Inherited Bleeding Disorders in the Obstetric Patient

Development and validation of an algorithm to better identify pregnant women with inherited bleeding disorders within electronic health records

BACKGROUND

When using electronic health records (EHRs) to conduct population-based studies on inherited bleeding disorders (IBDs), using diagnosis codes alone results in a high number of false positive identifications.

OBJECTIVE

The objective of this study was to develop and validate an algorithm that uses multiple data elements of EHRs to identify pregnant women with IBDs.

METHODS

The population included pregnant women who had at least one live birth or fetal death (>20 weeks gestation) at our institution from 2016 to 2023. We iteratively developed the algorithm using a composite criteria of encounter diagnosis codes, laboratory and medications data. We assessed the performance of the algorithm for sensitivity and positive predictive value (PPV) using our local registry and manual chart review.

RESULTS

Using the source population between 2016 and 2020, the initial algorithm identified 25 pregnant women with IBDs. Eight women with a known diagnosis of an IBD were missed resulting in a sensitivity of 75.8 % and a PPV of 100 %. We revised the algorithm to remove certain IBD diagnosis codes that resulted in contamination and added additional criteria to improve the sensitivity. The revised algorithm had a sensitivity of 97.0 % and a PPV of 91.4 %. The revised algorithm was validated using the source population between 2021 and 2023 and had a sensitivity of 97.1 % and a PPV of 91.7 %.

CONCLUSION

This study demonstrates the utility of an algorithm to better identify pregnant women with specific types of IBD, mainly hemophilia and hemophilia carriers, and von Willebrand disease, within EHRs.

One day at a time: Life with Glanzmann thrombasthenia - Qualitative results from the GT 360 study

INTRODUCTION

Glanzmann thrombasthenia (GT) is a platelet function disorder. Symptoms include bruising and bleeding, which may be severe and life-threatening. The day-to-day experiences of those affected remain poorly documented.

AIMS

The Glanzmann's 360 study aimed to better understand the daily realities of living with GT, exploring psychological, social and medical challenges to identify unmet need.

METHODS

People with GT over 18 and caregivers of children with GT participated. Mixed methods research was used, including a survey and in-depth interviews. The interviews, reported here, were audio-recorded, transcribed and thematically analysed.

RESULTS

Nineteen interviews were conducted; 14 with people with GT and five caregivers. Mean age of those with GT was 32.9 years (range 2-78 years). Eight themes emerged: Diagnosis, Bleeding and Treatment, Menstruation, Fatigue, Identity, Abuse, Pregnancy, and The Future. Three participants described misdiagnosis. Caregivers reported early recognition and prompt diagnosis of their children. Bruising, the most commonly reported symptom, led to assumption of abuse. Six (32%) participants reported joint bleeds. External bleeding was normalised. Access to home treatment and local care were limited. Fatigue caused by anaemia was described. All women reported heavy menstrual bleeding. Choices around pregnancy were limited by 'medical pessimism'. Nevertheless, participants remained hopeful for the development of improved treatment options.

CONCLUSION

People with GT face significant and often overlooked challenges. There is need for improved medical and psychological treatment and support, increased awareness of these needs amongst healthcare professionals, and research into developing comprehensive care models that address medical and psychosocial needs of people with GT.

How I approach bleeding in hospitalized patients

Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.

Bernard-Soulier Syndrome from the Perspective of the Obstetrician: A Case Report with a Review of the Literature

OBJECTIVE

Bernard-Soulier syndrome (BSS) is one of the rare inherited platelet disorders that is characterized by macrothrombocytopenia and adhesion abnormality due to the absence or malfunctioning of the membrane GPIb-IX-V complex. There is no high-quality evidence on obstetric management of BSS owing to its rarity. Here we report an uncomplicated delivery of an adolescent with BSS and review the literature on the topic of BSS and pregnancy.

METHODS

PUBMED, EMBASE, COCHRANE, and Google Scholar databases were searched up to April 2022 without language and year restriction using the terms "Bernard Soulier" and "Pregnancy". The primary objectives were to evaluate maternal and fetal outcomes. The secondary objectives were to analyze pregnancy complications, gestational age at delivery, mode of delivery, administered prophylaxis, treatment approaches, duration of postpartum hospitalization, and the postpartum requirement of blood and blood product.

