Fetal alloimmune thrombocytopenia and maternal intravenous immunoglobulin infusion

Abstract

The online version of this article has a Supplementary Appendix. BackgroundDifferent therapeutic approaches have been used in fetal-neonatal alloimmune thrombocytopenia, but many centers administer immunoglobulin G infusions to the pregnant woman. We studied the effect of maternal antenatal immunoglobulin infusions on fetal platelet counts in pregnancies with fetal alloimmune thrombocytopenia. Design and MethodsWe retrospectively analyzed the clinical courses of fetuses with fetal alloimmune thrombocytopenia whose mothers were treated with immunoglobulin G infusions in a single center between 1999 and 2005. In a center-specific protocol, weekly maternal immunoglobulin G infusions were given to 25 pregnant women with previously affected neonates and four women with strong platelet antibodies, but no previous history of fetal alloimmune thrombocytopenia; before each infusion diagnostic fetal blood sampling was performed to determine fetal platelet counts and immunoglobulin G levels. ResultsThere were 30 fetuses with fetal alloimmune thrombocytopenia, confirmed by initial fetal blood sampling showing fetal platelet counts between 4¥10 9 /L and 130¥10 9 /L and antibodycoated fetal platelets using a glycoprotein specific assay. Despite weekly antenatal maternal immunoglobulin G infusions fetal platelet counts did not change significantly. Maternal and fetal immunoglobulin G levels, measured before every infusion, increased significantly with the number of maternal immunoglobulin G infusions. ConclusionsIn this group of fetuses with fetal alloimmune thrombocytopenia no consistent increase of fetal platelets was achieved as a result of regular maternal immunoglobulin G infusions.Key words: fetal alloimmune thrombocytopenia, maternal IgG infusion, intrauterine therapy. Haematologica. 201095(11):1921-1926. doi:10.3324/haematol.2010 This is an open-access paper. Citation: Giers G, Wenzel F, Stockschläder M, Riethmacher R, Lorenz H, and Tutschek B. Fetal alloimmune thrombocytopenia and maternal intravenous immunoglobulin infusion Fetal alloimmune thrombocytopenia and maternal intravenous immunoglobulin infusion

Antenatal treatment of fetal alloimmune thrombocytopenia: a current perspective

“…4 This approach of providing IVIG-based medical therapy administered to the mother to increase the fetal platelet count has since been extensively investigated in hundreds of maternal-fetal pairs. 5 The efficacy of IVIG-based therapy has been supported by numerous studies [6][7][8][9][10][11][12][13][14][15][16] (Table 1A) but not by others [17][18][19] (Table 1B). The studies presented in Tables 1A and 1B surprisingly report virtually identical percentages of cases of intracranial hemorrhage: 2.7% versus 2.9%, respectively.…”

“…The data are equally compelling that fetal blood sampling cannot be considered routine in most centers and that Giers et al 19 were exceptional and fortunate in their skilled performance of this technicallydemanding procedure. …”

“…In one study Yinon et al suggested that IVIG without fetal blood sampling is safe and effective in women who, like the subjects featured in the study conducted by Giers et al, 19 lacked a history of fetal or neonatal intracranial hemorrhage in a previous child. The 24 fetuses who underwent this treatment had significantly higher platelet counts at birth comEditorials and Perspectives haematologica | 2010; 95 (11) 1809 /L, respectively; P<0.05).…”

“…The study by Giers et al 19 in this issue of the journal introduces an entirely novel approach to management in which serial weekly fetal blood samples are taken and intra-uterine platelet transfusions are given only at the final sampling. Twenty-nine pregnancies were studied, 25 of which were from mothers with one to four previously affected children; sibling history was negative for intracranial hemorrhage in all cases.…”

“…Because the lack of adverse events associated with fetal blood sampling was attributed to one highly-skilled operator performing all procedures, as in a series of more than 5000 such procedures in France, 26 the reproducibility of such a complication-free outcome may not be generalizable to other centers. 19 Finally, the overall poor response to IVIG may stem from additional factors beyond the use of a dose of only 1 g/kg/week. These include the brand of IVIG (Endobulin) and the large number of fetal blood sampling procedures performed, as serial sampling may contribute to maternal sensitization, thus masking the therapeutic effects of maternal IVIG.…”