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Iorio A, James P, Ma A, Srivastava A. Hemostatic management of von Willebrand disease during childbirth with a plasma-derived von Willebrand factor/factor VIII concentrate. J Thromb Haemost 2024; 22:2739-2744. [PMID: 38950781 DOI: 10.1016/j.jtha.2024.06.015] [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: 11/23/2023] [Revised: 03/27/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Females with von Willebrand disease (VWD) do not show the same increases in von Willebrand factor and factor (F)VIII levels during pregnancy as females without VWD and are at higher risk of excessive bleeding associated with childbirth. Data on hemostatic management for childbirth in VWD patients are limited. OBJECTIVES To evaluate the dosing, efficacy, and safety of plasma-derived von Willebrand factor/FVIII (wilate) for prevention of excessive bleeding associated with childbirth in females with any type of VWD. METHODS Data for females with VWD who received wilate for hemostatic coverage for childbirth during 2 prospective clinical studies were analyzed. RESULTS Ten females with VWD and a mean age at enrolment of 29.6 years were treated with wilate to prevent excessive bleeding associated with childbirth. Two patients had type 1, 4 had type 2 (2 2A, 1 2B, and 1 2M), and 4 had type 3 VWD. Of the 10 deliveries, 5 were by cesarean section. Patients received a mean of 9.5 infusions of wilate over 6.8 exposure days, with a mean total dose of 234 IU/kg per delivery and 25 IU/kg per infusion. Hemostatic management for all deliveries was rated excellent or good, with no excessive bleeding during delivery and no postpartum bleeding during the period of wilate treatment in any patient. Two patients experienced 8 possible or probable treatment-related adverse events; all were mild or moderate and resolved. No thromboembolic events were observed. CONCLUSION The results of this case series indicate that wilate provided effective hemostatic cover for childbirth in females with VWD during delivery and postpartum.
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Affiliation(s)
- Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alice Ma
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alok Srivastava
- Department of Haematology, Christian Medical College Vellore, Ranipet Campus, Tamil Nadu, India
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Seidizadeh O, Eikenboom JCJ, Denis CV, Flood VH, James P, Lenting PJ, Baronciani L, O'Donnell JS, Lillicrap D, Peyvandi F. von Willebrand disease. Nat Rev Dis Primers 2024; 10:51. [PMID: 39054329 DOI: 10.1038/s41572-024-00536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/27/2024]
Abstract
von Willebrand disease (VWD) is the most common inherited bleeding disorder. The disorder is characterized by excessive mucocutaneous bleeding. The most common bleeding manifestations of this condition include nosebleeds, bruising, bleeding from minor wounds, menorrhagia or postpartum bleeding in women as well as bleeding after surgery. Other less frequent symptoms include gastrointestinal bleeding, haematomas or haemarthroses. VWD pathophysiology is complex and results from defects in von Willebrand factor (VWF) glycoprotein. Quantitative deficiencies are responsible for type 1 VWD with a partial decrease of VWF and type 3 with the complete absence of VWF. Qualitative abnormalities cause type 2 VWD, being further divided into types 2A, 2B, 2M and 2N. Although common, VWD is at risk of misdiagnosis, overdiagnosis and underdiagnosis owing to several factors, including complex diagnosis, variability of bleeding symptoms, presence of external variables (blood groups and other physiological modifiers such as exercise, thyroid hormones, oestrogens, and ageing), and lack of disease awareness among non-specialist health-care providers. Establishing the correct VWD diagnosis requires an array of specialized phenotypic assays and/or molecular genetic testing of the VWF gene. The management of bleeding includes increasing endogenous VWF levels with desmopressin or infusion of exogenous VWF concentrates (plasma-derived or recombinant). Fibrinolytic inhibitors, topical haemostatic agents and hormonal therapies are used as effective adjunctive measures.
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Affiliation(s)
- Omid Seidizadeh
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Jeroen C J Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Cécile V Denis
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Veronica H Flood
- Department of Paediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Peter J Lenting
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Luciano Baronciani
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
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Reitsma SE, Barsoum JR, Hansen KC, Sassin AM, Dzieciatkowska M, James AH, Aagaard KM, Ahmadzia HK, Wolberg AS. Agnostic identification of plasma biomarkers for postpartum hemorrhage risk. Am J Obstet Gynecol 2024:S0002-9378(24)00576-3. [PMID: 38710264 DOI: 10.1016/j.ajog.2024.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/20/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Postpartum hemorrhage is difficult to predict, is associated with significant maternal morbidity, and is the leading cause of maternal mortality worldwide. The identification of maternal biomarkers that can predict increased postpartum hemorrhage risk would enhance clinical care and may uncover mechanisms that lead to postpartum hemorrhage. OBJECTIVE This retrospective case-control study employed agnostic proteomic profiling of maternal plasma samples to identify differentially abundant proteins in controls and postpartum hemorrhage cases. STUDY DESIGN Maternal plasma samples were procured from a cohort of >60,000 participants in a single institution's perinatal repository. Postpartum hemorrhage was defined as a decrease in hematocrit of ≥10% or receipt of transfusion within 24 hours after delivery. Postpartum hemorrhage cases (n=30) were matched by maternal age and delivery mode (vaginal or cesarean) with controls (n=56). Mass spectrometry was used to identify differentially abundant proteins using integrated peptide peak areas. Statistically significant differences between groups were defined as P<.05 after controlling for multiple comparisons. RESULTS By study design, cases and controls did not differ in race, ethnicity, gestational age at delivery, blood type, or predelivery platelet count. Cases had slightly but significantly lower predelivery and postdelivery hematocrit and hemoglobin. Mass spectrometry detected 1140 proteins, including 77 proteins for which relative abundance differed significantly between cases and controls (fold change >1.15, P<.05). Of these differentially abundant plasma proteins, most had likely liver or placental origins. Gene ontology term analysis mapped to protein clusters involved in responses to wound healing, stress response, and host immune defense. Significantly differentially abundant proteins with the highest fold change (prostaglandin D2 synthase, periostin, and several serine protease inhibitors) did not correlate with predelivery hematocrit or hemoglobin but identified postpartum hemorrhage cases with logistic regression modeling revealing good-to-excellent area under the operator receiver characteristic curves (0.802-0.874). Incorporating predelivery hemoglobin with these candidate proteins further improved the identification of postpartum hemorrhage cases. CONCLUSION Agnostic analysis of maternal plasma samples identified differentially abundant proteins in controls and postpartum hemorrhage cases. Several of these proteins are known to participate in biologically plausible pathways for postpartum hemorrhage risk and have potential value for predicting postpartum hemorrhage. These findings identify candidate protein biomarkers for future validation and mechanistic studies.
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Affiliation(s)
- Stéphanie E Reitsma
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Julia R Barsoum
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Science, Washington DC
| | - Kirk C Hansen
- Biochemistry and Molecular Genetics, The University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Alexa M Sassin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Monika Dzieciatkowska
- Biochemistry and Molecular Genetics, The University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology Duke University School of Medicine, Durham, NC; Department of Medicine under Hematology, Duke University School of Medicine, Durham, NC
| | - Kjersti M Aagaard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Science, Washington DC.
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC.
