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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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Okoshi C, Takahashi T, Fukatsu M, Suganuma R, Ikezoe T, Fujimori K. A case of delayed postoperative bleeding after excision of endometrial polyp using resectoscope in an infertile woman with von Willebrand disease:a case report and literature review. Fukushima J Med Sci 2023; 69:197-204. [PMID: 37853641 PMCID: PMC10694516 DOI: 10.5387/fms.2023-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/08/2023] [Indexed: 10/20/2023] Open
Abstract
Von Willebrand disease (VWD) is a bleeding disorder caused by a congenital quantitative reduction, deficiency, or qualitative abnormality of the von Willebrand factor (VWF). Here, we report a case of delayed postoperative bleeding in an infertile woman with endometrial polyps complicated by VWD. The patient was a 39-year-old infertile woman with type 2A VWD. At 38 years of age, she was referred to our hospital for infertility and heavy menstrual bleeding. Hysteroscopy revealed a 15-mm polyp lesion in the uterus. The patient was scheduled for transcervical resection (TCR) of the endometrial polyp. Gonadotropin-releasing hormone agonists were preoperatively administered to prevent menstruation. The VWF-containing concentrate was administered for 3 days according to guidelines. The patient was discharged on postoperative day 3 after confirming the absence of uterine bleeding. Uterine bleeding began on postoperative day 6. The patient was readmitted on postoperative day 7 and treated with VWF-containing concentrate for 5 days, after which hemostasis was confirmed. TCR surgery for endometrial lesions is classified as a minor surgery, and guidelines recommend short-term VWF-containing concentrate replacement. However, it should be kept in mind that only short-term VWF-containing concentrate replacement may cause rebleeding postoperatively.
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Affiliation(s)
- Chihiro Okoshi
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Masahiko Fukatsu
- Department of Haematology Fukushima Medical University School of Medicine
| | - Ryota Suganuma
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Takayuki Ikezoe
- Department of Haematology Fukushima Medical University School of Medicine
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
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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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Von Willebrand Disease, Hemophilia, and Other Inherited Bleeding Disorders in Pregnancy. Obstet Gynecol 2023; 141:493-504. [PMID: 36800851 DOI: 10.1097/aog.0000000000005083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/07/2022] [Indexed: 02/05/2023]
Abstract
Inherited bleeding disorders, which comprise von Willebrand disease (VWD), hemophilia, other congenital clotting factor deficiencies, inherited platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Although mild platelet defects may actually be more prevalent, the most common diagnosed bleeding disorder among women is VWD. Other bleeding disorders, including hemophilia carriership, are much less common, but hemophilia carriers are unique in that they are at risk of giving birth to a severely affected male neonate. General guidance for maternal management of inherited bleeding disorders includes obtaining clotting factor levels in the third trimester, planning for delivery at a center with hemostasis expertise if factor levels do not meet the minimum threshold (eg, less than 0.50 international units/1 mL [50%] for von Willebrand factor, factor VIII, or factor IX), and using hemostatic agents such as factor concentrates, desmopressin, or tranexamic acid. General guidance for fetal management includes prepregnancy counseling, the option of preimplantation genetic testing for hemophilia, and consideration of delivery of potentially affected male neonates with hemophilia by cesarean delivery to reduce the risk of neonatal intracranial hemorrhage. In addition, delivery of possibly affected neonates should occur in a facility where there is newborn intensive care and pediatric hemostasis expertise. For patients with other inherited bleeding disorders, unless a severely affected neonate is anticipated, mode of delivery should be dictated by obstetric indications. Nonetheless, invasive procedures such as fetal scalp clip or operative vaginal delivery should be avoided, if possible, in any fetus potentially affected with a bleeding disorder.
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Abou-Ismail MY, James PD, Flood VH, Connell NT. Beyond the guidelines: how we approach challenging scenarios in the diagnosis and management of von Willebrand disease. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:204-214. [PMID: 36700502 DOI: 10.1016/j.jtha.2022.11.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 01/26/2023]
Abstract
Although von Willebrand disease (VWD) is the most common inherited bleeding disorder, its diagnosis and management are often challenging. Clinical practice guidelines, developed through systematic review of the medical literature and considering the best available evidence, provide guidance for common clinical scenarios. However, in the clinical setting, patients often present with characteristics and nuances that may fall outside the realm of available evidence and guidelines, and hence, shared decision-making will be essential in the evaluation and management of these patients. The challenges in the diagnosis of VWD are mainly attributable to the heterogeneity of the disorder, limitations of laboratory assays, and the significant impact of various physiologic processes on von Willebrand factor. The impact of physiologic normalization of von Willebrand factor, which may occur in various settings such as pregnancy, inflammation, or aging, remains uncertain, as is the optimal management in these scenarios. Multidisciplinary and individualized care, based on evolving evidence supported by clinicians, patients, caregivers, and stakeholders, will be needed to ensure the highest quality care for those who live with VWD.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Veronica H Flood
- Versiti Blood Research Institute and Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nathan T Connell
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Miljic P, Noureldin A, Lavin M, Kazi S, Sanchez-Luceros A, James PD, Othman M. Challenges in the management of women with type 2B von Willebrand disease during pregnancy and the postpartum period: evidence from literature and data from an international registry and physicians' survey-communication from the Scientific and Standardization Committees of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:154-163. [PMID: 36695378 DOI: 10.1016/j.jtha.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Management of women with type 2B von Willebrand disease (VWD) during pregnancy is challenging because of dysfunctional von Willebrand factor (VWF) and the complexity resulting from discrepant VWF/factor VIII (VWF/FVIII) levels, impaired platelet-dependent VWF activity, progressive thrombocytopenia, and risks associated with the use of desmopressin. There is a lack of high-quality evidence to support clinical decision making. OBJECTIVES In this study, we examined the current diagnostic and management approaches and outcomes in women with VWD during pregnancy. METHODS Data were collected via 3 avenues: literature review, an international registry, and an international survey on physicians' practices for the management of pregnancy in women with VWD. The registry and survey were supported by the International Society on Thrombosis and Haemostasis. RESULTS Data on clinical and laboratory features, management and bleeding complications, and pregnancy outcomes of a total of 55 pregnancies from 49 women across the globe (literature: 35, registry: 20) and data reported by 112 physicians were analyzed. We describe the largest dataset on pregnancies in women with type 2B VWD available to date. The data highlight the following key issues: a) bleeding complications remain a concern in these patients, b) the target safe VWF level and the ideal monitoring approach are unknown, c) there is a wide range of hemostatic management practices in the type and timing of treatment, and d) physicians have diverse views on the mode of delivery and use of neuraxial anesthesia. CONCLUSION We conclude that an international consensus and guidance are critically required for better care and improved outcomes in this patient cohort.
