlarged platelets is common. The number of circulating platelets will depend on platelet production, consumption and lifespan. The bulk of macrothrombocytopenias arise from defects in megakaryopoiesis with causal variants in transcription factor genes giving rise to altered stem cell differentiation and changes in early megakaryocyte development and maturation. Genes encoding surface receptors, cytoskeletal and signaling proteins also feature prominently and Sanger sequencing associated with careful phenotyping has allowed their early classification. It quickly became apparent that many inherited thrombocytopenias are syndromic while others are linked to an increased risk of hematologic malignancies. In the last decade, the application of next-generation sequencing, including whole exome sequencing, and the use of gene platforms for rapid testing have greatly accelerated the discovery of causal genes and extended the list of variants in more common disorders. Genes linked to an increased platelet turnover and apoptosis have also been identified. The current challenges are now to use next-generation sequencing in first-step screening and to define bleeding risk and treatment better.
Collapse
Affiliation(s)
- Alan T Nurden
- Institut Hospitalo-Universitaire LIRYC, Pessac, France
| | | |
Collapse
|
20
|
Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
Collapse
Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
| |
Collapse
|
21
|
Baccini V, Geneviève F, Jacqmin H, Chatelain B, Girard S, Wuilleme S, Vedrenne A, Guiheneuf E, Toussaint-Hacquard M, Everaere F, Soulard M, Lesesve JF, Bardet V. Platelet Counting: Ugly Traps and Good Advice. Proposals from the French-Speaking Cellular Hematology Group (GFHC). J Clin Med 2020; 9:jcm9030808. [PMID: 32188124 PMCID: PMC7141345 DOI: 10.3390/jcm9030808] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 12/25/2022] Open
Abstract
Despite the ongoing development of automated hematology analyzers to optimize complete blood count results, platelet count still suffers from pre-analytical or analytical pitfalls, including EDTA-induced pseudothrombocytopenia. Although most of these interferences are widely known, laboratory practices remain highly heterogeneous. In order to harmonize and standardize cellular hematology practices, the French-speaking Cellular Hematology Group (GFHC) wants to focus on interferences that could affect the platelet count and to detail the verification steps with minimal recommendations, taking into account the different technologies employed nowadays. The conclusions of the GFHC presented here met with a "strong professional agreement" and are explained with their rationale to define the course of actions, in case thrombocytopenia or thrombocytosis is detected. They are proposed as minimum recommendations to be used by each specialist in laboratory medicine who remains free to use more restrictive guidelines based on the patient’s condition.
Collapse
Affiliation(s)
- Véronique Baccini
- Laboratoire d’hématologie, CHU de la Guadeloupe, INSERM UMR S_1134, 97159 Pointe-à-Pitre, France
- Correspondence:
| | - Franck Geneviève
- Fédération Hospitalo-Universitaire ‘Grand Ouest Against Leukemia’ (FHU GOAL), 49033 Angers, France;
| | - Hugues Jacqmin
- Université Catholique de Louvain, CHU UCL Namur, Laboratoire d’hématologie, Namur Thrombosis and Hemostasis Center, 5530 Yvoir, Belgium; (H.J.); (B.C.)
| | - Bernard Chatelain
- Université Catholique de Louvain, CHU UCL Namur, Laboratoire d’hématologie, Namur Thrombosis and Hemostasis Center, 5530 Yvoir, Belgium; (H.J.); (B.C.)
| | - Sandrine Girard
- Hospices Civils de Lyon, Centre de biologie et pathologie Est, Service d’hématologie biologique, 69500 Bron, France;
| | - Soraya Wuilleme
- Laboratoire d’Hématologie, Institut de Biologie, CHU de Nantes; 44093 Nantes CEDEX, France;
| | - Aurélie Vedrenne
- Service de biologie clinique, Hôpital Foch, 92150 Suresnes, France;
| | - Eric Guiheneuf
- Service d’Hématologie Biologique, CHU Amiens-Picardie, 80054 Amiens CEDEX, France;
| | | | | | - Michel Soulard
- Plateau technique d’hématologie, Laboratoire Biogroup, 92300 Levallois-Perret, France;
| | | | - Valérie Bardet
- Service d’Hématologie-Immunologie-Transfusion, CHU Ambroise Paré, INSERM UMR 1184, AP-HP, Université Paris Saclay, 92100 Boulogne-Billancourt, France;
| |
Collapse
|
22
|
Gresele P, Falcinelli E, Bury L. Inherited platelet disorders in women. Thromb Res 2020; 181 Suppl 1:S54-S59. [PMID: 31477229 DOI: 10.1016/s0049-3848(19)30368-8] [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: 01/25/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023]
Abstract
Inherited platelet disorders (IPD) are a heterogeneous group of hemorrhagic diseases affecting both men and women, but usually associated with more evident bleeding symptoms in women due to the exposure to sexspecific hemostatic challenges, like menstruation and delivery. Indeed, up to 50% of women presenting with menorrhagia are diagnosed an IPD, moreover women with IPD can have ovulation-associated bleeding events and are at higher risk of endometriosis. Large retrospective studies have shown that women with IPD have a significantly increased risk of post-partum hemorrhage, predicted by a high bleeding score at previous history and by a platelet count below 50X109/L. In addition, in patients with IPD, female sex was associated with a higher frequency of excessive bleeding after surgery, even when excluding gynecological procedures. In conclusion, IPD may represent a serious problem for women's health, and their diagnosis and appropriate management is crucial to ensure female patients a good quality of life.
