Púrpura trombocitopénica trombótica en el embarazo: diagnóstico diferencial con síndrome HELLP y preeclampsia severa.
Palabras clave:
Púrpura trombocitopénica trombótica, embarazo, síndrome HELLP, preeclampsia.Resumen
La púrpura trombocitopénica trombótica es una microangiopatía trombótica rara y potencialmente mortal, caracterizada por la presencia de anemia hemolítica microangiopática, trombocitopenia severa y daño orgánico. El embarazo constituye un importante factor desencadenante de esta enfermedad, ya que durante la gestación se presenta, de manera fisiológica, una disminución de la actividad de la enzima ADAMTS13, un aumento de la actividad del factor von Willebrand y una mayor reactividad plaquetaria. Se estima que esta patología tiene una incidencia de 1 en 200.000 partos y se asocia con una elevada tasa de mortalidad maternofetal, cercana al 80%. Las manifestaciones clínicas de la púrpura trombocitopénica trombótica durante el embarazo pueden superponerse con las de otras patologías más frecuentes, como la preeclampsia y el síndrome HELLP (hemólisis, elevación de enzimas hepáticas y trombocitopenia); por ello, la monitorización de la actividad de ADAMTS13 resulta clave para confirmar el diagnóstico.
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1. Joly BS, Coppo P, Veyradier A. Thrombotic thrombocytopenic purpura. Blood. 2017; 129(21):2836-46. DOI: 10.1182/blood-2016-10-709857.
2. Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med. 2021; 10(3):536. DOI: 10.3390/jcm10030536.
3. Singer K, Bornstein FP, Wile SA. Thrombotic thrombocytopenic purpura: hemorrhagic diathesis with generalized platelet thromboses. Blood. 1947; 2(6):542-54.
4. Iqbal S, Zaidi SZ, Motabi IH, Alshehry NF, AlGhamdi MS, Tailor IK. Thrombotic thrombocytopenic purpura - analysis of clinical features, laboratory characteristics and therapeutic outcome of 24 patients treated at a Tertiary Care Center in Saudi Arabia. Pak J Med Sci 2016; 32(6):1494-99. DOI: 10.12669/pjms.326.11274.
5. Amorosi EL, Ultmann JE. Thrombotic thrombocytopenic purpura: report of 16 cases and review of the literature. Medicine. 1966; 45(2):139-160.
6. Mariotte E, Azoulay E, Galicier L, Rondeau E, Zouiti F, Boisseau P, et al. Epidemiology and pathophysiology of adulthood-onset thrombotic microangiopathy with severe ADAMTS13 deficiency (thrombotic thrombocytopenic purpura): a cross-sectional analysis of the French national registry for thrombotic microangiopathy. Lancet Haematol. 2016; 3(5): e237-45. DOI: 10.1016/S2352-3026(16)30018-7.
7. Zhou L, Zhu Y, Jiang M, Su J, Liu X, Jiang Y, et al. Pregnancy-associated thrombotic thrombocytopenic purpura complicated by Sjögren’s syndrome and non-neutralising antibodies to ADAMTS13: a case report. BMC Pregnancy Childbirth. 2021; 21(1):804. DOI: 10.1186/s12884-021-04167-9.
8. Béranger N, Coppo P, Tsatsaris V, Boisseau P, Provôt F, Delmas Y, et al. Management and follow-up of pregnancy-onset thrombotic thrombocytopenic purpura: the French experience. Blood Adv. 2024; 8(1):183-93. DOI: 10.1182/bloodadvances.2023011972.
9. Fakhouri F, Scully M, Provôt F, Blasco M, Coppo P, Noris M, et al. Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood. 2020; 136(19):2103-17. DOI: 10.1182/blood.2020005221.
10. Scully M. How to evaluate and treat the spectrum of TMA syndromes in pregnancy. Hematology Am Soc Hematol Educ Program. 2021; 2021(1):545-51. DOI: 10.1182/hematology.2021000290.