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Affiliation(s)
- Predrag Miljic
- Clinic of Haematology, University Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Abdelrahman Noureldin
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michelle Lavin
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Sajida Kazi
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Paula D James
- Division of Hematology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St. Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Wayson J, Allen JT, Laks S, Allen M. Case of postpartum uterine artery pseudoaneurysm associated with von Willebrand disease. BMJ Case Rep 2022; 15:15/12/e253804. [PMID: 36564091 PMCID: PMC9791432 DOI: 10.1136/bcr-2022-253804] [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] [Indexed: 12/25/2022] Open
Abstract
A woman in early 20s with type 1 von Willebrand disease (vWD) presented to the emergency department with abdominal pain and vaginal bleeding at 5 weeks post partum following primary caesarean section. Imaging revealed a uterine artery pseudoaneurysm (UAP), which is a rare condition that can cause postpartum haemorrhage. Caesarean birth and vWD are two risk factors for pseudoaneurysm. Swift postpartum recognition of a pseudoaneurysm is essential to prevent a potentially life-threatening outcome. Successful diagnosis and treatment of the patient's symptoms required interdisciplinary teamwork between obstetricians, interventional radiologists and haematologists. Uterine artery embolisation (UAE) was performed and complete resolution of the pseudoaneurysm was noted 6 weeks after the procedure. Haemorrhage was averted due to early detection of UAP prior to its rupture, and future fertility was preserved. The patient successfully conceived a second child 1 year after UAE and delivered via caesarean birth without haemorrhage or recurrence of UAP.
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Affiliation(s)
- Jesse Wayson
- ObGyn, Augusta University, Augusta, Georgia, USA
| | | | - Shahar Laks
- ObGyn, Augusta University, Augusta, Georgia, USA
| | - Michael Allen
- Emergency Medicine, Augusta University, Augusta, Georgia, USA
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8
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Influence of Von Willebrand Disease (VWD) and pregnancy on the expression of angiogenic factors in the porcine female reproductive tract. Reprod Biol 2022; 22:100700. [DOI: 10.1016/j.repbio.2022.100700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 11/05/2022]
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Swaminathan N, Sharathkumar A, Dowlut-McElroy T. Reproductive Tract Bleeding in Adolescent and Young Adult Females with Inherited Bleeding Disorders: An Underappreciated Problem. J Pediatr Adolesc Gynecol 2022; 35:614-623. [PMID: 35830928 DOI: 10.1016/j.jpag.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.
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Affiliation(s)
- Neeraja Swaminathan
- Division of Pediatric Hematology Oncology, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Anjali Sharathkumar
- Division of Pediatric Hematology Oncology, Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 1322 BT, 200 Hawkins Drive, Iowa City, IA 52242, United States.
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Eladly F, Miesbach W. Von Willebrand Disease—Specific Aspects in Women. Hamostaseologie 2022; 42:330-336. [DOI: 10.1055/a-1891-9976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractVon Willebrand disease (VWD) is the most common inherited bleeding disorder, which results from a deficiency or dysfunction of von Willebrand factor (VWF). The major symptoms of patients affected by VWD include mucocutaneous and gastrointestinal bleeding, easy bruising, and prolonged provoked bleeding due to injury or surgery. Although women and men are equally likely to be affected by VWD, women continue to be disproportionately affected by the bleeding challenges. Women with VWD suffer from sex-specific symptoms, such as menorrhagia, and are at higher risk of reproductive problems and recurrent miscarriage. Furthermore, pregnant women with VWD are more likely at higher risk of suffering from primary and secondary peripartal hemorrhage and anemia and the need for transfusions. Despite being affected by gynecologic and obstetrical bleeding, women face multiple barriers in obtaining an accurate diagnosis. This constitutes a problem that needs to be addressed, and early appropriate medical care should be ensured. There are several effective treatment options for women with VWD that can significantly improve their quality of life, including desmopressin, VWF concentrates, hormonal therapy, and antifibrinolytic therapy. During pregnancy, the monitoring of VWF activity levels is essential. The peripartal management depends on the type of VWD and on the measured levels of VWF levels and activity prior to delivery.
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Affiliation(s)
- Fagr Eladly
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
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Janbain M, Kouides P. Managing Pregnant Women with Hemophilia and von Willebrand Disease: How Do We Provide Optimum Care and Prevent Complications? Int J Womens Health 2022; 14:1307-1313. [PMID: 36119805 PMCID: PMC9480585 DOI: 10.2147/ijwh.s273043] [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: 04/15/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
The challenge of pregnancy can be significant to the point of being life-threatening in a woman with a bleeding disorder. Additionally there can be a risk to the fetus and the neonate. A hemostatic defect can affect the course of the pregnancy, but the impact is most feared around delivery in the immediate and the extended post partum period, requiring rapid identification and prompt referral to a hematologist for assistance in management. Identifying the type of congenital bleeding disorder and knowing its inheritance pattern is crucial during counseling prior to conception and in preparation for delivery. A comprehensive approach by a specialized and experienced team in a tertiary care center with access to adequate laboratory monitoring and therapies can facilitate the process. The multidisciplinary team should include a hematologist, an obstetrician, a pediatric hematologist, an anesthesiologist, and in select cases a clinical geneticist and a maternal fetal medicine specialist. In this review article, we will detail the diagnostic path and management of pregnancy and delivery in women with some inherited bleeding disorders, in particular those affected by hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD).