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Alam AU, Wu C, Kaul P, Jain V, Sun HL. Impact of inherited bleeding disorders on maternal bleeding and other pregnancy outcomes: A population-based cohort study. Haemophilia 2024; 30:478-489. [PMID: 38266510 DOI: 10.1111/hae.14922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 01/26/2024]
Abstract
INTRODUCTION Increasing rate of postpartum haemorrhage (PPH) has been observed between 2003 and 2010 in Canada. Inherited bleeding disorders contribute to the risk of PPH. AIM To identify the trend in PPH in the last decade, assess the impact of bleeding disorders on pregnancy outcomes and evaluate their coagulation workup during pregnancy. METHODS We conducted a population-based retrospective cohort study using the Alberta Pregnancy Birth Cohort from 2010 to 2018. We included women with von Willebrand disease (VWD) and haemophilia, identified by previously validated algorithm and matched with controls. Logistic regression was used to compute odds of PPH and other pregnancy outcomes. RESULTS We identified 311,330 women with a total of 454,400 pregnancies with live births. The rate of PPH did not change significantly from 10.13 per 100 deliveries (95% CI 10.10-10.16) in 2010-10.72 (95% CI 10.69-10.75) in 2018 (p for trend = .35). Women with bleeding disorders were significantly more likely to experience PPH (odds ratio [OR] 2.3; 95% CI 1.5-3.6), antepartum haemorrhage (OR 2.9; 95% CI 1.5-5.9) and red cell transfusion (OR 2.8; 95% CI 1.1-7.0). We observed a nonsignificant rise in the rate of PPH in women with VWD and haemophilia. Only 49.5% pregnancies with bleeding disorders had third trimester coagulation factor levels checked. Higher odds of PPH and antepartum haemorrhage were observed even with factor levels ≥0.50 IU/mL in third trimester. CONCLUSION Despite comprehensive care in women with bleeding disorders, they are still at higher risk of adverse pregnancy outcomes compared to population controls.
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Affiliation(s)
- Arafat Ul Alam
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Cynthia Wu
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Padma Kaul
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Venu Jain
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
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Lim MY, Rodgers GM, Branch DW, Simonsen SE. Targeting a higher plasma VWF level at time of delivery in pregnant individuals with von Willebrand disease: Outcomes at a single-institution cohort study. Haemophilia 2024; 30:470-477. [PMID: 38343098 DOI: 10.1111/hae.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Guidelines on the management of pregnant individuals with von Willebrand disease (VWD) at the time of delivery recommend that von Willebrand factor (VWF) and factor VIII:C (FVIII:C) levels be ≥50% to prevent postpartum haemorrhage (PPH). Yet, high PPH rates persist despite these levels or with prophylactic factor replacement therapy to achieve these levels. AIMS The current practice at our centre has been to target peak plasma VWF and FVIII:C levels of ≥100 IU/dL at time of delivery. The objective of this study was to describe obstetric outcomes in pregnant individuals with VWD who were managed at our centre. METHODS Demographics and outcomes on pregnant individuals with VWD who delivered between January 2015 and April 2023 were collected. RESULTS Forty-seven singleton deliveries (among 41 individuals) resulting in 46 live births and one foetal death were included. Twenty-one individuals had at least one prior birth by the start date of this study, of which 11 (52.4%) self-reported a history of PPH. Early PPH occurred in 12.8% (6/47) of deliveries. Two individuals required blood transfusion, of which one also had an unplanned hysterectomy and transfer to ICU. There were no thrombotic events reported. CONCLUSION The strategy of targeting higher peak plasma VWF and FVIII:C levels (≥100 IU/dL) at the time of delivery may be effective in reducing the risk of delivery-associated bleeding complications in VWD patients. Yet, the rate of early PPH remains unsatisfactory compared to the non-VWD population.
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Affiliation(s)
- Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - George M Rodgers
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Sara E Simonsen
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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6
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Al Arashi W, Romano LGR, Leebeek FWG, Kruip MJHA, van Galen KPM, Turan O, Kadir RA, Cnossen MH. Desmopressin to prevent and treat bleeding in pregnant women with an inherited bleeding disorder: a systematic literature review. J Thromb Haemost 2024; 22:126-139. [PMID: 37778511 DOI: 10.1016/j.jtha.2023.09.021] [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: 05/23/2023] [Revised: 08/28/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Although desmopressin (DDAVP) is an accessible and inexpensive hemostatic drug, its use in pregnancy is still debated due to safety uncertainties. OBJECTIVES We aimed to review the safety and effectiveness of DDAVP in women with an inherited bleeding disorder during pregnancy and delivery. METHODS Databases were searched for articles up to July 25, 2022, reporting maternal and/or neonatal outcomes. PRISMA methodology for systematic reviews and meta-analyses was followed (PROSPERO CRD42022316490). RESULTS Fifty-three studies were included, comprising 273 pregnancies. Regarding maternal outcomes, DDAVP was administered in 73 women during pregnancy and in 232 during delivery. Safety outcome was reported in 245 pregnancies, with severe adverse events reported in 2 (1%, hyponatremia with neurologic symptoms). Overall, DDAVP was used as monotherapy in 234 pregnancies, with effectiveness reported in 153 pregnancies (82% effective; 18% ineffective). Regarding neonatal outcomes, out of 60 pregnancies with reported neonatal outcomes after DDAVP use during pregnancy, 2 children (3%) had a severe adverse event (preterm delivery n = 1; fetal growth restriction n = 1). Of the 232 deliveries, 169 neonates were exposed to DDAVP during delivery, and in 114 neonates, safety outcome was reported. Two children (2%) experienced a moderate adverse event (low Apgar score n = 1; transient hyperbilirubinemia not associated with DDAVP n = 1). CONCLUSION DDAVP use during pregnancy and delivery seems safe for the mother, with special attention to the occurrence of hyponatremia and for the child, especially during delivery. However, due to poor study designs and limited documentation of outcomes, a well-designed prospective study is warranted.
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Affiliation(s)
- Wala Al Arashi
- Department of Pediatric and Oncology Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Lorenzo G R Romano
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin P M van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Ozlem Turan
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, UK
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, UK
| | - Marjon H Cnossen
- Department of Pediatric and Oncology Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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James AH. Management of pregnant women who have bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:229-236. [PMID: 38066866 PMCID: PMC10727034 DOI: 10.1182/hematology.2023000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management of bleeding disorders in pregnant women requires not only an understanding of bleeding disorders but also an understanding of when and how bleeding occurs in pregnancy. Bleeding does not occur during a normal pregnancy with a healthy placenta. Bleeding occurs during pregnancy when there is an interruption of the normal utero-placental interface, during miscarriage, during an ectopic pregnancy, or at the time of placental separation at the conclusion of pregnancy. Although mild platelet defects may be more prevalent, the most commonly diagnosed bleeding disorder among women is VWD. Other bleeding disorders are less common, but hemophilia carriers are unique in that they are at risk of bleeding themselves and of giving birth to an affected male infant. General guidance for maternal management of a woman who is moderately or severely affected includes obtaining coagulation factor levels at a minimum in the third trimester; planning for delivery at a center with hemostasis expertise; and anticipating the need for hemostatic agents. General guidance for fetal management includes pre-pregnancy counseling; the option of preimplantation genetic testing for hemophilia; delivery at a tertiary care center with pediatric hematology and newborn intensive care; consideration of cesarean delivery of a potentially severely affected infant; and avoidance of invasive procedures such as scalp electrodes and operative vaginal delivery in any potentially affected infant.
