1
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Lim MY, Rodgers GM, Branch DW, Simonsen SE. Targeting a higher plasma VWF level at time of delivery in pregnant individuals with von Willebrand disease: Outcomes at a single-institution cohort study. Haemophilia 2024; 30:470-477. [PMID: 38343098 DOI: 10.1111/hae.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Guidelines on the management of pregnant individuals with von Willebrand disease (VWD) at the time of delivery recommend that von Willebrand factor (VWF) and factor VIII:C (FVIII:C) levels be ≥50% to prevent postpartum haemorrhage (PPH). Yet, high PPH rates persist despite these levels or with prophylactic factor replacement therapy to achieve these levels. AIMS The current practice at our centre has been to target peak plasma VWF and FVIII:C levels of ≥100 IU/dL at time of delivery. The objective of this study was to describe obstetric outcomes in pregnant individuals with VWD who were managed at our centre. METHODS Demographics and outcomes on pregnant individuals with VWD who delivered between January 2015 and April 2023 were collected. RESULTS Forty-seven singleton deliveries (among 41 individuals) resulting in 46 live births and one foetal death were included. Twenty-one individuals had at least one prior birth by the start date of this study, of which 11 (52.4%) self-reported a history of PPH. Early PPH occurred in 12.8% (6/47) of deliveries. Two individuals required blood transfusion, of which one also had an unplanned hysterectomy and transfer to ICU. There were no thrombotic events reported. CONCLUSION The strategy of targeting higher peak plasma VWF and FVIII:C levels (≥100 IU/dL) at the time of delivery may be effective in reducing the risk of delivery-associated bleeding complications in VWD patients. Yet, the rate of early PPH remains unsatisfactory compared to the non-VWD population.
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Affiliation(s)
- Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - George M Rodgers
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Sara E Simonsen
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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2
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Muñoz Vargas BA, Contreras Valero SJ, Aragon Mendoza RL, Gallo Roa R, Enciso Olivera LJ. Von Willebrand Disease and Pregnancy: Management Protocol From Labor to the Postpartum Period. Cureus 2024; 16:e53465. [PMID: 38435184 PMCID: PMC10909449 DOI: 10.7759/cureus.53465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Von Willebrand disease (VWD) is a hemostatic disorder characterized by a quantitative or qualitative deficiency of the Von Willebrand factor (VWF). It affects males and females equally. This pathology has more severe clinical manifestations in females of reproductive age, with a mean age of diagnosis at 19 years. In the pregnant patient, Von Willebrand disease poses an increased risk of complications during labor or the postpartum period, attributed to a higher likelihood of experiencing postpartum hemorrhage and its consequential complications arising from transfusion support and multiorgan injury due to tissue hypoperfusion. We present the case of a 25-year-old G3P2V2A1 patient with a preexisting diagnosis of Von Willebrand disease prior to gestation. The institutional protocol for managing this condition involved the administration of Von Willebrand factor and factor VIII (FVIII) during vaginal delivery and the postpartum period. This resulted in the effective control of perinatal and postpartum bleeding, with an elevation in Von Willebrand factor levels, thereby avoiding the need for blood transfusions and signs of secondary hypoperfusion. This case underscores the significance of specialized management for Von Willebrand disease during pregnancy and childbirth, emphasizing adherence to institutional protocols involving specific hemostatic factors. The collaborative efforts of a multidisciplinary team, including hematologists, obstetricians, and other healthcare professionals, are crucial for the comprehensive care of females with this condition during the perinatal period.
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Affiliation(s)
| | | | | | - Roberto Gallo Roa
- Obstetrics and Gynecology, Hospital Universitario de La Samaritana, Bogotá, D.C., COL
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3
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Bank TC, Ma'ayeh M, Rood KM. Maternal Coagulation Disorders and Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:384-398. [PMID: 37130381 DOI: 10.1097/grf.0000000000000787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.
