Neurodevelopmental Outcome After Fetal Neonatal AlloImmune Thrombocytopenia

Overview

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a disease caused by allo-immunisation during pregnancy. If left untreated, FNAIT can lead to severe fetal intracranial haemorrhage. This complication can be prevented by weekly administration of intravenous immunoglobulin (IVIg) to the mother during pregnancy. Knowledge on long-term development of FNAIT survivors with or without IVIg treatment is very limited but an important subject in the counselling of parents of newly diagnosed cases. To evaluate the long-term neurodevelopmental outcome in two groups of children with FNAIT will be asked to participate in our study in an outpatient clinic setting.

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Retrospective
  • Study Primary Completion Date: December 17, 2020

Detailed Description

INTRODUCTION AND RATIONALE Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the most common cause of thrombocytopenia in otherwise healthy term-born neonates. FNAIT is a rare disease with an incidence estimated around 1 per 1000 live newborns. During pregnancy alloimmunization can occur due to incompatibility of the Human Platelet Antigens (HPA) on the maternal and fetal platelets. Alloimmunization and maternal production of antibodies directed against the HPA-positive fetal platelets, leads to thrombocytopenia and an increased risk of intracranial hemorrhages (ICH) in the fetus. Clinical presentation can vary from skin bleedings to severe ICH leading to lifelong neurologic sequelae or intrauterine death. In the past, FNAIT was managed with invasive and high-risk interventions including intrauterine platelet transfusion (IUPT). Since the end of the 20th century, invasive intrauterine transfusions (IUT) were replaced by a new, non-invasive therapy: maternal administration of intravenous immunoglobulin (IVIg). This novel therapy resulted in a significant lower risk of intrauterine fetal death and ICH. Intervention with immune modulation in the semi -allogenic environment of the fetus by administration of immunoglobulins (Ig) is successful, especially in preventing ICH. However antenatal treatment with IVIg has been implemented as standard of care without strong methodological follow-up research of children from mothers treated with IVIg. To date, only two follow-up studies have been published in children with anticipated FNAIT cases. The first study of a FNAIT cohort treated with IVIg was done by Ward et al. in 2006. They concluded that development of children treated for FNAIT was better compared to their non-treated siblings. Their conclusions were based on non-validated questionnaires taken by telephone, assessing the behavioral outcome of the children and were limited by a ~40% lost-to-follow-up rate. A second follow-up study including 39 children was published by a research group from our center in 2004. This research stated that the outcome in children with FNAIT and exposed to maternal IVIg treatment was similar to the normal population. However, this study included a heterogenic group of children with different treatment strategies including IUT, hampering definitive conclusions and substantiating the need for more research. No long-term standardized follow-up studies were performed on FNAIT cases without antenatal treatment and/or ICH. The natural course of the disease and long-term effects of thrombocytopenia on the developing fetus and newborn are unknown. FNAIT is defined as a disease caused by alloantibodies, resulting in thrombocytopenia and a risk of bleeding in the neonate. In the last years, evidence is increasing that the maternal alloantibodies can also bind to the fetal endothelium and may impair angiogenesis in the developing fetuses It is not known at which moment in pregnancy the developing brain is most vulnerable for damage induced by these kind of alloantibodies. The timing in fetal life FNAIT associated ICH ranges from 23 to 42 weeks, but small bleeding may not be diagnosed. It may also be that these type of alloantibodies not lead to ICH but to other type of cerebral damage. These lesions can remain subclinical directly after birth but lead to developmental delay on the long term. This knowledge can be of great interest when counseling parents with a risk of FNAIT or in writing guidelines. For 3 decades a nationwide screening on FNAIT to detect pregnancies with alloantibodies in time and start treatment to prevent bleedings is being discussed. If alloantibodies lead to cerebral damage on the long term also in patients without large ICH this might have large implications in the debate on the introduction of a national screening programme. Therefore the investigators want to underline that more knowledge about the long-term development of FNAIT survivors is required. The Leiden University Medical Center (LUMC), a national fetal therapy center in The Netherlands, has a close and long-lasting collaboration with Sanquin. This collaboration offers a unique opportunity to evaluate a large and complete cohort of children with FNAIT. LUMC and Sanquin are both nationwide referral centers for FNAIT and committed to improve timely detection of high-risk cases who need intra-uterine therapy. This research group from the national expertise centers are designated to assess long-term outcome in children with FNAIT and describe the natural history of children affected by FNAIT and the long term effects of a given therapy. OBJECTIVE The primary objective is to determine the cognitive test score of children diagnosed with FNAIT without and with antenatal treatment. STUDY DESIGN The investigators will perform an observational cohort study. The long-term neurodevelopmental outcome of children affected by FNAIT will be evaluated. All children born between 2002 and 2017 and diagnosed with FNAIT are eligible for follow-up assessment and will be invited for an assessment at our outpatient clinic. The FNAIT survivors will be collected in two cohorts; cohort 1 will consist of FNAIT survivors without antenatal treatment, cohort 2 will consist of FNAIT survivors that were antenatally anticipated and therefore IVIg treatment to the mother was given. Enrollment in this study will take place via the LUMC and Stichting Sanquin Bloedvoorziening. The LUMC is national referral center for intrauterine therapy and Sanquin is national reference laboratory to diagnose FNAIT. Retrospectively FNAIT cases will be collected and asked for permission directly or via referring specialist. After informed consent, child cognitive functioning will be assessed with a formal psychological test of cognitive functioning. According to age, the parents will complete a standardized behavioral and HRQoL questionnaire. Academic performance will be assessed by collecting the most recent CITO test scores from the Dutch Pupil monitoring system developed by the National Institute for Educational Measurement. Assessment of the prevalence of possible late effects of IVIg on the immune system will be assessed by questionnaires about the prevalence of allergies, astma, eczema and course of infections by questionnaires. Parents and children, when 12 years old or older, are asked for consent to request the medical letters from the maternity or neonatology ward to obtain perinatal and neonatal data. No laboratory tests will be performed in this study, however data of the laboratory tests that were performed at timepoint of diagnosing FNAIT will be involved in this study. After assessment a report will be made from the observations and test results, this report will be sent to the parents.