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Affiliation(s)
- Andra H. James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology; and Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC
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Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
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9
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Niu B, Duffett L, El-Chaâr D, Tinmouth A, Wang TF, Khalife R. Bleeding disorders and postpartum hemorrhage by mode of delivery: a retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100166. [PMID: 37255855 PMCID: PMC10225912 DOI: 10.1016/j.rpth.2023.100166] [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: 09/09/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 06/01/2023] Open
Abstract
Background Pregnant persons with bleeding disorders and their potentially affected newborns are at a higher risk of peripartum bleeding complications. The safest mode of delivery for persons with bleeding disorders remains debated, leading to uncertainties in decision-making between the patient and her multidisciplinary team. Objectives This study aimed to describe maternal outcomes for pregnant persons with bleeding disorders by mode of delivery and to examine whether postpartum hemorrhage (PPH) and neonatal hemorrhagic manifestations are associated with the mode of delivery. Methods We collected retrospective data on pregnant persons with bleeding disorders who delivered at a single center from 2010 to 2021. Descriptive statistics, Fisher exact test, and odds ratios were used for analysis. Results A total of 82 pregnancies in 56 subjects were included. Hemophilia A and von Willebrand disease represented the largest cohort, at 30% (17/56) each. Overall rates of primary and secondary PPH were 7.3% (6/82) and 17.4% (12/69), respectively. We did not find a statistically significant difference between mode of delivery and PPH. Upon comparing vaginal and cesarian deliveries, we found an odds ratio of 0.7 (95% CI, 0.1-3.4) for primary PPH and 2.6 (95% CI, 0.4-16.4) for secondary PPH. One male newborn with severe hemophilia A was treated for a suspected intracranial hemorrhage. Conclusion In our cohort, high rates of PPH remained an important complication for pregnant persons with bleeding disorders. There was no significant difference in PPH based on modes of delivery. The small sample size likely limited the power of our study, and consequently, future larger studies are needed.
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Affiliation(s)
- Bonnie Niu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Duffett
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Darine El-Chaâr
- Department of Obstetrics and Gynecology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Roy Khalife
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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10
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Maas DPMSM, Saes JL, Blijlevens NMA, Cnossen MH, den Exter PL, van der Heijden OWH, Kruis IC, Meijer K, Peters M, Schutgens REG, van Heerde WL, Nieuwenhuizen L, Schols SEM. High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study. J Thromb Haemost 2023; 21:499-512. [PMID: 36696205 DOI: 10.1016/j.jtha.2022.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/27/2022] [Accepted: 11/22/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. OBJECTIVE To describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. METHODS In the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient-reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). RESULTS A total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. CONCLUSION PPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.
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Affiliation(s)
- Dominique P M S M Maas
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Joline L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Ilmar C Kruis
- Netherlands Hemophilia Society, Nijkerk, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Peters
- Department of Pediatric Hematology, Amsterdam University Medical Centers, Location Emma Children's Hospital, Amsterdam, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht and University Utrecht, Utrecht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Laurens Nieuwenhuizen
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands; Department of Hematology, Maxima Medical Center, Eindhoven, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands; Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, The Netherlands.
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11
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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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12
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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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13
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Hews-Girard JC, Galica J, Goldie C, James P, Tranmer JE. Identifying the effect of inherited bleeding disorders on the development of postpartum hemorrhage: a population-based, retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100104. [PMID: 37063757 PMCID: PMC10099304 DOI: 10.1016/j.rpth.2023.100104] [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: 07/11/2022] [Revised: 12/19/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
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.
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Affiliation(s)
- Julia C. Hews-Girard
- School of Nursing, Queen’s University, Kingston, Ontario, USA
- Faculty of Nursing, University of Calgary, Calgary, Alberta, USA
| | | | | | - Paula James
- Department of Medicine, Queen’s University, Kingston, Ontario, USA
| | - Joan E. Tranmer
- School of Nursing, Queen’s University, Kingston, Ontario, USA
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14
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Kalvehalli Kashinath S, Kouides PA. The diagnosis, natural history, and management of von Willebrand disease in women in the age of guidelines. Expert Rev Hematol 2023:1-16. [PMID: 36609196 DOI: 10.1080/17474086.2023.2166925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Women and girls with bleeding disorders face multiple bleeding challenges throughout their life. The most significant morbidity and mortality are due to heavy menstrual bleeding and postpartum hemorrhage in their reproductive years. The ASH/ISTH/NHF/WFH 2021 guidelines on diagnosing and managing von Willebrand disease (VWD) provide several new updates. AREAS COVERED Women with VWD have a higher prevalence of heavy menstrual bleeding. The subpopulation of adolescents is particularly vulnerable, as the diagnosis is often delayed with increased comorbidity of iron deficiency anemia and associated symptoms. A detailed review is done on the prevalence of bleeding-related complications, especially heavy menstrual bleeding (HMB) and post-partum hemorrhage (PPH). The management strategies are also reviewed in detail, with a specific focus on the target factor levels and the use of antifibrinolytics. EXPERT OPINION The 2021 ASH/ISTH/NHF/WFH diagnostic and management recommendations are reviewed with a specific focus on hormonal methods of HMB management and antifibrinolytics in this situation. The reviewed topics include neuraxial anesthesia, factor cutoff, and tranexamic acid use in the postpartum period.
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Affiliation(s)
- Sanjana Kalvehalli Kashinath
- Department of Hematology Oncology, Mary M. Gooley Hemophilia Center, Inc., The Rochester General Hospital, 14621, Rochester, NY, USA
| | - Peter A Kouides
- Department of Hematology Oncology, Mary M. Gooley Hemophilia Center, Inc., The Rochester General Hospital, 14621, Rochester, NY, USA.,Department of Hematology Oncology, University of Rochester School of Medicine, Rochester, NY, USA
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15
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Du P, Bergamasco A, Moride Y, Truong Berthoz F, Özen G, Tzivelekis S. Von Willebrand Disease Epidemiology, Burden of Illness and Management: A Systematic Review. J Blood Med 2023; 14:189-208. [PMID: 36891166 PMCID: PMC9987238 DOI: 10.2147/jbm.s389241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/06/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Although hereditary von Willebrand disease (VWD) is the most common bleeding disorder, its epidemiology is not well understood. A systematic review (PROSPERO CRD42020197674/CRD42021244374) on the epidemiology/burden of illness of VWD was conducted to better understand patients' unmet needs. Methods Observational studies (published January 1, 2010 to April 14, 2021) were identified in MEDLINE and Embase databases, using free-text keywords and thesaurus terms for VWD and outcomes of interest. Pragmatic web-based searches of the gray literature, including conference abstracts, were performed, and reference lists of retained publications were manually searched for additional sources. Case reports and clinical trials (phase 1-3) were excluded. Outcomes of interest were incidence, prevalence, mortality, patient characteristics, burden of illness, and therapeutic management/treatments currently used for VWD. Results Of the 3095 identified sources, 168 were included in this systematic review. Reported VWD prevalence (22 sources) ranged from 108.9 to 2200 per 100,000 in population-based studies and from 0.3 to 16.5 per 100,000 in referral-based studies. Reported times between first symptom onset and diagnosis (two sources; mean 669 days; median 3 years) highlighted gaps in timely VWD diagnosis. Bleeding events reported in 72-94% of the patients with VWD (all types; 27 sources) were mostly mucocutaneous including epistaxis, menorrhagia, and oral/gum bleeding. Poorer health-related quality of life (three sources) and greater health care resource utilization (three sources) were reported for patients with VWD than in general populations. Conclusion Available data suggest that patients with VWD experience high disease burden in terms of bleeding, poor quality of life, and health care resource utilization.
