REVIEW OF LITERATURE

OVERVIEW

Hemophilia A and hemophilia B are bleeding disorders

caused by a deficiency of plasma clotting factors (F) VIII and IX,

respectively. The hemophilias are the most common X-linked

inherited bleeding disorders, which if not properly managed can

lead to chronic disease and lifelong disabilities (Kulkarni R,

Soucie, 2011).

Epidemiology

Hemophilia is prevalent worldwide and occurs in all racial

and socioeconomic groups. In the United States, the incidence of

hemophilia A in males is 1:5000 and hemophilia B in males is

1:30,000; hemophilia A accounts for 80 to 85% of cases. In

approximately one-third of newly diagnosed infants or young

children, there is no family history of hemophilia and the disorder

may be due to a spontaneous mutation in the FVIII or FIX gene

(Tagariello et al., 2009).

Surveillance

Since 1998, following the human immunodeficiency virus

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(HIV) epidemic, the U.S. Centers for Disease Control and

Prevention Universal Data Collection has collected surveillance

information on more than 24,000 persons with bleeding disorders

(of whom 18,000 have hemophilia) at 135 hemophilia treatment

centers (Soucie et al.,2010).

Since 2003, enrolment was extended to infants (age range,

0 to 2 years) and there were 1028 babies including 864 with

hemophilia (Kulkarni et al., 2009).

Similar surveillance systems exist in many countries. A

World Federation of Hemophilia global survey showed that

worldwide, hemophilia A is the most common factor deficiency

(World Federation of Hemophilia Annual Global Survey,

2011).

A motivation for instituting blood safety surveillance in the

United States for persons with hemophilia is that they were

considered a ‘‘canary in the mine’’ as they were treated with

pooled plasma-derived concentrates of 15,000 donors per lot of

finished product; even a single infected donor had the potential of

infecting many patients. This was the case with the HIV epidemic

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that claimed the lives of many persons with hemophilia in the

1980s (Evatt, 2006).

Many individuals were also infected with hepatitis C and B

as a result of using these products. Although there have been no

recent documented instances of transmission of HIV or hepatitis

attributable to clotting factors, due to increasing use of

recombinant and virally attenuated plasma-derived concentrates,

concern remains that certain non enveloped viruses (such as

human parvovirus B19 and hepatitis A virus) and prion diseases

or transmissible spongiform encephalopathies causing

neurodegenerative disorders, such as variant Creutzfeldt-Jakob

disease could be transmitted by some plasma-derived clotting

factor concentrates (Trimble et al., 2010).

Inheritance of hemophilia

There is a 50% chance that a carrier mother will transmit

the defective X-linked gene to the male or female child. All

female offspring born to a hemophilic father are obligatory

carriers (Fig. 1) (Leuer et al., 2001).

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Fig. (1) X-linked inheritance in hemophilia: The inheritance is shown in families

To identify the females at risk of being a carrier, it is

important to understand the inheritance. Sporadic cases result

from de novo mutations. Apart from assessing levels of FVIII

coagulant (FVIII:C), molecular genetic analysis is required to

reliably determine carrier status. However, one needs to consider

the potential risk of somatic mosaicism in families with sporadic

hemophilia (10%), as it causes uncertainty about the recurrence

risk in parents who appear to be non carriers. In this situation,

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conventional mutation detection procedures may fail to detect the

underlying genetic defect if the proportion of mutated alleles is

<5% of wild-type allele background (Leuer et al., 2001).

Clinical Manifestations

The manifestations are almost exclusively in males while

females are often asymptomatic carriers. Plasma levels of FVIII

or FIX correlate with clinical severity and predict bleeding risk.

As a general rule, all affected members of kindred will have the

same degree of severity. Severe hemophilia is defined as plasma

FVIII or FIX levels less than 1% of normal (normal plasma levels

are 50–100 U/dL), moderate hemophilia, as 1 to 5%; and mild

hemophilia, as >5 to 30%. Approximately two-thirds of persons

with hemophilia have severe disease; 15% have moderate

disease; and 20% have mild disease. While the clinical

manifestations may be the same, the clinical severity of

hemophilia A is different from that of hemophilia B; the latter

tends to be milder with less handicaps, with a significantly less

proportion undergoing joint arthroplasties (Tagariello et al.,

2009).

