Diagnosis and treatment of von Willebrand disease

Type 3 von Willebrand Disease in Pregnancy: A Systematic Literature Review

OBJECTIVE

von Willebrand disease (VWD) is a hereditary bleeding disorder. Type 3 VWD is the most severe and rare phenotype that presents many challenges for management of pregnant women. The aim of this study was to review the maternal characteristics and complications in pregnant women with Type 3 VWD.

STUDY DESIGN

A systematic literature search was performed to include all publications that address Type 3 VWD in pregnancy.

RESULTS

Thirteen studies met the inclusion criteria. There were 28 pregnancies with Type 3 VWD in 17 women. All were diagnosed with Type 3 VWD prior to pregnancy. Concentrate treatment was administered before delivery for 19 pregnancies and postpartum for 26 pregnancies. Eight pregnancies required blood products postpartum. Primary postpartum hemorrhage (PPH) was reported in 48% (10/21) and secondary PPH was reported in 56% (5/9). Secondary PPH occurred between 7 and 22 days. No study reported hysterectomies, intensive care unit admissions, or maternal mortality. All 28 pregnancies resulted in 28 live births at term.

CONCLUSION

Our review highlights the maternal outcomes in patients with Type 3 VWD and the different approaches in management during pregnancy and delivery. Despite prior knowledge of this bleeding disorder, PPH was still a significant complication.

Successful Desensitization of a Patient with Possible IgE-Mediated Anaphylactic Reaction to FVIII/VWF Concentrate

Background: Type 3 von Willebrand disease (VWD) is a severe bleeding disorder with a prevalence of 1:1 million live births. There are several von Willebrand factor (VWF) replacement products used in the treatment of acute bleeding episodes or as prophylaxis. Patients who receive multiple transfusions have an increased risk of developing antibodies against these products. These antibodies can lead to life-threatening anaphylactic reactions. Previous studies have identified immune complex formation and complement activation as the trigger for anaphylaxis, rather than IgE. IgE-mediated anaphylaxis against VWF concentrates has not yet been published. Case: A 4-year-old female patient with type 3 VWD was referred to our hospital because of an anaphylactic reaction during FVIII/VWF concentrate (Immunate^®) infusion. She had previously received FVIII/VWF concentrate (Haemate P^®) infusions 8 times without any complications. She did not have antibodies against VWF and FVIII, and serum IgA level was normal. Since she needed factor replacement therapy as a result of a growing hematoma on her scalp, we performed skin prick and intradermal tests 2 days after the reaction. The prick test, with FVIII/VWF (Immunate), was negative, but the intradermal test was positive. We administered a 12-step desensitization protocol with FVIII/VWF concentrate (Immunate) successfully without any reactions. Conclusion: Anaphylactic reaction to factor replacement products is a major problem for patients with VWD, especially type 3 VWD requiring multiple factor infusions. We achieved a successful desensitization with FVIII/VWF concentrate in a patient who had an anaphylactic reaction during the infusion of this product. Our patient is important since she represents the first case of IgE-mediated anaphylaxis against VWF concentrate reported in the literature.

Post-tonsillectomy hemorrhagic outcomes in children with bleeding disorders at a single institution

OBJECTIVE

To report on the post-tonsillectomy bleeding outcomes and factors associated with hemorrhage among children with pre- or post-operatively diagnosed bleeding disorders treated with an institutional protocol.

METHODS

Retrospective cohort study of patients with hematologic disorders who underwent tonsillectomy between 2003 and 2016 and were treated with perioperative desmopressin or factor replacement and/or aminocaproic acid. Postoperative outcomes were compared to controls matched for age, sex, and indication for surgery. Analysis of factors associated with hemorrhage was performed in patients with bleeding disorders using Mann-Whitney U or chi-squared tests.