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Affiliation(s)
- Maissaa Janbain
- Deming Department of Internal Medicine, Section of Hematology and Medical Oncology, Tulane School of Medicine, New Orleans, LA, USA
| | - Peter Kouides
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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12
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Johnsen JM, MacKinnon HJ. JTH in Clinic - Obstetric bleeding: VWD and other inherited bleeding disorders. J Thromb Haemost 2022; 20:1568-1575. [PMID: 35621921 DOI: 10.1111/jth.15770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Jill M Johnsen
- Bloodworks Research Institute, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
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Berntorp E, Trakymienė SS, Federici AB, Holstein K, Corrales-Medina FF, Pierce GF, Srivastava A, Prondzinski MVD, Johnsen JM, Zupan IP, Halimeh S, Nummi V, Roberts JC. Sixth Åland Island Conference on von Willebrand disease. Haemophilia 2022; 28 Suppl 5:3-15. [PMID: 35861919 PMCID: PMC9543245 DOI: 10.1111/hae.14495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 01/19/2023]
Abstract
Introduction The sixth Åland Islands Conference on von Willebrand disease (VWD) on the Åland Islands, Finland, was held from 20 to 22 September 2018. Aim The meeting brought together experts in the field of VWD from around the world to share the latest advances and knowledge in VWD. Results and discussion The topics covered both clinical aspects of disease management, and biochemical and laboratory insights into the disease. The clinical topics discussed included epidemiology, diagnosis and treatment of VWD in different countries, management of children with VWD, bleeding control during surgery, specific considerations for the management of type 3 VWD and bleeding control in women with VWD. Current approaches to the management of acquired von Willebrand syndrome were also discussed. Despite significant advances in the understanding and therapeutic options for VWD, there remain many challenges to be overcome in order to optimise patient care. In comparison with haemophilia A, there are very few registries of VWD patients, which would be a valuable source of data on the condition and its management. VWD is still underdiagnosed, and many patients suffer recurrent or severe bleeding that could be prevented. Awareness of VWD among healthcare practitioners, including non‐haematologists, should be improved to allow timely diagnosis and intervention. Diagnosis remains challenging, and the development of fast, simple assays may help to facilitate accurate and rapid diagnosis of VWD.
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Affiliation(s)
- Erik Berntorp
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sonata S Trakymienė
- Clinic of Children's Diseases, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Augusto B Federici
- Department of Oncology and Oncologic Haematology, Haematology and Transfusion Medicine, L. Sacco University Hospital, University of Milan, Milan, Italy
| | - Katharina Holstein
- Department of Hematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Fernando F Corrales-Medina
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Miami - Miller School of Medicine and University of Miami - Hemophilia Treatment Center, Miami, Florida, USA
| | | | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Jill M Johnsen
- Research Institute, Bloodworks, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Irena P Zupan
- Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Vuokko Nummi
- Coagulation Disorders Unit, Helsinki University Hospital, Helsinki, Finland
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14
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The Effect of Von Willebrand Disease on Pregnancy, Delivery, and Postpartum Period: A Retrospective Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060774. [PMID: 35744037 PMCID: PMC9231104 DOI: 10.3390/medicina58060774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/13/2022] [Accepted: 06/04/2022] [Indexed: 11/16/2022]
Abstract
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.
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15
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Postpartum hemorrhage in women with von Willebrand disease: Consider other etiologies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:972-977. [PMID: 35569789 DOI: 10.1016/j.jogc.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Higher rates of postpartum hemorrhage (PPH) have been reported for women with von Willebrand disease (VWD). Comprehensive multidisciplinary care reduces these rates; thus PPH may not be secondary to VWD. METHODS We conducted a retrospective review for the period of 2009-2018, including all VWD pregnancies at two tertiary care academic hospitals to determine rates, etiology, and timing of PPH. RESULTS A total of 63 women with 80 pregnancies were included. Three women had twin pregnancies. Sixty-six pregnancies (82.5%) involved type 1 VWD; 4 (5.0%), type 2 (unclear subtype); 3 (3.8%) type 2A; 3 (3.8%) type 2B; and 2 (2.5%), type 2M. Median age of patients was 32.9 years (range 19-43 y). Most patients were blood type O (65%), and 33 of 80 preganancies (41.3%) were nulliparous. The mean bleeding assessment score was 8 (range 0-16). Thirty-seven pregnancies (46.3%) received prophylactic hemostatic treatment prior to delivery. Seventy-four percent of pregnancies were delivered vaginally, and 88% received epidural anaesthesia. The majority of pregnancies (78.8%) had von Willebrand factor (VWF) levels assessed during the third trimester, with most (71.3%) achieving VWF levels above 1.00 IU/mL. Four pregnancies (5.2%) were complicated by primary PPH; uterine atony in 2 and placenta previa in 1. Delayed postpartum bleeding occurred in 5 pregnancies (6.3%). CONCLUSION Multidisciplinary care of pregnancies with VWD improves outcomes. Rates of primary and delayed PPH in this study are lower than previously described and are similar to those of women without VWD. In women with VWD, uterine etiologies for primary PPH need to be considered, in a manner similar to the assessment of women without VWD, to ensure hemostasis is achieved.