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Bleeding is the hallmark of hemophilia; the bleeding, sites

and pattern, however, varies over the lifetime of a patient. While

hemartherosis is the hallmark of hemophilia in older children and

adults, head bleeding including intera cranial hemorrhage and

extra cranial hemorrhage, bleeding from circumcision and oral

cavity occur more frequently in toddlers and newborns

(Chalmers, 2004).

Age of Diagnosis of Hemophilia

Although over the years the diagnosis of hemophilia is

being made at an earlier age, recognition and optimal evidence-

based management of bleeding events and complications remains

a challenge (Chalmers, 2004).

In a recent report from the Prevention Universal Data

Collection, 633/864 (73%) male infants (age range, 0 to 2 years)

were diagnosed with hemophilia within 1 month of birth. Thirty

newborns were diagnosed prenatally of whom 24 (80%) were

born to carrier mothers. The reasons for diagnosis included

known carrier status of mother (47.2%), family history of

hemophilia (23.2%), bleeding event (28.8%), and unknown

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reason (0.8%). The median age of diagnosis was 1 day in infants

whose mothers were known carriers, 2 days in those with a

family history, 7 days in those who presented with a bleeding

episode, and 152 days when the history was unknown (Kenet et

al., 2010).

Hemophilia severity, family history, and year of birth often

influence the diagnosis; severe hemophilia cases were diagnosed

earlier compared with mild and moderate cases. Over the years,

there has been a trend for early diagnosis probably as a result of

awareness and improved laboratory support. In the UDC, median

age of diagnosis was 2 days for those with severe, 2.5 days for

those with moderate, and 4 days for those with mild disease. By

15 years of age, over 95% of hemophiliacs of all severities had

been diagnosed and by age 30 years, almost all were diagnosed

(Kulkarni et al.,2009).

Many cases of mild hemophilia may escape detection in

childhood and are often diagnosed following a bleeding episode

resulting from trauma or surgery.

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Bleeding In The Newborn

Newborns with hemophilia have distinctly different

bleeding patterns as compared with older children and adults; the

trauma of the birthing process and iatrogenic insults such as

circumcision, heel sticks, and venipuncture are often

superimposed on an age-dependent developmental hemostatic

process. Among the 633 newborns with hemophilia reported in

the UDC, 278 (44%) had a bleeding episode by 1 month of age.

The most common sites of bleeding were as follows: secondary to

circumcision in 126 (45.5%), cranial hemorrhages 49 (17.7%) of

which ICH accounted for 33%, iatrogenic heel-stick bleeding in

21.7%, hemartherosis in 1 (0.4%), and other sites (such as soft

tissue, oral, organ, etc.) in 15% (Fig. 2).

Fig. (2) Sites of initial bleeding episodes in 633 newborns with hemophilia in the
Universal Data Collection system in the United States.

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Of the 633 newborns, 44 (7%) did not receive vitamin K at

birth. Approximately 60 (9.5%) received factor concentrate

within 24 hour after birth, in 48% it was administered for

prophylaxis (Kenet et al., 2010). In a large retrospective study

similar bleeding patterns were noted in 349 newborns (Kulkarni

and Lusher, 2001).

Circumcision appears to be the most common site of

bleeding in newborns and even a recent study reported 23%

circumcision bleeding in 48 patients with hemophilia (Rodriguez

et al.,2010).

Hemophilia In Children And Adolescents

While uncommon in newborns, joint and soft tissue

hemorrhages become more evident as the child grows and

mobility increases. Oral mucosal bleeding, particularly

troublesome because of the abundant fibrinolytic activity of

saliva, sometimes leads to the diagnosis of hemophilia. It is often

associated with torn frenulum or eruption of dentition. In the

UDC, the most common sites of first bleeding episodes in 87

infants (age range, 1 to 6 months) were cranial bleeding 12.8%

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(45.5% ICH), soft tissue bleeding 3% (Pollmann et al.,1999),

joint bleeding 9.3% and intramuscular injection 9.3%, and oral

mucosa 8.1%. In infants >6 months to 19 months of age, 30% had

oral mucosal bleeding, 24% had cranial bleeding (8.3%), 16.2%

had joint bleeding, and 7% had soft tissue bleeding, (Kulkarni et

al., 2009) organ bleeds such as hematuria and gastrointestinal

bleeding are sometimes seen in older children or adolescents.

