Neonatal alloimmune thrombocytopenia

Fetal and Neonatal Alloimmune Thrombocytopenia
Classification and external resources
Specialty pediatrics
ICD-10 P61.0
ICD-9-CM 776.1
DiseasesDB 33767
eMedicine med/3256 med/3480

Neonatal alloimmune thrombocytopenia (NAITP or NAIT or NATP or NAT for short; or fetal and neonatal alloimmune thrombocytopenia, FNAIT, feto-maternal alloimmune thrombocytopenia, FMAITP or FMAIT) is a disease that affects fetuses and newborns, in which the platelet count is decreased (a state known as thrombocytopenia). Platelet antigens are inherited from both mother and father. NAIT is caused by antibodies specific for platelet antigens inherited from the father but which are absent in the mother.[1] Fetomaternal transfusions (or fetomaternal hemorrhage) results in the recognition of these antigens by the mother's immune system as non-self, with the subsequent generation of allo-reactive antibodies which cross the placenta. NAIT, hence, is caused by transplacental passage of maternal platelet-specific alloantibody and rarely human leukocyte antigen (HLA) allo-antibodies [2] (which are expressed by platelets) to fetuses whose platelets express the corresponding antigens. NAIT occurs in somewhere between 1/800[3] and 1/5000[4] live births. More recent studies of NAIT seem to indicate that it occurs in around 1/600 live births in the Caucasian population.[5]

Signs and symptoms

Frequently, the thrombocytopenia is mild and the affected neonates remain largely asymptomatic. In these cases, therapeutic interventions are not indicated. In case of severe thrombocytopenia, the neonates may exhibit hemorrhagic complication at or a few hours after delivery. The most serious complication is intracranial hemorrhage, leading to death in approximately 10% or neurologic sequelae in 20% of cases.

Pathophysiology

About 80% of cases of NAIT are caused by antibodies against platelet antigen HPA-1a, 15% by anti-HPA-5b, and 5% by other antibodies (e.g. HPA-1b, HPA-15, HPA-3 and HPA-9b).[6][7] HPA-1a is present in 98% of the population of the United States, suggesting that approximately 2% of women who are HPA-1a negative may be at risk for NAIT during pregnancy.[1][8] Of course, the antigen expression of the father must also be taken into account—in most cases the father is HPA-1a/1a or 1a/1b and the mother is HPA-1b/1b with anti-HPA-1a antibodies. In Asians, HPA-4 antigens are the most frequently implicated.[9]

Studies have shown a relationship between maternal HLA type DRw52a (DRB3* 0101) and the development of anti-HPA-1a.[10][11][12][13]

The offending antibodies are IgG subtype and therefore capable of crossing the placenta and entering the fetal circulation.

Unlike hemolytic disease of the fetus and newborn, NAIT occurs during the first pregnancy in up to 50% of cases,[1] and the affected fetuses may develop severe thrombocytopenia (<50,000 μL-1) very early during pregnancy (as early as 20 weeks gestation, consistent with the development of platelet antigens,[1] and the majority of the time in utero[14]). Usually, the thrombocytopenia increases as gestation progresses. During the first pregnancy, NAIT is often not detected until birth when the newborn presents with classic symptoms of thrombocytopenia including petechiae, bruising or intracranial hemorrhage.[1] In utero intracranial hemorrhage occurs in about 10% to 30% of affected cases (and NAIT is thought to be the underlying cause in the majority of cases of intracranial hemorrhage due to thrommbocytopenia- greater than all other etiologies of thrombocytopenia combined). The risk of hemorrhage is inversely related to the platelet count with the greatest risk when the platelet count is below 100,000 μL-1.[1]

The recurrence of NAIT has been estimated to be more than 80% in subsequent pregnancies with incompatible fetuses (i.e. subsequent pregnancies which also carry the target platelet antigen). Subsequent cases of NAIT may be equivalent or more severe.