Collapse
Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| |
Collapse
|
23
|
Punt MC, Schuitema PCE, Bloemenkamp KWM, Kremer Hovinga ICL, van Galen KPM. Menstrual and obstetrical bleeding in women with inherited platelet receptor defects-A systematic review. Haemophilia 2020; 26:216-227. [PMID: 32004416 PMCID: PMC7155109 DOI: 10.1111/hae.13927] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/30/2019] [Accepted: 01/03/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Women with inherited platelet receptor defects (IPRD) may have an increased risk of heavy menstrual bleeding (HMB) and postpartum haemorrhage (PPH). AIM To present a systematic overview of the literature on the prevalence and management of menstrual and obstetrical bleeding in women with IPRD. METHODS Electronic databases were searched for original patient data on the prevalence and management of HMB and PPH in women with known IPRD or who were being investigated for IPRD. RESULTS Sixty-nine papers (61 case reports/series and 8 cohort studies) were included. Overall, studies were rated as 'poor quality'. The included cohort studies reported HMB in 25% (13/52) of women with Bernard-Soulier syndrome and in 22.1% (34/154) of women with Glanzmann thrombasthenia. In total, 164 deliveries in women with IPRD were described. Excessive bleeding occurred in 16.9% (11/65) of deliveries described in the largest cohort. PPH occurred in 63.2% (55/87) of deliveries described in case reports/series. PPH occurred in 73.7% (14/19) of deliveries that were not covered by prophylaxis compared with 54.2% (32/59) of deliveries that were (OR = 2.36, 95% CI 0.75-7.40). Neonatal bleeding complications were reported in 10.0% (8/80) of deliveries. In all (6/6) deliveries with neonatal bleeding complications wherein the presence of alloantibodies was investigated, either antiplatelet or anti-HLA antibodies were detected. DISCUSSION/CONCLUSION Menstrual and particularly obstetrical bleeding problems frequently occur in women with IPRD, based on small case reports and series of poor quality. International collaboration, preferably on prospective studies, is needed to improve clinical management of women-specific bleeding in IPRD.
Collapse
Affiliation(s)
- Marieke C. Punt
- Van CreveldkliniekUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
| | - Pauline C. E. Schuitema
- Van CreveldkliniekUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
| | - Kitty W. M. Bloemenkamp
- Division Woman and BabyDepartment of ObstetricsBirth Centre Wilhelmina’s Children HospitalUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
| | | | - Karin P. M. van Galen
- Van CreveldkliniekUniversity Medical Center UtrechtUniversity of UtrechtUtrechtThe Netherlands
| |
Collapse
|
24
|
Gresele P, Orsini S, Noris P, Falcinelli E, Alessi MC, Bury L, Borhany M, Santoro C, Glembotsky AC, Cid AR, Tosetto A, De Candia E, Fontana P, Guglielmini G, Pecci A. Validation of the ISTH/SSC bleeding assessment tool for inherited platelet disorders: A communication from the Platelet Physiology SSC. J Thromb Haemost 2020; 18:732-739. [PMID: 31750621 DOI: 10.1111/jth.14683] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/11/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Careful assessment of bleeding history is the first step in the evaluation of patients with mild/moderate bleeding disorders, and the use of a bleeding assessment tool (BAT) is strongly encouraged. Although a few studies have assessed the utility of the ISTH-BAT in patients with inherited platelet function disorders (IPFD) none of them was sufficiently large to draw conclusions and/or included appropriate control groups. OBJECTIVES The aim of the present study was to test the utility of the ISTH-BAT in a large cohort of patients with a well-defined diagnosis of inherited platelets disorder in comparison with two parallel cohorts, one of patients with type-1 von Willebrand disease (VWD-1) and one of healthy controls (HC). PATIENTS/METHODS We enrolled 1098 subjects, 482 of whom had inherited platelet disorders (196 IPFD and 286 inherited platelet number disorders [IT]) from 17 countries. RESULTS IPFD patients had significantly higher bleeding score (BS; median 9) than VWD-1 patients (median 5), a higher number of hemorrhagic symptoms (4 versus 3), and higher percentage of patients with clinically relevant symptoms (score > 2). The ISTH-BAT showed excellent discrimination power between IPFD and HC (0.9 < area under the curve [AUC] < 1), moderate (0.7 < AUC < 0.9) between IPFD and VWD-1 and between IPFD and inherited thrombocytopenia (IT), while it was inaccurate (AUC ≤ 0.7) in discriminating IT from HC. CONCLUSIONS The ISTH-BAT allows to efficiently discriminate IPFD from HC, while it has lower accuracy in distinguishing IPFD from VWD-1. Therefore, the ISTH-BAT appears useful for identifying subjects requiring laboratory evaluation for a suspected IPFD once VWD is preliminarily excluded.
Collapse
Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Munira Borhany
- Department of Hematology, Haemostasis & Thrombosis at National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, Pakistan
| | - Cristina Santoro
- Hematology, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Ana C Glembotsky
- Instituto de Investigaciones Médicas A. Lanari, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento Hematología Investigación, Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Universidad de Buenos Aires, Instituto de Investigaciones Médicas (IDIM), Buenos Aires, Argentina
| | - Ana Rosa Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | - Erica De Candia
- Hemostasis and Thrombosis Unit, Fondazione Policlinico Agostino Gemelli IRCCS, Roma, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Pierre Fontana
- Platelet Group and Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Giuseppe Guglielmini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
25
|
Zaninetti C, Greinacher A. Diagnosis of Inherited Platelet Disorders on a Blood Smear. J Clin Med 2020; 9:jcm9020539. [PMID: 32079152 PMCID: PMC7074415 DOI: 10.3390/jcm9020539] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 12/12/2022] Open
Abstract
Inherited platelet disorders (IPDs) are rare diseases featured by low platelet count and defective platelet function. Patients have variable bleeding diathesis and sometimes additional features that can be congenital or acquired. Identification of an IPD is desirable to avoid misdiagnosis of immune thrombocytopenia and the use of improper treatments. Diagnostic tools include platelet function studies and genetic testing. The latter can be challenging as the correlation of its outcomes with phenotype is not easy. The immune-morphological evaluation of blood smears (by light- and immunofluorescence microscopy) represents a reliable method to phenotype subjects with suspected IPD. It is relatively cheap, not excessively time-consuming and applicable to shipped samples. In some forms, it can provide a diagnosis by itself, as for MYH9-RD, or in addition to other first-line tests as aggregometry or flow cytometry. In regard to genetic testing, it can guide specific sequencing. Since only minimal amounts of blood are needed for the preparation of blood smears, it can be used to characterize thrombocytopenia in pediatric patients and even newborns further. In principle, it is based on visualizing alterations in the distribution of proteins, which result from specific genetic mutations by using monoclonal antibodies. It can be applied to identify deficiencies in membrane proteins, disturbed distribution of cytoskeletal proteins, and alpha as well as delta granules. On the other hand, mutations associated with impaired signal transduction are difficult to identify by immunofluorescence of blood smears. This review summarizes technical aspects and the main diagnostic patterns achievable by this method.