RESULTS

45 patients with hematologic disorders met inclusion criteria. Platelet dysfunction, including von Willebrand Disease (vWD), was the most common diagnosis (77.8%). Most patients had a preoperative diagnosis of a bleeding disorder and received perioperative hematologic medications (86.7%). Compared to matched controls, patients with hematologic disorders experienced more postoperative bleeding (15.5%; 12 bleeds, 7 patients vs. 1.7%; 1 bleed, 1 patient, p = 0.05) and had longer postoperative stays (1.3 days vs. 0.4 days, p < 0.001). Among the patients with hematologic disorders, patients who experienced a postoperative bleed were significantly more likely to have a factor deficiency (e.g. Hemophilia over vWD) and have a postoperative diagnosis (compared to preoperative diagnosis) for which they did not receive perioperative hematologic medication. Of patients with a postoperative bleed, all those diagnosed postoperatively required at least one surgical intervention to control bleeding compared to 33% of patients with a preoperative diagnosis. A history of post-surgical bleeding, male sex, age at surgery, and pharyngitis as surgical indication were not associated with higher hemorrhage rates in this group.

CONCLUSIONS

This study suggests a clinically important magnitude of increased bleeding risk in patients with hematologic disease. This risk appears to decrease with the use of an institutional protocol consisting of desmopressin or factor replacement and an antifibrinolytic agent extending through postoperative day 10.

Management of children with inherited mild bleeding disorders undergoing adenotonsillar procedures

OBJECTIVE

To evaluate the incidence of perioperative bleeding among children with mild bleeding disorders who underwent adenotonsillar surgery in our hospital and were treated with our perioperative bleeding prophylaxis protocol.

METHODS

Retrospective chart review was aimed at determining the perioperative bleeding rate in children with mild bleeding disorders subjected to our prophylactic protocol while undergoing adenotonsillar procedures. Low von Willebrand factor (LVWF), unspecific platelet function disorders (UPFD) and mild factor VII deficiency were considered as mild bleeding disorders. The protocol utilizes intravenous desmopressin, tranexamic acid, NSAID avoidance, and overnight observation.

RESULTS

Between 2004 and 2009, 44 children with mild bleeding disorders underwent adenotonsillar procedures in our hospital and were treated with the protocol. One patient (LVWF+UPFD) developed perioperative bleeding (2.3%).

CONCLUSIONS

It is possible to obtain low rates of perioperative bleeding in children with mild bleeding disorders undergoing adenotonsillar procedures, provided there is a well-timed diagnosis and an adequate prophylaxis protocol. We believe that further efforts must be directed at preoperative diagnosis of mild bleeding disorders to ensure safer surgeries.

Post-tonsillectomy bleeding in children with von Willebrand disease: a single-institution experience

OBJECTIVES

1) Compare rates of post-tonsillectomy bleeding in pediatric patients with and without von Willebrand disease (vWD). 2) Identify factors that may increase the risk for post-tonsillectomy bleeding in children with and without vWD.

STUDY DESIGN

Historical cohort study.

SETTING

Tertiary care, university-based pediatric hospital.

SUBJECTS AND METHODS

Medical records were examined for 99 patients with vWD and 99 patients without vWD younger than 18 years who underwent tonsillectomy with or without adenoidectomy from August 1997 to October 2005. Subjects were matched for age, year of surgery, type of surgery, and indication for surgery.

RESULTS

Post-tonsillectomy hemorrhage occurred in eight of 99 (8%) vWD patients and in six of 99 (6%) non-vWD patients (P = 0.58, odds ratio 1.36, 95% CI 0.45-4.08). A two-sample test of proportions demonstrated lower and upper limits of -0.051 and 0.092. Four of eight children with vWD and two of six non-vWD patients required surgical intervention for control of bleeding. Ninety-three of 99 vWD patients received desmopressin acetate (DDAVP) preoperatively. In patients with vWD who responded to DDAVP challenge, there was no increased likelihood of post-tonsillectomy bleeding compared with non-vWD patients. No significant difference in the number of bleeding events was noted on the basis of demographics, preoperative laboratories, or use of aminocaproic acid.

CONCLUSION

Children with vWD undergoing tonsillectomy have a postoperative bleeding rate similar to that of a matched group. However, the sample size was not sufficient to eliminate the possibility of a clinically important difference between the two groups.

Incidence of bleeding complications in pediatric patients with type 1 von Willebrand disease undergoing adenotonsillar procedures

OBJECTIVE

To review the incidence of postoperative bleeding in children with type 1 von Willebrand disease (VWD) who were treated with a single institution protocol.