11. Moatti-Cohen M, Garrec C, Wolf M, Boisseau P, Galicier L, Azoulay E, et al. Unexpected frequency of Upshaw-Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Blood. 2012; 119(24):5888-97. doi:10.1182/blood-2012-02-408914.
12. Urra M, Lyons S, Teodosiu CG, Burwick R, Java A. Thrombotic Microangiopathy in Pregnancy: Current Understanding and Management Strategies. Kidney Int Rep. 2024; 9(8):2353-71. DOI: 10.1016/j.ekir.2024.05.016.
13. George JN. The association of pregnancy with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Curr Opin Hematol. 2003;10(5):339-44. DOI: 10.1097/00062752-200309000-00003.
14. Sikka P, Chopra S, Aggarwal N, Suri V, Chandrasekaran A. Thrombotic thrombocytopenic purpura in the first trimester of pregnancy. Asian J Transfus Sci. 2013; 7(1):79-80. DOI: 10.4103/0973-6247.106746.
15. Rozdzinski E, Hertenstein B, Schmeiser T, Seifried E, Kurrle E, Heimpel H. Thrombotic thrombocytopenic purpura in early pregnancy with maternal and fetal survival. Ann Hematol. 1992; 64(5):245-8. DOI: 10.1007/BF01738304.
16. Mokrzycki MH, Rickles FR, Kaplan AA, Kohn OF. Thrombotic thrombocytopenic purpura in pregnancy: successful treatment with plasma exchange. Case report and review of the literature. Blood Purif. 1995;13(5):271-82. DOI: 10.1159/000170210.
17. George JN, Nester CM, McIntosh JJ. Syndromes of thrombotic microangiopathy associated with pregnancy. Hematology Am Soc Hematol Educ Program. 2015; 2015:644-8. DOI: 10.1182/asheducation-2015.1.644.
18. Delmas Y, Helou S, Chabanier P, Ryman A, Pelluard F, Carles D, et al. Incidence of obstetrical thrombotic thrombocytopenic purpura in a retrospective study within thrombocytopenic pregnant women. A difficult diagnosis and a treatable disease. BMC Pregnancy Childbirth. 2015; 15:137. DOI: 10.1186/s12884-015-0557-5.
19. Fakhouri F. Pregnancy-related thrombotic microangiopathies: Clues from complement biology. Transfus Apher Sci. 2016; 54(2):199-202. DOI: 10.1016/j.transci.2016.04.009.
20. Neave L, Scully M. Microangiopathic Hemolytic Anemia in Pregnancy. Transfus Med Rev. 2018; 32(4):230-36. DOI: 10.1016/j.tmrv.2018.08.002.
21. Coppo P, Veyradier A; French Reference Center for Thrombotic Microangiopathies (CNR‐MAT). TTP in the setting of pregnancy: The story still has to be written. J Thromb Haemost. 2020; 18(10):2775-7. DOI: 10.1111/jth.15030.
22. Sadler JE. Pathophysiology of thrombotic thrombocytopenic purpura. Blood. 2017; 130(10):1181-8. DOI: 10.1182/blood-2017-04-636431.
23. Levy GG, Nichols WC, Lian EC, Foroud T, McClintick JN, McGee BM, et al. Mutations in a member of the ADAMTS gene family cause thrombotic thrombocytopenic purpura. Nature. 2001; 413(6855):488-94. DOI: 10.1038/35097008.
24. Terrell DR, Vesely SK, Kremer Hovinga JA, Lämmle B, George JN. Different disparities of gender and race among the thrombotic thrombocytopenic purpura and hemolytic-uremic syndromes. Am J Hematol. 2010; 85(11):844-7.
25. Shelat SG, Ai J, Zheng XL. Molecular biology of ADAMTS13 and diagnostic utility of ADAMTS13 proteolytic activity and inhibitor assays. Semin Thromb Hemost. 2005; 31(6):659-72.
26. Chiasakul T, Cuker A. Clinical and laboratory diagnosis of TTP: an integrated approach. Hematology Am Soc Hematol Educ Program. 2018;2018(1):530-8.