Collapse
Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany;
- University of Pavia, and IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy
- PhD Program of Experimental Medicine, University of Pavia, 27100 Pavia, Italy
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany;
- Correspondence: ; Tel.: +49-3834-865482; Fax: +49-3834-865489
| |
Collapse
|
26
|
Rabbolini D, Connor D, Morel-Kopp MC, Donikian D, Kondo M, Chen W, Alessi MC, Stevenson W, Chen V, Joseph J, Brighton T, Ward C. An integrated approach to inherited platelet disorders: results from a research collaborative, the Sydney Platelet Group. Pathology 2020; 52:243-255. [PMID: 31932033 DOI: 10.1016/j.pathol.2019.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/11/2019] [Accepted: 10/16/2019] [Indexed: 01/01/2023]
Abstract
Inherited disorders of platelet function (IPFD) and/or number (IPND) are heterogeneous conditions that result in variable mucocutaneous bleeding symptoms as a result of deranged primary haemostasis caused by platelet dysfunction or thrombocytopenia. Diagnosis is important to guide post-operative bleeding prophylactic strategies, to avoid treatment with inappropriate medications, and inform prognosis. Achieving an accurate diagnosis has traditionally been hampered by the requirement of multiple, often complex, laboratory tests that are not always available at single centres. To improve the diagnosis of these disorders a research collaborative was established, the Sydney Platelet Group, that explored an integrated approach combining traditional and contemporary platelet phenotypic and genetic diagnostic platforms available at four Sydney tertiary hospitals. Herein we report the outcomes of the first 50 patients evaluated using this approach. The cohort included 22 individuals with suspected IPFD and 28 with thrombocytopenia. Bleeding scores were higher in individuals with IPFD (mean 5.75; SD 4.83) than those with IPNDs (mean 2.14; SD 2.45). In cases with suspected IPFD, diagnosis to the level of the defective pathway was achieved in 71% and four individuals were found not to have a definitive platelet function defect. Dense granule secretion disorders were the most common platelet pathway abnormality detected (n=5). Mean bleeding scores in these individuals were not significantly different to individuals with defects in other commonly detected platelet pathways (dense granules, signal transduction and 'undetermined'). A molecular diagnosis was achieved in 52% of individuals with IPNDs and 5% with IPFD. Likely pathogenic and pathogenic variants detected included variants associated with extra-haematological complications (DIAPH1, MYH9) and potential for malignancy (ANKRD26 and RUNX1). The level of platelet investigation undertaken by this initiative is currently not available elsewhere in Australia and initial results confirm the utility of this integrated phenotypic-genetic approach.
Collapse
Affiliation(s)
- David Rabbolini
- Lismore Base Hospital, Lismore, NSW, Australia; Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia.
| | - David Connor
- St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia
| | - Marie-Christine Morel-Kopp
- Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Dea Donikian
- Prince of Wales Hospital, Sydney, NSW, Australia; Haematology NSW Health Pathology Randwick, Sydney, NSW, Australia
| | - Mayuko Kondo
- Prince of Wales Hospital, Sydney, NSW, Australia; Haematology NSW Health Pathology Randwick, Sydney, NSW, Australia
| | - Walter Chen
- Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Marie-Christine Alessi
- Laboratory of Haematology, University Hospital of La Timone, French Reference Centre for Rare Platelet Disorders, Marseille, France
| | - William Stevenson
- Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Vivien Chen
- ANZAC Research Institute and Concord Repatriation Hospital, Concord, NSW, Australia; Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Joanne Joseph
- St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia; St Vincent's Hospital, Sydney, NSW, Australia
| | - Timothy Brighton
- Prince of Wales Hospital, Sydney, NSW, Australia; Haematology NSW Health Pathology Randwick, Sydney, NSW, Australia
| | - Christopher Ward
- Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | | |
Collapse
|
27
|
Pishko AM, Levine LD, Cines DB. Thrombocytopenia in pregnancy: Diagnosis and approach to management. Blood Rev 2019; 40:100638. [PMID: 31757523 DOI: 10.1016/j.blre.2019.100638] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 02/06/2023]
Abstract
Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.
Collapse
Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas B Cines
- Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
28
|
Shapiro A. The use of prophylaxis in the treatment of rare bleeding disorders. Thromb Res 2019; 196:590-602. [PMID: 31420204 DOI: 10.1016/j.thromres.2019.07.014] [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: 02/08/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
Abstract
Rare bleeding disorders (RBDs) are a heterogeneous group of coagulation factor deficiencies that include fibrinogen, prothrombin, α2-antiplasmin, plasminogen activator inhibitor-1, and factors II, V, V/VIII, VII, X, XI and XIII. The incidence varies based upon the disorder and typically ranges from 1 in 500,000 to 1 per million population. Symptoms vary with the disorder and residual level of the clotting factor, and can range from relatively minor such as epistaxis, to life threatening, such as intracranial hemorrhage. Rapid treatment of bleeding episodes in individuals with severe bleeding phenotypes is essential to preserve life or limb and to prevent long-term sequelae; therapeutic options depend on the deficiency and range from plasma-derived (eg, fresh frozen plasma, prothrombin complex concentrates, factor X concentrate) to highly purified and recombinant single factor concentrates. The rarity of these disorders limits the feasibility of conventional prospective clinical trials; instead, clinicians rely upon registries, published case reports/series and experience to guide treatment. In some disorders, long-term prophylactic therapy is administered in response to the bleeding phenotype in an individual patient or based on the known natural history and severity of the deficiency. Intermittent prophylaxis, surrounding surgery, pregnancy, labor, and menstruation may be required to prevent or control excessive bleeding. This review summarizes therapeutic options, guidelines, recommendations and observations from the published literature for long-term, surgical, gynecological, and obstetric prophylaxis in deficiencies of fibrinogen; prothrombin; factors II, V, V/VIII, VII, X, XI and XIII; combined vitamin-K dependent factors; α2-antiplasmin; and plasminogen activator inhibitor 1. Platelet disorders including Glanzmann's thrombasthenia and Bernard-Soulier syndrome are also addressed.