Interventions

  • Diagnostic Test: Cognitive testing (Bayley III, WPPSI III and WISC V)
    • Parents and children will be invited to come for an outpatient clinic visit where cognitive testing and neurologic examination will be performed. In addition to this parents will be asked to fill in questionnaires, provide latest school results and medical files will be requested from treating physicians.

Arms, Groups and Cohorts

  • Cohort 1: Unanticipated FNAIT cases
    • All children born between 2002 and 2017 and diagnosed with FNAIT are eligible for this study. Children in cohort 1 will be FNAIT cases that were not antenatally treated with by maternal IVIg administration (or other forms of fetal therapy).
  • Cohort 2: Anticipated FNAIT cases
    • All children born between 2002 and 2017 and diagnosed with FNAIT are eligible for this study. Children in cohort 2 will be FNAIT cases which were anticipated antenatally by maternal IVIg administration according to our local protocol.

Clinical Trial Outcome Measures

Primary Measures

  • Cognitive test score
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • IQ test score calculated from a standardized cognitive test.

Secondary Measures

  • Neurodevelopmental injury (NDI)
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • NDI is a composite outcome of: Cerebral palsy ≥ grade II according to Gross Motor Classification System (GMFCS) Impaired cognitive, language and/or motor development (test scores <70) Bilateral blindness and/or bilateral deafness Bilateral deafness requiring amplification
  • Health Related Quality of Life
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Health Related Quality of Life score calculated from the PedsQol questionnaire.
  • Cerebral Palsy
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Spastic bilateral, spastic unilateral or mixed Classification by European CP Network
  • Bilateral blindness
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Blind or partially sighted.
  • Bilateral deafness
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Needing hearing aids.
  • Behaviour test score
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Behaviour test score bases on Child Behavior Checklist
  • Abnormal course or incidence of infections
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Need to refer to an immunologist or the need to preform diagnostics based on history taking according to the Dutch guidelines.
  • Prevalence of eczema
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Number of children that suffer from eczema.
  • Prevalence of allergies
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Number of children that suffer from allergies
  • Patient reported anaphylaxis
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • Serious allergic reaction, requiring urgent medical treatment with epinephrine.
  • Poor control of allergic rhinitis
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • CARAT score of upper airways < 8
  • Poor control of asthma
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • CARAT score of lower airways < 16.
  • Academic performance
    • Time Frame: From birth until study enrollment. Average age of the participants is expected to be 8 years old.
    • The latest test scores from primary school will be requested. Three academic domains will be assessed; arithmetic and spelling performance and measurements on reading comprehension.

Participating in This Clinical Trial

Inclusion Criteria

  • Children diagnosed with FNAIT during pregnancy or postnatal, at moment of inclusion 2 to 16 years of age. – Children living in the Netherlands. – Parents or guardian aged ≥ 18 years old, with parental authority. – Written informed consent form both parents with, form being approved by Ethic Committee. Exclusion Criteria:

  • Children born with congenital and/or chromosomal abnormalities. – Children that passed away before inclusion.

Gender Eligibility: All

Minimum Age: 18 Months

Maximum Age: 17 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Leiden University Medical Center
  • Collaborator
    • Sanquin-LUMC J.J van Rood Center for Clinical Transfusion Research
  • Provider of Information About this Clinical Study
    • Principal Investigator: elopriore, Prof. E. Lopriore – Leiden University Medical Center
  • Overall Official(s)
    • Enrico Lopriore, Prof. MD PhD, Principal Investigator, Department of Neonatology, Leiden University Medical Center
    • Masja de Haas, Prof. MD PhD, Principal Investigator, Stichting Sanquin Bloedvoorziening

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