RESULTS

The patient was a 19-year-old and 39-week pregnant woman who was diagnosed with BSS at the age of 10 by flow cytometry and genetic analysis. Single donor platelet transfusions and oral tranexamic acid were administered as prophylaxis at the peripartum period. She was delivered by cesarean section due to failure of labor. The postpartum period was uneventful for both mother and neonate. In the literature review, postpartum hemorrhage (PPH) was found in 52.9% (27/51) of deliveries. Late PPH occurred more frequently than early PPH (35.3 and 31.4%, respectively). 49% (25/51) of pregnancies had severe thrombocytopenia, and antepartum hemorrhage was observed in 11.8% (6/51) of those. The platelet count was in close relation to antenatal complications. 64.7% (33/51) of the patients were delivered via cesarean section. PPH and late PPH were found to be more common in those who delivered vaginally compared to those who delivered by caesarean section. It was observed that PPH was less common in women who were given prophylaxis in the peripartum period.

CONCLUSION

BSS is an inherited macro-thrombocytopathy that may cause adverse maternal and neonatal outcomes. The optimal mode and timing of delivery remain unclear. A multidisciplinary approach with prophylaxis at the peripartum period should be applied.

Identifying the effect of inherited bleeding disorders on the development of postpartum hemorrhage: a population-based, retrospective cohort study

Background

Women with inherited bleeding disorders (IBDs) are at an increased risk of postpartum hemorrhage (PPH). However, the impact of other maternal predelivery risk factors, including anemia, on the association between IBD and maternal bleeding remains poorly understood. Additionally, studies examining potential pathways linking IBD and PPH are limited.

Objectives

We aimed to determine the risk of PPH associated with IBD.

Methods

A retrospective cohort study was conducted using data held within ICES (formerly the Institute for Clinical Evaluative Sciences). Women with an in-hospital, live, or stillborn delivery between January 2014 and December 2019 were included. Poisson regression with robust error variance was used to determine the risk (RR) and 95% CIs of PPH among women with or without an IBD diagnosis. Models were stratified for primiparous and multiparous women.

Results

Among the total population of 601,773 women, 29,661 (4.93%) experienced PPH. Multivariate models demonstrated that IBD was an independent risk factor for PPH among both the total cohort (adjusted RR [aRR] = 1.26; 95% CI: 1.08, 1.46) and primiparous women (aRR = 1.36; 95% CI: 1.12, 1.66). Among multiparous women, prior PPH was associated with an increased risk of PPH (aRR = 8.65; 95% CI: 8.32, 8.99), whereas IBD had no effect (aRR = 1.1; 95% CI: 0.86, 1.4). Predelivery anemia, placental conditions, multifetal gestation, and induction of labor were associated with increased PPH risk among all cohorts.

Conclusions

IBD significantly increases the risk of PPH. The management of delivery should be based on individualized assessment of risk factors to ensure optimal maternal outcomes.

Pregnancy and childbirth in women with bleeding disorders: A retrospective cohort study

INTRODUCTION

Reproductive-age women with bleeding disorders (BDs) are underdiagnosed and understudied, despite their increased risk for adverse health outcomes and pregnancy complications.

AIM

This study examines pregnancy outcomes and obstetric complications of Utah women with BDs.

METHODS

This retrospective cohort study utilized linked birth records and clinical billing data from two large Utah healthcare systems. Utah residents who had their first birth at > 20 weeks gestation (2008-2015) and who received non-emergent care within either system before delivery were included (n = 61 226). Multivariable logistic regression models were used to examine relationships between BDs and neonatal and obstetric outcomes.

RESULTS

A total of 295 women (.48%) were included in the BD study population. Women with BDs had significantly increased odds of preterm birth (aOR 1.85, 95% CI 1.32-2.60), Caesarean delivery (aOR 1.38, 95% CI 1.06-1.79), postpartum blood transfusion (aOR 2.55, 95% CI 1.05-6.22), unplanned postpartum hysterectomy (aOR 33.96, 95% CI 7.30-157.89) and transfer to an intensive care unit (aOR 18.18, 95% CI 7.17-46.08). All of the women with BDs who experienced these serious complications were not diagnosed with a BD until the year of their first birth. Additionally, those with BDs were more likely to experience maternal and infant mortality.