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Affiliation(s)
- Ping Du
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | - Yola Moride
- YOLARX Consultants, Paris, France.,Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | | | - Gülden Özen
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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16
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Young A, Lim MY, Sanders J, Branch DW, Simonsen SE. Pregnancy and childbirth in women with bleeding disorders: A retrospective cohort study. Haemophilia 2023; 29:240-247. [PMID: 36395791 DOI: 10.1111/hae.14688] [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: 04/28/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ashli Young
- University of Utah Health, Salt Lake City, Utah, USA
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Sara E Simonsen
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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17
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Astermark J, Blatný J, Königs C, Hermans C, Jiménez-Yuste V, Hart DP. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Ther Adv Hematol 2023; 14:20406207231165857. [PMID: 37113810 PMCID: PMC10126613 DOI: 10.1177/20406207231165857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Abstract
Recent advances in therapeutics are now providing a wide range of options for adults and children living with hemophilia. Although therapeutic choices are also increasing for the youngest individuals with severe disease, challenges remain about early management decisions, as supporting data are currently limited. Parents and healthcare professionals are tasked with helping children achieve an inclusive quality of life and maintain good joint health into adulthood. Primary prophylaxis is the gold standard to optimize outcomes and is recommended to start before 2 years of age. A range of topics need to be discussed with parents to aid their understanding of the decisions they can make and how these will affect the management of their child/children. For those with a family history of hemophilia, prenatal considerations include the possibility of genetic counseling, prenatal investigations, and planning for delivery, together with monitoring of the mother and neonate, as well as diagnosis of the newborn and treatment of any birth-associated bleeding. Subsequent considerations, which are also applicable to families where infant bleeding has resulted in a new diagnosis of sporadic hemophilia, involve explaining bleed recognition and treatment options, practical aspects of initiating/continuing prophylaxis, dealing with bleeds, and ongoing aspects of treatment, including possible inhibitor development. Over time, optimizing treatment efficacy, in which individualizing therapy around activities can play a role, and long-term considerations, including retaining joint health and tolerance maintenance, become increasingly important. The evolving treatment landscape is creating a need for continually updated guidance. Multidisciplinary teams and peers from patient organizations can help provide relevant information. Easily accessible, multidisciplinary comprehensive care remains a foundation to care. Equipping parents early with the knowledge to facilitate truly informed decision-making will help achieve the best possible longer-term health equity and quality of life for the child and family living with hemophilia. Plain language summary Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.
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Affiliation(s)
| | - Jan Blatný
- Department of Pediatric Hematology, University
Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Christoph Königs
- Clinical and Molecular Hemostasis, Department
of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt,
Germany
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of
Hematology, Cliniques Universitaires Saint-Luc, Université catholique de
Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hematology Department, Hospital Universitario
La Paz, Autónoma University, Madrid, Spain
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18
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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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19
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Castle D, Desborough MJR, Kemp M, Lowe G, Thomas W, Obaji S. Outcomes and management of pregnancy in women with bleeding disorder of unknown cause. J Thromb Haemost 2022; 20:2519-2525. [PMID: 36053176 DOI: 10.1111/jth.15871] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/29/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with a bleeding tendency with normal laboratory tests have been described as having an unclassified bleeding disorder or bleeding disorder of unknown cause (BDUC). There are very little data available on how to manage pregnancy. OBJECTIVES To study management and outcomes of these patients at four United Kingdom hemophilia comprehensive care centers. METHODS Retrospective case note review from 2010-2020. RESULTS Sixty deliveries in 36 patients were recorded. The median International Society on Thrombosis and Haemostasis bleeding assessment tool score was 9. In 54 cases for which data were available, the odds ratio for post partum hemorrhage (PPH) was 6.3 for no primary hemostatic prophylaxis versus prophylaxis (95% confidence interval 1.2-34.2, p < .05); 7/9 (78%) versus 16/45 (36%) PPH incidence for the groups, respectively. Hemostatic prophylaxis was with tranexamic acid but some patients received desmopressin or platelet infusions. Secondary PPH was seen in 5/60 (8%) of cases. No neonatal bleeding complications or maternal thromboembolic complications were noted. Avoidance of regional anesthesia and fetal delivery precautions were commonly advised, but in the small number of cases in which they occurred no complications were noted. CONCLUSIONS Despite hemostatic prophylaxis PPH was commonly seen. Further prospective studies of BDUC patients are required to determine optimal management in pregnancy as well as determine the pathophysiological basis of bleeding.
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Affiliation(s)
- Daniel Castle
- Haemophilia Centre, University Hospital of Wales, Cardiff, UK
| | - Michael J R Desborough
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Haemophilia and Thrombosis Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michelle Kemp
- Department of Obstetrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gillian Lowe
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Samya Obaji
- Haemophilia Centre, University Hospital of Wales, Cardiff, UK
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20
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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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21
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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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22
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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] [MESH Headings] [Grants] [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 HaemostasisSkåne University HospitalLund UniversityMalmöSweden
| | - Sonata S. Trakymienė
- Clinic of Children's DiseasesVilnius University Hospital Santaros KlinikosVilnius UniversityVilniusLithuania
| | - Augusto B. Federici
- Department of Oncology and Oncologic HaematologyHaematology and Transfusion MedicineL. Sacco University HospitalUniversity of MilanMilanItaly
| | - Katharina Holstein
- Department of Hematology and OncologyUniversity Medical Centre Hamburg‐EppendorfHamburgGermany
| | - Fernando F. Corrales‐Medina
- Department of Pediatrics, Division of Pediatric Hematology‐OncologyUniversity of Miami ‐ Miller School of Medicine and University of Miami ‐ Hemophilia Treatment CenterMiamiFloridaUSA
| | | | - Alok Srivastava
- Department of HaematologyChristian Medical CollegeVelloreIndia
| | | | - Jill M. Johnsen
- Research Institute, BloodworksSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Irena P. Zupan
- Department of HaematologyUniversity Medical Centre LjubljanaLjubljanaSlovenia
| | | | - Vuokko Nummi
- Coagulation Disorders Unit, Helsinki University HospitalHelsinkiFinland
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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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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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25
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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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26
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Lim HI, DeSancho MT. Management and outcomes of mild hemophiliacs and hemophilia carriers during pregnancy and peripartum period: a hemophilia treatment center experience in the United States. J Matern Fetal Neonatal Med 2022; 35:9759-9764. [PMID: 35414333 DOI: 10.1080/14767058.2022.2051699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pregnancy, peripartum management, and outcomes of mild hemophiliacs and hemophilia carriers in the United States are not well established. AIM To describe the management and outcomes of mild hemophiliacs and hemophilia carriers during assisted conception, pregnancy, peripartum and post-partum period at our hemophilia treatment center (HTC). METHODS Retrospective review of electronic medical records of pregnant women with mild hemophilia A or B (Factor VIII [FVIII] or Factor IX [FIX] level <0.4 IU/mL) and hemophilia A and B carriers followed at our HTC from January 2008 to October 2020. Demographics, the reason for diagnosis, FVIII and FIX levels at baseline and third trimester, bleeding phenotype and genotype were obtained. Method of conception, factor replacement, iron supplementation, mode of delivery, type of anesthesia, peripartum complications, and offspring outcomes was recorded. RESULTS There was a total of 18 pregnancies in 12 women (2 with mild hemophilia A, 2 mild hemophilia B, 6 hemophilia A carriers, and 2 hemophilia B carriers). Eleven pregnancies (61%) were conceived naturally and 7 (39%) via in-vitro fertilization (IVF). Eight (44.4%) and 10 (55.6%) pregnancies were vaginal and C-section deliveries, respectively. Neuraxial anesthesia was administered in 17 (94.4%) deliveries without complications. Four pregnancies (22.2%) had bleeding complications, 2 of which were post-partum hemorrhages not requiring transfusion. CONCLUSION In our case series of pregnant hemophilia carriers and mild hemophiliacs, successful outcomes were achieved with a carefully detailed multidisciplinary-driven approach.