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Affiliation(s)
- Tracy C Bank
- Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Marwan Ma'ayeh
- Department of Obstetrics & Gynecology, ChristianaCare, Newark, Delaware
| | - Kara M Rood
- Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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4
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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5
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Franchini M, Seidizadeh O, Mannucci PM. Prophylactic management of patients with von Willebrand disease. Ther Adv Hematol 2022; 12:20406207211064064. [PMID: 34987743 PMCID: PMC8721401 DOI: 10.1177/20406207211064064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/15/2021] [Indexed: 01/19/2023] Open
Abstract
Von Willebrand disease, the most common inherited bleeding disorder that affects both males and females, is due to quantitative or qualitative defects of the multimeric glycoprotein von Willebrand factor, which cause mucous membrane bleeding but also soft tissue bleeding owing to the secondary deficiency of factor VIII. The aim of treatment is to correct this dual defect of hemostasis. In addition to the episodic management of bleeding episodes, therapy includes their short- or long-term prevention. Short-term prophylaxis is mainly warranted in order to provide effective hemostatic coverage to patients undergoing surgery or invasive procedures and to affected women at the time of delivery or during menstruations associated with excessive bleeding. The aim of long-term prophylaxis is to prevent bleeding in particular categories of patients at increased risk of frequent and spontaneous bleeding in the joints, nose, and gastrointestinal tract.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, 46100 Mantova, Italy
| | - Omid Seidizadeh
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
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6
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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7
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Xu Z, Dargaud Y, Chamouard V, Le Quellec S, Lienhart A, Meunier S, Rugeri L. A single-centre study of management of pregnant women with von Willebrand disease. Haemophilia 2018; 25:e54-e57. [DOI: 10.1111/hae.13653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Zizhen Xu
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
- Department of Laboratory Medicine, Ruijin Hospital; Shanghai Jiao Tong University School of Medicine; Shanghai China
| | - Yesim Dargaud
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Valérie Chamouard
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Sandra Le Quellec
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Anne Lienhart
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Sandrine Meunier
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
| | - Lucia Rugeri
- Hospices Civils de Lyon, Unité d'Hémostase Clinique/Centre Régional de Traitement de l'Hémophilie; Hôpital Louis Pradel; Bron Cedex France
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8
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Rottenstreich A, Kleinstern G, Amsalem H, Kalish Y. The course of acquired von Willebrand syndrome during pregnancy among patients with essential thrombocytosis. J Thromb Thrombolysis 2018; 46:304-309. [PMID: 29654448 DOI: 10.1007/s11239-018-1663-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To investigate the course of acquired type 2A von Willebrand syndrome (AVWS) in relation to patient management and outcomes among pregnant patients with essential thrombocytosis (ET). A review of pregnant women with ET evaluated for AVWS at the beginning of pregnancy and at the third trimester. Eighteen women with 24 pregnancies were included in this study. A history of bleeding was noted in 8 (44%) patients. In 20 (83%) pregnancies AVWS was evident at the initial testing. Following initial testing, antithrombotic therapy was administered in 22 (92%) pregnancies (aspirin, n = 20 and low-molecular-weight heparin, n = 2). In the remaining two pregnancies, VWF:RCo levels were below 30%; thus, aspirin was given only after repeat testing at 14-16 weeks. At third trimester testing, median VWF:RCo levels were significantly higher than at the initial testing (86 vs. 48%, P < 0.001), with no evidence of AVWS in any of the patients. Significant increases were also observed in the VWF:Ag level (127 vs. 84%, P < 0.001), the VWF:RCo/VWF:Ag ratio (0.75 vs. 0.54, P < 0.001) and the FVIII level (103 vs. 68%, P < 0.001); while platelet count (359 vs. 701 × 109/l, P < 0.001) and hemoglobin level (11.6 vs. 13.4 g/dl, P < 0.001) decreased. Neuraxial anesthesia was safely performed in 17 (71%) pregnancies. No significant bleeding events occurred during pregnancy and delivery. AVWS-related abnormalities in women with ET mostly improved during pregnancy, with favorable maternal and fetal outcomes. VWF parameters should be tested at early pregnancy and repeated at the third trimester, to guide pregnancy and delivery management.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Geffen Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, Jerusalem, Israel.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Hagai Amsalem
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
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9
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Brennan Y, Favaloro EJ, Curtin J, Curnow J. Management of pregnancy complications in type 2N von Willebrand disease associated to a novel mutation. Haemophilia 2018; 24:e148-e152. [PMID: 29656540 DOI: 10.1111/hae.13481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Y Brennan