CONCLUSION

Women with BDs had an increased risk for preterm birth, Caesarean delivery, blood transfusion, unplanned hysterectomy, intensive care unit admission, maternal and infant mortality. Those who were not diagnosed with a BD before the year of their first birth were at an increased risk for serious pregnancy complications.

Recurrent miscarriage in a woman with congenital factor V deficiency: a case report

BACKGROUND

Factor V deficiency is a rare bleeding disorder that can be either congenital or acquired. Factor V deficiency mostly present with mucosal bleeding. Coagulation factor V does not increase considerably during normal gestation. Since pregnancy can be threatened by blood clotting disorders, abnormal changes in coagulation factors level can pose challenges to pregnant women.

CASE PRESENTATION

We report a 40-year-old pregnant woman with prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy. Her past medical history included two unexplained abortions. Physical examination was unremarkable, but the blood test showed elevated PT and PTT with a considerable decrease in factor V activity, while other factors were within normal range. Subsequently, the patient was diagnosed with congenital factor V deficiency. After treatment with fresh frozen plasma, she underwent vaginal delivery and a baby with factor V deficiency was born.

CONCLUSIONS

This is the second report of recurrent miscarriage in congenital factor V deficiency patients. Clinicians should consider the possibility of factor V deficiency in women with a history of idiopathic miscarriage even in patients without any symptoms.

Determining the incidence of postpartum haemorrhage among Ontario women with and without inherited bleeding disorders: A population-based cohort study

INTRODUCTION

At a population level, there is a poor understanding of the incidence and pre-disposing risk factors of postpartum haemorrhage (PPH) among women with inherited bleeding disorders (IBD).

AIM

To determine the incidence of PPH, and identify maternal factors associated with risk of PPH among women with IBD.

METHODS

We conducted a retrospective cohort study using data housed within ICES (formerly known as the Institute for Clinical Evaluative Sciences). The cohort included women with an in-hospital, live or stillborn delivery, between January 2014 and December 2019. The primary outcome was PPH (identified by ICD-10 code O72). PPH incidence and risk factors were compared between women with and without IBD. Temporal trends were assessed using the Cochrane-Armitage test. Between group differences were assessed using standardised differences (std. difference).

RESULTS

Total 601,773 women were included; 2002 (.33%) had an IBD diagnosis. PPH incidence was 1.5 times higher (7.3 vs. 4.9 cases/100 deliveries, std. difference .1) among women with IBD compared to women without. Women with IBD were slightly older (31.7 vs. 30.7 years), had higher rates of hypertension, previous PPH, and induction of labour. Women with IBD were more frequently diagnosed with anaemia (4.8% vs. 1.8%; std difference .17) and had lower haemoglobin levels at admission for delivery compared to women without IBD.

CONCLUSIONS

This study contributes to the literature regarding obstetric bleeding among women with IBD, showing that anaemia at delivery may be an important risk factor for PPH. Given their predisposition to anaemia, clarifying this relationship will optimise management and outcomes.

JTH in Clinic - Obstetric bleeding: VWD and other inherited bleeding disorders

Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.

Blood type association with bleeding outcomes at delivery in a large multi-center study

Postpartum hemorrhage is a leading cause of maternal death globally. Recent studies have associated Type-O group to increased risk of bleeding. We aimed to determine if women with Type-O blood are at higher risk of PPH. This is a retrospective cohort analysis of a multi-center database included women admitted to labor and delivery from January 2015 to June 2018. All deliveries resulting in live birth were included. Association between Type-O and non Type-O were examined using chi-square test and fishers exact test. Prevalence of postpartum hemorrhage, estimated blood loss, drop in hematocrit and red blood cell transfusion were compared. The matched sample included 40,964 Type-O and the same number of no Type-O. The overall prevalence of postpartum hemorrhage was 6.4%, and there was no difference in the prevalence of PPH among Type-O compared to non Type-O (6.38% vs. 6.37% respectively; p = 0.96). There was no difference in hematocrit drop and estimated blood loss between Type-O and non Type-O in all deliveries. However, in cesarean delivery there was a significant difference in blood loss among the two groups. Finally, Type-O had 1.09-fold increased risk for transfusion compared to non Type O (95% CI 0.9-1.34). There is an association between Type-O group and risk of bleeding in women undergoing cesarean delivery. More prospective studies, taking into account coagulation profile, platelet count and tissue factors, are needed to draw a conclusion on whether ABO system can be considered a heritable risk of postpartum hemorrhage.