Collapse
Affiliation(s)
- Amy Shapiro
- Indiana Hemophilia & Thrombosis Center, 8326 Naab Rd., Indianapolis, IN 46260, USA.
| |
Collapse
|
29
|
Boknäs N, Macwan AS, Södergren AL, Ramström S. Platelet function testing at low platelet counts: When can you trust your analysis? Res Pract Thromb Haemost 2019; 3:285-290. [PMID: 31011713 PMCID: PMC6462761 DOI: 10.1002/rth2.12193] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/09/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although flow cytometry is often brought forward as a preferable method in the setting of thrombocytopenia, the relative effects of low sample counts on results from flow cytometry-based platelet function testing (FC-PFT) in comparison with light transmission aggregometry (LTA) and multiple electrode aggregometry (MEA) has not been reported. OBJECTIVES To compare the effects of different sample platelet counts (10, 50, 100, and 200 × 109 L-1) on platelet activation measured with FC-PFT, LTA, and MEA using the same anticoagulant and agonist concentrations as for the commercial MEA test. METHODS Platelets were stimulated with two commonly used platelet agonists (ADP [6.5 μmol L-1] and PAR1-AP [TRAP, 32 μmol L-1]). The specified sample platelet counts were obtained by combining platelet-rich and platelet poor hirudinized plasma in different proportions with or without red blood cells. RESULTS For FC, P-selectin exposure and PAC-1 binding was reduced at 10 × 109 L-1 after stimulation with PAR1-AP (by approximately 20% and 50%, respectively), but remained relatively unchanged when ADP was used as agonist (n = 9). The platelet count-dependent effects observed with PAR1-AP were eliminated when samples were pre-incubated with apyrase, implying that reduced purinergic signaling was the main underlying factor (n = 5). Both aggregometry-based PFTs showed a 50% reduction at 50 × 109 L-1 and more than 80% reduction at 10 × 109 L-1, irrespective of agonist used (n = 7). CONCLUSIONS Although FC-PFT is generally preferable to aggregometry-based PFTs in situations with low sample platelet counts, a careful optimization of experimental parameters is still required in order to eliminate platelet count-related effects.
Collapse
Affiliation(s)
- Niklas Boknäs
- Department of Haematology and Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
- Australian Centre for Blood DiseasesMonash UniversityMelbourneAustralia
| | - Ankit S. Macwan
- Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
| | - Anna L. Södergren
- Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental MedicineLinköping UniversityLinköpingSweden
- Cardiovascular Research CentreÖrebro UniversitySchool of Medical SciencesÖrebroSweden
| |
Collapse
|
30
|
Baliakas P, Kättström M, Rossing M, Amini R. Refractory chronic "ITP": When platelet size matters. Clin Case Rep 2018; 6:1779-1780. [PMID: 30214762 PMCID: PMC6132098 DOI: 10.1002/ccr3.1711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/11/2018] [Indexed: 11/08/2022] Open
Abstract
Inherited conditions associated with thrombocytopenia should be included in the differential diagnosis of young patients with refractory immune thrombocytopenia (ITP), even in the absence of a positive family history. Early identification of such conditions is of vital importance in order to reach the right diagnosis and avoid unnecessary or even harmful medication.
Collapse
Affiliation(s)
- Panagiotis Baliakas
- Department of Clinical GeneticsUppsala University HospitalUppsalaSweden
- Science for Life LaboratoryDepartment of Immunology, Genetics and PathologyUppsala UniversityUppsalaSweden
| | - Magdalena Kättström
- Section of HematologyDepartment of MedicineÖrebro University HospitalÖrebroSweden
| | - Maria Rossing
- Center for Genomic MedicineCopenhagen University HospitalCopenhagenDenmark
| | - Rose‐Marie Amini
- Department of Immunology, Genetics and PathologyClinical and Experimental PathologyUppsala University and Uppsala University HospitalUppsalaSweden
| |
Collapse
|
31
|
Grainger JD, Thachil J, Will AM. How we treat the platelet glycoprotein defects; Glanzmann thrombasthenia and Bernard Soulier syndrome in children and adults. Br J Haematol 2018; 182:621-632. [DOI: 10.1111/bjh.15409] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- John D. Grainger
- Faculty of Medical & Human Sciences; University of Manchester; England UK
- Department of Paediatric Haematology; Royal Manchester Children's Hospital; Manchester University NHS Foundation Trust; Manchester UK
| | - Jecko Thachil
- Department of Haematology; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - Andrew M. Will
- Department of Paediatric Haematology; Royal Manchester Children's Hospital; Manchester University NHS Foundation Trust; Manchester UK
| |
Collapse
|
32
|
Inherited platelet disorders : Management of the bleeding risk. Transfus Clin Biol 2018; 25:228-235. [PMID: 30077511 DOI: 10.1016/j.tracli.2018.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 01/19/2023]
Abstract
Inherited platelet disorders are rare bleeding syndromes due to either platelet function abnormalities or thrombocytopenia which may be associated with functional defects. The haemorrhagic symptoms observed in these patients are mostly muco-cutaneous and of highly variable severity. Although 30 to 50% of the platelet disorders are still of unknown origin, the precise diagnosis of these pathologies by specialized laboratories together with haemorrhagic scores enables an assessment of the risk of bleeding in each patient. Depending on the diagnostic elements collected, an appropriate medical procedure can be proposed for each situation: scheduled or emergency surgical interventions and pregnancy follow-up. The pathologies most at risk correspond to Glanzmann's thrombasthenia, Bernard-Soulier syndrome, severe thrombocytopenia (<40,000 platelets/μL) and signalling protein abnormalities affecting the activation of GPIIb-IIIa, a membrane glycoprotein essential for platelet aggregation. For these particular patients, in whom the risk of bleeding can be increased by a factor of 40, management protocols during surgical procedures are generally based on the use of conventional platelet concentrates, for both prophylaxis and the control of active bleeding. The perinatal period in women with platelet disorders and their new-born also require special attention. Indeed, beyond unpredictable delivery haemorrhages, bleeding requiring a blood transfusion is observed after delivery in more than 50% of women with Glanzmann's thrombastenia or Bernard-Soulier syndrome.