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Castaman G, Borchiellini A, Coppola A, Cultrera D, Marino R, Federici AB, Giuffrida AC, Marchesini E, Molinari AC, Maria SS, Zanon E. Use of the von Willebrand factor concentrate with low factor VIII content to manage patients with inherited von Willebrand disease requiring surgical or secondary long-term prophylaxis: An expert opinion paper from an Italian panel. Eur J Haematol 2022; 109:121-128. [PMID: 35531770 DOI: 10.1111/ejh.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present review aims to summarize the state-of-the-art von Willebrand disease (VWD) treatment focusing on specific clinical settings (obstetrics, surgery, long-term prophylaxis and comorbidities) as well as on the use of a Von Willebrand factor (VWF) concentrate with low FVIII content. METHODS Literature research and case reports. RESULTS AND CONCLUSIONS Considering that patients affected by VWD have an intact ability to synthesize FVIII, in order to avoid excessive levels of FVIII, a highly purified plasma VWF concentrate with low FVIII content could be particularly useful in those patients and clinical circumstances at high thrombotic risk as well as for long-term prophylaxis. When deciding the optimal therapeutic strategy, physicians should take into account both the patient's history and the differences among available concentrates according to the clinical situations requiring treatment.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Alessandra Borchiellini
- RRC Thrombosis & Haemophilia Centre, AOU Città della Salute e della Scienza - Molinette Hospital, Turin, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Dorina Cultrera
- Department of Haematology, Haemophilia Regional Reference Centre, University Hospital of Catania, Catania, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Centre, Policlinico Giovanni XXIII, Bari, Italy
| | - Augusto B Federici
- Division of Haematology and Transfusion Medicine, L. Sacco University Hospital and Department of Oncology and Haematology Oncology, University of Milan, Milan, Italy
| | | | - Emanuela Marchesini
- Department of Vascular and Emergency Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Angelo Claudio Molinari
- Regional Reference Centre for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Siboni Simona Maria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Ezio Zanon
- Haemophilia Center, General Medicine, Department of Medicine, University of Padua Medical School, Padua, Italy
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17
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Lenting PJ, Kizlik-Manson C, Casari C. Towards novel treatment options in von Willebrand disease. Haemophilia 2022; 28 Suppl 4:5-10. [PMID: 35521728 DOI: 10.1111/hae.14518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
Deficiency or dysfunction of von Willebrand factor (VWF) is associated with a bleeding disorder known as von Willebrand disease (VWD). The clinical manifestations of VWD are heterogeneous, and are in part dictated by the structural or functional defects of VWF. The tools to control bleeding in VWD are dominated by VWF concentrates, desmopressin and antifibrinolytic therapy. In view of these treatments being considered as effective, it is surprising that quality-of-life studies consistently demonstrate a significant mental and physical burden in VWD patients, particularly in women. Apparently, the current weaponry to support the management of VWD is insufficient to fully address the needs of the patients. It is important therefore to continue to search for innovative treatment options which could better serve the VWD patients. In this short review, two of such options are discussed in more detail: emicizumab to correct for the deficiency of factor VIII (FVIII), and the pegylated aptamer BT200 to increase endogenous levels of the VWF/FVIII complex.
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Affiliation(s)
- Peter J Lenting
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Claire Kizlik-Manson
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Caterina Casari
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
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18
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Sadler B, Castaman G, O’Donnell JS. von Willebrand disease and von Willebrand factor. Haemophilia 2022; 28 Suppl 4:11-17. [PMID: 35521725 PMCID: PMC9094051 DOI: 10.1111/hae.14547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 12/31/2022]
Abstract
Progress in both basic and translational research into the molecular mechanisms of VWD can be seen in multiple fields. GENETICS OF VWD In the past several decades, knowledge of the underlying pathogenesis of von Willebrand disease (VWD) has increased tremendously, thanks in no small part to detailed genetic mapping of the von Willebrand Factor (VWF) gene and advances in genetic and bioinformatic technology. However, these advances do not always easily translate into improved management for patients with VWD and low-VWF levels. VWD AND PREGNANCY For example, the treatment of pregnant women with VWD both pre- and postpartum can be complicated. While knowledge of the VWF genotype at some amino acid positions can aid in knowledge of who may be at increased risk of thrombocytopenia or insufficient increase in VWF levels during pregnancy, in many cases, VWF levels and bleeding severity is highly heterogeneous, making monitoring recommended during pregnancy to optimize treatment strategies. VWF AND COVID-19: New challenges related to the consequences of dysregulation of hemostasis continue to be discovered. The ongoing COVID-19 pandemic has highlighted that VWF has additional biological roles in the regulation of inflammatory disorders and angiogenesis, disruption of which may contribute to COVID-19 induced vasculopathy. Increased endothelial cell activation and Weibel-Palade body exocytosis in severe COVID-19 lead to markedly increased plasma VWF levels. Coupled with impairment of normal ADAMTS13 multimer regulation, these data suggest a role for VWF in the pathogenesis underlying pulmonary microvascular angiopathy in severe COVID-19. CONCLUSION With the increased affordability and availability of next-generation sequencing techniques, as well as a push towards a multi-omic approach and personalized medicine in human genetics, there is hope that translational research will improve VWD patient outcomes.
