Classification of von Willebrand's disease

Pregnancy and delivery in patients with von Willebrand's disease

OBJECTIVE

To explore the obstetrical problems that are encountered in women with von Willebrand's disease (vWD).

METHODS

Case histories of 6 women whose pregnancies were complicated by vWD were reviewed retrospectively over an 11-year period. The disease had been diagnosed before pregnancy in only 2 cases. The 6 women had a total of 10 deliveries, 3 induced abortions, and 1 spontaneous abortion.

RESULTS

Although all 6 women had Type-I vWD, their laboratory data and bleeding symptoms varied. The 10 full-term deliveries were all vaginal. Heat-treated concentrated Factor-VIII preparations were administered in 2 cases, in both of which abortions were induced during the 2nd trimester. Genital bleeding persisted in the second case, so that the administration of Factor VIII was repeated, and the patient underwent uterine curettage on the 12th day after abortion. Desmopressin was administered before the early induction of abortion in 1 case. The patient with persistent genital bleeding after spontaneous abortion received Factor VIII for 5 consecutive days.

CONCLUSION

Bleeding problems occurred about 1 week after delivery or at the time of induced abortion in the 6 women with vWD. Thus, such patients require special care during pregnancy.

Haemorrhagic problems in obstetrics and gynaecology in patients with congenital coagulopathies

OBJECTIVE

To review the obstetric and gynaecological problems in women with congenital coagulopathies.

DESIGN

Retrospective review.

SETTING

Regional Adult Haemophilia Unit, Glasgow Royal Infirmary.

SUBJECTS

All women in contact with the Unit over a period of 30 years, comprising eight with von Willebrand's disease, 18 obligate carriers of haemophilia A and five obligate carriers of Christmas disease. Each woman was interviewed and details of their obstetric and gynaecological histories were obtained and their case records were reviewed.

MAIN OUTCOME MEASURES

Haemostatic changes associated with pregnancy and gynaecological problems.

RESULTS

In 14 pregnancies in seven patients with von Willebrand's disease, there were four primary and four secondary post-partum haemorrhages and a large perineal haematoma complicating an episiotomy. These problems arose despite the endogenous rise in factor VIIIc seen with pregnancy. All women seen with von Willebrand's disease complained of menorrhagia and had been referred to gynaecologists. Treatment included danazol, tranexamic acid and the contraceptive pill. Diagnostic curettage resulted in severe haemorrhage in one woman and two women with pelvic pain and dyspareunia were found to have spontaneous broad ligament haematomas, one requiring surgery. In 43 pregnancies in obligate carriers of haemophilia A and Christmas disease there were five post-partum haemorrhages and a large perineal haematoma.

CONCLUSION

In von Willebrand's disease it should be noted that adequate laboratory correction of factor VIIIc levels does not ensure clinical haemostasis; hence platelet function should also be measured. Patients with congenital coagulopathies pose particular problems for the obstetrician and gynaecologist and should be managed in close association with the local haemophilia centre.

A relatively high frequency of severe (type III) von Willebrand's disease in Israel

Sixty patients with von Willebrand's disease belonging to 34 unrelated families were classified into the various types of the disease by analysis of the multimer patterns of von Willebrand factor. Type I disease was observed in 62% of the families, a finding similar to the recently published British and Swedish series of patients. Type III (severe) von Willebrand's disease was observed more frequently in the Israeli group (29%) than in the other two series. Of the 16 patients with type III disease eight were Arabs living in Israel, the West Bank and the Gaza Strip (total population about 1.5 X 10(6). Thus, it appears that the frequency of type III disease is very high among Arabs (5.3/10(6]. Sibship analysis of all families affected by the type III mutant gene was compatible with an autosomal recessive mode of inheritance. An attempt was made to define carriers of type III disease and to distinguish them from type I patients and from healthy subjects. In 15 obligate carriers of type III disease mean levels of factor VIII clotting activity, of von Willebrand factor and of ristocetin cofactor were significantly higher than the corresponding mean values observed in 31 symptomatic and 12 asymptomatic type I patients, and in turn significantly lower than the corresponding mean values observed in 30 healthy subjects. Ristocetin cofactor was the best criterion for discrimination among carriers of type III disease, normal subjects and type I patients.

von Willebrand syndromes and mitral-valve prolapse; linked mesenchymal dysplasias

We searched for mitral-valve prolapse by two-dimensional echocardiography in 15 patients with von Willebrand syndromes to test the hypothesis that this bleeding disorder is actually a mesenchymal dysplasia that resembles the heritable disorders of connective tissue. This valvular abnormality was found in nine (60 per cent) of these patients, as compared with four (13.3 per cent) of 30 sex-matched and age-matched healthy controls. This difference was statistically significant (P less than 0.01). The association between these two disorders encourages a search for mitral-valve prolapse in persons with a von Willebrand syndrome. The complex of a von Willebrand syndrome and mitral-valve prolapse may be an example of a newly recognized category of related coagulation and cardiovascular disorders.