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Krahforst A, Yadegari H, Pavlova A, Pezeshkpoor B, Müller J, Pötzsch B, Scholz U, Richter H, Trobisch H, Liebscher K, Olivieri M, Trautmann-Grill K, Knöfler R, Halimeh S, Oldenburg J. Unravelling the spectrum of von Willebrand factor variants in quantitative von Willebrand disease: results from a German cohort study. J Thromb Haemost 2024:S1538-7836(24)00391-X. [PMID: 39002731 DOI: 10.1016/j.jtha.2024.06.026] [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: 12/22/2023] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Von Willebrand disease (VWD), the most prevalent hereditary bleeding disorder, results from deficiency of von Willebrand factor (VWF). OBJECTIVES This large cohort study aims to offer a comprehensive exploration of mutation spectra and laboratory features in quantitative VWF deficiencies, shedding light on genetic underpinnings and genotype-phenotype associations. METHODS Our cohort consisted of 221 Caucasian index patients with quantitative VWD, along with 47 individuals whose plasma VWF levels fell within the lower normal boundaries (50-70 IU/dL). We conducted comprehensive VWF assays and genetic analyses, encompassing VWF gene sequencing, copy number variation investigations, and bioinformatic assessments. RESULTS Following International Society on Thrombosis and Haemostasis-Scientific and Standardization Committee VWF guidelines, 77 index patients were characterized as having type 1 VWD (VWF antigen [VWF:Ag] < 30 IU/dL), 111 as having type 1 VWD (VWF:Ag, 30-50 IU/dL), and 33 as having type 3 VWD. Mutation detection rates were 88%, 65%, and 92%, respectively. Notably, blood group O overrepresentation was evident in type 1 with VWF:Ag of 30 to 50 IU/dL, particularly among mutation-negative patients, suggesting a potential causal role of blood group O. A total of 223 VWF variants, comprising 147 distinct variations, were identified in quantitative VWD patients, of which 57 were novel variants (39%). Additionally, approximately 70% of individuals with VWF levels within the lower normal boundaries (50-70 IU/dL) displayed VWF variants. CONCLUSION Our data advance our understanding of the molecular mechanisms underlying quantitative VWD, offering valuable insights for future research and clinical management. Distinct mutation patterns were observed among subgroups, particularly the contrast between type 1 VWD (VWF:Ag < 30 IU/dL) and type 1 VWD (VWF:Ag, 30-50 IU/dL), an area with limited prior investigation.
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Affiliation(s)
- Alexander Krahforst
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Hamideh Yadegari
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany.
| | - Anna Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Behnaz Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Ute Scholz
- Center of Hemostasis, Medizinisches Versorgungszentrum Labor Leipzig, Leipzig, Germany
| | | | - Heiner Trobisch
- Laboratory and Ambulance for Coagulation Disorders, Duisburg, Germany
| | - Karin Liebscher
- Institute of Transfusion Medicine and Clinical Hemostaseology, Klinikum St. Georg GmbH, Leipzig, Germany
| | - Martin Olivieri
- Pediatric Thrombosis and Hemostasis Unit, Dr Von Hauner Children's Hospital, LMU Klinikum, Munich, Germany
| | | | - Ralf Knöfler
- Department of Pediatric Hemostaseology, Medical Faculty Carl Gustav Carus, Technical University Dresden, Children's Hospital, Dresden, Sachsen, Germany
| | | | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
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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:S1538-7836(24)00374-X. [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] [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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Oktaviana J, Lui B, Ho P, Lim HY. A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism. Blood Coagul Fibrinolysis 2023; 34:191-198. [PMID: 36966765 DOI: 10.1097/mbc.0000000000001213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE Intra-abdominal venous thromboembolism is rare with heterogeneous management. We aim to evaluate these thrombosis and compare them to deep vein thrombosis and/or pulmonary embolism. METHOD A 10-year retrospective evaluation of consecutive venous thromboembolism presentations (January 2011-December 2020) at Northern Health, Australia, was conducted. A subanalysis of intraabdominal venous thrombosis involving splanchnic, renal and ovarian veins was performed. RESULTS There were 3343 episodes including 113 cases of intraabdominal venous thrombosis (3.4%) - 99 splanchnic vein thrombosis, 10 renal vein thrombosis and 4 ovarian vein thrombosis. Of the splanchnic vein thrombosis presentations, 34 patients (35 cases) had known cirrhosis. Patients with cirrhosis were numerically less likely to be anticoagulated compared to noncirrhotic patients (21/35 vs. 47/64, P = 0.17). Noncirrhotic patients ( n = 64) were more likely to have malignancy compared to those with deep vein thrombosis and/or pulmonary embolism (24/64 vs. 543/3230, P < 0.001), including 