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - E J Favaloro
- Diagnostic Haemostasis Laboratory, Laboratory Haematology, NSW Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
| | - J Curtin
- Department of Haematology, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - J Curnow
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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10
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O’Connor D, Lester W, Willoughby S, Wilde JT. Pregnancy in platelet-type VWD: A case series. Thromb Haemost 2017; 106:386-7. [DOI: 10.1160/th11-02-0108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 04/15/2011] [Indexed: 11/05/2022]
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11
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Postpartum Hemorrhage in Women with Von Willebrand Disease - A Retrospective Observational Study. PLoS One 2016; 11:e0164683. [PMID: 27780267 PMCID: PMC5079555 DOI: 10.1371/journal.pone.0164683] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction von Willebrand disease (VWD) is a hereditary bleeding disorder, caused by a deficiency in the levels and/or function of von Willebrand factor (VWF). Women with VWD appear to be at increased risk of experiencing postpartum hemorrhage (PPH), though the levels of VWF increase during pregnancy. There is limited knowledge of how PPH is associated with the subtype of VWD, plasma levels of other coagulations factors than VWF and given hemostatic treatment. Aims The aims were to investigate the incidence of PPH in women with VWD and to analyse the correlation between PPH and: (1) type of VWD, (2) laboratory monitoring of VWF and FVIII and (3) hemostatic drug treatment. Methods This was a retrospective observational study. The study participants (n = 34) were recruited from the Coagulation Unit, Karolinska University hospital. Fifty-nine deliveries, which occurred in 14 different obstetrics units (years 1995–2012) were included in the study. Results The incidence of primary PPH was 44%, severe primary PPH 20% and secondary PPH 12%. VWD type 3 was associated with a higher risk of experiencing severe primary PPH compared to other subtypes. FVIII:C in pregnancy was inversely correlated to blood loss during delivery. There was a significantly higher incidence of secondary PPH when the VWD diagnosis was unknown at time of delivery. Conclusions The women with VWD are at higher risk of PPH, especially those with type 3 VWD or when diagnosis is unknown prior to delivery. Identification of pregnant women with undiagnosed VWD may be of importance in order to prevent PPH.
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12
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Roth CK, Syed LJ. von Willebrand disease in pregnancy. Nurs Womens Health 2016; 20:501-505. [PMID: 27719779 DOI: 10.1016/j.nwh.2016.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/30/2016] [Indexed: 11/25/2022]
Abstract
von Willebrand disease is the most prevalent inherited bleeding disorder, affecting up to 1.3% of the population. It is caused by a defect or deficiency of the von Willebrand factor. Women with the condition may not be aware of their condition at the time of childbirth, but they are at high risk of postpartum hemorrhage even days after birth. In this article we briefly review the condition and specific considerations for the antepartum, intrapartum, and postpartum phases. It is important for nurses who care for women during childbirth to have a keen understanding of this condition.
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13
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Hawke L, Grabell J, Sim W, Thibeault L, Muir E, Hopman W, Smith G, James P. Obstetric bleeding among women with inherited bleeding disorders: a retrospective study. Haemophilia 2016; 22:906-911. [PMID: 27704714 DOI: 10.1111/hae.13067] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Women with inherited bleeding disorders are at increased risk for bleeding complications during pregnancy and the postpartum period, particularly postpartum haemorrhage (PPH). AIM This retrospective study evaluates pregnancy management through the Inherited Bleeding Disorders Clinic of Southeastern Ontario, the clinical factors associated with pregnancy-related abnormal bleeding and assesses tranexamic acid use in the postpartum treatment of bleeding disorder patients. METHODS A chart review of 62 pregnancies, from 33 women, evaluated patient characteristics (age, haemostatic factor levels) and delivery conditions (mode of delivery, postpartum treatment) in relation to abnormal postpartum bleeding. RESULTS This cohort revealed increased risk of immediate PPH with increased age at delivery (mean age: 30.1 years with PPH, 26.5 years without PPH, P < 0.013), and birth by vaginal delivery (P < 0.042). Low von Willebrand factor (VWF) antigen or factor VIII (FVIII) in the third trimester was not associated with an increased risk of PPH; however, low VWF:RCo was associated with increased immediate PPH despite treatment with continuous factor infusion (P < 0.042). Women treated with tranexamic acid postpartum had less severe bleeding in the 6-week postpartum (P < 0.049) with no thrombotic complications. CONCLUSIONS This study contributes to the growing body of work aimed at optimizing management of bleeding disorder patients through pregnancy and the postpartum period, showing patients are at a higher risk of PPH as they age. Risk factors such as low third trimester VWF:RCo have been identified. Treatment with tranexamic acid in the postpartum period is associated with a reduced incidence of abnormal postpartum bleeding.