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Affiliation(s)
- Brooke Sadler
- Washington University School of Medicine, Department of Pediatrics, Division of Hematology/Oncology, St. Louis, MO USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - James S. O’Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland,National Coagulation Centre, St James’s Hospital, Dublin, Ireland
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19
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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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20
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[Chinese guideline on the diagnosis and management of von Willebrand disease (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:1-6. [PMID: 35231984 PMCID: PMC8980664 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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[Interpretation of Chinese guideline on the diagnosis and management of von Willebrand disease (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:13-15. [PMID: 35231986 PMCID: PMC8980658 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Turan O, Kadir RA. Pregnancy in special populations: challenges and solutions practical aspects of managing von Willebrand disease in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:552-558. [PMID: 34889419 PMCID: PMC8791099 DOI: 10.1182/hematology.2021000321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Pregnancy and childbirth pose an important hemostatic challenge for women with von Willebrand disease (VWD) and can be associated with an increased risk of maternal and neonatal bleeding complications. VWD is a genetically and clinically heterogeneous bleeding disorder caused by a deficiency or an abnormality in the function of von Willebrand factor. Understanding inheritance pattern, hemostatic response to pregnancy, and response to treatment is essential for provision of individualized obstetric care and optimal outcome. A multidisciplinary approach to management with a close liaison between the obstetric team and the hemophilia treatment center is required for continuity of care from preconception counseling through to antenatal, peripartum, and postpartum care. Delivery plan must be coordinated by the multidisciplinary team and include decisions on place and mode of delivery, implementation of safe analgesia/anesthesia, and peripartum hemostasis. In this clinical case-based review, we aim to deliver evidence-based practical guidance for challenges encountered during pregnancy and management of childbirth and puerperium.
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Affiliation(s)
- Ozlem Turan
- Katharine Dormandy Haemophilia and Thrombosis Unit and Department of Obstetrics and Gynecology, Royal Free Hospital NHS Trust, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Rezan Abdul Kadir
- Katharine Dormandy Haemophilia and Thrombosis Unit and Department of Obstetrics and Gynecology, Royal Free Hospital NHS Trust, London, UK
- EGA Institute for Women's Health, University College London, London, UK
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23
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Alqahtany FS, ALBackr HB, Aldakhil LO, Alharbi AA, Alqahtani NA, Algahtani FH. Hemostatic profile detailing in apparent VWD cases: A cross sectional study. Saudi J Biol Sci 2021; 28:6701-6704. [PMID: 34866968 PMCID: PMC8626209 DOI: 10.1016/j.sjbs.2021.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 11/02/2022] Open
Abstract
The von willebrand disease (vWD) accounts to be one of the most common hereditary bleeding ailment that amounts its incidence to almost 1.5% of normal population. It is mostly associated with a defect in primary hemostasis as well as secondary defect in coagulation factor VIII as diagnosis of vwd happened to be challenging with earlier diagnostic criteria's. Testing Vwd in menorrhagia patients was not at ease. A cross-sectional study was conducted in female patients who have visited obstetrics and gynecology clinic at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. The inclusion criteria consist of adult female patients between 16 and 45 years old with menorrhagia. A sample of 45 patients were screened and selected for the above-mentioned study. The SPSS Statistical analysis package was performed to analyze the data's. The fisher's exact test was conducted to compare the demographic variables. The independent samples t-test was conducted to compare the means of subjects. The P value of ≤0.05 considered as statistically significant. The cases manifested with a history of bleeding during periods stretching from 7 to 90 days. The vWD was reported in 6.6 % (n = 3) women out of the total 45 patients. The vWF: Ac mean ± SD (51.4 ± 6.3) and vWF: Ag Mean ± SD (93 ± 67) were significantly lesser in vWD patients with that of non-vWD (98.7 ± 22.6) vs (116 ± 42.4) (p = 0.027) (p = 0.032) respectively. WBC, ESR, MCV, MCH, Hemoglobin, PLT count, INR, PT, APTT and FVIII showed no significant difference among the groups (p > 0.05).
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Affiliation(s)
- Fatmah S Alqahtany
- Hematopathology Unit, Department of Pathology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Hanan B ALBackr
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Lateefa O Aldakhil
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf Abdullah Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Farjah H Algahtani
- Division of Oncology/Hematology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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24
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Weyand AC, Flood VH. Von Willebrand Disease: Current Status of Diagnosis and Management. Hematol Oncol Clin North Am 2021; 35:1085-1101. [PMID: 34400042 DOI: 10.1016/j.hoc.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Von Willebrand disease (VWD) is a common bleeding disorder, affecting male and female individuals equally, that often manifests in mucosal bleeding. VWD can be secondary to a quantitative (Type 1 and Type 3) or qualitative (Type 2) defects in Von Willebrand factor (VWF). Initial testing includes VWF antigen, as well as a platelet binding assay to differentiate between qualitative and quantitative defects. Further subtyping requires additional testing and is needed to ensure appropriate treatment. Desmopressin, antifibrinolytics, hormonal treatments for heavy menstrual bleeding, and VWF concentrates are commonly used in the treatment of VWD.
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Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, 1150 W. Medical Center Dr, MSRB III, Room 8220E, Ann Arbor, MI 48109, USA
| | - Veronica H Flood
- Department of Pediatrics, Medical College of Wisconsin and Versiti Blood Research Institute, Milwaukee, WI, USA; Comprehensive Center for Bleeding Disorders, 8739 Watertown Plank Road, PO Box 2178, Milwaukee, WI 53201-2178, USA.
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25
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Recombinant vs plasma-derived von Willebrand factor to prevent postpartum hemorrhage in von Willebrand disease. Blood Adv 2021; 4:3234-3238. [PMID: 32692849 DOI: 10.1182/bloodadvances.2020002046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/25/2020] [Indexed: 01/03/2023] Open
Abstract
von Willebrand disease (VWD) is a congenital bleeding disorder characterized by deficient or defective von Willebrand factor (VWF). Among women with VWD, postpartum hemorrhage (PPH) is common. Treatment options at delivery include plasma-derived VWF (pdVWF) and recombinant VWF (rVWF). However, limited data are available regarding their efficacy. We conducted a retrospective observational study comparing PPH in women with VWD treated at the Hemophilia Center of Western Pennsylvania between 1 February 2017 and 31 January 2018 with either rVWF or pdVWF. We compared postpartum outcomes, including PPH frequency and estimated blood loss (EBL) at delivery. There were a total of 12 deliveries, 7 vaginal and 5 cesarean. At delivery and for 3 days postpartum, 6 women received 80 IU/kg of rVWF and 6 received 80 IU/kg of pdVWF, based on prepregnancy weight, insurance, and/or patient choice. Treatment groups had similar demographics, including median age (32.0 vs 27.0 years; P = .075), bleeding scores (3.0 vs 3.5; P = .734), and prepregnancy body mass index (29.0 vs 29.2 kg/m2; P = .691). PPH occurred in 3 (25.0%) of 12 deliveries, with no difference by treatment group (2 of 6 rVWF vs 1 of 6 pdVWF; P = 1.000) and no difference in EBL by treatment group (685 vs 462 mL; P = .384) or delivery type (vaginal, P = .722 vs cesarean, P = .531). In summary, PPH occurred in one-fourth of the deliveries in women with VWD, despite a higher dose (80 IU/kg) of rVWF or pdVWF. Future trials are needed to develop and assess novel strategies to prevent PPH in VWD.