STUDY DESIGN

We performed a retrospective study to determine the postoperative hemorrhage rate in pediatric patients with type 1 VWD who were treated via the Children's Hospital of Philadelphia institutional protocol. This protocol utilizes intravenous desmopressin (DDAVP), oral aminocaproic acid, and overnight observation.

RESULTS

Between the years of 2000 to 2006, 41 children with type 1 VWD underwent an adenotonsillar procedure and were treated with this protocol. Seven patients (17%) experienced delayed (>24 hours after surgery) postoperative hemorrhage requiring intervention. Five of the 7 patients required cautery to control the bleeding, and the remaining 2 patients responded to DDAVP and aminocaproic acid alone. Older age and lower VW antigen levels were associated with postoperative hemorrhage (P = .05).

CONCLUSIONS

Despite therapeutic intervention to decrease the risk of postoperative hemorrhage, the incidence of hemorrhage was higher in pretreated patients with type 1 VWD than in children without bleeding disorders. Further prospective studies are necessary to determine the optimal treatment to reduce bleeding complications in these patients.

Treatment of urgent bleeding in von Willebrand disease

von Willebrand factor (VWF) is a complex plasma protein that promotes platelet adhesion to the subendothelial matrix of injured blood vessels and provides stability to factor VIII in the circulation. von Willebrand disease (VWD) is a haemorrhagic disorder of highly variable severity caused by qualitative and quantitative abnormalities of VWF. The approach to treating urgent bleeding in patients with VWD is dependent on an accurate diagnosis of the patient's type of VWD and knowledge of the expected responses to treatment modalities. These include administration of desmopressin (DDAVP), a vasopressin analogue that promotes the release of VWF and factor VIII (FVIII) from storage sites, and replacement therapy with a viral-inactivated concentrate containing normal VWF and FVIII. Monitoring of an individual's response in the non-bleeding state is required to determine the response to desmopressin that may be achieved and to determine the individual pharmacokinetics of infused VWF and FVIII. In this article, specific approaches to the choice of treatment modalities, calculation of dosages, monitoring of therapy, possible side effects and complications of the treatment of the various types of VWD will be discussed.

Perioperative management of von Willebrand disease in dermatologic surgery

BACKGROUND

Von Willebrand disease (VWD) is the most common inherited bleeding disorder, affecting an estimated 0.1% to 1% of the population. It is caused by a qualitative or quantitative defect of von Willebrand factor. Primary manifestations include intractable mucocutaneous bleeding after surgery or trauma.

OBJECTIVE

The objective was to review the pathophysiology and clinical features of VWD and to propose a perioperative management strategy for patients with this condition undergoing dermatologic surgery.

METHODS AND MATERIALS

Literature is reviewed.

RESULTS

The various types and clinical manifestations of this condition are reviewed, and a perioperative strategy is presented for managing patients with VWD who undergo cutaneous oncologic or cosmetic surgical procedures.

CONCLUSIONS

In most cases, dermatologic surgery can be safely performed in patients with VWD. The use of appropriate therapeutic prophylaxis in conjunction with a hematologist is indicated in high-risk, nonelective procedures.

Acute abdominal pain caused by a spontaneous intramyometrial hematoma in type III von Willebrand disease

OBJECTIVES

To discuss the clinical picture, differential diagnosis and management of a pediatric patient with von Willebrand disease (vWD) presenting with severe abdominal pain caused by an intramyometrial hematoma.

METHODS

A 17-year-old girl with type III vWD was admitted to the emergency department with a complaint of severe lower abdominal pain different from her usual dysmenorrhea. She had no history of trauma to the pelvic region or any sexual intercourse. Transabdominal ultrasonography and magnetic resonance imaging revealed an intramyometrial hematoma in anterofundal region of uterus.

RESULTS

A favorable clinical outcome was obtained through a treatment with factor VIII concentrates containing von Willebrand factor which resulted in complete resolution of the sonographic findings within 3 weeks.

CONCLUSIONS

Intramyometrial hematoma can be an unusual cause of severe abdominal pain in patients with vWD applying to emergency departments. Especially in adolescence years, when transvaginal sonography could not be performed, transabdominal ultrasonography and magnetic resonance imaging are useful tools for the diagnosis.