Collapse
|
33
|
Nurden P, Nurden A, Favier R, Gleyze M. Management of pregnancy for a patient with the new syndromic macrothrombocytopenia, DIAPH1-related disease. Platelets 2018; 29:737-738. [PMID: 29985732 DOI: 10.1080/09537104.2018.1492710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The number of genes involved in the identification of macrothrombocytopenia (MTP) is growing but the clinical consequences for the affected patients are not well determined. Here, we report the management of the bleeding risk for a patient with the newly reported and rare DIAPH1-related disease during surgery for infertility and then during her subsequent pregnancy. The R1213* DIAPH1 variant responsible for a mild bleeding syndrome in six families was considered a potential risk factor for our patient. Preliminary laparoscopic surgery was followed by neosalpingostomy to open the obstructed fallopian tube that was followed by an ectopic pregnancy requiring further surgery, tranexamic acid was used on each occasion and no bleeding complications were observed. A second pregnancy proceeded to term; the mother's platelet count was controlled throughout the gestation period and remained close to her basal values. No bleeding occurred at delivery or during the postpartum period. In conclusion, with strict repeated assessments of blood parameters and maintenance of the platelet count, the bleeding risk in pregnancy in DIAPH1-related disease can be successfully controlled.
Collapse
Affiliation(s)
- Paquita Nurden
- a Institut Hospitalo-Universitaire LIRYC , Hôpital Xavier Arnozan , Pessac , France
| | - Alan Nurden
- a Institut Hospitalo-Universitaire LIRYC , Hôpital Xavier Arnozan , Pessac , France
| | - Rémi Favier
- b Assistance Publique-Hôpitaux de Paris , Hôpital A Trousseau , Paris , France
| | - Matthieu Gleyze
- c Service de Gynécologie-Obstétrique , Hôpital Pellegrin , Bordeaux , France
| |
Collapse
|
34
|
Gresele P, Falcinelli E, Bury L. Laboratory diagnosis of clinically relevant platelet function disorders. Int J Lab Hematol 2018; 40 Suppl 1:34-45. [DOI: 10.1111/ijlh.12814] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 02/12/2018] [Indexed: 10/25/2022]
Affiliation(s)
- P. Gresele
- Section of Internal and Cardiovascular Medicine; Department of Medicine; University of Perugia; Perugia Italy
| | - E. Falcinelli
- Section of Internal and Cardiovascular Medicine; Department of Medicine; University of Perugia; Perugia Italy
| | - L. Bury
- Section of Internal and Cardiovascular Medicine; Department of Medicine; University of Perugia; Perugia Italy
| |
Collapse
|
35
|
Estcourt LJ, Malouf R, Hopewell S, Doree C, Van Veen J. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev 2018; 4:CD011980. [PMID: 29709077 PMCID: PMC5957267 DOI: 10.1002/14651858.cd011980.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016. OBJECTIVES To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count). SEARCH METHODS We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018. SELECTION CRITERIA We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively. MAIN RESULTS We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 106/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 106/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life. AUTHORS' CONCLUSIONS We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.
Collapse
Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Joost Van Veen
- Sheffield Teaching Hospitals NHS Foundation TrustDepartment of HaematologyGlossop RoadRoom H101D, H floorSheffieldUKS10 2JF
| | | |
Collapse
|
36
|
Favier R, De Carne C, Elefant E, Lapusneanu R, Gkalea V, Rigouzzo A. Eltrombopag to Treat Thrombocytopenia During Last Month of Pregnancy in a Woman With MYH9-Related Disease. A A Pract 2018; 10:10-12. [DOI: 10.1213/xaa.0000000000000621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
37
|
|
38
|
Cines DB, Levine LD. Thrombocytopenia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:144-151. [PMID: 29222249 PMCID: PMC6142617 DOI: 10.1182/asheducation-2017.1.144] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/12/2017] [Indexed: 05/31/2023]
Abstract
Thrombocytopenia develops in 5% to 10% of women during pregnancy or in the immediate postpartum period. A low platelet count is often an incidental feature, but it might also provide a biomarker of a coexisting systemic or gestational disorder and a potential reason for a maternal intervention or treatment that might pose harm to the fetus. This chapter reflects our approach to these issues with an emphasis on advances made over the past 5 to 10 years in understanding and managing the more common causes of thrombocytopenia in pregnancy. Recent trends in the management of immune thrombocytopenia translate into more women contemplating pregnancy while on treatment with thrombopoietin receptor agonists, rituximab, or mycophenylate, which pose known or unknown risks to the fetus. New criteria to diagnose preeclampsia, judicious reliance on measurement of ADAMTS13 to make management decisions in suspected thrombotic thrombocytopenic purpura, new evidence supporting the efficacy and safety of anticomplement therapy for atypical hemolytic uremic syndrome during pregnancy, and implications of thrombotic microangiopathies for subsequent pregnancies are evolving rapidly. The goals of the chapter are to help the hematology consultant work through the differential diagnosis of thrombocytopenia in pregnancy based on trimester of presentation, severity of thrombocytopenia, and coincident clinical and laboratory manifestations, and to provide guidance for dealing with some of the more common and difficult diagnostic and management decisions.