Joint bleeding, the hallmark of hemophilia starts in the

toddler age and persists into adolescence and adulthood.

Pollmann et al., (1999) reported the average age for the first joint

bleeding was 2.75 years. Repeated joint bleeding leads to target

joints, defined in the UDC as recurrent bleeding into the joint on

four or more occasions in the past 6 months, and chronic

arthropathy (Soucie et al., 2010).

Once arthropathy develops, functional outcome is poor.

Pain and impaired mobility leads to disability and poor QOL in

this population. Patients with severe hemophilia bleed as often as

once or twice a week. Hemartherosis is asymmetric, involving

ankles in the toddler as they learn to walk and other weight-

bearing joints such as the knee and hip as the child grows older.

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Early stages of joint bleeding are characterized by synovial

membrane thickening. With repeated joint hemorrhages,

proteolytic enzymes released from granulocytes and subsynovial

iron laden macrophages from heme breakdown cause

inflammation and cellular proliferation of synovium. The friable

fronds of synovial proliferation bleed with minimal trauma

causing recurrent hemorrhages that eventually lead to erosion of

cartilage resulting in pain, crepitus, decreased range of motion

(ROM), joint fusion, and muscle atrophy. Although any joint can

be affected, 80% of bleeding involves knees, ankles, and elbows

(Valentino, 2010).

In the U.S. joint outcome study, radiologic evidence of joint

damage was seen by age 6 years in subjects with no or minimal

episodes of hemartherosis (Manco-Johnson et al., 2007).

Joint ROM limitation occurs regardless of hemophilia

severity and is evident by 8 years of age in severe/moderate and

by 13 years in mild hemophilia. Besides severity and increasing

age, a high body mass index (BMI), repeated joint hemorrhages,

inhibitors, non-white race are significant risk factors for joint

ROM limitation (Soucie et al., 2004).

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Muscle hematomas account for 10 to 25% of all bleeds in

hemophilia and are generally the result of trauma or injections.

The symptoms are vague and include pain on motion and

sometimes swelling. The most common muscles involved are the

iliopsoas, calf, thigh quadriceps, and glutei. Inadequate treatment

of muscle hematomas can lead to pain, compartment syndrome,

reduced ROM, loss of function, wasting, contractures, blood loss,

infections, pseudo tumor formation, and nerve damage. Iliopsoas

bleeding characterized by flexion deformity of the hip can be life

and limb threatening and should be treated aggressively (Beyer et

al., 2010).

Investigations

1. Genetic testing

 Fetal testing

Prenatal diagnostic techniques in hemophilia have evolved

through the early sex-determination techniques of offering a

nonspecific diagnosis in case of a male fetus through the various

mutation screening techniques to the more recent gene array

techniques. Each of these techniques has specific advantages and

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disadvantages. The sampling techniques have evolved

simultaneously to suit the requirements of each technique and

also the different gestation periods. The DNA-based testing

methods provide a range of aberrations detected with different

levels of genomic resolution. The more recent gene array analysis

is poised to have substantial impact on prenatal diagnosis

of hemophilia not only in studying the highly heterogeneous

mutations but may also be useful in studying the effect of various

ameliorating or epistatic genetic mutations/ polymorphisms

simultaneously, providing a wide range of options to the prenatal

diagnosis experts, the genetic counselors, and the couples opting

for prenatal diagnosis (Ghosh et al., 2009).

 Neonatal testing

Cord blood testing of the fetus is the most readily available

method of detecting new patients. After delivery, the cord is

clamped and a plasma specimen can be analyzed for factor VIII

or factor IX coagulant activity (Panigrahi et al., 2005).