The fetal response to NAIT is variable and may include compensatory extramedullary hematopoiesis. Rarely, fetal hydrops may develop. Fetal anemia (in presence of red cell incompatibility) may also occur.[1]

Diagnosis

Maternal and paternal platelet antigen phenotyping and screening of the maternal serum for anti-platelet antibodies can be performed.[8]

Additionally, platelet antigen genotyping can be performed on the maternal and paternal blood to determine the exact nature of the incompatibility.

Neonatal platelet counts on laboratory testing are typically under 20,000 μL-1. Higher counts may suggest a different diagnosis, such as maternal immune thrombocytopenic purpura.

Treatment

During pregnancy

Cordocentesis can be performed in utero to determine the platelet count of the fetus. This procedure is only performed if a prior pregnancy was affected by NAIT. Intrauterine transfusions can be performed during cordocentesis for primary prevention of intracerebral hemorrhage. Any administered cellular blood products must be irradiated to reduce the risk of graft-versus-host disease in the fetus. Additionally, all administered blood products should be CMV reduced-risk (CMV seronegative and leukoreduced are considered essentially equivalent for the purposes of CMV risk reduction).[1]

If intrauterine platelet transfusions are performed, they are generally repeated weekly (platelet lifespan after transfusion is approximately 8 to 10 days). Platelets administered to the fetus must be negative for the culprit antigen (often HPA-1a, as stated above). Many blood suppliers (such as American Red Cross and United Blood Services) have identified HPA-1a negative donors. An alternative donor is the mother who is, of course, negative for the culprit antigen. However, she must meet general criteria for donation and platelets received from the mother must be washed to remove the offending alloantibody and irradiated to reduce the risk of graft-versus-host disease. If platlet transfusions are needed urgently, incompatible platelets may be used, with the understanding that they may be less effective and that the administration of any blood product carries risk.[1]

The use of Intravenous immunoglobulin (IVIG) during pregnancy and immediately after birth has been shown to help reduce or alleviate the effects of NAIT in infants and reduce the severity of thrombocytopenia. The most common treatment is weekly IVIG infusions at a dosage of 1 g/kg beginning at 16 to 28 weeks of pregnancy, depending on the severity of the disease in the previous affected child, and continuing until the birth of the child.[15][16] In some cases this dosage is increased to 2 g/kg and/or combined with a course of prednisone depending on the exact circumstances of the case. Although this treatment has not been shown to be effective in all cases it has been shown to reduce the severity of thrombocytopenia in some. Also, it is suspected that (though not understood why) IVIG provides some added protection from intercranial haemorrhage (ICH) to the fetus. Even with IVIG treatment, the fetal platelet count may need to be monitored and platelet transfusions may still be required.

The goal of both IVIG and platelet transfusion is to avoid hemorrhage. Ultrasound monitoring to detect hemorrhage is not recommended as detection of intracranial hemorrhage generally indicates permanent brain damage (there is no intervention that can be performed to reverse the damage once it has occurred).

Before delivery, the fetal platelet count should be determined. A count of >50,000 μL-1 is recommended for vaginal delivery and the count should be kept above 20,000 μL-1 after birth.[1]

After birth

The most rapidly effective treatment in infants with severe hemorrhage and/or severe thrombocytopenia (<30,000 μL-1) is the transfusion of compatible platelets (i.e. platelets from a donor who, like the mother, lacks the causative antigen). Additionally, if the thrombocytopenia in the infant at birth is not severe enough to warrant a transfusion of platelets (>30,000 μL-1) an infusion of IVIG (1 g/kg/day for two days) in the infant has been shown to rapidly increase platelet count and reduce the risk of related injury.

After a first affected pregnancy, if a mother has plans for a subsequent pregnancy, then the mother and father should be typed for platelet antigens and the mother screened for alloantibodies. Testing is available through reference laboratories (such as ARUP). DNA testing of the father can be used to determine zygosiity of the involved antigen and therefore risk to future pregnancies (if homozygous for the antigen, all subsequent pregnancies will be affected, if heterozygous, there is an approximate 50% risk to each subsequent pregnancy). During subsequent pregnancies, the genotype of the fetus can also be determined using amniotic fluid analysis or maternal blood as early as 18 weeks gestation to definitively determine the risk to the fetus.[1]

Research

PROFNAIT is a collaborative project that involves nine of the leading Northern European companies, universities and health care institutions within NAIT prevention and therapy.