10 patients diagnosed at time of splanchnic vein thrombosis presentation. Cirrhotic patients reported more recurrent thrombosis/clot progression (6/34) compared to noncirrhotic patients (3/64) (15.6 vs. 2.3 events/100-person-years; hazard ratio 4.7 (95% confidence interval 1.2-18.9), P = 0.030) and other venous thromboembolism patients (2.6/100-person-years; hazard ratio 4.7, 95% confidence interval 2.1-10.7; P < 0.001) with comparable major bleeding rates. All renal vein thrombosis were provoked including five malignant-related cases while three ovarian vein thrombosis occurred postpartum. No recurrent thrombotic or bleeding complications were reported in renal vein thrombosis and ovarian vein thrombosis. CONCLUSION These rare intraabdominal venous thromboses are often provoked. Splanchnic vein thrombosis (SVT) patients with cirrhosis have a higher rate of thrombotic complications, while SVT without cirrhosis was associated with more malignancy. Given the concurrent comorbidities, careful assessment and individualized anticoagulation decision is needed.
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Affiliation(s)
- Jesica Oktaviana
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Brandon Lui
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Prahlad Ho
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Y Lim
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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Othman M, Pradhan A. Laboratory Testing of Hemostasis in Pregnancy: A Brief Overview. Methods Mol Biol 2023; 2663:111-125. [PMID: 37204707 DOI: 10.1007/978-1-0716-3175-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Normal pregnancy is associated with significant physiological changes in the coagulation and fibrinolytic systems with an inclination toward a hypercoagulable state. This includes an increase in plasma levels of most clotting factors, a decrease in endogenous anticoagulants, and inhibition of fibrinolysis. Although these changes are critical in maintaining placental function and reducing postpartum hemorrhage, they may contribute to an increased risk of thromboembolism, particularly toward the end of pregnancy and during puerperium. Hemostasis parameters and the non-pregnant population reference ranges cannot be used in the assessment of bleeding or thrombotic complication risk during pregnancy, and pregnancy-specific information and reference ranges are not always available to support the interpretation of laboratory tests. This review aims to summarize the use of relevant hemostasis tests to promote evidence-based interpretation of laboratory test results as well as discuss challenges associated with testing during pregnancy.
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Affiliation(s)
- Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada.
- Department of Clinical Pathology, School of Medicine, Mansoura University, Mansoura, Egypt.
| | - Anushka Pradhan
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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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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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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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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8
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Deng L, Li Z, Tang C, Han Y, Zhang L, Liao Q. Quantitative analysis of the serum proteome during early pregnancy in mares. Anim Sci J 2022; 93:e13727. [PMID: 35476278 DOI: 10.1111/asj.13727] [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: 08/11/2021] [Revised: 02/02/2022] [Accepted: 03/18/2022] [Indexed: 11/30/2022]
Abstract
Equine pregnancy is currently diagnosed by rectal palpation, ultrasonographic examination, or by measuring changes in hormones in the blood. In the present study, we identified proteins that are differentially expressed in the sera of early pregnant and non-pregnant mares in order to develop a novel method for diagnosing equine pregnancy. Serum samples were obtained from 18 adult mares, pregnancy at day 32 after ovulation (n = 9) and in diestrus (n = 9). Proteomic analysis of the samples was conducted using liquid chromatography-electrospray ionization-tandem mass spectrometry. We identified 467 proteins from a total of 3514 peptides. Thirty-two proteins (15 upregulated and 17 downregulated) were significantly differentially expressed between the two groups. The Gene Ontology enrichment analysis revealed that they are related to extracellular matrix assembly, blood coagulation, and hemostasis, and the prominent molecular functions were integrin binding, cell adhesion molecule binding, and glycine C-acetyltransferase activity. The pathway analysis of Kyoto Encyclopaedia of Genes and Genomes showed that the top three pathways identified were glycine, serine, and threonine metabolism; cysteine and methionine metabolism; and ether lipid metabolism. The selected five serum proteins were newly potential candidates for pregnancy diagnosis in mares.