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Affiliation(s)
- Hana I Lim
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Maria T DeSancho
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
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27
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Langer AL, Connell NT. Update on pregnancy-associated venous thromboembolism. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Brignardello-Petersen R, El Alayli A, Husainat N, Kalot MA, Shahid S, Aljabirii Y, Britt A, Alturkmani H, El-Khechen H, Motaghi S, Roller J, Abdul-Kadir R, Couper S, Kouides P, Lavin M, Ozelo MC, Weyand A, James PD, Connell NT, Flood VH, Mustafa RA. Gynecologic and obstetric management of women with von Willebrand disease: summary of 3 systematic reviews of the literature. Blood Adv 2022; 6:228-237. [PMID: 34673921 PMCID: PMC8753192 DOI: 10.1182/bloodadvances.2021005589] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
Abstract
von Willebrand disease (VWD) disproportionately affects women because of the potential for heavy menstrual bleeding (HMB), delivery complications, and postpartum hemorrhage (PPH). To systematically synthesize the evidence regarding first-line management of HMB, treatment of women requiring or desiring neuraxial analgesia, and management of PPH. We searched Medline and EMBASE through October 2019 for randomized trials, comparative observational studies, and case series comparing the effects of desmopressin, hormonal therapy, and tranexamic acid (TxA) on HMB; comparing different von Willebrand factor (VWF) levels in women with VWD who were undergoing labor and receiving neuraxial anesthesia; and measuring the effects of TxA on PPH. We conducted duplicate study selection, data abstraction, and appraisal of risk of bias. Whenever possible, we conducted meta-analyses. We assessed the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. We included 1 randomized trial, 3 comparative observational studies, and 10 case series. Moderate-certainty evidence showed that desmopressin resulted in a smaller reduction of menstrual blood loss (difference in mean change from baseline, 41.6 [95% confidence interval, 16.6-63.6] points in a pictorial blood assessment chart score) as compared with TxA. There was very-low-certainty evidence about how first-line treatments compare against each other, the effects of different VWF levels in women receiving neuraxial anesthesia, and the effects of postpartum administration of TxA. Most of the evidence relevant to the gynecologic and obstetric management of women with VWD addressed by most guidelines is very low quality. Future studies that address research priorities will be key when updating such guidelines.
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Affiliation(s)
| | - Abdallah El Alayli
- Outcomes and Implementation Research Unit, Department of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, KS
| | - Nedaa Husainat
- Department of Internal Medicine, St. Mary’s Hospital, St. Louis, MO
| | - Mohamad A. Kalot
- Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Shaneela Shahid
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Alec Britt
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Hani Alturkmani
- Department of Cardiovascular Medicine University of Arkansas for Medical Sciences, Little Rock, AR
| | - Hussein El-Khechen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shahrzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John Roller
- Department of Hematology/Oncology, University of Kansas Medical Center, Kansas City, KS
| | - Rezan Abdul-Kadir
- The Royal Free National Health Service Foundation (NHS) Hospital and Institute for Women’s Health, University College London, London, United Kingdom
| | | | - Peter Kouides
- Mary M. Gooley Hemophilia Treatment Center, University of Rochester, Rochester, NY
| | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Coagulation Centre, St. James’ Hospital, Dublin, Ireland
| | | | - Angela Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Nathan T. Connell
- Hematology Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Veronica H. Flood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; and
- Versiti Blood Research Institute, Milwaukee, WI
| | - Reem A. Mustafa
- Outcomes and Implementation Research Unit, Department of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, KS
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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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30
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Lavin M, Sánchez Luceros A, Kouides P, Abdul-Kadir R, O'Donnell JS, Baker RI, Othman M, Haberichter SL. Examining international practices in the management of pregnant women with von Willebrand disease. J Thromb Haemost 2022; 20:82-91. [PMID: 34661341 DOI: 10.1111/jth.15561] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The management of pregnant women with von Willebrand disease (VWD) is complex as physiological pregnancy-induced increases in plasma von Willebrand factor (VWF) may be blunted or absent. Women with VWD experience a heightened risk of postpartum hemorrhage (PPH) and special consideration must be given regarding neuraxial anesthesia (NA) and the need for prophylaxis at time of delivery. These challenges are compounded by a lack of robust evidence to guide clinical decision-making. OBJECTIVES AND METHODS To determine the current international clinical practices in the management of pregnancy for women with VWD, the International Society on Thrombosis and Haemostasis (ISTH) conducted an international survey of health-care providers (HCP). RESULTS One hundred thirty-two respondents from 39 countries were included in the final analysis. Variations in clinical practice were identified in antenatal (monitoring of plasma VWF and ferritin levels), peripartum (optimal plasma VWF target at delivery) and postpartum management (definitions used for PPH and postpartum monitoring). A key area of divergence was suitability for NA for women with type 2 and type 3 VWD, with many respondents advising against the use of NA even with VWF supplementation (29% type 2 VWD, 37% type 3 VWD) but others advising use once plasma VWF activity was >50 IU/dL (57% type 2 VWD; 50% type 3 VWD). CONCLUSIONS This survey highlighted areas of uncertainty surrounding common management issues for pregnant women with VWD. These data underscore the need for international collaborative research efforts focused on peripartum management to improve care for pregnant women with VWD.
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Affiliation(s)
- Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, RCSI, Dublin, Ireland
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Analia Sánchez Luceros
- Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina, Buenos Aires, Argentina
- Instituto de Medicina Experimental-CONICET, Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynecology and Katharine Dormandy Hemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, UK
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, RCSI, Dublin, Ireland
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Ross I Baker
- Western Australian Centre for Thrombosis and Hemostasis, Perth Blood Institute, Murdoch University, Perth, Western Australia, Australia
- Hollywood Hospital Haemophilia Treatment Centre, Perth, Western Australia, Australia
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
- School of Baccalaureate Nursing, St .Lawrence College, Kingston, Ontario, Canada
| | - Sandra L Haberichter
- Diagnostic Laboratories and Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
- Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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31
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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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32
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Pierce-Williams RAM, Makhamreh MM, Blakey-Cheung S, Gao Z, Al-Kouatly HB. Postpartum Hemorrhage in Patients with Type 1 von Willebrand Disease: A Systematic Review. Semin Thromb Hemost 2021; 48:219-228. [PMID: 34749402 DOI: 10.1055/s-0041-1736572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Type 1 von Willebrand disease (VWD) is the most common subtype of VWD, comprising 75% of VWD patients. We provide a systematic review of type 1 VWD in pregnancy. Our objective was to evaluate the rate of postpartum hemorrhage (PPH) in patients with known type 1 VWD. The primary outcome was rate of PPH. Primary PPH was defined as a cumulative blood loss ≥1,000 mL, or blood loss accompanied by signs and symptoms of hypovolemia within 24 hours postpartum or requiring blood products. Secondary PPH was defined as significant bleeding 24 hours to 12 weeks postpartum. Relevant articles published in English pertaining to VWD and pregnancy were identified without any time or study limitations. Seven articles (n = 144 pregnancies) met inclusion criteria. The rate of primary PPH was 4/144 (2.8%). The secondary PPH rate was reported in four studies, and occurred in 7/48 pregnancies (14.6%), ranging from 2 to 19 days postpartum. In conclusion, according to this systematic review, the frequency of primary PPH in pregnancies with known type 1 VWD is 2.8%. This is similar to the overall PPH rates of 3% reported in the literature. Although the sample size was small, secondary PPH occurred in almost 15% of pregnancies, while in the overall obstetrical population this occurs in approximately 1% of cases. Patients with known type 1 VWD may not be at increased risk of primary PPH, though they appear to bear increased risk of secondary PPH.