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 Carrier testing

Carrier detection and prenatal diagnosis are possible by

direct or indirect genetic analysis of the F8 or F9 genes. In

countries with more advanced molecular facilities and higher

budget resources, the most appropriate choice in general is a

direct strategy for mutation detection by prescreening techniques

or direct mutation detection. However, in countries with limited

facilities and low budget resources, carrier detection and prenatal

diagnosis are usually performed by linkage analysis with genetic

markers (Peyvandi, 2005).

2. Laboratory findings

 Activated partial thromboplastin time

The activated partial thromboplastin time (aPTT) measures

the interaction between all of the coagulation cascade proteins,

with the exception of factors VII and XIII; therefore, it will be

elevated in most patients who have factors VIII and IX

deficiencies. Most commercially-available reagents are sensitive

to mild factor VIII deficiency but may miss mild factor IX

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deficiencies that are 25% to 30% of normal (Goodnight and

Hathaway, 2001).

Timing of aPTT testing also is important because the

neonate often displays a slightly prolonged aPTT due to

decreased vitamin K dependant factor activity and decreased

contact activation factors (factor XI and factor XII). Heparin

contamination of the specimen also may elevate the aPTT falsely.

The stress response can elevate factor VIII levels and may

decrease the aPTT falsely. Therefore, when one suspects

hemophilia in a child, a factor VIII or factor IX assay should be

obtained (Goodnight and Hathaway, 2001).

 Factor assays

The diagnosis of hemophilia hinges on the factor activity

that is present in the circulation. Results are expressed in %

activity. One unit of factor per mL of plasma is equivalent to 1%

activity. In most laboratories, factor VIII is assayed using a one-

stage assay. In this assay, factor VIII deficient plasma and the test

substance are added to preincubated activated partial

thromboplastin. The mixture is recalcified which leads to fibrin

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clot formation. A standard normal plasma curve is constructed

and then serial dilutions of the patient’s plasma are performed to

determine the patient’s baseline activity. Less commonly, a

chromogenic assay is used which resembles, but not exactly

duplicates, the older two-stage assay. Stage one involves the

addition of the patient’s plasma to a mixture of bovine factor IX,

factor X, and thrombin along with phospholipid. A chromogenic

substrate that is specific for factor Xa is added in the second stage

and light absorbance is measured which correlates to the percent

activity. It is important to know which method is used as results

may vary (Lollar,2003).

Most patients who have hemophilia have total absence of

factor antigen and a functional activity assay is sufficient for

diagnosis. If a dysproteinemia is suspected, an antigen level also

should be measured, although this is encountered more

commonly in acquired hemophilia, seen predominantly in the

adult population. Testing of how factor VIII binds to the vWF is

necessary in the evaluation of a patient who has suspected von

Willebrand Normandy disease where there is decreased binding

of factor VIII to the vWF. As a result, the factor VIII is degraded

more rapidly in the circulation and patients may seem to have

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hemophilia A. Typically, factor VIII levels are in the moderate to

mild range and are lower than expected in comparison with the

vWF factor antigen in patients who have type 1 von Willebrand

disease. Additionally, these patients typically present with

bleeding symptoms that are more suggestive of von Willebrand

disease (Lollar,2003).

 Bethesda assay

An inhibitory antibody to factor VIII or factor IX can

develop in patients who have congenital hemophilia. The

antibody titer is measured using the Bethesda assay and is

expressed in Bethesda units (BU). One BU is the level of

antibody that decreases the plasma factor level by 50% and is

expressed in logarithmic fashion. These antibodies can develop in

patients who do not have hemophilia and leads to a condition that

is known as acquired hemophilia; however, this is rare in

pediatric patients. In the Nijmegen modification of the

original Bethesda method, the pH and the protein concentration

of the test mixture is further standardized. As a result, the

FVIII:C in the test mixture is less prone to artifactual

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deterioration and the test has improved specificity (Duncan et al.,

2013).

Approach to Genetic Diagnosis

There are two different approaches to the genetic evaluation

of hemophilia. Analysis of single-nucleotide polymorphism

(SNP) or microsatellite variable number tandem repeat (VNTR)

markers in the F8 or F9 gene to track the defective X

chromosome in the family (linkage analysis) or identification of

the disease causing mutation in the defective F8 or F9 gene

(direct mutation detection) are employed (Peyvandi, 2005).