Assessment of von Willebrand disease and pregnancy outcomes at regional Australian hospitals

BACKGROUND

von Willebrand disease (vWD) is a heterogeneous hereditary bleeding disorder and is associated with risk of primary postpartum haemorrhage (PPH).

DESIGN AND METHODS

An observational study at a tertiary referral centre in Australia of 16 women with 23 deliveries with a median age of 27.5 years (range, 21-39; IQR = 9). Median gestational age at delivery was 39 weeks (range, 35-41; IQR = 1.1).

RESULTS

All cases had type 1 vWD, apart from one case with type 2. Patients were managed in combined obstetrics and haematology clinics. PPH occurred in ten deliveries (44%). Intravenous desmopressin was administered in 6 cases, and IV human vWF was administered in 4 cases. Two cases with mild vWD had received oral tranexamic acid. The median Apgar score at 1 and 5 min was 9 (IQR = 1.0), while the median Apgar score at 10 min was 10.0 (IQR = 0.0). One case required transfusion of blood products postdelivery. There were no other significant complications observed.

CONCLUSIONS

vWD was associated with a high incidence of primary PPH. Individualised treatment to restore haemostasis, according to the severity of the disease, could achieve as possible, normal haemostasis with favourable outcomes for both mothers and their infants. Further studies to confirm our findings are warranted.

Disease Burden in Patients with Glanzmann's Thrombasthenia: Perspectives from the Glanzmann's Thrombasthenia Patient/Caregiver Questionnaire

Purpose

Glanzmann’s thrombasthenia (GT) is a rare bleeding disorder caused by a mutation in the αIIbβ3 integrin essential for optimal platelet function and hemostasis. The aim of this study was to identify the burden of GT on patients and caregivers through better understanding of the management and psychosocial impact of this disorder.

Patients and Methods

Participants for this online survey were recruited using a rare disease specialty recruiter from Comprehensive Health Education Services. Data were collected from January 31 through March 12, 2019. The questionnaire was designed to collect information regarding demographics, diagnosis, treatment, and psychosocial impact.

Results

Of the 45 respondents (24 patients and 21 caregivers), the majority were female (58%), white (64%), and employed full-time (53%) and had no family history of GT (64%). Many patients reported significant bruising at birth (76%), and the mean age at diagnosis was 2.6 years. About half of the patients experienced 1 bleed per day, and 13% had over 500 bleeds of any severity per year. Most bleeds were skin bruising or mouth bleeds, but patients also reported joint/muscle and gastrointestinal bleeds. Most patients reported receiving a platelet transfusion (82%), and some had developed platelet refractoriness (38%) or antibodies (32%). Common treatments were antifibrinolytics (82%) and recombinant activated factor VII (rFVIIa) (42%), likely due to the presence of antibodies. Many (58%) patients experienced issues with excessive bleeding at school; 38% reported missing school as a result. Female patients struggled to find a gynecologist with knowledge of the management of GT. Most patients were satisfied with the support they receive from their current partner (65%) and their friends (76%).

Conclusion

Most patients with GT are diagnosed early. Patients experience considerable psychosocial impact. Patient and physician education concerning treatment alternatives and the support of the GT community are critical.

Psychosocial Impact and Disease Management in Patients with Congenital Factor VII Deficiency

Purpose

Congenital factor VII (FVII) deficiency is a rare bleeding disorder of variable phenotype with predominantly mucocutaneous bleeding. The aim of this study was to identify the burden of FVII deficiency on patients and caregivers through a better understanding of the management and psychosocial impact of this disease.

Materials and Methods

A rare disease specialty recruiter from Comprehensive Health Education Services recruited participants for this online survey, which was conducted from January 31 to March 12, 2019. A moderator-assisted questionnaire was used to collect data on demographics, diagnosis, treatment, and psychosocial impact.

