Noninvasive antenatal management of fetal and neonatal alloimmune thrombocytopenia: safe and effective

Abstract

Objective To describe the outcome of pregnancies with fetal and neonatal alloimmune thrombocytopenia (FNAIT) in relation to the invasiveness of the management protocol.Design Retrospective analysis of prospectively collected data from a national cohort.Setting Leiden University Medical Centre, the national centre for management of severe red cell and platelet alloimmunisation in pregnancy.Population Ninety-eight pregnancies in 85 women with FNAIT having a previous child with thrombocytopenia with (n = 16) or without (n = 82) an intracranial haemorrhage (ICH).Methods Our management protocol evolved over time from (1) serial fetal blood samplings (FBS) and platelet transfusion (n = 13) via (2) combined FBS with maternal intravenous immunoglobulins (n = 33) to (3) completely noninvasive treatment with immunoglobulins only (n = 52 pregnancies, resulting in 53 neonates). Perinatal outcome was assessed according to the three types of management.Main outcome measures Occurrence of ICH, perinatal survival, gestational age at birth and complications of FBS.Results All but one of 98 pregnancies ended in a live birth; none of the neonates had an ICH. The median gestational age at birth was 37 weeks (range 32-40). In groups 1 and 2, three emergency caesarean sections were performed after complicated FBS, resulting in two healthy babies and one neonatal death.Conclusion Noninvasive antenatal management of pregnancies complicated by FNAIT appears to be both effective and safe.

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.…”

“…Since fetuses with alloimmune thrombocytopenia are vulnerable to compromised hemostasis due to severe thrombocytopenia, impaired platelet function, and endothelial dysfunction; the risks of fetal blood sampling are considerable and well-documented. [10][11][12]14,15,17,18,22,23 Birchall and colleagues from Europe reported a number of procedure-related complications, including exsanguination and emergency Cesarean deliveries attributed to infection, needle dislodgement, severe fetal bradycardia, cord spasm and thrombosis. 11 For these reasons, fetal blood sampling is generally coupled with intra-uterine platelet transfusion if platelet counts are low (e.g., < 50¥10 9 /L).…”

“…20,25 Overall, as treatment results with maternal IVIG-based therapy have improved substantially 6,7,12,14,16 (Table 3), while the morbidity and mortality from fetal blood sampling remain considerable, the consensus at many centers at present is to minimize its use, and, if possible, to avoid fetal blood sampling completely. 9,13,15,23 This requires the use of "blind" treatment and, therefore, therapy that will be effective in fetuses with all degrees of severity since; for example, it is unknown whether the fetal platelet count is below or above 20¥10 9 /L without pre-treatment fetal blood sampling.…”

“…The current focus on non-invasive approaches 9,13,15,23 serves both as a response to the high complication rate of invasive strategies [10][11][12]14,15,17,18,22,23 and as a testament to the efficacy of maternal IVIG-based treatment. 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.…”

Neonatal Transfusion Practices

“…60 However, in 50% of the cases in which NAITP presents unexpectedly in a firstborn, HPA-compatible platelets might not be available and production and testing of washed (to remove antibodies) maternal platelets will cause a delay of 12-24 h. In a retrospective study in 27 newborns with FNAITP, Kiefel and colleagues observed a moderate to good increment in 24 children after random platelet transfusions and, moreover, no adverse effects. 61 Random platelet transfusions can thus be used, awaiting matched platelets or effect of other therapy (i.e. IVIG), although the benefits of concomitant IVIG have not yet been shown.…”