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Affiliation(s)
- Rebecca A M Pierce-Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mona M Makhamreh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Sophia Blakey-Cheung
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, South Shore University Hospital, Bay Shore, New York
| | - Zimeng Gao
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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Krishnaswamy S, Ageno W, Arabi Y, Barbui T, Cannegieter S, Carrier M, Cleuren AC, Collins P, Panicot-Dubois L, Freedman JE, Freson K, Hogg P, James AH, Kretz CA, Lavin M, Leebeek FWG, Li W, Maas C, Machlus K, Makris M, Martinelli I, Medved L, Neerman-Arbez M, O'Donnell JS, O'Sullivan J, Rajpurkar M, Schroeder V, Spiegel PC, Stanworth SJ, Green L, Undas A. Illustrated State-of-the-Art Capsules of the ISTH 2020 Congress. Res Pract Thromb Haemost 2021; 5:e12532. [PMID: 34296056 PMCID: PMC8285574 DOI: 10.1002/rth2.12532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/17/2022] Open
Abstract
This year's Congress of the International Society of Thrombosis and Haemostasis (ISTH) was hosted virtually from Philadelphia July 17-21, 2021. The conference, now held annually, highlighted cutting-edge advances in basic, population and clinical sciences of relevance to the Society. Despite being held virtually, the 2021 congress was of the same scope and quality as an annual meeting held in person. An added feature of the program is that talks streamed at the designated times will then be available on-line for asynchronous viewing. The program included 77 State of the Art (SOA) talks, thematically grouped in 28 sessions, given by internationally recognized leaders in the field. The SOA speakers were invited to prepare brief illustrated reviews of their talks that were peer reviewed and are included in this article. The topics, across the main scientific themes of the congress, include Arterial Thromboembolism, Coagulation and Natural Anticoagulants, COVID-19 and Coagulation, Diagnostics and Omics, Fibrinogen, Fibrinolysis and Proteolysis, Hemophilia and Rare Bleeding Disorders, Hemostasis in Cancer, Inflammation and Immunity, Pediatrics, Platelet Disorders, von Willebrand Disease and Thrombotic Angiopathies, Platelets and Megakaryocytes, Vascular Biology, Venous Thromboembolism and Women's Health. These illustrated capsules highlight the major scientific advances with potential to impact clinical practice. Readers are invited to take advantage of the excellent educational resource provided by these illustrated capsules. They are also encouraged to use the image in social media to draw attention to the high quality and impact of the science presented at the congress.
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Affiliation(s)
- Sriram Krishnaswamy
- Hematology Department of Pediatrics Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA USA
| | | | - Yaseen Arabi
- King Abdulaziz Medical City Ministry of NGHA King Saud Bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia
| | - Tiziano Barbui
- Research Foundation Papa Giovanni XXIII Hospital Bergamo Italy
| | - Suzanne Cannegieter
- Depertments of Clinical Epidemiology and Thrombosis & Haemostasis Leiden University Medical Center Leiden The Netherlands
| | - Marc Carrier
- Department of Medicine Ottawa Hospital Research Institute University of Ottawa Ottawa ON Canada
| | | | - Peter Collins
- School of Medicine Cardiff University Haemophilia Centre University Hospital of Wales Cardiff UK
| | | | - Jane E Freedman
- Vanderbilt University Medical Center The Albert Sherman Center Worcester MA USA
| | - Kathleen Freson
- Center for Molecular and Vascular Biology KU Leuven Leuven Belgium
| | - Philip Hogg
- Charles Perkins Centre University of Sydney Sydney NSW Australia
| | | | | | - Michelle Lavin
- National Coagulation Centre St. James's Hospital Dublin Ireland
- Irish Centre for Vascular Biology RCSI Dublin Ireland
| | - Frank W G Leebeek
- Department of Hematology Erasmus MC University Medical Center Rotterdam The Netherlands
| | - Weikai Li
- Washington University in St. Louis Medical School St. Louis MO USA
| | - Coen Maas
- University Medical Center Utrecht Utrecht The Netherlands
| | - Kellie Machlus
- Vascular Biology Program and Harvard Medical School Boston Children's Hospital Boston MA USA
| | | | - Ida Martinelli
- Hemophilia and Thrombosis Center IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico Milano Italy
| | - Leonid Medved
- Center for Vascular and Inflammatory Diseases and Department of Biochemistry and Molecular Biology University of Maryland School of Medicine Baltimore MD USA
| | - Marguerite Neerman-Arbez
- Deartment of Genetic Medicine and Development Faculty of Medicine University of Geneva Geneva Switzerland
| | - James S O'Donnell
- Haemostasis Research Group Irish Centre for Vascular Biology School of Pharmacy and Biomolecular Sciences Royal College of Surgeons in Ireland Dublin Ireland
- National Children's Research Centre Our Lady's Children's Hospital Dublin Ireland
- National Centre for Coagulation Disorders St James's Hospital Dublin Ireland
| | - Jamie O'Sullivan
- Irish Centre for Vascular Biology School of Pharmacy and Biomolecular Science Royal College of Surgeons in Ireland Dublin Ireland
| | - Madhvi Rajpurkar
- Children's Hospital of Michigan Central Michigan University Detroit MI USA
- Wayne State University Detroit MI USA
| | - Verena Schroeder
- Department for BioMedical Research University of Bern Bern Switzerland
| | | | - Simon J Stanworth
- Transfusion Medicine NHS Blood and Transplant Oxford UK
- Department of Haematology Oxford University Hospitals NHS Foundation Trust Oxford UK
- Radcliffe Department of Medicine NIHR Oxford Biomedical Research Centre University of Oxford Oxford UK
| | - Laura Green
- Transfusion Medicine NHS Blood and Transplant (London) and Barts Health NHS Trust London UK
- Blizzard Institute Queen Mary University of London London UK
| | - Anetta Undas
- Jagiellonian University Medical College Krakow Poland
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34
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Spence M, de Repentigny K, Bowman M, Hopman W, Thibeault L, James P. Validation of the pictorial blood loss assessment chart using modern sanitary products. Haemophilia 2021; 27:e632-e635. [PMID: 34185363 DOI: 10.1111/hae.14373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/31/2021] [Accepted: 06/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Michaela Spence
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Mackenzie Bowman
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Wilma Hopman
- Kingston Health Sciences Centre Clinical Research Services, Kingston, Ontario, Canada
| | - Lisa Thibeault
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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35
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Bade NA, Kazma JM, Amdur RL, Ellis-Kahana J, Ahmadzia HK. Blood type association with bleeding outcomes at delivery in a large multi-center study. J Thromb Thrombolysis 2021; 50:439-445. [PMID: 31858381 DOI: 10.1007/s11239-019-02023-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Najeebah A Bade
- Division of Hematology and Oncology, The George Washington University, Washington, DC, USA
| | - Jamil M Kazma
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University, 2150 Pennsylvania Ave, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, DC, USA
| | - Julia Ellis-Kahana
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University, 2150 Pennsylvania Ave, Washington, DC, 20037, USA.
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36
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Carriers of haemophilia: pregnancy, childbirth and postpartum. Blood Coagul Fibrinolysis 2021; 31:S9-S11. [PMID: 33351495 DOI: 10.1097/mbc.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Management of haemophilia carrier women during labour and postpartum is yet to be standardized. Pregnancy was accompanied by a marked rise in factor VIII levels compared with only a small rise in factor IX levels. After delivery, a carrier's factor level drops down to prepregnancy levels, which increases the chance of postpartum haemorrhage. Availability of management guideline and care provided in a multidisciplinary approach can help to minimize bleeding complications in carriers of haemophilia and their newborns.
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37
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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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38
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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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39
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Byrne B, Ryan K, Lavin M. Current Challenges in the Peripartum Management of Women with von Willebrand Disease. Semin Thromb Hemost 2021; 47:217-228. [PMID: 33636752 DOI: 10.1055/s-0041-1723797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For many women, pregnancy and childbirth represent their first major hemostatic challenges. Despite advancements in obstetric care, up to 2 to 5% of all deliveries are complicated by postpartum hemorrhage (PPH). To mitigate bleeding risk, physiological changes occur in pregnancy, including increases in plasma von Willebrand factor (VWF) and factor VIII levels. For women with von Willebrand disease (VWD), these physiological alterations are blunted or absent. As a result, women with VWD have a heightened risk of PPH, both primary (in the first 24 hours) and secondary (>24 hours to 6 to 12 weeks postpartum). Pregnancy and delivery management for women with VWD should therefore be carefully coordinated as part of a multidisciplinary team approach. In the absence of large-scale clinical trials, the management of women with VWD during pregnancy is guided by expert consensus guidelines. Clinical practices internationally are not uniform, and areas of considerable clinical uncertainty exist. Traditional peripartum plasma VWF thresholds for hemostatic cover and therapeutic targets are currently under scrutiny, as PPH is not eliminated in women with VWD who receive replacement therapy. The benefit and optimal duration of postpartum tranexamic acid have yet to be defined, and standardized methods of quantification of blood loss at the time of delivery are currently lacking. In this article, we review the evidence base to date and explore the current clinical challenges in the management of pregnant women with VWD.