Collapse
Affiliation(s)
- Douglas B. Cines
- Department of Pathology and Laboratory Medicine
- Department of Medicine, and
| | - Lisa D. Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
39
|
Noris P, Pecci A. Hereditary thrombocytopenias: a growing list of disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:385-399. [PMID: 29222283 PMCID: PMC6142591 DOI: 10.1182/asheducation-2017.1.385] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The introduction of high throughput sequencing (HTS) techniques greatly improved the knowledge of inherited thrombocytopenias (ITs) over the last few years. A total of 33 different forms caused by molecular defects affecting at least 32 genes have been identified; along with the discovery of new disease-causing genes, pathogenetic mechanisms of thrombocytopenia have been better elucidated. Although the clinical picture of ITs is heterogeneous, bleeding has been long considered the major clinical problem for patients with IT. Conversely, the current scenario indicates that patients with some of the most common ITs are at risk of developing additional disorders more dangerous than thrombocytopenia itself during life. In particular, MYH9 mutations result in congenital macrothrombocytopenia and predispose to kidney failure, hearing loss, and cataracts, MPL and MECOM mutations cause congenital thrombocytopenia evolving into bone marrow failure, whereas thrombocytopenias caused by RUNX1, ANKRD26, and ETV6 mutations are characterized by predisposition to hematological malignancies. Making a definite diagnosis of these forms is crucial to provide patients with the most appropriate treatment, follow-up, and counseling. In this review, the ITs known to date are discussed, with specific attention focused on clinical presentations and diagnostic criteria for ITs predisposing to additional illnesses. The currently available therapeutic options for the different forms of IT are illustrated.
Collapse
Affiliation(s)
- Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| |
Collapse
|
40
|
Zaninetti C, Santini V, Tiniakou M, Barozzi S, Savoia A, Pecci A. Inherited thrombocytopenia caused by ANKRD26 mutations misdiagnosed and treated as myelodysplastic syndrome: report on two cases. J Thromb Haemost 2017; 15:2388-2392. [PMID: 28976612 DOI: 10.1111/jth.13855] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Indexed: 08/31/2023]
Abstract
Essentials Thrombocytopenia 2 (THC2) is an inherited thrombocytopenia (IT) with dysmegakaryopoiesis. Physicians often do not suspect the genetic origin of thrombocytopenia in patients with THC2. We report two THC2 patients misdiagnosed with myelodysplasia and treated with chemotherapy. IT should be always considered in patients with isolated thrombocytopenia and dysmegakaryopoiesis. SUMMARY Thrombocytopenia 2 (THC2) is an autosomal-dominant disorder caused by point substitutions in the 5'UTR of the ANKRD26 gene. Patients have congenital thrombocytopenia, normal platelet morphology and function, and dysmegakaryopoiesis. Thrombocytopenia is frequently discovered only in adulthood and physicians often do not suspect its genetic origin. We describe two unrelated patients referred to two different institutions for investigation of thrombocytopenia. Based on the finding of dysmegakaryopoiesis at bone marrow examination, patients were diagnosed with myelodysplastic syndrome (MDS) (refractory thrombocytopenia) and treated with several courses of 5-azacytidine. Subsequently, demonstration of thrombocytopenia in their relatives eventually led to molecular diagnosis of THC2 in both families. These cases highlight that patients with THC2 are at risk of being misdiagnosed with MDS and receiving undue myelosuppressive treatments. Because dysmegakaryopoiesis is a feature also of other forms of inherited thrombocytopenia, a genetic disorder must always be considered when a patient presents with isolated thrombocytopenia and dysmegakaryopoiesis.
Collapse
Affiliation(s)
- C Zaninetti
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - V Santini
- Division of Hematology, Careggi Hospital and University of Florence, Firenze, Italy
| | - M Tiniakou
- Division of Hematology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - S Barozzi
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - A Savoia
- Department of Medical, Surgical and Health Sciences, IRCCS Burlo Garofolo and University of Trieste, Trieste, Italy
| | - A Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| |
Collapse
|
41
|
Canault M, Saultier P, Fauré S, Poggi M, Nurden AT, Nurden P, Morange PE, Alessi MC, Gris JC. Peripartum bleeding management in a patient with CalDAG-GEFI deficiency. Haemophilia 2017; 23:e533-e535. [PMID: 28976076 DOI: 10.1111/hae.13352] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2017] [Indexed: 11/26/2022]
Affiliation(s)
- M Canault
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France
| | - P Saultier
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France
| | - S Fauré
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France
| | - M Poggi
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France
| | - A T Nurden
- Institut-Hospitalo-Universitaire LIRYC, Plateforme Technologique et d'Innovation Biomédicale, Pessac, France
| | - P Nurden
- Institut-Hospitalo-Universitaire LIRYC, Plateforme Technologique et d'Innovation Biomédicale, Pessac, France
| | - P E Morange
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France.,APHM, CHU Timone, French Reference Centre for Rare Platelet Disorders, Marseille, France
| | - M-C Alessi
- Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France.,APHM, CHU Timone, French Reference Centre for Rare Platelet Disorders, Marseille, France
| | - J-C Gris
- Laboratoire d'hématologie, Groupe Hospitalo-Universitaire Caremeau, Nîmes, France
| |
Collapse
|
42
|
Abstract
Thrombocytopenia develops in 5% to 10% of women during pregnancy or in the immediate postpartum period. A low platelet count is often an incidental feature, but it might also provide a biomarker of a coexisting systemic or gestational disorder and a potential reason for a maternal intervention or treatment that might pose harm to the fetus. This chapter reflects our approach to these issues with an emphasis on advances made over the past 5 to 10 years in understanding and managing the more common causes of thrombocytopenia in pregnancy. Recent trends in the management of immune thrombocytopenia translate into more women contemplating pregnancy while on treatment with thrombopoietin receptor agonists, rituximab, or mycophenylate, which pose known or unknown risks to the fetus. New criteria to diagnose preeclampsia, judicious reliance on measurement of ADAMTS13 to make management decisions in suspected thrombotic thrombocytopenic purpura, new evidence supporting the efficacy and safety of anticomplement therapy for atypical hemolytic uremic syndrome during pregnancy, and implications of thrombotic microangiopathies for subsequent pregnancies are evolving rapidly. The goals of the chapter are to help the hematology consultant work through the differential diagnosis of thrombocytopenia in pregnancy based on trimester of presentation, severity of thrombocytopenia, and coincident clinical and laboratory manifestations, and to provide guidance for dealing with some of the more common and difficult diagnostic and management decisions.