The goal of the PROFNAIT project is to develop a new drug that can protect HPA-1a negative women from being immunized against HPA-1a and prevent the development of NAIT. The project also aims at preparing the country-wide screens of pregnant women that are required in order to identify the women who would benefit from prophylaxis.

The project is divided into three stages: Collection of plasma from women who are already immunized against HPA-1a. This plasma is required to make the drug. We will need to collect plasma from hundreds of HPA-1a immunized women and we encourage all potential doners to sign up. if you have given birth to an NAIT child and want to help the project saving lives of babies at risk of developing NAIT you may consider signing up as a plasma donor, visit the project website www.profnait.eu/parents to sign up.

In the second phase, we will show that the drug is both safe and effective. Firstly, we will see how well it works in healthy men; secondly, we will screen 75,000 pregnant women for HPA-1a status and invite the 1,500 HPA-1a negative women that we expect to find to participate in the final testing.

In the last phase, we will seek approval of the drug and prepare for the implementation of HPA-1a typing and prophylaxis worldwide.

Immune thrombocytopenic purpura (ITP), sometimes called idiopathic thrombocytopenic purpura is a condition in which autoantibodies are directed against a patient's own platelets, causing platelet destruction and thrombocytopenia. Anti-platelet autoantibodies in a pregnant woman with immune thrombocytopenic purpura will attack the patient's own platelets and will also cross the placenta and react against fetal platelets. Therefore, ITP is a significant cause of fetal and neonatal immune thrombocytopenia. Approximately 10% of newborns affected by ITP will have platelet counts <50,000 μL-1 and 1% to 2% will have a risk of intracerebral hemorrhage comparable to infants with NAIT.[1][17]

