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Dear Editor,
We read with interest the paper written by Ruiz-Argüelles et al.1 in your journal describing sticky platelet syndrome (SPS) as a thrombophilic platelet function disorder2,3. We report on a 35-year-old patient with SPS type II and recurrent complicated pregnancies. In 2011, she had a fetal demise in 24th week of gestation (WG); in 2012 cesarean section in 32nd WG due to preeclampsia; in 2013 premature birth in 29th WG for preeclampsia, transient loss of vision, oligohydramnion, and intrauterine growth restriction. Her father had deep venous thrombosis at the age of 50 years.
In the last pregnancy, where she carried twins, since 5th WG, besides acetylsalicylic acid (ASA) 100 mg daily, she used nadroparin 2 850 IU (anti Xa)/0.3 mL daily. Due to the allergy in the 11th WG, she switched to enoxaparin 4000 IU (40 mg)/0.4 mL daily. In the 18th WG, she complained of headaches. In the 24th WG, the patient was hospitalized due to proteinuria (0.229-0.320 g/24 h). In the 27th WG, she reported transient edema of the right leg. In the 31st WG, the patient noticed stars in the field of vision with accompanying headache. Moreover, one of the fetuses had growth restriction and reduction in placental blood flow. Therefore, an increase in the enoxaparin dose to 0.6 mL daily was recommended.
In the 33rd WG, ultrasonography normalized. After the pause in ASA (from 36th WG), enoxaparin 0.8 mL daily was recommended. In the 38th WG, she delivered healthy twins. Laboratory results are shown in Table 1; the summary of the drugs employed for the treatment, the evolution of the proteinuria and the development of the obstetric complications of the patient are outlined in Figure 1. Based on the available literature, this is the first case of a patient with combined SPS and proteinuria.
ASA: acetylsalicylic acid; PAMBA: para-aminobenzoic acid; WG: week of gestation.
Figure 1. Timeline of the development of patient's complications during at-risk pregnancy.
Table 1. Changes in hemostasis and further important parameters measured during pregnancy
| WG | Weight (kg) | D-dimers (mg/L) | Fbg (g/L) | PLT (× 109/l) | PS function (%) | PS antigen (%) | FVIII (IU/mL) | ProC Global NR | Anti-Xa activity (IU/mL) |
|---|---|---|---|---|---|---|---|---|---|
| 11 | 59 | 0.32 | 3.3 | 264 | 44.2 | 98 | 2.085 | 0.28 | |
| 18 | 62 | 0.56 | 3.2 | 223 | |||||
| 27 | 67 | 0.89 | 3 | 175 | 50.7 | 109 | 0.54 | 0.66 | |
| 31 | 71 | 0.58 | 3.1 | 176 | 0.46 | ||||
| 33 | 72 | 1.28 | 3.2 | 152 | 0.58 | 0.68 | |||
| 9 AD | 62 | 0.13 | 2.5 | 268 | 47.4 | 1.294 | 0.63 | 0.62 |
AD: after delivery; Fbg: fibrinogen; FVIII: coagulation factor VIII; PLT: platelet count; ProC Global NR: ProC Global normalized ratio; PS: protein S; WG: week of gestation.
Reference ranges for the parameters in Table 1 according to our National Center of Hemostasis and Thrombosis: D-dimers (0.0-0.5 mg/L), Fbg (1.8-4.2 g/L), PLT (140-400 × 109/L), PS function (60-130%), PS antigen (70-140%), FVIII (0.6-1.5 IU/mL), ProC Global NR (0.75-1.20), anti-Xa activity for the prophylactic dose of LMWH (0.2-0.4 IU/mL), for the therapeutic dose of LMWH (0.5-1.2 IU/mL).