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Affiliation(s)
- L Hawke
- Queen's University, Kingston, ON, Canada
| | - J Grabell
- Queen's University, Kingston, ON, Canada
| | - W Sim
- Queen's University, Kingston, ON, Canada
| | - L Thibeault
- Kingston General Hospital, Kingston, ON, Canada
| | - E Muir
- Queen's University, Kingston, ON, Canada
| | - W Hopman
- Queen's University, Kingston, ON, Canada
| | - G Smith
- Queen's University, Kingston, ON, Canada
| | - P James
- Queen's University, Kingston, ON, Canada.,Kingston General Hospital, Kingston, ON, Canada
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14
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15
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Stoof SCM, van Steenbergen HW, Zwagemaker A, Sanders YV, Cannegieter SC, Duvekot JJ, Leebeek FWG, Peters M, Kruip MJHA, Eikenboom J. Primary postpartum haemorrhage in women with von Willebrand disease or carriership of haemophilia despite specialised care: a retrospective survey. Haemophilia 2015; 21:505-12. [PMID: 25688733 DOI: 10.1111/hae.12635] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
Abstract
Pregnant women with bleeding disorders require specialised peripartum care to prevent postpartum haemorrhage (PPH). If third trimester coagulation factor levels are <0.50 IU mL(-1) , prophylactic treatment is indicated and administered according to international guidelines. However, optimal dose and duration are unknown and bleeding may still occur. The aim of this study was to investigate the outcome in women with von Willebrand disease (VWD) or haemophilia carriership treated according to current practice guidelines. From the period 2002-2011, 185 deliveries in 154 VWD women or haemophilia carriers were retrospectively included. Data on blood loss, bleeding disorder characteristics and obstetric risk factors were obtained. The outcome was primary PPH, defined as blood loss ≥500 mL within 24 h postpartum and severe PPH as blood loss ≥1000 mL. Primary PPH was observed in 62 deliveries (34%), 14 (8%) of which resulted in severe PPH. In 26 deliveries prophylactic treatment was administered due to factor levels below the 0.50 IU mL(-1) cut-off in the third trimester, 14 of which (54%) were complicated by PPH. We found an increased PPH risk in deliveries given prophylactic treatment compared with deliveries without (OR 2.7, 95% CI 1.2-6.3). In conclusion, PPH incidence was highest in deliveries with the lowest factor levels in the third trimester. Currently, delivery outcome in women with bleeding disorders is unsatisfactory, given the high PPH incidence despite specialised care. Future studies are required to optimise management of deliveries in this patient population.
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Affiliation(s)
- S C M Stoof
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - H W van Steenbergen
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Zwagemaker
- Department of Paediatric Haematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Y V Sanders
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - F W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Peters
- Department of Paediatric Haematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - M J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J Eikenboom
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
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16
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Rahbar N, Faranoush M, Ghorbani R, Sadr Alsadat B. Screening of von Willebrand disease in Iranian women with menorrhagia. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e18244. [PMID: 25763275 PMCID: PMC4341408 DOI: 10.5812/ircmj.18244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 11/12/2014] [Accepted: 12/06/2014] [Indexed: 11/16/2022]
Abstract
Background: Menorrhagia is a common health problem in women, particularly those with bleeding disorders. Little is known about the course of menorrhagia or other bleeding symptoms in women with the most common congenital bleeding disorder, von Willebrand disease (vWD). Objectives: The aim of this study was to estimate the prevalence of vWD in women with diagnosed menorrhagia. Materials and Methods: In this cross-sectional study, a total of 460 consecutive patients, presenting menorrhagia, were analyzed. The initial screening and confirmation tests for the diagnosis of vWD included determination of prothrombin time (PT), partial thromboplastin time (PTT), bleeding time (BT), fibrinogen, factor VIII, vWF antigen, and vWF activity. A questionnaire was filled for every patient. The data were then analyzed using the SPSS software. Results: Mean age of our patients was 32.5 ± 10.6 years. The level of von Willebrand factor in 22.5% and von Willebrand activity in 19.6% of patients was abnormal. The prevalence of vWD among patients with menorrhagia was 24%. Conclusions: The high prevalence of vWD among our patients was the same as other previous reports, suggesting low awareness about this disease and under diagnosis of mild cases.