27. Dane K, Chaturvedi S. Beyond plasma exchange: novel therapies for thrombotic thrombocytopenic purpura. Hematology Am Soc Hematol Educ Program. 2018; 2018(1):539-47.
28. Liu S, Zheng XL. Immune thrombotic thrombocytopenic purpura: pathogenesis and novel therapies: a narrative review. Ann Blood. 2023; 8:26. DOI: 10.21037/aob-22-29.
29. Alwan F, Vendramin C, Liesner R, Clark A, Lester W, Dutt T, et al. Characterization and treatment of congenital thrombotic thrombocytopenic purpura. Blood. 2019; 133(15):1644-51. DOI: 10.1182/blood-2018-11-884700.
30. Joly BS, Boisseau P, Roose E, Stepanian A, Biebuyck N, Hogan J, et al. ADAMTS13 Gene Mutations Influence ADAMTS13 Conformation and Disease Age-Onset in the French Cohort of Upshaw-Schulman Syndrome. Thromb Haemost. 2018; 118(11):1902-17. DOI: 10.1055/s-0038-1673686.
31. Joly BS, Stepanian A, Leblanc T, Hajage D, Chambost H, Harambat J, et al. Child-onset and adolescent-onset acquired thrombotic thrombocytopenic purpura with severe ADAMTS13 deficiency: a cohort study of the French national registry for thrombotic microangiopathy. Lancet Haematol. 2016; 3(11):e537-e546. DOI: 10.1016/S2352-3026(16)30125-9.
32. Tsai HM. Pathophysiology of thrombotic thrombocytopenic purpura. Int J Hematol. 2010; 91(1):1-19. DOI: 10.1007/s12185-009-0476-1.
33. Sánchez-Luceros A, Farías CE, Amaral MM, Kempfer AC, Votta R, Marchese C, et al. von Willebrand factor-cleaving protease (ADAMTS13) activity in normal non-pregnant women, pregnant and post-delivery women. Thromb Haemost. 2004; 92(6):1320-6. DOI: 10.1160/TH03-11-0683.
34. Scully M, Thomas M, Underwood M, Watson H, Langley K, Camilleri RS, et al. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood. 2014; 124(2):211-9. doi:10.1182/blood-2014-02-553131.
35. Fujimura Y, Matsumoto M, Isonishi A, Yagi H, Kokame K, Soejima K, et al. Natural history of Upshaw-Schulman syndrome based on ADAMTS13 gene analysis in Japan. J Thromb Haemost. 2011; 9 Suppl 1:283-301. DOI: 10.1111/j.1538-7836.2011.04341.
36. Atrash S, Sajjad H, Jeanette R, Konstantinos A. Thrombotic thrombocytopenic purpura. J Ark Med Soc. 2015; 111(9):187-9.
37. Lavender Z, Collin L. Thrombotic thrombocytopenic purpura. JAAPA. 2021;34(7):54-5. DOI: 10.1097/01.JAA.0000750992.29972.11.
38. Page EE, Kremer Hovinga JA, Terrell DR, Vesely SK, George JN. Thrombotic thrombocytopenic purpura: diagnostic criteria, clinical features, and long-term outcomes from 1995 through 2015. Blood Adv. 2017; 1(10):590-600. DOI: 10.1182/bloodadvances.2017005124.
39. Griffin D, Al-Nouri ZL, Muthurajah D, Ross JR, Ballard RB, Terrell DR, et First symptoms in patients with thrombotic thrombocytopenic purpura: what are they and when do they occur? Transfusion. 2013; 53(1):235-7. DOI: 10.1111/j.1537-2995.2012.03934.x.
40. Hansen DL, Nilsson AC, Frederiksen H. Thrombotic thrombocytopenic purpura. Ugeskr Laeger. 2021; 183(42):V03210230.
41. Scully M, Yarranton H, Liesner R, Cavenagh J, Hunt B, Benjamin S, et al. Regional UK TTP registry: correlation with laboratory ADAMTS 13 analysis and clinical features. Br J Haematol. 2008; 142(5):819-26. DOI: 10.1111/j.1365-2141.2008.07276.x.