Results

Of the 45 respondents (25 patients and 20 caregivers), the majority were female (56%). Respondents reported a wide variety of initial bleeding symptoms, including bruising (58%), epistaxis (56%), and menorrhagia (36% of females). Because symptoms varied between individuals and were not always severe, diagnosis was often delayed. Mean time to obtain a diagnosis was 6.5 years and mean age at first diagnosis was 12.9 years. One-quarter (24%) of the respondents reported more than 100 bleeds of any severity over the previous year. When treating bleeds, 44% of patients reported using antifibrinolytics, and 42% reported using recombinant activated factor VII. Almost 31% of respondents reported missing schooldays as children, and 16% reported losing or resigning from a job in adulthood as a direct result of their disease. Notably, 29% of caregivers and 10% of their partners had also experienced issues with employment. Forty percent of respondents reported not participating in contact sports during childhood, and 22% continued to avoid contact sports in adulthood.

Conclusion

Overall, FVII deficiency has a substantial psychosocial impact, but most patients are satisfied with their disease management and are optimistic about their future. Patients desire additional educational, social, and financial support.

The experience of postpartum bleeding in women with inherited bleeding disorders

INTRODUCTION

Postpartum hemorrhage (PPH) affects 6% of all deliveries and is the leading cause of maternal death worldwide (19.7%). The incidence of PPH in women with inherited bleeding disorders is substantially greater than in unaffected women; however, estimates of relative risk are highly variable. To date, their experience with postpartum bleeding has not been well studied.

OBJECTIVE

We set out to explore the experience with, understanding of, and attitudes regarding postpartum bleeding among women with inherited bleeding disorders.

METHODS

This qualitative study involved focused interviews of women with inherited bleeding disorders about postpartum bleeding. Women followed at a multidisciplinary clinic for women with inherited bleeding disorders who have experienced childbirth within the last 5 years were included in the study. The interview style was semistructured. Interviews continued until the point of saturation of themes. All interviews were transcribed and then analyzed using qualitative descriptive analysis.

RESULTS

We interviewed 10 women with inherited bleeding disorders. Themes that emerged were normalization of excessive vaginal bleeding, difficulty distinguishing normal from abnormal postpartum bleeding, and empowerment of women by having a clear delivery care plan.

CONCLUSION

In this study, women with inherited bleeding disorders were desensitized to heavy vaginal blood loss. As a result, excessive postpartum bleeding was not recognized by many of the women we interviewed. Results highlight the importance of a multidisciplinary delivery care plan for these women. Findings revealed key areas for targeted multidisciplinary intervention.

Women and inherited bleeding disorders - A review with a focus on key challenges for 2019

The area of women and inherited bleeding disorders has undergone quick expansion in recent years. More patients are being identified and expertise to diagnose and manage these patients is now essential for practising physicians. Programs to help educate and empower patients and caregivers are now in place. Common inherited bleeding disorders affecting women include von Willebrand disease (VWD), inherited platelet disorders, and rare inherited bleeding disorders such as factor VII (FVII) deficiency and factor XI (FXI) deficiency. Specific clinical tools have been developed to help clinicians and patients screen for the presence of these bleeding disorders in both adult and pediatric populations. Affected women can experience heavy menstrual bleeding and resulting iron deficiency anemia, postpartum hemorrhage, and hemorrhagic ovarian cysts which need to be properly managed. Excessive bleeding can adversely affect quality of life in these women. Front line therapy for bleeding in mild cases focuses on the use of non-specific hemostatic agents such as DDAVP ®, tranexamic acid and hormonal agents but specific factor replacement and/or blood products may be required in more severe cases, in severe bleeding or as second line treatment when bleeding is not responsive to first line agents. Iron status should be optimised in these women especially in pregnancy and use of an electronic app can now help clinicians achieve this. These patients should ideally be managed by a multidisciplinary team whenever possible even remotely. Although clinical research has closed some knowledge gaps regarding the diagnosis and management of these women, there remains significant variation in practise and lack of evidence-based guidelines still exists in many spheres of clinical care in which caregivers must rely on expert opinion. Ongoing efforts in education and research will continue to improve care for these women and restore quality of life for them.