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26
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von Willebrand disease: what does the future hold? Blood 2021; 137:2299-2306. [PMID: 33662989 DOI: 10.1182/blood.2020008501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
von Willebrand disease (VWD) is characterized by its heterogeneous clinical manifestation, which complicates its diagnosis and management. The clinical management of VWD has remained essentially unchanged over the last 30 years or so, using von Willebrand factor (VWF) concentrates, desmopressin, and anti-fibrinolytic agents as main tools to control bleeding. This is in contrast to hemophilia A, for which a continuous innovative path has led to novel treatment modalities. Despite current VWD management being considered effective, quality-of-life studies consistently reveal a higher than anticipated burden of VWD on patients, which is particularly true for women. Apparently, despite our perceived notion of current therapeutic efficiency, there is space for innovation with the goal of reaching superior efficacy. Developing innovative treatments for VWD is complex, especially given the heterogeneity of the disease and the multifunctional nature of VWF. In this perspective article, we describe several potential strategies that could provide the basis for future VWD treatments. These include genetic approaches, such as gene therapy using dual-vector adenoassociated virus and transcriptional silencing of mutant alleles. Furthermore, protein-based approaches to increase factor FVIII levels in VWD-type 3 or 2N patients are discussed. Finally, antibody-based options to interfere with VWF degradation (for congenital VWD-type 2A or acquired von Willebrand syndrome-type 2A) or increase endogenous VWF levels (for VWD-type 1) are presented. By highlighting these potential strategies, we hope to initiate an innovative path, which ultimately would allow us to better serve VWD patients and their specific needs.
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27
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Reale SC, Farber MK, Lumbreras-Marquez MI, Connors JM, Carabuena JM. Anesthetic Management of Von Willebrand Disease in Pregnancy: A Retrospective Analysis of a Large Case Series. Anesth Analg 2021; 133:1244-1250. [PMID: 33913917 DOI: 10.1213/ane.0000000000005502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although Von Willebrand disease (vWD) is the most common heritable bleeding disorder, there are limited reports regarding the safety of neuraxial anesthesia in the obstetric population and no definitive guidelines specifying recommended pretreatment or therapies for patients with vWD. The aim of this study is to describe the anesthetic management of pregnant patients with vWD at a large tertiary-care center. METHODS In this retrospective analysis, the study population was identified from vWD patients evaluated by our high-risk obstetric anesthesia consultation service and by diagnosis codes from our institutional research database registry. We manually reviewed records of patients with vWD in pregnancy who delivered at our institution between January 1, 2000 and January 1, 2019 for demographic characteristics, circumstances of vWD diagnosis, history of bleeding, laboratory studies, and overall management of vWD. Anesthetic management of vWD was at the discretion of individual providers, based on multidisciplinary consensus and the specific circumstances of each patient's disease and obstetric presentation. RESULTS We identified 106 deliveries among 71 individual vWD patients. Of the unique patients, 54 had vWD type 1, 6 had vWD type 2, and 11 had vWD type unknown. Forty-three cases (40.6%) were cesarean deliveries. Neuraxial techniques were used in 94 of 106 deliveries (88.7%). Treatment with desmopressin or Von Willebrand factor/factor VIII concentrate before neuraxial anesthesia occurred in 27 of 94 neuraxial anesthetics (28.7%). Eleven deliveries (10.4%) were complicated by postpartum hemorrhage (PPH), defined as estimated blood loss of ≥1000 mL. There were no noted adverse anesthetic outcomes (0 of 106; 0% [95% confidence interval, 0-3.4]), including neuraxial hematoma or thromboembolic events. CONCLUSIONS In this large case series, the majority of vWD patients received neuraxial anesthesia for labor and delivery, with no noted adverse events. This suggests that neuraxial anesthesia can be safely performed with the peripartum management that we describe. Pretreatment was dictated by the type and severity of vWD. Multidisciplinary planning is important to optimize the coagulation status of patients with vWD and facilitate options for analgesia and anesthesia.
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Affiliation(s)
- Sharon C Reale
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | - Michaela K Farber
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | | | - Jean M Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jean M Carabuena
- From the Department of Anesthesiology, Perioperative and Pain Medicine
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28
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How I manage pregnancy in carriers of hemophilia and patients with von Willebrand disease. Blood 2021; 136:2143-2150. [PMID: 32797211 DOI: 10.1182/blood.2019000964] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Women with inherited bleeding disorders, including carriers of hemophilia A and B, or with von Willebrand disease, have an increased risk of bleeding during pregnancy and delivery. The unborn child may also be affected by the bleeding disorder for which specific measures have to be considered. This requires a multidisciplinary approach, with a team that includes a hematologist, a pediatric hematologist, a clinical geneticist, an obstetrician-perinatologist, and an anesthesiologist. An optimal approach includes prepregnancy genetic counseling, prenatal diagnostic procedures, and a treatment plan for delivery for both the mother and child. Recent retrospective studies show that even if strict guidelines are followed, these women are still at risk of postpartum bleeding. This occurs even if coagulation factor levels are normalized, either due to the pregnancy-induced rise of factor levels or by infusion of coagulation factor concentrates at the time of delivery. In this article, we describe our current diagnostic and clinical management of pregnancy and delivery in women with inherited bleeding disorders. We also briefly discuss possible interventions to improve the outcome of current strategies by increasing target factor levels during and after delivery.