Collapse
|
43
|
Orsini S, Noris P, Bury L, Heller PG, Santoro C, Kadir RA, Butta NC, Falcinelli E, Cid AR, Fabris F, Fouassier M, Miyazaki K, Lozano ML, Zúñiga P, Flaujac C, Podda GM, Bermejo N, Favier R, Henskens Y, De Maistre E, De Candia E, Mumford AD, Ozdemir GN, Eker I, Nurden P, Bayart S, Lambert MP, Bussel J, Zieger B, Tosetto A, Melazzini F, Glembotsky AC, Pecci A, Cattaneo M, Schlegel N, Gresele P. Bleeding risk of surgery and its prevention in patients with inherited platelet disorders. Haematologica 2017; 102:1192-1203. [PMID: 28385783 PMCID: PMC5566025 DOI: 10.3324/haematol.2016.160754] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 04/04/2017] [Indexed: 11/16/2022] Open
Abstract
Excessive bleeding at surgery is a feared complication in patients with inherited platelet disorders. However, very few studies have evaluated the frequency of surgical bleeding in these hemorrhagic disorders. We performed a worldwide, multicentric, retrospective study to assess the bleeding complications of surgery, the preventive and therapeutic approaches adopted, and their efficacy in patients with inherited platelet disorders: the Surgery in Platelet disorders And Therapeutic Approach (SPATA) study. We rated the outcome of 829 surgical procedures carried out in 423 patients with well-defined forms of inherited platelet disorders: 238 inherited platelet function disorders and 185 inherited platelet number disorders. Frequency of surgical bleeding was high in patients with inherited platelet disorders (19.7%), with a significantly higher bleeding incidence in inherited platelet function disorders (24.8%) than in inherited platelet number disorders (13.4%). The frequency of bleeding varied according to the type of inherited platelet disorder, with biallelic Bernard Soulier syndrome having the highest occurrence (44.4%). Frequency of bleeding was predicted by a pre-operative World Health Organization bleeding score of 2 or higher. Some types of surgery were associated with a higher bleeding incidence, like cardiovascular and urological surgery. The use of pre-operative pro-hemostatic treatments was associated with a lower bleeding frequency in patients with inherited platelet function disorders but not in inherited platelet number disorders. Desmopressin, alone or with antifibrinolytic agents, was the preventive treatment associated with the lowest bleedings. Platelet transfusions were used more frequently in patients at higher bleeding risk. Surgical bleeding risk in inherited platelet disorders is substantial, especially in inherited platelet function disorders, and bleeding history, type of disorder, type of surgery and female sex are associated with higher bleeding frequency. Prophylactic pre-operative pro-hemostatic treatments appear to be required and are associated with a lower bleeding incidence.
Collapse
Affiliation(s)
- Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Paula G Heller
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | | | - Rezan A Kadir
- Haemophilia Centre and Haemostasis Unit, Royal Free Hospital, London, UK
| | - Nora C Butta
- Unidad de Hematología, Hospital Universitario La Paz-IDIPaz, Madrid, Spain
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Ana Rosa Cid
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Fabrizio Fabris
- Clinica Medica 1 - Medicina Interna CLOPD, Dipartimento Assistenziale Integrato di Medicina, Azienda-Ospedale Università di Padova and Dipartimento di Medicina, Università di Padova, Italy
| | | | - Koji Miyazaki
- Department of Hematology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Maria Luisa Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia 30003 and Grupo de Investigación CB15/00055 del Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pamela Zúñiga
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claire Flaujac
- Service d'Hématologie Biologique Cochin Hospital, Paris, France
| | - Gian Marco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nuria Bermejo
- Department of Hematology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Remi Favier
- Assistance Publique-Hôpitaux de Paris, Armand Trousseau Children's Hospital, French Reference Centre for Inherited Platelet Disorders, Paris, France
| | - Yvonne Henskens
- Hematological Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Emmanuel De Maistre
- Department of Biology and Haematology, Centre Hospitalier Universitaire Dijon, France
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Institute of Internal Medicine, Policlinico Agostino Gemelli-Università Cattolica Sacro Cuore, Rome, Italy
| | | | - Gul Nihal Ozdemir
- Cerrahpasa Medical Faculty, Pediatric Hematology Department, Istanbul, Turkey
| | - Ibrahim Eker
- Gülhane Military Medical Faculty, Pediatric Hematology Department, Ankara, Turkey
| | - Paquita Nurden
- Reference Centre for Platelet Disorders, Bordeaux University Hospital Centre, Rythmology and Cardiac Modeling Institute (LIRYC), Xavier Arnozan Hospital, Pessac, France
| | - Sophie Bayart
- Centre Régional de Traitement des Hémophiles, Centre Hospitalier Universitaire de Rennes, France
| | - Michele P Lambert
- 1 Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PN, USA
| | - James Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | | | - Federica Melazzini
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Ana C Glembotsky
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Marco Cattaneo
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nicole Schlegel
- Centre de Référence des Pathologies Plaquettaires (CRPP), Service d'Hématologie Biologique, CHU Robert Debré, AP-HP, Paris, France
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | | |
Collapse
|
44
|
Bariana TK, Ouwehand WH, Guerrero JA, Gomez K. Dawning of the age of genomics for platelet granule disorders: improving insight, diagnosis and management. Br J Haematol 2016; 176:705-720. [PMID: 27984638 DOI: 10.1111/bjh.14471] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inherited disorders of platelet granules are clinically heterogeneous and their prevalence is underestimated because most patients do not undergo a complete diagnostic work-up. The lack of a genetic diagnosis limits the ability to tailor management, screen family members, aid with family planning, predict clinical progression and detect serious consequences, such as myelofibrosis, lung fibrosis and malignancy, in a timely manner. This is set to change with the introduction of high throughput sequencing (HTS) as a routine clinical diagnostic test. HTS diagnostic tests are now available, affordable and allow parallel screening of DNA samples for variants in all of the 80 known bleeding, thrombotic and platelet genes. Increased genetic diagnosis and curation of variants is, in turn, improving our understanding of the pathobiology and clinical course of inherited platelet disorders. Our understanding of the genetic causes of platelet granule disorders and the regulation of granule biogenesis is a work in progress and has been significantly enhanced by recent genomic discoveries from high-powered genome-wide association studies and genome sequencing projects. In the era of whole genome and epigenome sequencing, new strategies are required to integrate multiple sources of big data in the search for elusive, novel genes underlying granule disorders.