Complications

 Disabilities

The long-term consequences of repeated hemartherosis

include cartilage damage and irreversible arthropathy, resulting in

severe impairments in locomotion. Musculoskeletal impairments

in PWH may stem from structural and functional abnormalities,

which have traditionally been evaluated radiologically or

clinically. Lobet et al., (2013) suggested three-

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dimensional gait analysis (3DGA) as an innovative approach

designed to focus on the functional component of the joint during

the act of walking. This is of the utmost importance, as pain

induced by weight-bearing activities influences the functional

performance of the arthropathic joints significantly.

Significant correlation exists between academic

achievement and the number of bleeding episodes; children with

fewer bleeding episodes have normal physical functioning and

health related QOL (Shapiro et al.,2001).

Compared to national norms, borderline range scores on

the attention-deficit/hyperactivity disorder (ADHD)-related

dimensions of hyperactivity-impulsivity (HI) and

psychometrically measured impulsivity characterized the boys

with hemophilia. Although not addressing formal diagnoses, it

was found that boys with hemophilia risk ADHD-spectrum

problems, especially HI, and special education participation, but

not frank academic deficits (Spencer et al., 2009).

The long-term consequences of ICH in children with

hemophilia include a high frequency of visual motor and

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psychomotor abnormalities; some manifest only when children

attend school ,(Bladen et al.,2009) the impact of prophylaxis on

disabilities and QOL needs future study.

 Cranial Hemorrhages

Cranial Hemorrhages in hemophilia ICH is one of the most

serious complications of hemophilia and in the post-HIV era

accounts for the highest number of deaths in hemophilia with a

reported overall mortality of 20% (Nuss et al.,2001). Persons

with hemophilia are 20 to 50 times more likely to develop ICH

compared with those without hemophilia (Ljung, 2008).

Furthermore, it is a significant cause of disability and long-

term neurologic sequelae in as many as 60 to 75% of the cases

(Stieltjes et al., 2005). The prevalence of symptomatic ICH in

hemophilia of all ages varies from 3 to 12% with a substantial

proportion occurring in children. In newborns with hemophilia

rates of ICH range from 3.5 to 4% compared with a low rate of

0.11 to 0.04% rates in non hemophilic newborns (Gupta et al.,

2009).

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Risk factors for ICH include hemophilia severity, head

trauma, mode of delivery, and presence of inhibitors. Patients

with severe hemophilia may experience spontaneous or

unprovoked ICH whereas trauma is a major risk factor in

mild/moderate hemophilia. While data on ECH are scarce, ECH

can be equally life threatening and is often associated with trauma

and the birthing process (Nakar et al., 2010).

Mode of delivery and duration of labor plays a crucial role

in ICH in the newborn period. Controversy exists regarding the

optimal mode of delivery (Ljung , 2010).

Nonetheless there is no doubt that instrumental deliveries

such as forceps and vacuum carry a significant risk of ECH and

ICH. In the UDC, 22/633 (3.47%) newborns with hemophilia had

an ICH associated with delivery. There was no significant

difference in the occurrence of ICH rates with vaginal or cesarean

deliveries when newborns were grouped separately by family

history, maternal carrier status, and bleeding symptom. However,

when newborns were grouped by presence or absence of family

history (combined carrier status and other family history), ICH

occurred more in vaginal births than cesarean deliveries. The

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most common sites were subdural (68%), intra cerebral (13.6%),

and cerebellar (9%) (Kenet et al., 2010).

The incidence of asymptomatic ICH in hemophilia is

unknown. (Looney et al., 2007) reported a 26% prevalence of

magnetic resonance imaging (MRI)-proven asymptomatic ICH in

term non hemophilic newborns delivered by the vaginal route. A

single-institution study reported ICH in 3/20 (15%) hemophilic

newborns, detected on radiologic screening obtained immediately

following diagnosis; all were delivered by instrumental delivery

and had no family history of hemophilia (Smith et al., 2008).

Even beyond the newborn period, ICH is 20 to 50 times

more frequent in persons with hemophilia than in the general

population with a reported prevalence of 2.7 to 12%. Trauma

appears to be a major risk factor reported in 22 to 53% of cases

(Ljung , 2008).

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