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29
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Makhamreh MM, Russo ML, Karl T, Delgado N, Lackritz K, Skupski DW, Al-Kouatly HB. Type 2B von Willebrand Disease in Pregnancy: A Systematic Literature Review. Semin Thromb Hemost 2021; 47:201-216. [PMID: 33636751 DOI: 10.1055/s-0041-1723799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Our objective was to review the maternal characteristics and obstetric complications in women with type 2B von Willebrand disease (VWD). A systematic literature search was conducted using PubMed, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included all publications that addressed type 2B VWD in pregnancy. Our primary and secondary outcomes were incidence of postpartum hemorrhage (PPH) and incidence of thrombocytopenia in pregnancy. Two reviewers independently identified eligible studies and abstracted data including maternal characteristics, hematologic characteristics, treatment, and delivery outcomes. Twenty studies met inclusion criteria. There were 27 women (32 pregnancies) with type 2B VWD. Primary PPH was reported in 9/20 women (45%) and secondary PPH was reported in 6/13 women (46%). Thrombocytopenia in pregnancy was present in 27/28 women (96%); 23/27 women (85%) had platelet count <100 × 109/L, mean 33.7 ± 22.7 × 109/L. Factor concentrate treatment was administered before delivery (n = 16) and postpartum (n = 18), some women received both. Seventeen deliveries required blood products postpartum with 13/17 (76%) platelet transfusions and 6/17 (35%) red blood cell transfusions. No maternal mortality was reported. Women with type 2B VWD have significant morbidity in pregnancy related to high incidence of severe thrombocytopenia and primary and secondary PPH.
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Affiliation(s)
- Mona M Makhamreh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Melissa L Russo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Taylor Karl
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Natalie Delgado
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Lackritz
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel W Skupski
- Departments of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York, and New York Presbyterian-Queens, Flushing, New York
| | - Huda B Al-Kouatly
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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30
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Wilson E, Hanna F, Hyppa A, Orlowski E, Dawar HU, Sanga Z, Dennis A, Pavlov T, Khalafallah AA. Assessment of von Willebrand disease and pregnancy outcomes at regional Australian hospitals. Eur J Haematol 2021; 106:456-466. [PMID: 33289927 DOI: 10.1111/ejh.13562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/03/2020] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Emily Wilson
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, TAS, Australia
| | - Fayez Hanna
- Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia
| | | | - Ella Orlowski
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, TAS, Australia
| | | | - Zar Sanga
- Augusta Medical Centre, Hobart, TAS, Australia
| | - Amanda Dennis
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, TAS, Australia
| | - Toly Pavlov
- Department of Obstetrics and Gynaecology, Launceston General Hospital, Launceston, TAS, Australia
| | - Alhossain A Khalafallah
- Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia.,Specialist Care Australia, Launceston, TAS, Australia
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Thachil J. Dual origins and dual roles for von Willebrand factor. J Thromb Haemost 2021; 19:308-309. [PMID: 33405379 DOI: 10.1111/jth.15152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
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32
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Puthenveettil N, Mathew J, Rajan S, Kumar L. Anesthesia for cesarean section in a patient with von willebrand's Disease. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.4103/joacc.joacc_52_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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33
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Castaman G. How I treat von Willebrand disease. Thromb Res 2020; 196:618-625. [DOI: 10.1016/j.thromres.2020.07.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/17/2023]
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Wheeler AP, Hemingway C, Gailani D. The clinical management of factor XI deficiency in pregnant women. Expert Rev Hematol 2020; 13:719-729. [PMID: 32437625 DOI: 10.1080/17474086.2020.1772745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Factor XI (FXI) deficiency is associated with highly variable bleeding, including excessive gynecologic and obstetrical bleeding. Since approximately 20% of FXI-deficient women will experience pregnancy-related bleeding, careful planning and knowledge of appropriate hemostatic management is pivotal for their care. AREAS COVERED In this manuscript, authors present our current understanding of the role of FXI in hemostasis, the nature of the bleeding phenotype caused by its deficiency, and the impact of deficiency on obstetrical care. The authors searched PubMed with the terms, 'factor XI', 'factor XI deficiency', 'women', 'pregnancy', and 'obstetrics' to identify literature on these topics. Expectations of pregnancy-related complications in women with FXI deficiency, including antepartum, abortion-related, and postpartum bleeding, as well as bleeding associated with regional anesthesia are discussed. Recommendations for the care of these women are considered, including guidance for management of prophylactic care and acute bleeding. EXPERT COMMENTARY FXI deficiency results in a bleeding diathesis in some, but not all, patients, making treatment decisions and clinical management challenging. Currently available laboratory assays are not particularly useful for distinguishing patients with FXI deficiency who are prone to bleeding from those who are not. There is a need for alternative testing strategies to address this limitation.