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Affiliation(s)
- Bridgette Byrne
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin Ryan
- Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland.,National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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40
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O'Donnell JS. Toward Personalized Treatment for Patients with Low von Willebrand Factor and Quantitative von Willebrand Disease. Semin Thromb Hemost 2021; 47:192-200. [PMID: 33636750 DOI: 10.1055/s-0041-1722864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The biological mechanisms involved in the pathogenesis of type 2 and type 3 von Willebrand disease (VWD) have been studied extensively. In contrast, although accounting for the majority of VWD cases, the pathobiology underlying partial quantitative VWD has remained somewhat elusive. However, important insights have been attained following several recent cohort studies that have investigated mechanisms in patients with type 1 VWD and low von Willebrand factor (VWF), respectively. These studies have demonstrated that reduced plasma VWF levels may result from either (1) decreased VWF biosynthesis and/or secretion in endothelial cells and (2) pathological increased VWF clearance. In addition, it has become clear that some patients with only mild to moderate reductions in plasma VWF levels in the 30 to 50 IU/dL range may have significant bleeding phenotypes. Importantly in these low VWF patients, bleeding risk fails to correlate with plasma VWF levels and inheritance is typically independent of the VWF gene. Although plasma VWF levels may increase to > 50 IU/dL with progressive aging or pregnancy in these subjects, emerging data suggest that this apparent normalization in VWF levels does not necessarily equate to a complete correction in bleeding phenotype in patients with partial quantitative VWD. In this review, these recent advances in our understanding of quantitative VWD pathogenesis are discussed. Furthermore, the translational implications of these emerging findings are considered, particularly with respect to designing personalized treatment plans for VWD patients undergoing elective procedures.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital at Crumlin, Dublin, Ireland
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41
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Connell NT, Flood VH, Brignardello-Petersen R, Abdul-Kadir R, Arapshian A, Couper S, Grow JM, Kouides P, Laffan M, Lavin M, Leebeek FWG, O'Brien SH, Ozelo MC, Tosetto A, Weyand AC, James PD, Kalot MA, Husainat N, Mustafa RA. ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease. Blood Adv 2021; 5:301-325. [PMID: 33570647 PMCID: PMC7805326 DOI: 10.1182/bloodadvances.2020003264] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is a common inherited bleeding disorder. Significant variability exists in management options offered to patients. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and health care professionals in their decisions about management of VWD. METHODS ASH, ISTH, NHF, and WFH formed a multidisciplinary guideline panel. Three patient representatives were included. The panel was balanced to minimize potential bias from conflicts of interest. The University of Kansas Outcomes and Implementation Research Unit and the McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline development process, including performing and updating systematic evidence reviews (through November 2019). The panel prioritized clinical questions and outcomes according to their importance to clinicians and patients. The panel used the GRADE approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 12 recommendations and outlined future research priorities. CONCLUSIONS These guidelines make key recommendations regarding prophylaxis for frequent recurrent bleeding, desmopressin trials to determine therapy, use of antiplatelet agents and anticoagulant therapy, target VWF and factor VIII activity levels for major surgery, strategies to reduce bleeding during minor surgery or invasive procedures, management options for heavy menstrual bleeding, management of VWD in the context of neuraxial anesthesia during labor and delivery, and management in the postpartum setting.
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Affiliation(s)
- Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Veronica H Flood
- Versiti Blood Research Institute, Medical College of Wisconsin, Milwaukee, WI
| | | | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | | | | | - Jean M Grow
- Department of Strategic Communication, Marquette University, Milwaukee, WI
| | - Peter Kouides
- Mary M. Gooley Hemophilia Treatment Center, University of Rochester, Rochester, NY
| | - Michael Laffan
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland and National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | | | - Alberto Tosetto
- Hemophilia and Thrombosis Center, Hematology Department, S. Bortolo Hospital, Vicenza, Italy
| | - Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada; and
| | - Mohamad A Kalot
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Nedaa Husainat
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Reem A Mustafa
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
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42
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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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43
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Presky KO, Kadir RA. Women with inherited bleeding disorders – Challenges and strategies for improved care. Thromb Res 2020; 196:569-578. [DOI: 10.1016/j.thromres.2019.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/26/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
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44
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d'Oiron R, O'Brien S, James AH. Women and girls with haemophilia: Lessons learned. Haemophilia 2020; 27 Suppl 3:75-81. [PMID: 32985086 DOI: 10.1111/hae.14094] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022]
Abstract
Severe and moderate factor VIII (FVIII) or IX (FIX) deficiencies in female carriers of haemophilia are rarely observed, but mild deficiency is quite frequent, although insufficiently recognized and registered. The confusion between the genetic diagnosis of the carriership, mainly assessed at adult age and the diagnosis of the bleeding disorder for those who have low factor levels often prevents early diagnosis of a potential bleeding risk. The factor levels in obligate or potential carriers of haemophilia can be assessed during childhood, possibly apart from genetic assays. The absence of early recognition of the bleeding disorder precludes the anticipation of menarche and the prevention of potential heavy menstrual bleeding to heavy menstrual bleeding. Standardized bleeding assessment tools (BAT) have demonstrated that women and girls with haemophilia (WGWH) have increased bleeding scores as compared to the general female population, however weakly correlating with factor levels. More recent evidence has highlighted that hemarthroses affect 4% to 19% of carriers and that some of them could experience sub-clinical joint bleeding. Desmopressin for women with FVIII deficiency and abnormal ISTH-BAT scores had a significantly lower FVIII response to DDAVP compared to those with normal bleeding scores, which could at least partially explain more postsurgical bleeding. Management of delivery of haemophilia carriers requires attention to the risks of maternal bleeding, the risks of foetal bleeding, preconception and prenatal care, strategies to reduce maternal bleeding, choice of mode of delivery to reduce foetal/neonatal bleeding, and postpartum care. Either prior to pregnancy, or during early pregnancy, a plan should be developed that addresses the needs of both the mother and her unborn baby. If the unborn baby is a male proven to be or potentially affected by moderate or severe form of haemophilia, there is a risk of severe foetal bleeding, so a planned caesarean delivery may be preferred. If the unborn baby is a carrier, or potentially affected carrier, there is still the risk of non-severe bleeding so invasive foetal procedures and operative vaginal delivery (forceps or vacuum) should be avoided. Further studies based on large cohorts will help the community to favour earlier diagnosis, increase knowledge on WGWH and promote better care.
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Affiliation(s)
- Roseline d'Oiron
- Centre de Référence de l'Hémophilie, Hôpital Bicêtre APHP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,HITh, UMR_S1176, INSERM, Hôpital Bicêtre APHP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sarah O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.,Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC, USA
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45
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Prior C, Sims K, Seligman K, Jackson S, Chau A. Peripartum management of a parturient with type 1C (clearance) von Willebrand disease. Int J Obstet Anesth 2020; 44:112-115. [PMID: 32942216 DOI: 10.1016/j.ijoa.2020.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 11/25/2022]
Abstract
Peripartum replacement of factor VIII and von Willebrand factor is not usually required in type 1 von Willebrand disease, as the levels of endogenous factors tend to increase to within the normal range as a physiological change of pregnancy. However, there is wide heterogeneity of genotypes and phenotypes associated with type 1 von Willebrand disease. Here, we describe the anesthetic management of a parturient with type 1C von Willebrand disease, a subtype characterized by decreased plasma von Willebrand factor survival.