42. Hughes C, McEwan JR, Longair I, Hughes S, Cohen H, Machin S, et al. Cardiac involvement in acute thrombotic thrombocytopenic purpura: association with troponin T and IgG antibodies to ADAMTS 13. J Thromb Haemost. 2009; 7(4):529-36. DOI: 10.1111/j.1538-7836.2009.03285.x.
43. Hawkins BM, Abu-Fadel M, Vesely SK, George JN. Clinical cardiac involvement in thrombotic thrombocytopenic purpura: a systematic review. Transfusion. 2008; 48(2):382-92. DOI: 10.1111/j.1537-2995.2007.01534.x.
44. Benhamou Y, Boelle PY, Baudin B, Ederhy S, Gras J, Galicier L, et al. Cardiac troponin-I on diagnosis predicts early death and refractoriness in acquired thrombotic thrombocytopenic purpura. Experience of the French Thrombotic Microangiopathies Reference Center. J Thromb Haemost. 2015; 13(2):293-302. DOI: 10.1111/jth.12790.
45. Scully M, Hunt BJ, Benjamin S, Liesner R, Rose P, Peyvandi F, et al. Guidelines on the diagnosis and management of thrombotic thrombocytopenic purpura and other thrombotic microangiopathies. Br J Haematol. 2012; 158(3):323-35. DOI: 10.1111/j.1365-2141.2012.09167.
46. Saha M, McDaniel JK, Zheng XL. Thrombotic thrombocytopenic purpura: pathogenesis, diagnosis and potential novel therapeutics. J Thromb Haemost. 2017; 15(10):1889-1900. DOI: 10.1111/jth.13764.
47. Zheng XL, Kaufman RM, Goodnough LT, Sadler JE. Effect of plasma exchange on plasma ADAMTS13 metalloprotease activity, inhibitor level, and clinical outcome in patients with idiopathic and nonidiopathic thrombotic thrombocytopenic purpura. Blood. 2004; 103(11):4043-9. DOI: 10.1182/blood-2003-11-4035.
48. Rock GA, Shumak KH, Buskard NA, Blanchette VS, Kelton JG, Nair RC, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. N Engl J Med. 1991; 325(6):393-7. DOI: 10.1056/NEJM199108083250604.
49. Tsai HM, Lian EC. Antibodies to von Willebrand factor-cleaving protease in acute thrombotic thrombocytopenic purpura. N Engl J Med. 1998; 339(22):1585-94. DOI: 10.1056/NEJM199811263392203.
50. Furlan M, Robles R, Galbusera M, Remuzzi G, Kyrle PA, Brenner B, et al. von Willebrand factor-cleaving protease in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. N Engl J Med. 1998; 339(22):1578-84. DOI: 10.1056/NEJM199811263392202.
51. Vyas A, Isaac S, Kaur D, Yadav U. Role of the PLASMIC Score in the Management of Thrombotic Thrombocytopenic Purpura. Cureus. 2023; 15(3):e36188. DOI: 10.7759/cureus.36188.
52. Muñoz NG, Ortega S, Solanich X, Cid J, Díaz M, Moreno AB, et al. Diagnosis and clinical management of thrombotic thrombocytopenic purpura (TTP): a consensus statement from the TTP Catalan group. Blood Transfus. 2024; 22(2):176-84. DOI: 10.2450/BloodTransfus.522.
53. Hoffman P. Púrpura trombocitopénica trombótica. Stern S.C., & Cifu A.S., & Altkorn D, editores, Diagnóstico basado en los síntomas: Una guía basada en evidencias, 4e. McGraw-Hill Education. 2021.
54. Coppo P, Schwarzinger M, Buffet M, Wynckel A, Clabault K, Presne C, et al. Predictive features of severe acquired ADAMTS13 deficiency in idiopathic thrombotic microangiopathies: the French TMA reference center experience. PLoS One. 2010; 5(4):e10208. DOI: 10.1371/journal.pone.0010208.
