A JH
Introduction
Myeloproliferative neoplasms (MPNs) are hematological diseases due to a stem-cell-derived clonal myeloproliferation. These diseases have many
clinical features including a predisposition to vascular events, and progression to myelofibrosis and acute myeloid leukemia. Thrombosis is the
main cause of morbidity and mortality: blood rheology, possibly relating to leukocyte adhesion, platelet activation and platelet-leukocyte aggregates
[1,2], is believed to have a leading role in the development of these complications.
MPNs have a peak incidence in the sixth and seventh decades of life, but they do occur in younger patients too, consequently posing a challenge for
their management in pregnancy [3]. The most common MPN in women of childbearing age is essential thrombocythemia (ET) [46], whereas polycythemia vera (PV) is unusual in young patients [3]. Key factors influencing pregnancy outcome include an adequate placental development and the
maintenance of a normal uterine blood flow. Thromboses can occur in any vessel in MPN patients, including the placental vessels, as documented in
patients with late fetal loss, preterm delivery [7], and intrauterine growth restriction (IUGR) [8]. As a higher incidence of thromboembolic events and
pregnancy complications are both associated with MPN, the possibility of a relationship between these complications is a matter of concern.
In this retrospective study, we correlated thrombotic events with pregnancy outcome in a large population of young women with ET.
1
Dept of Medicine -DIMED, Internal Medicine, University of Padua, Padua, Italy; 2Department of Hematology, University of Pavia, IRCCS Policlinico S Matteo, Pavia,
Italy; 3Hematology Division, Ospedale Papa Giovanni XXII, Bergamo, Italy; 4Institute of Hematology Lorenzo e Ariosto Seragnoli, Department of Hematology and
Oncology, Bologna, Italy; 5Department of Hematology, Ospedale di Vicenza, Vicenza, Italy; 6Division of Hematology, University of Florence, Florence, Italy; 7Hematology
Unit, Department of Oncology, Arcispedale Santa Maria NuovaIRCCS, Reggio Emilia, Italy; 8Hematology Division, Fondazione Ca Granda IRCCS, Ospedale Policlinico, Milan, Italy; 9Hematology Division, San Gerardo Hospital, Monza (Milan), Italy; 10Department of Hematology and Cell Therapy, University of Torino, Torino,
Italy; 11Hematology Division, Research Foundation, Ospedale Papa Giovanni XXII, Bergamo, Italy.
306
doi:10.1002/ajh.23635
RESEARCH ARTICLE
158
28 (1740)
10.9 (3.2427.1)
46 (29%)
14 (8.515)
1093 (5003140)
17 (10.7%)
29 (18%)
10 (6.3%)
237
152
85 (36%)
69 (29%)
60 (87%)
8 (11.5%)
1 (1.5%)
16 (7%)
9 (56%)
7 (44%)
In each patients clinical and laboratory data were collected at diagnosis (Table
I). Before pregnancies, 23.4% patients received low-dose-aspirin and 17.7% cytoreductive drugs (14 hydroxyurea, 3 anagrelide, 9 interferon-a, and 2 alkylating
agents). Each physician treated pregnant ET in agreement with guide-lines available
at the time of pregnancy.
A total of 237 pregnancies in patients with ET (median age at conception 32,
range 1840 years) were followed up. Pregnancy outcomes, risk factors for miscarriage (age, smoking, diabetes, hypertension, hyperlipidemia, thrombophilia), cardiovascular events, cardiovascular risk factors (smoking, diabetes, hypertension,
hyperlipidemia), and prothrombotic conditions (oral contraception, lupus anticoagulant, congenital thrombophilia) were assessed. Fetal outcome was classified as live
birth, spontaneous first-trimester abortion, or advanced fetal loss (2nd- and 3rdtrimester abortions or stillbirths).
