Training and Education
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question and
ask you to send your responses. See how your answer matches
up to the experts in the next print issue.
This month, Joel S. Bennett, MD, tackles management of thrombocytosis in a
pregnant patient.
Clinical Dilemma:
How would you manage a 35-year-old woman with thrombocytosis (platelet count >1 million per mm3) who would
like to get pregnant? She had a prior uncomplicated pregnancy (she used prophylactic low-molecular-weight heparin
[LMWH] for six weeks post-partum), followed by two first-trimester miscarriages. She is not iron-deficient and results
from a JAK2 mutation test are pending.
Experts Make the Call
• decreasing platelet count with hydroxyurea,
anagrelide, or interferon-alpha
her history of two consecutive first-trimester miscarriages — notably, this is typically the time when miscarriages usually occur in patients with ET. If she had not
had miscarriages and had otherwise uncomplicated ET,
I would recommend treatment with aspirin. However,
in view of her history, I would be concerned that aspirin
would be insufficient. If I were the consultant, I would
suggest decreasing her platelet count with interferonalpha.
If she has a successful pregnancy while receiving
interferon, it might be possible that she would have had
a successful pregnancy anyway, and that the interferon was unnecessary — but that is not the kind of
experiment that one can repeat. Moreover, the doses of
interferon-alpha required to treat ET seem to be quite
well-tolerated, as opposed to the dose used to treat
chronic myeloid leukemia, for example. It also probably
would not hurt to give aspirin.
• inhibiting thrombosis with aspirin or LMWH
For your patient, I think only two (aspirin and interferon) merit further consideration.
The benefits of aspirin in this situation are not clear:
some papers report fewer thrombotic complications
and miscarriages, while some do not. One problem with
the available research in this area is that most reports
are retrospective. On the other hand, aspirin is welltolerated with few complications. So, to paraphrase
Ayalew Tefferi, MD, and Francesco Passamonti, MD,
in their review of management of ET and pregnancy:
“Why not?”1
On the other hand, interferon-alpha has been reported
to increase the rate of successful pregnancies from 60 percent to 90 percent,2 although Drs. Tefferi and Passamonti
suggest this may not apply to low-risk patients.
My recommendations for your patient are colored by
36
ASH Clinical News
What is your opinion on the use of pegfilgrastim with ABVD for classical Hodgkin lymphoma? Is it necessary, or would
you treat without regard to neutrophil
count and include it only if the patient
has a neutropenic fever event?
How would you respond? Email us at
[email protected].
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:
Joel S. Bennett, MD
Professor of Medicine in the Division of
Hematology-Oncology
Perelman School of Medicine
University of Pennsylvania
Let’s assume that there is good reason to believe that
your patient has essential thrombocythemia (ET),
regardless of whether or not she is JAK2-positive. Assessing JAK2, c-MPL, and calreticulin mutations can
account for at least 90 percent of patients with ET, if the
diagnosis is a concern.
Nonetheless, from your description, I assume that
your patient had a high platelet count during her first
pregnancy and during the subsequent ones in which she
suffered first-trimester miscarriages.
As I am sure you are well-aware, the literature on the
management of pregnancy in patients with ET is both
scanty and awful. That being said, there is no obvious
right answer.
F