55. Bendapudi PK, Hurwitz S, Fry A, Marques MB, Waldo SW, Li A, et al. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol. 2017; 4(4):e157-e164. DOI: 10.1016/S2352-3026(17)30026-1.
56. Giannubilo SR, Marzioni D, Tossetta G, Ciavattini A. HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy. Diagnostics (Basel). 2024; 14(4):352. DOI: 10.3390/diagnostics14040352.
57. Dashe JS, Ramin SM, Cunningham FG. The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy. Obstet Gynecol. 1998; 91(5 Pt 1):662-8. DOI: 10.1016/s0029-7844(98)00031-3.
58. Mol BWJ, Roberts CT, Thangaratinam S, Magee LA, de Groot CJM, Hofmeyr GJ. Pre-eclampsia. Lancet. 2016;387(10022):999-1011. DOI: 10.1016/S0140-6736(15)00070-7.
59. Gupta M, Feinberg BB, Burwick RM. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens. 2018; 12:29-34. DOI: 10.1016/j.preghy.2018.02.007.
60. Ramos Mayordomo P, Capilla Díez M, Ticona Espinoza DA, Torres Jaramillo MV, Martínez Tejeda N, Ticona Espinoza TG,et al. Thrombotic microangiopathy (TMA) associated with pregnancy: role of the clinical laboratory in differential diagnosis. Adv Lab Med. 2024; 5(3):340-4. DOI: 10.1515/almed-2024-0053.
61. Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, et al. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia. 2015; 35(5):421-47. DOI: 10.1016/j.nefro.2015.07.005.
62. Romero MA, Orós D, Vigil-De Gracia P, Fabre E. Estados hipertensivos del embarazo, 7th ed. Barcelona, Spain: Elsevier; 2018.
63. Geary M. The HELLP syndrome. Br J Obstet Gynaecol. 1997; 104(8):887-91. DOI: 10.1111/j.1471-0528.1997.tb14346.x.
64. Karumanchi SA, Maynard SE, Stillman IE, Epstein FH, Sukhatme VP. Preeclampsia: a renal perspective. Kidney Int. 2005; 67(6):2101-13. DOI: 10.1111/j.1523-1755.2005.00316.x.
65. Arigita Lastra M, Martínez Fernández GS. Síndrome HELLP: controversias y pronóstico [HELLP syndrome: controversies and prognosis]. Hipertens Riesgo Vasc. 2020; 37(4):147-51. DOI: 10.1016/j.hipert.2020.07.002.
66. Sociedad Española de Ginecología y Obstetricia. Guía de Asistencia Práctica: Trastornos hipertensivos en la gestación. Progresos Obstet Ginecol 2020; 63:244–72.
67. Nikuei P, Rajaei M, Roozbeh N, Mohseni F, Poordarvishi F, Azad M, et al. Diagnostic accuracy of sFlt1/PlGF ratio as a marker for preeclampsia. BMC Pregnancy Childbirth. 2020; 20(1):80. DOI: 10.1186/s12884-020-2744-2.
68. Schaarschmidt W, Rana S, Stepan H. The course of angiogenic factors in early- vs. late-onset preeclampsia and HELLP syndrome. J Perinat Med. 2013; 41(5):511-6. DOI: 10.1515/jpm-2012-0248.
69. Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennström M, et al. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia. N Engl J Med. 2016; 374(1):13-22. DOI: 10.1056/NEJMoa1414838.
70. Verlohren S, Herraiz I, Lapaire O, Schlembach D, Zeisler H, Calda P, et al. New gestational phase-specific cutoff values for the use of the soluble fms-like tyrosine kinase-1/placental growth factor ratio as a diagnostic test for preeclampsia. Hypertension. 2014; 63(2):346-52. DOI: 10.1161/HYPERTENSIONAHA.113.01787.