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Affiliation(s)
- Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University , Nashville, TN, USA
| | - Celeste Hemingway
- Department of Obstetrics and Gynecology, Vanderbilt University , Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA
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Hobgood DK. ABO O gene frequency increase in the US might be causing increased maternal mortality. Med Hypotheses 2020; 144:109971. [PMID: 32540606 DOI: 10.1016/j.mehy.2020.109971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 10/24/2022]
Abstract
Maternal mortality rate has increased in the United States over the past 30 years from 16 deaths per 100,000 births to 28 deaths per 100,000 births while the rest of the world is experiencing declining rates. Increasing obesity and c-section rates in the US have been cited as contributing factors needing remediation, and because of the two to three fold difference in maternal mortality rates in non-Hispanic black women compared to white women, inequality and implicit racial bias has been targeted as well for remediation. Using an epidemiologic approach, a hypothesis here brought to bear is that US immigration policy changes over the past 50 years have brought changes in the gene pool that have caused increasing obstetric hemorrhage and other causes of maternal death. ABO gene frequencies have changed in the US during this time such that ABO O, a gene associated with hemorrhage and mortality in pregnancy, has increased in frequency in the US thus increasing population maternal mortality rate. Using mendelian randomization logic, noting the increase in ABO O gene in the US population over the past 30 years and the association of ABO O gene with both hemorrhage and lower longevity, the increase in frequency of the ABO O gene in the past 30 years in the US population might be causative of an increase in maternal mortality rate. Consequences of this hypothesis would include recognition of the role of ABO gene and thus ABO blood group in prediction of risk of obstetric hemorrhage. Thus those at risk on this basis would be under high surveillance and would have medications and treatment strategies readily available. While research on ABO gene and pregnancy has been done, much of the research is being done in countries other than the US, and given the increasing mortality in the US as well as the role that ABO gene may have in that, further research needs to be done in US populations to quantify risk for all adverse events in pregnancy related to ABO blood type including hemorrhage as well as inter-related causes including pre-eclampsia, cardiovascular disease, thromboembolic disease and infection.
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Affiliation(s)
- Donna K Hobgood
- Chattanooga Units of UT College of Medicine, Chattanooga, Tennessee 37403, 1751 Gunbarrel Road, Suite 200, Chattanooga, TN 37421, USA
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James AH. Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the obstetrician's view. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:148-151. [PMID: 31808870 PMCID: PMC6913476 DOI: 10.1182/hematology.2019000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This is the obstetrician's view on 3 different clinical scenarios involving bleeding and thrombotic disorders. In the first scenario, an 18 year old with a history of heavy menstrual bleeding since menarche presents with abdominal pain and ultrasound findings suggestive of a hemorrhagic ovarian cyst. The association with an underlying bleeding disorder is recognized. The goals of management, which are controlling hemorrhage and preserving fertility, are stated. Ovarian suppression, the most effective method to prevent recurrent hemorrhagic ovarian cysts, is outlined. Long-term management of heavy menstrual bleeding with hormonal contraception is described. In the second scenario, the same patient returns 5 years later for a preconception visit. The potential risks to an unborn baby with von Willebrand disease (VWD) are addressed. The natural rise in von Willebrand factor (VWF) during pregnancy is discussed, but the fact that women with VWD do not achieve the same VWF levels as women without VWD is emphasized and the implications are presented. In anticipation of pregnancy, the need for nonhormonal management of heavy menstrual bleeding and hemorrhagic ovarian cysts is mentioned. In the third and final scenario, the patient's cousin with factor V Leiden seeks consultation regarding the risks of thrombosis with in vitro fertilization. The steps of assisted reproductive technology are described. The strategies to prevent venous thromboembolism by preventing ovarian hyperstimulation and reducing the likelihood of multiple gestation are detailed.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC
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37
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Itzhar-Baikian N, Boisseau P, Joly B, Veyradier A. Updated overview on von Willebrand disease: focus on the interest of genotyping. Expert Rev Hematol 2019; 12:1023-1036. [PMID: 31536379 DOI: 10.1080/17474086.2019.1670638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Von Willebrand disease (VWD) is the most common inherited bleeding disorder, characterized by a quantitative or qualitative defect of von Willebrand factor (VWF), a multimeric glycoprotein crucial for primary hemostasis and coagulation. VWD pathophysiology is heterogeneous as it includes several types and subtypes which therapeutic management is different. The mainstays of VWD treatment are desmopressin and replacement therapy based on both plasma-derived concentrates and a recently developed recombinant VWF. VWD definitive diagnosis is achieved by a battery of phenotypic biologic assays and genotyping is currently performed mostly for research.Areas covered: This narrative review will firstly present a general overview on VWD epidemiology, pathophysiology, classification, clinics, phenotypic biologic diagnosis, and treatment. Secondly, a focus on VWD genotyping will be presented with specific emphasis on the evolution of its technical aspects, its applications for research dedicated to a better understanding of VWD pathophysiology and epidemiology and its interest in both a faster diagnosis and an optimal treatment of VWD.Expert opinion: Based on analysis of the literature, it can be concluded that the fast evolution of genetic techniques together with the development of innovating treatments may significantly change diagnostic flow charts for VWD and their use for specific and personalized treatment.
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Affiliation(s)
- Nathalie Itzhar-Baikian
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Pierre Boisseau
- Service de Génétique médicale, Hôpital Hôtel-Dieu, CHU de Nantes, Nantes, France
| | - Bérangère Joly
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Agnès Veyradier
- Service d'Hématologie biologique Hôpital Lariboisière and EA-3518 Institut de Recherche Saint Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
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38
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Leebeek FWG, Atiq F. How I manage severe von Willebrand disease. Br J Haematol 2019; 187:418-430. [PMID: 31498884 PMCID: PMC6899759 DOI: 10.1111/bjh.16186] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder. Most patients with mild and moderate VWD can be treated effectively with desmopressin. The management of severe VWD patients, mostly affected by type 2 and type 3 disease, can be challenging. In this article we review the current diagnosis and treatment of severe VWD patients. We will also discuss the management of severe VWD patients in specific situations, such as pregnancy, delivery, patients developing alloantibodies against von Willebrand factor and VWD patients with recurrent gastrointestinal bleeding. Moreover, we review emerging treatments that may be applied in future management of patients with severe VWD.
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Affiliation(s)
- Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Ferdows Atiq
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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