von Willebrand disease and pregnancy

The Effect of Von Willebrand Disease on Pregnancy, Delivery, and Postpartum Period: A Retrospective Observational Study

Background and Objectives Several reports indicate that women with von Willebrand disease (VWD) are at an increased risk of bleeding and other complications during pregnancy and childbirth. The aim of this study was to investigate the effect of VWD on the course of pregnancy, childbirth, and the postpartum period. Materials and Methods This was a retrospective study that compared many variables between women with VWD (n = 26) and women without VWD (n = 297,111) who gave birth between 2002 and 2016 in Slovenia. Data were obtained from the Slovenian National Perinatal Information System. Results Women with VWD were not more likely to have a miscarriage, vaginal bleeding during pregnancy, anemia, intrauterine growth restriction, or imminent premature labor. However, women with VWD were more likely to experience childbirth trauma-related bleeding (OR, 10.7; 95% CI: 1.4, 78.9), primary postpartum hemorrhage (OR, 3.7; 95% CI: 0.9, 15.8), and require blood transfusion after childbirth (OR, 16.3; 95% CI: 2.2, 120.3). No cases of stillbirth or early neonatal death were observed in women with VWD. Conclusion Although women with VWD did not demonstrate an increased risk of vaginal bleeding during pregnancy or poor fetal outcomes, they had a higher risk of primary postpartum hemorrhage and requiring blood transfusion.

Successful management of multiple pregnancies in a family with varying severity of Von Willebrand disease

We present the obstetric history of a family of three sisters with Von Willebrand disease, managed in our centre over the course of nine successful pregnancies. The abnormalities result from inheritance of an exon 50 skipping mutation in the Von Willebrand factor gene, resulting from consanguinity. Two of the sisters were identified as having a severe phenotype with a Von Willebrand factor level of less than 5 IU/dl, with the other having a mild phenotype. Of the sisters with a severe phenotype, one had a number of prenatal complications and required early onset prophylaxis with Von Willebrand factor concentrate, whilst the other had a less complicated clinical course, only requiring Von Willebrand factor concentrate to cover labour. The sister with mild Von Willebrand disease had a rise in Von Willebrand factor levels during pregnancy and required no specialist treatment. The report highlights the markedly different clinical courses that can occur in patients with Von Willebrand disease and the different approaches to management.

Management of VWD

VWD is the most common inherited bleeding disorder known. It is caused by a deficiency or dysfunction of the VWF molecule. Bleeding risk varies between modest increases in bleeding seen only with procedures to major risk of spontaneous hemorrhage depending upon the type of VWD. The treatment approach to VWD has changed little in the past 2 decades, but there are numerous subtleties in optimal management. Management includes the prevention or treatment of bleeding by raising endogenous VWF levels with medications such as desmopressin or providing exogenous VWF concentrates. Fibrinolytic inhibitors and topical hemostatic agents are also effective adjunctive measures. Bleeding specific to women presents a special challenge because of heavy menstrual bleeding and pregnancy. Successful management of pregnancy in patients with VWD involves coordination with obstetrics, anesthesia, and the coagulation laboratory monitoring VWF:RCo and FVIII:C levels. Prophylactic treatment with VWF concentrates is emerging as an effective preventive therapy in patients with severe disease. Antibodies to VWF present a special challenge in the management of rare patients with type 3 disease. New therapies on the horizon include recombinant VWF, anti-VWF aptamers, and medications such as IL-11 to raise VWF levels. The key to effective treatment of VWD is an accurate diagnosis of the specific type and selection of hemostatic products appropriate for the clinical situation.

Inherited bleeding disorders in pregnancy

Women with inherited bleeding disorders may face several haemostatic challenges during pregnancy and childbirth. Pregnancy in these women requires specialised and individualised care. Prenatal diagnosis is primarily considered in families affected by severe bleeding disorder such as haemophilia. Non-invasive fetal sex determination by analysis of free fetal DNA in maternal blood offers carriers of haemophilia a means of avoiding invasive testing and its associated risks in female pregnancies. With the exception of fibrinogen and factor XIII deficiencies, it is currently unclear whether women with inherited bleeding disorders are at increased risk of miscarriage or antepartum haemorrhage. However, they are at increased risk of primary and secondary postpartum haemorrhage. The fetus, if severely affected, is at risk of cranial bleeding during labour and delivery. Appropriate haemostatic cover during labour and delivery, avoidance of prolonged labour and traumatic delivery, and active management of third stage of labour can minimise the risk of bleeding complications for the mother and her fetus.