Collapse
Affiliation(s)
- Tadbir K Bariana
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.,Department of Haematology, University College London Cancer Institute, London, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Willem H Ouwehand
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK.,NIHR BioResource, Cambridge University Hospitals, Cambridge Biomedical Campus, Cambridge, UK.,Human Genetics, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
| | - Jose A Guerrero
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | |
Collapse
|
45
|
Gernsheimer TB. Congenital and acquired bleeding disorders in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:232-235. [PMID: 27913485 PMCID: PMC6142506 DOI: 10.1182/asheducation-2016.1.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Obstetrical hematology represents challenges not only for the patient, but also for her progeny. In particular, bleeding disorders, both congenital and acquired, not only present problems both for delivery and in the immediate postpartum period, but also may have significant implications for the fetus and neonate. Women with congenital bleeding disorders or who are carriers of X-linked or autosomal disorders should be counseled prior to conception so that pregnancy can be safely undertaken with careful preparation. A treatment plan should be set up by a specialized care team that includes the hematologist, obstetrician, and anesthesiologist; the patient should be followed closely during pregnancy, through delivery, and in the immediate postpartum period. Acquired disorders of hemostasis that occur with pregnancy may present particular diagnostic difficulties and require rapid diagnosis and management.
Collapse
Affiliation(s)
- Terry B Gernsheimer
- Division of Hematology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| |
Collapse
|
46
|
Gresele P, Falcinelli E, Bury L. Inherited platelet function disorders. Diagnostic approach and management. Hamostaseologie 2016; 36:265-278. [PMID: 27484722 DOI: 10.5482/hamo-16-02-0002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/16/2016] [Indexed: 12/25/2022] Open
Abstract
Inherited platelet function disorders (IPFDs) make up a significant proportion of congenital bleeding diatheses, but they remain poorly understood and often difficult to diagnose. Therefore, a rational diagnostic approach, based on a standardized sequence of laboratory tests, with consecutive steps of increasing level of complexity, plays a crucial role in the diagnosis of most IPFDs. In this review we discuss a diagnostic approach through platelet phenotyping and genotyping and we give an overview of the options for the management of bleeding in these disorders and an account of the few systematic studies on the bleeding risk associated with invasive procedures and its treatment.
Collapse
Affiliation(s)
- Paolo Gresele
- Paolo Gresele, MD, PhD, Division of Internal and Cardiovascular Medicine Department of Medicine, University of Perugia, Via E. dal Pozzo, 06126 Perugia, Italy, Tel. +39/07 55 78 39 89, Fax +39/07 55 71 60 83, E-Mail:
| | | | | |
Collapse
|
47
|
Kouides PA. Present day management of inherited bleeding disorders in pregnancy. Expert Rev Hematol 2016; 9:987-95. [DOI: 10.1080/17474086.2016.1216312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
48
|
Engert A, Balduini C, Brand A, Coiffier B, Cordonnier C, Döhner H, de Wit TD, Eichinger S, Fibbe W, Green T, de Haas F, Iolascon A, Jaffredo T, Rodeghiero F, Salles G, Schuringa JJ. The European Hematology Association Roadmap for European Hematology Research: a consensus document. Haematologica 2016; 101:115-208. [PMID: 26819058 PMCID: PMC4938336 DOI: 10.3324/haematol.2015.136739] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/27/2016] [Indexed: 01/28/2023] Open
Abstract
The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.
Collapse
Affiliation(s)
| | | | - Anneke Brand
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | | | | | | | | | | | - Willem Fibbe
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Tony Green
- Cambridge Institute for Medical Research, United Kingdom
| | - Fleur de Haas
- European Hematology Association, The Hague, the Netherlands
| | | | | | | | - Gilles Salles
- Hospices Civils de Lyon/Université de Lyon, Pierre-Bénite, France
| | | |
Collapse
|
49
|
Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:795-802. [PMID: 26634939 PMCID: PMC4678382 DOI: 10.3238/arztebl.2015.0795] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge. METHODS In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed. RESULTS Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease. CONCLUSION The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.
Collapse
Affiliation(s)
| | - Werner Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
| |
Collapse
|
50
|
Noris P, Balduini CL. Inherited thrombocytopenias in the era of personalized medicine. Haematologica 2015; 100:145-8. [PMID: 25638803 DOI: 10.3324/haematol.2014.122549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Patrizia Noris
- Department of Internal Medicine, University of Pavia - IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Carlo L Balduini
- Department of Internal Medicine, University of Pavia - IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| |
Collapse
|