Pregnancy risk was stratified according to Griesshammer et al. [11]: low-risk
pregnancies were those occurring in patients with no prior MPN-related complications, no hereditary thrombophilia factors, age under 35 years, and a platelet count
below 1000 3 109/L. When these criteria were not met, or severe complications had
occurred in a previous pregnancy, the pregnancy risk was considered high. The
highest risk was associated with recent acute thromboembolic events and previous
major thrombotic or hemorrhagic complications in the mother.
Statistical analysis
All the statistical analyses were run considering the parameters at the time of the
patients MPN diagnosis. Patient groups with nominal variables were compared with the
X2 test. Thrombosis-free survival curves were prepared using the KaplanMeier method,
and were compared with the log-rank test. Coxs proportional hazards regression model
was used for multivariate analyses. P values of <0.05 were considered significant.
Results
Pregnancy outcome
Within our 158 females with ET, 95 females (60.1%) had one, 50
had two, 10 had three, and 3 had four or more pregnancies.
Overall, 69 pregnancies in ET patients (29%) ended in fetal loss. The
live birth rate was 71%. Complications for the mother were recorded in
16 women; they all regressed rapidly after delivery (Table I).
The impact of several pregnancies was investigated in 50 women
who had two pregnancies with no differences in managing. The outcome of their two pregnancies was concordant, i.e., both pregnancies
were either complicated or uncomplicated, in 29 cases (58%), while it
was discordant in 21 (42%). Pregnancy outcome was not significantly
influenced by the outcome of a previous pregnancy.
doi:10.1002/ajh.23635
1st
preg
2nd
preg
3rd
preg
4th
preg
49
16
3
10
5
.
.
3
.
1
.
.
64
15
2
3
.
3
.
27
10
2
6
4
2
.
5
2
.
3
2
1
.
.
1
.
1
1
.
.
Hemorrhagic complications
Hemorrhagic complications were recorded in 23 women (14.5%),
15 minor hemorrhages and 8 gastro-intestinal bleedings. No postpartum bleeding was observed. No relationship emerged between platelet count and bleeding complications. In particular, only 4 of the 17
ET patients with >1,500 3 109/L platelets had minor bleeding episodes, a proportion statistically no different from the hemorrhage episodes occurring in patients with lower platelet counts.
Thrombotic events
Twenty-five patients developed thrombosis at or after their ET was
diagnosed, at a median 28 (range 2347) years old. We recorded: 2
myocardial infarctions, 3 strokes, 6 peripheral vein thromboses with or
without pulmonary embolism, 13 splanchnic vein thromboses, and 1
cerebral vein thrombosis. No correlation was found between WBC
counts and thrombosis. In particular, only 6 (14.3%) of the 42 patients
with PMN >10 3 109/L had thrombotic complications, a proportion
statistically much the same as in for patients with lower WBC counts.
307
RESEARCH ARTICLE
Randi et al.
HR (95% CI)
1.12 (0.841.5)
0.99 (0.991)
0.64 (0.152.46)
0.92 (0.312.7)
1.0 (6.91.45)
9.33 (2.3536.97)
1.0 (0.941.2)
6.57 (1.4230.25)
0.434
0.074
0.554
0.890
0.976
0.001
0.301
0.016
Multivariate analysis
Multivariate analysis on the patients thrombosis-free survival was
conducted on data for all 158 ET patients and included several covariates of potential prognostic relevance, i.e. age, WBC and platelet
counts, hemoglobin level, JAK2V617F mutation, one or more cardiovascular risk factor(s), and history of abortion. The presence of at
least one cardiovascular risk factor (P 5 0.016) and a history of miscarriage (P 5 0.001) emerged as independent risk factors for the onset
of a thrombotic event (Table III).
Discussion
Although ET occurs typically in middle-aged and older adults, a small
but significant number of patients are women of childbearing age, and
the disease poses a challenge when it comes to managing pregnancy [3].
A number of studies have shown that women with ET are at
higher risk of developing pregnancy complications [35,11] and placental thrombosis has been documented in cases complicated by late
fetal loss [7], preterm delivery [7], and IUGR [8].