Obstetric management of adolescents with bleeding disorders

Adolescents with bleeding disorders who become pregnant must contend with the dual challenges of their bleeding disorder and their pregnancy. Adolescents are more likely to terminate a pregnancy than adult women, and when they do carry a pregnancy, they are more likely to deliver prematurely. Otherwise, they are at risk for the same complications that adult women with bleeding disorders experience, particularly bleeding complications postpartum. Since one half to two thirds of adolescent pregnancies are unplanned, issues related to reproduction should be addressed during routine visits with the pediatrician, hematologist or gynecologist. Girls who are at risk of being carriers for hemophilia A and B, severe von Willebrand disease, and other severe bleeding disorders should have their bleeding disorder status determined before they become pregnant. During pregnancy, a plan should be established to ensure that both mother and fetus deliver safely. Young women at risk for severe bleeding or at risk of having a severely affected infant should be referred for prenatal care and delivery to a center where, in addition to specialists in high-risk obstetrics, there is a hemophilia treatment center or a hematologist with expertise in hemostasis. Prior to delivery or any invasive procedures, young women at risk for severe bleeding should receive prophylaxis. Since administration of desmopressin may result in hyponatremia, whenever available, virally inactivated or recombinant clotting factor concentrates should be used for replacement as opposed to fresh frozen plasma or cryoprecipitate.

Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel

Reproductive tract bleeding in women is a naturally occurring event during menstruation and childbirth. In women with menorrhagia, however, congenital bleeding disorders historically have been underdiagnosed. This consensus is intended to allow physicians to better recognize bleeding disorders as a cause of menorrhagia and consequently offer effective disease-specific therapies.

The obstetric and gynaecological management of women with inherited bleeding disorders - review with guidelines produced by a taskforce of UK Haemophilia Centre Doctors' Organization

The gynaecological and obstetric management of women with inherited coagulation disorders requires close collaboration between obstetrician/gynaecologists and haematologists. Ideally these women should be managed in a joint disciplinary clinic where expertise and facilities are available to provide comprehensive assessment of the bleeding disorder and a combined plan of management. The haematologist should arrange and interpret laboratory tests and make provision for appropriate replacement therapy. These guidelines have been provided for healthcare professionals for information and guidance and it is also intended that they are readily available for women with bleeding disorders.

Current understanding of von Willebrand's disease in women - some answers, more questions

Considerable progress has been made in the past decade in describing the obstetrical and gynaecological aspects of von Willebrand's disease (VWD). In addition, epidemiological studies have established an approximately 11-16% prevalence of the laboratory diagnosis of VWD in women presenting with menorrhagia. However, it is not established presently whether an upfront VWD screening should be a part of the standard evaluation of menorrhagia. This is because it is presently not known whether therapy in the VWD patient tailored specifically for VWD will appreciably alter the natural history of menorrhagia compared with the non-VWD menorrhagia patient. There are also subtleties involved in securing the diagnosis of VWD in women presenting with menorrhagia in terms of fluctuation of von Willebrand factor (VWF) levels vis-à-vis the menstrual cycle and the potential impact of oral contraceptive on VWF levels. Regarding management of VWD-related menorrhagia, pending ongoing comparative trials of intranasal desmopressin (DDAVP), tranexamic acid, oral contraceptive and the levonorgestrel intrauterine device, specific recommendations cannot be made presently regarding the superiority of one intervention compared with the other. The management of VWD-related postpartum haemorrhage is also an area of active debate in terms of 'best practice' in type 1 (? prophylactic DDAVP), type 2 [? expectant management if factor VIII:C (FVIII:C) level normalizes] and type 3 patients (? intensity and duration of infusional therapy with a VWF-containing plasma-derived FVIII concentrate). This review summarizes the present state of knowledge and highlights numerous questions for future study based on our present understanding of VWD in women.

More than menorrhagia: a review of the obstetric and gynaecological manifestations of bleeding disorders

In women, menorrhagia may be the most common manifestation of a bleeding disorder, but it is not the only reproductive tract abnormality that women with bleeding disorders experience. Women with bleeding disorders appear to be at an increased risk of developing haemorrhagic ovarian cysts and possibly endometriosis. As they grow older, they may be more likely to manifest conditions, which present with bleeding such as fibroids, endometrial hyperplasia and polyps. Women with bleeding disorders are more likely to undergo a hysterectomy and are more likely to have the operation at a younger age. During pregnancy, they may be at greater risk of miscarriage and bleeding complications. At the time of childbirth, women with bleeding disorders appear to be more likely to experience postpartum haemorrhage, particularly delayed or secondary postpartum haemorrhage. Vaginal or vulvar haematomas, extremely rare in women without bleeding disorders, are not uncommon. While women with bleeding disorders are at risk for the same obstetrical and gynaecological problems that affect all women, they appear to be disproportionately affected by conditions that manifest with bleeding.