71. Young B, Levine RJ, Salahuddin S, Qian C, Lim KH, Karumanchi SA, et al. The use of angiogenic biomarkers to differentiate non-HELLP related thrombocytopenia from HELLP syndrome. J Matern Fetal Neonatal Med. 2010; 23(5):366-70. DOI: 10.1080/14767050903184207.
72. Ferrari B, Peyvandi F. How I treat thrombotic thrombocytopenic purpura in pregnancy. Blood. 2020; 136(19):2125-32. DOI: 10.1182/blood.2019000962.
73. Keiser SD, Boyd KW, Rehberg JF, Elkins S, Owens MY, Sunesara I, et al. A high LDH to AST ratio helps to differentiate pregnancy-associated thrombotic thrombocytopenic purpura (TTP) from HELLP syndrome. J Matern Fetal Neonatal Med. 2012; 25(7):1059-63. DOI: 10.3109/14767058.2011.619603.
74. Lim MY, Abou-Ismail MY, Branch DW. Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol. 2023; 141(1):85-108. DOI: 10.1097/AOG.0000000000005024.
75. Papakonstantinou A, Kalmoukos P, Mpalaska A, Koravou EE, Gavriilaki E. ADAMTS13 in the New Era of TTP. Int J Mol Sci. 2024; 25(15):8137. DOI: 10.3390/ijms25158137.
76. Scully M, Cataland S, Coppo P, de la Rubia J, Friedman KD, Kremer Hovinga J,et al.Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies. J Thromb Haemost. 2017; 15(2):312-22. DOI: 10.1111/jth.13571.
77. Matsumoto M, Yagi H, Ishizashi H, Wada H, Fujimura Y. The Japanese experience with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Semin Hematol. 2004; 41(1):68-74. DOI: 10.1053/j.seminhematol.2003.10.009.
78. Scully M, McDonald V, Cavenagh J, Hunt BJ, Longair I, Cohen H, et al. A phase 2 study of the safety and efficacy of rituximab with plasma exchange in acute acquired thrombotic thrombocytopenic purpura. Blood. 2011; 118(7):1746-53. DOI: 10.1182/blood-2011-03-341131.
79. Peyvandi F, Scully M, Kremer Hovinga JA, Cataland S, Knöbl P, Wu H, et al. Caplacizumab for Acquired Thrombotic Thrombocytopenic Purpura. N Engl J Med. 2016; 374(6):511-22. DOI: 10.1056/NEJMoa1505533.
80. Scully M, Cataland SR, Peyvandi F, Coppo P, Knöbl P, Kremer Hovinga JA, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. N Engl J Med. 2019; 380(4):335-46. DOI: 10.1056/NEJMoa1806311.
81. Matsumoto M, Miyakawa Y, Kokame K, Ueda Y, Wada H, Higasa S, et al. Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. Int J Hematol. 2023; 118(5):529-46. DOI: 10.1007/s12185-023-03657-0.
82. Froissart A, Buffet M, Veyradier A, Poullin P, Provôt F, Malot S, et al. Efficacy and safety of first-line rituximab in severe, acquired thrombotic thrombocytopenic purpura with a suboptimal response to plasma exchange. Experience of the French Thrombotic Microangiopathies Reference Center. Crit Care Med. 2012; 40(1):104-11. DOI: 10.1097/CCM.0b013e31822e9d66.
83. Miyakawa Y, Imada K, Ichinohe T, Nishio K, Abe T, Murata M, et al. Efficacy and safety of rituximab in Japanese patients with acquired thrombotic thrombocytopenic purpura refractory to conventional therapy. Int J Hematol. 2016; 104(2):228-35. DOI: 10.1007/s12185-016-2019-x.
84. Scully M, Thomas M, Underwood M, Watson H, Langley K, Camilleri RS, et al Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood. 2014; 124(2):211-9. DOI: 10.1182/blood-2014-02-553131.
85. Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020; 18(10):2496-2502. DOI: 10.1111/jth.15010.
86. Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020; 18(10):2503-12. DOI: 10.1111/jth.15009.
87. Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020; 18(10):2496-2502. DOI: 10.1111/jth.15010
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