Both venous and arterial thrombotic events are typical of the clinical phenotype of patients with ET, and are considered significant
prognostic indicators [12]. These events may occur at any time leading to severe morbidities [13]. Although young ET patients with no
308
doi:10.1002/ajh.23635
RESEARCH ARTICLE
References
1. Falanga A, Marchetti M, Evangelista V, et al.
Polymorphonuclear leukocyte activation and
hemostasis in patients with essential thrombocythemia and polycythemia vera. Blood 2000;96:
42614266.
2. Jensen MK, De Nully BP, Lund BV, et al.
Increased circulating platelet-leukocytes aggregates in myeloproliferative disorders is correlated
to previous thrombosis, platelet activation and
platelet count. Eur J Haematol 2001;66:143151.
3. Harrison C. Pregnancy and its management in
the Philadelphia negative myeloproliferative diseases. Br J Haematol 2005;129:293306.
4. Passamonti F, Randi ML, Rumi E, et al. Increased
risk of pregnancy complications in patients with
essential
thrombocythemia
carrying
the
JAK2V617F mutation. Blood 2007;110:485489.
5. Melillo L, Tieghi A, Candoni A, et al. Outcome
of 122 pregnancies in essential thrombocythemia patients: A report from the Italian registry.
Am J Hematol 2009;84:636640.
6. Gangat N, Wolanskyi AP, Schwager S, et al. Predictors of pregnancy outcome in essential thrombocythemia: A single institution study of 63
pregnancies. Eur J Haematol 2008;82:350353.
7. Pagliaro P, Arrigoni L, Muggiasca MI, et al. Primary thrombocythemia and pregnancy: Treatment and outcome in fifteen cases. Am J
Hematol 1996;53:610.
8. Falconer J, Pineo G, Blahey T, et al. Essential
thrombocythemia associated with recurrent
abortions and fetal growth retardation. Am J
Hematol 1987;25:345347.
doi:10.1002/ajh.23635
Acknowledgment
A detailed description of the AGIMM project is available at http://
www.progettoagimm.it.
Author Contributions
M.L.R., T.B., designed the research, contributed patients, participated in data analysis and interpretation and wrote the article; G.F.,
F.L., I.B. reviewed the article and contributed patients; F.F. and C.M.
reviewed the article; all other authors contributed patients and read
and approved the final draft.
9. Murphy S, Peterson P, Iland H, Laszlo J. Experience of the polycythemia vera study group with
essential thrombocythemia: A final report on
diagnostic criteria, survival, and leukemic transition by treatment. Semin Hematol 1997;34:2939.
10. Vardiman JW, Thiele J, Arber DA, et al. The
2008 revision of the WHO classification of myeloid neoplasms and acute leukemia: Rationale and
important changes. Blood 2009;114:937951.
11. Griesshammer M, Struve S, Barbui T. Management of Philadelphia negative chronic myeloproliferative disorders in pregnancy. Blood Rev
2008;22:235245.
12. Passamonti F, Rumi E, Pungolino E, et al.
Life expectancy and prognostic factors for survival
in patients with polycythemia vera and essential
thrombocythemia. Am J Med 2004;117:755761.
13. Schafer A. Bleeding and thrombosis in myeloproliferative disorders. Blood 1984;64:112.
14. Cortelazzo S, Viero P, Finazzi G, et al. Incidence
and risk factors for thrombotic complications in
a historical cohort of 100 patients with essential
thrombocythemia. J Clin Oncol 1990;8:556562.
15. Elliott MA, Tefferi A. Thrombocythemia and
pregnancy. Best Pract Res Clin Hematol 2003;
16:227242.
16. Campbell PJ, Scott LM, Buck G, et al. Definition
of subtypes of essential thrombocythaemia and
relation to polycythaemia vera based on JAK2
V617F mutation status: A prospective study.
Lancet 2005;366:19451953.
17. Kralovics R, Passamonti F, Buser AS, et al. A gainof-function mutation of JAK2 in myeloproliferative
disorders. N Engl J Med 2005;352:17791790.
309