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Affiliation(s)
- C Prior
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada.
| | - K Sims
- Adult Bleeding Disorders Program of British Columbia, St Paul's Hospital, Vancouver, BC, Canada
| | - K Seligman
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - S Jackson
- Adult Bleeding Disorders Program of British Columbia, St Paul's Hospital, Vancouver, BC, Canada; Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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46
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Lavin M, Horan M, Durand O'Connor A, Doherty D, Manning C, Lynch C, Regan C, Ryan K, Byrne B. The impact of foetal restrictions on mode of delivery in women with inherited bleeding disorders. Eur J Haematol 2020; 105:555-560. [PMID: 32602982 DOI: 10.1111/ejh.13481] [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: 05/05/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Management of pregnancy in women with congenital bleeding disorders (CBD) is challenging and requires understanding of risks conferred to both the mother and the foetus. Some elements of labour management are considered to increase the risk of neonatal bleeding and are not recommended for neonates at risk of a significant bleeding disorder. The impact of these restrictions on obstetric outcomes in women with CBD is unknown. METHODS We retrospectively reviewed obstetric outcomes in a large cohort of women with CBD attending a specialised obstetric/haematology antenatal clinic over a 6-year period. RESULTS Ninety-four pregnancies in 76 women with a wide variety of CBDs were assessed. Foetal precautions were recommended in the majority of cases (88%). Twenty (21.2%) were delivered by elective Caesarean section (CS), predominantly for obstetric indications. Of the 63 women who laboured with foetal precautions in place, 6 (10%) had a CS that was performed because of these precautions. There was no neonatal bleeding but primary postpartum haemorrhage (PPH) occurred in 12.2% of women. CONCLUSIONS These data show that foetal precautions in labour recommended for women with CBDs will influence mode of delivery in approximately 10% of cases. This is important information for counselling these women about labour and delivery.
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Affiliation(s)
- Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maebh Horan
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Anna Durand O'Connor
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Catherine Manning
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Caoimhe Lynch
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Carmen Regan
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Kevin Ryan
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Bridgette Byrne
- RCSI Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
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47
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Laffan M, Sathar J, Johnsen JM. von Willebrand disease: Diagnosis and treatment, treatment of women, and genomic approach to diagnosis. Haemophilia 2020; 27 Suppl 3:66-74. [PMID: 32578345 DOI: 10.1111/hae.14050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023]
Abstract
von Willebrand disease (VWD) is the most common inherited bleeding disorder. VWD is caused by deficiencies in von Willebrand factor (VWF), a critical adhesive haemostatic protein. This review provides an overview of VWD diagnosis and treatment, special considerations in treating women with VWD, and current genomic approaches to VWD. For diagnosis and treatment in VWD, an accurate diagnosis is critical to providing effective treatments, determining appropriate laboratory monitoring and for counselling the patient and family. Diagnosis of VWD begins with the clinical assessment for the bleeding phenotype, which is usually characterized by mucocutaneous and provoked bleeding. The diagnosis of VWD is then made by laboratory investigation. Multiple assays are used to assess VWF levels and functions. The mainstays of VWD treatment are tailored by VWD type and symptoms, and can include antifibrinolytic treatment, desmopressin and VWF replacement treatment. Women with VWD are also at risk for excessive uterine bleeding, such as with menses and childbirth. In addition to standard VWD treatments, heavy menstrual bleeding can be treated with hormones. Interdisciplinary management of childbirth and prophylaxis in the postpartum period are needed to reduce the risk of postpartum haemorrhage. Genomic approaches to VWD can inform VWD diagnosis, treatment, test assay selection, reproductive planning and family counselling. Most VWD patients have an identifiable VWF gene DNA variant. Next-generation sequencing is rapidly being adopted to provide more comprehensive VWF sequence information for patients with known or suspected VWD.
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Affiliation(s)
- Michael Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia.,Clinical Trial Unit, Clinical Research Centre, Ministry of Health, Ampang, Selangor, Malaysia
| | - Jill M Johnsen
- Research Institute, Bloodworks Northwest, Seattle, WA, USA.,Washington Center for Bleeding Disorders, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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48
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O'Brien SH, Stanek JR, Kaur D, McCracken K, Vesely SK. Laboratory monitoring during pregnancy and post-partum hemorrhage in women with von Willebrand disease. J Thromb Haemost 2020; 18:604-608. [PMID: 31808272 DOI: 10.1111/jth.14696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/14/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend that von Willebrand factor (VWF) levels be obtained in the third trimester of pregnancy to facilitate peripartum planning for women with von Willebrand disease (VWD). OBJECTIVES To identify the frequency of third trimester monitoring in a nationally representative sample of pregnant women with VWD in the United States, as well as the frequency of reproductive bleeding after pregnancy. PATIENTS/METHODS Patient data were obtained from the Truven Health MarketScan Research Databases. International Classification of Diseases-9 codes were used to identify women with VWD and evidence of infant delivery. We defined third trimester monitoring as a laboratory claim for VWF levels during the 3 months before delivery. Clinical outcomes studied included postpartum hemorrhage (PPH) and heavy menstrual bleeding (HMB). RESULTS We identified 2238 unique pregnant females with VWD. Of these, 32% (n = 714) underwent third-trimester testing of VWF levels. Diagnostic codes consistent with PPH were recorded for 6.5% of women in the 6 weeks after infant delivery. The frequency of PPH in women who underwent VWF monitoring (4.9%) was significantly lower than in those who did not undergo monitoring (7.3%), (risk difference -2.4%, 95% CI -4.4% to -0.3%, P = .023). Diagnostic codes consistent with HMB were recorded for 4.7% of women in the 3 months after infant delivery. CONCLUSIONS Third-trimester VWF monitoring was associated with a lower risk of PPH, but testing was performed in only one-third of insured pregnant women with VWD in the United States despite expert recommendations.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
- Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Dominder Kaur
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Irving Medical Center, Children's Hospital of New York/New York Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Katherine McCracken
- Division of Pediatric and Adolescent Gynecology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Punt M, Waning M, Mauser-Bunschoten E, Kruip M, Eikenboom J, Nieuwenhuizen L, Makelburg A, Driessens M, Duvekot J, Peters M, Middeldorp J, Bloemenkamp K, Schutgens R, Lely A, Van Galen K. Maternal and neonatal bleeding complications in relation to peripartum management in women with Von Willebrand disease: A systematic review. Blood Rev 2020; 39:100633. [DOI: 10.1016/j.blre.2019.100633] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/06/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
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50
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Ragni MV. Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the hematologist's view. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:152-157. [PMID: 31808846 PMCID: PMC6913423 DOI: 10.1182/hematology.2019000022] [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
In the childbearing years, hormonal therapy or hormonal changes in the menstrual cycle or the puerperium may be complicated by bleeding or thrombosis; however, among women with congenital disorders of hemostasis and thrombosis, the risk of bleeding or thrombosis may be increased. In women with congenital bleeding disorders, heavy menstrual bleeding is the most common bleeding symptom, and postpartum hemorrhage occurs despite treatment. Given the limitations of current therapy and the associated medical and psychological burden in women with bleeding disorders, better treatment approaches are needed to improve health outcomes and quality of life. In women with congenital thrombotic disorders, thromboembolism may complicate exogenous hormonal therapy and endogenous hormonal change during pregnancy and procedures, but risk differs by type of thrombophilia, procedure, time at risk, and thrombosis risk factors, all of which affect management. In this article, I shall consider a case-based discussion of current issues in women with congenital bleeding and clotting disorders, including heavy menstrual bleeding in a woman with VWD, postpartum hemorrhage risk in VWD, and thrombosis risk with oocyte retrieval in a woman with factor V Leiden and past thromboembolism. The goals are to review bleeding or thrombosis risk in these cases, current data, limitations of current treatment guidelines, and areas for future study.
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Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology and Hemophilia Center of Western Pennsylvania, University of Pittsburgh, Pittsburgh, PA
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