TRAINING and EDUCATION
You Make the Call
Saskia Middeldorp, MD, discusses treatment of HELLP (hemolysis, elevated liver enzymes, low
platelet count) syndrome.
Clinical Dilemma:
I have a 31-year-old female patient with HELLP syndrome who is 12 weeks pregnant with her second
child. APL: DRVVT (+) not corrected with 1:1 mix and DRVVT confirmed (+); anticardiolipin
antibodies and beta-2 glycoprotein antibodies are normal. She is taking low-dose aspirin daily. Should
she be on enoxaparin sodium as well?
Consult a Colleague
Through ASH
Expert Opinion
Saskia Middeldorp, MD
Professor of Medicine, Department of Vascular Medicine
Amsterdam University Medical Centers, Location AMC
The Netherlands
Consult a Colleague is a service for ASH
members that helps facilitate the exchange
of information between hematologists
and their peers. ASH members can seek
consultation on clinical cases from qualified
experts in 11 categories:
• Anemias
The presence of HELLP syndrome (“late pregnancy
morbidity”) combined with two positive lupus
anticoagulant tests at least 12 weeks apart
would mean that your patients fulfills the
criteria for antiphospholipid syndrome
(APS). If you have not had the time to
repeat testing, she may not officially
meet the definition yet. Regardless,
there is consensus that she should
be treated with low-dose aspirin
to prevent recurrent preeclampsia
or other potential deleterious
outcomes to herself or the neo-
nate based on her history.
Regarding low-molecular-
weight heparin (LMWH), the
jury is out. Although narrative
reviews by renowned experts often
suggest the use of heparin (in the
absence of a history of thrombosis),
there are no high-quality data to support
this approach. To my knowledge, there are
no reliable data that LMWH improves preg-
nancy outcomes in women with late pregnancy
morbidity such as HELLP or preeclampsia. This is
a rather evidence-free zone, as well-sized trials have not
been conducted in this population. One randomized con-
trol trial with LMWH plus aspirin in this population was
stopped prematurely because of low accrual rates (n=32)
and observed a very low rate of recurrent hypertensive
pregnancy disorders in both groups. In AFFIRM (An Indi-
vidual Patient Data Meta-analysis of low-molecular-weight
heparin for prevention of Placenta-Mediated Pregnancy
Complications), about 4 percent of women (n=31) had
antiphospholipid antibodies, and LMWH did not show a
Next Month’s Clinical Dilemma:
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative neoplasms
• Myelodysplastic syndromes
• Thrombocytopenias
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clear beneficial effect, but obviously the sample size was
small. Hence, in my practice, I stick to aspirin and do not
prescribe LMWH for this indication.
REFERENCE
van Hoorn M, Hague W, van Pampus M, et al. Low-molecular-weight heparin and aspirin in the
prevention of recurrent early-onset pre-eclampsia in women with antiphospholipid antibodies:
the FRUIT-RCT. Eur J Obstet Gynecol Reprod Biol. 2016;197:168-73.
I have a 22-year-old female patient with stage 2a lymphocyte-predominant Hodgkin lymphoma involving lymph
nodes in the pelvis who presented while pregnant (she has since delivered a healthy child.). Her disease is progress-
ing slowly, but a recent CT scan showed slightly increasing nodes, so she needs to begin therapy. The radiation
oncologist does not want to treat her because of her fertility. I sent her to a fertility clinic that recommended
harvesting eggs, but the patient refused and “will let God decide” if she has children. I have presented her case at
our lymphoma rounds and the recommendation was for six cycles of R-CHOP rather than an ABVD regimen. What
would you do? If R-CHOP is the right approach, would you add an LHRH agonist?
How would you respond? Email us at [email protected]. ●
100
ASH Clinical News
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at your own risk.
December 2018