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Affiliation(s)
- Nahid Rahbar
- Research center of Abnormal Uterine Bleeding, Semnan University of Medical Science , Semnan , IR Iran
| | - Mohammad Faranoush
- Hazrat Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Mohammad Faranoush, Hazrat Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2188212106, Fax: +98-2188601580, E-mail:
| | - Raheb Ghorbani
- Research Center for Social Determinants of Health, Department of Community Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, IR Iran
| | - Bahare Sadr Alsadat
- Research center of Abnormal Uterine Bleeding, Semnan University of Medical Science , Semnan , IR Iran
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Mikhail S, Aldin ES, Streiff M, Zeidan A. An update on type 2B von Willebrand disease. Expert Rev Hematol 2014; 7:217-31. [PMID: 24521271 DOI: 10.1586/17474086.2014.868771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Type 2B von Willebrand disease (VWD) accounts for fewer than 5% of all VWD patients. In this disease, mutations in the A1 domain result in increased von Willebrand factor (VWF) binding to platelet GPIbα receptors, causing increased platelet clearance and preferential loss of high molecular weight VWF multimers. Diagnosis is complicated because of significant clinical variations even among patients with identical mutations. Platelet transfusion often provides suboptimal results since transfused platelets may be aggregated by the patients' abnormal VWF. Desmopressin may cause a transient decrease in platelet count that could lead to an increased risk of bleeding. Replacement therapy with factor VIII/VWF concentrates is the most effective approach to prevention and treatment of bleeding in type 2B VWD.
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Affiliation(s)
- Sameh Mikhail
- Department of Hematology, Ohio State University Medical Center, Columbus, OH, USA
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PEYVANDI F, KLAMROTH R, CARCAO M, FEDERICI AB, DI MINNO G, JIMÉNEZ-YUSTE V, RODRIGUEZ MERCHÁN EC. Management of bleeding disorders in adults. Haemophilia 2012; 18 Suppl 2:24-36. [DOI: 10.1111/j.1365-2516.2012.02797.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rizack T, Rosene-Montella K. Special Hematologic Issues in the Pregnant Patient. Hematol Oncol Clin North Am 2012; 26:409-32, x. [DOI: 10.1016/j.hoc.2012.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Type 2B von Willebrand disease (VWD) is a rare, inherited bleeding disorder resulting from a qualitative defect in von Willebrand factor (VWF). There is very little published information on how to quantify bleeding risk and manage haemostasis in type 2B VWD patients during pregnancy. This article presents the changes in VWF parameters and details of patient management and delivery outcomes for four pregnancies in three women with two different mutations causing type 2B VWD. We report an unexpected rise in the VWF:Ag at 37 weeks gestation in two sisters with R1306W associated with significant thrombocytopenia. These patients were supported with platelet transfusions as well as intermediate purity VWF-FVIII plasma concentrates during the peri- and postpartum periods. No thrombocytopenia was observed in our third case with a mutation encoding an R1308C substitution; haemostatic support was with intermediate purity VWF-FVIII plasma concentrates alone. No adverse bleeding events occurred and in all cases a live healthy infant was delivered. One patient was readmitted post partum with bleeding symptoms due to retained placenta; no further haemostatic support was given at this time. This case series is the first to detail the progression of laboratory parameters, management and outcomes of pregnancy in patients with type 2B VWD. The cases illustrate some of the challenges posed by the increased production of a VWF variant with a gain-of-function effect. The rapid coagulation changes observed in this series illustrate the need for continual monitoring of VWF parameters and platelet count throughout pregnancy in women with type 2B VWD.
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Affiliation(s)
- A Ranger
- Department of Haematology, Imperial College Academic Health Care Trust, Hammersmith Hospital, London, UK
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21
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Peyvandi F, Garagiola I, Menegatti M. Gynecological and obstetrical manifestations of inherited bleeding disorders in women. J Thromb Haemost 2011; 9 Suppl 1:236-45. [PMID: 21781260 DOI: 10.1111/j.1538-7836.2011.04372.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Patients affected by bleeding disorders present a wide spectrum of clinical symptoms that vary from a mild or moderate bleeding tendency to significant episodes. Women with inherited bleeding disorders are particularly disadvantaged since, in addition to suffering from general bleeding symptoms, they are also at risk of bleeding complications from regular haemostatic challenges during menstruation, pregnancy and childbirth. Moreover, such disorders pose important problems for affected women due to their reduced quality of life caused by limitations in activities and work, and alteration of their reproductive life. These latter problems include excessive menstrual bleeding or menorrhagia, miscarriage, bleeding complications during pregnancy and after delivery and their related complications such as acute or chronic anaemia. The management of these women is difficult because of considerable inter-individual variation. Moreover, reliable information on clinical management is scarce, only a few available long term prospective studies of large cohorts provide evidence-based guideline about diagnosis and treatment.
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Affiliation(s)
- F Peyvandi
- UOS Dipartimentale per la Diagnosi e la Terapia delle Coagulopatie, A Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Luigi Villa Foundation, Milan, Italy.
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22
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Lipe BC, Dumas MA, Ornstein DL. Von Willebrand Disease in Pregnancy. Hematol Oncol Clin North Am 2011; 25:335-58, viii. [DOI: 10.1016/j.hoc.2011.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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