Mothers with thrombocytopenia or a previous diagnosis of ITP should be tested for serum antiplatelet antibodies. A woman with symptomatic thrombocytopenia and an identifiable antiplatelet antibody should be started on therapy for their ITP which may include steroids or IVIG. Fetal blood analysis to determine the platelet count is not generally performed as ITP-induced thrombocytopenia in the fetus is generally less severe than NAIT. Platelet transfusions may be performed in newborns, depending on the degree of thrombocytopenia.[1]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 John D. Roback; et al., eds. (2008). Technical manual (16th ed.). Bethesda, Md.: American Association of Blood Banks (AABB). ISBN 1563952602.
  2. ↑ Porcelijn L, Van den Akker ES, Oepkes D (31 July 2008). "Fetal thrombocytopenia". Seminars in Fetal and Neonatal Medicine. 13 (4): 223–230. doi:10.1016/j.siny.2008.02.008. PMID 18400574.
  3. ↑ Kaplan, Cecile (1 January 2006). "Foetal and neonatal alloimmune thrombocytopaenia". Orphanet Journal of Rare Diseases. 1 (1): 39. doi:10.1186/1750-1172-1-39.
  4. ↑ McFarland, JG; Aster, RH; Bussel, JB; Gianopoulos, JG; Derbes, RS; Newman, PJ (Nov 1, 1991). "Prenatal diagnosis of neonatal alloimmune thrombocytopenia using allele-specific oligonucleotide probes." (PDF). Blood. 78 (9): 2276–82. PMID 1932744.
  5. ↑ Kamphuis MM, Paridaans N, Porcelijn L, De Haas M, Van Der Schoot CE, Brand A, Bonsel GJ, Oepkes D (1 October 2010). "Screening in pregnancy for fetal or neonatal alloimmune thrombocytopenia: systematic review". BJOG: an International Journal of Obstetrics & Gynaecology. 117 (11): 1335–1343. doi:10.1111/j.1471-0528.2010.02657.x. PMID 20618318.
  6. ↑ Mueller-Eckhardt, Christian; Grubert, Alfons; Weisheit, Marianne; Mueller-Eckhardt, Gertrud; Kiefel, Volker; Kroll, Hartmut; Schmidt, Sabine; Santoso, Sentot (31 January 1989). "348 cases of suspected neonatal alloimmune thrombocytopenia". The Lancet. 333 (8634): 363–366. doi:10.1016/S0140-6736(89)91733-9. PMID 2563515.
  7. ↑ Davoren, A; Curtis, BR; Aster, RH; McFarland, JG (August 2004). "Human platelet antigen-specific alloantibodies implicated in 1162 cases of neonatal alloimmune thrombocytopenia.". Transfusion. 44 (8): 1220–5. doi:10.1111/j.1537-2995.2004.04026.x. PMID 15265127.
  8. 1 2 Mais, Daniel D. (1 January 2008). Quick Compendium of Clinical Pathology. Amer Soc Of Clinical Path. ISBN 978-0-89189-567-1. Retrieved 15 September 2013.
  9. ↑ Yinon, Y; Spira, M; Solomon, O; Weisz, B; Chayen, B; Schiff, E; Lipitz, S (October 2006). "Antenatal noninvasive treatment of patients at risk for alloimmune thrombocytopenia without a history of intracranial hemorrhage.". American Journal of Obstetrics and Gynecology. 195 (4): 1153–7. doi:10.1016/j.ajog.2006.06.066. PMID 17000248.
  10. ↑ Birchall, Janet E.; Murphy, Michael F.; Kroll, Hartmut (1 July 2003). "European collaborative study of the antenatal management of feto-maternal alloimmune thrombocytopenia". British Journal of Haematology. 122 (2): 275–288. doi:10.1046/j.1365-2141.2003.04408.x. PMID 12846898.
  11. ↑ Valentin, N; Vergracht, A; Bignon, JD; Cheneau, ML; Blanchard, D; Kaplan, C; Reznikoff-Etievant, MF; Muller, JY (February 1990). "HLA-DRw52a is involved in alloimmunization against PL-A1 antigen.". Human immunology. 27 (2): 73–9. doi:10.1016/0198-8859(90)90104-w. PMID 2298610.
  12. ↑ L'Abbé, D; Tremblay, L; Filion, M; Busque, L; Goldman, M; Décary, F; Chartrand, P (June 1992). "Alloimmunization to platelet antigen HPA-1a (PIA1) is strongly associated with both HLA-DRB3*0101 and HLA-DQB1*0201.". Human immunology. 34 (2): 107–14. doi:10.1016/0198-8859(92)90036-m. PMID 1358865.
  13. ↑ Williamson, LM; Hackett, G; Rennie, J; Palmer, CR; Maciver, C; Hadfield, R; Hughes, D; Jobson, S; Ouwehand, WH (1 October 1998). "The natural history of fetomaternal alloimmunization to the platelet-specific antigen HPA-1a (PlA1, Zwa) as determined by antenatal screening.". Blood. 92 (7): 2280–7. PMID 9746765.
  14. ↑ Tiller, H; Kamphuis, MM; Flodmark, O; Papadogiannakis, N; David, AL; Sainio, S; Koskinen, S; Javela, K; Wikman, AT; Kekomaki, R; Kanhai, HH; Oepkes, D; Husebekk, A; Westgren, M (22 March 2013). "Fetal intracranial haemorrhages caused by fetal and neonatal alloimmune thrombocytopenia: an observational cohort study of 43 cases from an international multi centre registry". BMJ Open. 3 (3). doi:10.1136/bmjopen-2012-002490. PMC 3612794Freely accessible. PMID 23524102.
  15. ↑ Immune Thrombocytopenia and Pregnancy on eMedicine
  16. ↑ van den Akker, ESA; Oepkes, D; Lopriore, E; Brand, A; Kanhai, HHH (1 April 2007). "Noninvasive antenatal management of fetal and neonatal alloimmune thrombocytopenia: safe and effective". BJOG: an International Journal of Obstetrics & Gynaecology. 114 (4): 469–473. doi:10.1111/j.1471-0528.2007.01244.x. PMID 17309545.
  17. ↑ Webert, KE; Mittal, R; Sigouin, C; Heddle, NM; Kelton, JG (Dec 15, 2003). "A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura". Blood. 102 (13): 4306–11. doi:10.1182/blood-2002-10-3317. PMID 12947011.
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