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Affiliation(s)
- Liang Deng
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China
| | - Zheng Li
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China
| | - Chi Tang
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China.,Key Laboratory of Protection and Utilization of Biological Resources in Tarim Basin, College of Life Sciences, Tarim University, Alar, China
| | - Yuwei Han
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China
| | - Linxi Zhang
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China
| | - Qingchao Liao
- Department of Animal Genetics, Breeding and Reproduction, College of Animal Science and Veterinary Medicine, Shenyang Agricultural University, Shenyang, China
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Ullah K, Mukhtar H, Khalid U, Sarfraz Z, Sarfraz A. Is Antifibrinolytic Therapy Effective for Preventing Hemorrhage in Patients with Hemophilia Undergoing Dental Extractions? A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221114862. [PMID: 35850548 PMCID: PMC9309773 DOI: 10.1177/10760296221114862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives This systematic review aims to analyze the systemic administration of
antifibrinolytics (tranexamic acid and aminocaproic acid) to prevent
postoperative bleeding in patients with hemophilia. Methods This systematic review was conducted adhering to PRISMA guidelines. Only
randomized controlled trials that assessed human subjects of any age or
gender with any severity of hemophilia undergoing dental extractions, and
systemically administered antifibrinolytic therapy compared to placebo were
included. Post-operative bleeding episodes and adverse events were
presented. PubMed, Cochrane, Embase, CINAHL, Web of Science, and Scopus were
searched through April 15, 2022. The risk ratio (RR) and odds ratio (OR)
applying 95% confidence intervals (CI) were computed using RevMan 5.4.1
(Cochrane). Results Two randomized, placebo-controlled trials pooling in a total of 59 patients
were pooled in this analysis. Among patients administered antifibrinolytic
therapy, 84% reduced risk of post-operative bleeding was reported
(RR = 0.16, 95% CI = 0.05–0.47, P = 0.0009). The chances of post-operative
bleeding were reduced by 95% among the antifibrotics group (OR = 0.05, 95%
CI = 0.01–0.22, P < 0.0001). Conclusion This review finds favorable outcomes for the routine use of antifibrinolytic
therapy for dental extractions in hemophiliacs. Further trials are required
to rationalize existing evidence.
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Affiliation(s)
- Kaleem Ullah
- 194774Independent Medical College, Faisalabad, Pakistan
| | - Humza Mukhtar
- 194774Independent Medical College, Faisalabad, Pakistan
| | - Ushna Khalid
- 172462Sheikh Zayed Medical College, Rahim Yar Khan, Pakistan
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Siregar DIS, Siregar MFG, Siregar GA, Warli SM. von Willebrand Factor Gene Polymorphism in Preeclampsia Pregnant at Medan, Indonesia. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: von Willebrand Factor (vWF) is a large glycoprotein mediating hemostasis and thrombosis. The roles of vWF are platelets adhesion to sites of vascular damage and stabilization of coagulation factor VIII.
AIM: This study aimed to analyze the polymorphism of the vWF gene on preeclampsia (PE) in pregnancy in Medan, Indonesia.
MATERIALS AND METHODS: DNA was amplified using the polymerase chain reaction and was electrophoresed in agarose 2%. Electrophoresis results were detected using Gel Doc 1000 (Biorad, USA). The sequencing method was used to identify polymorphism from vWF gene.
RESULTS: From 50 samples of PE patients, the g.93308C>T vWF gene polymorphism was found with the percentage of TT, CT, and CC genotypes as 50%, 42%, and 8%, respectively.
CONCLUSION: The c.93308C>T vWF gene polymorphism was found in the genotype percentage of homozygous TT, and heterozygote CT was greater than wild-type CC.
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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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Jevtic SD, Malinowski AK, Othman M, Abdul Kadir RA. Physician experiences in management of COVID-19-associated coagulopathy in pregnancy: Communication from the ISTH SSC Subcommittee on Women's Health Issues in Thrombosis and Haemostasis. J Thromb Haemost 2021; 19:2539-2545. [PMID: 34260818 PMCID: PMC8420398 DOI: 10.1111/jth.15462] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) occurs following infection with the potentially fatal, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. Infection can be complicated by coagulopathy, at times featuring thrombocytopenia and thrombosis alongside other coagulation abnormalities, also termed COVID-19-associated coagulopathy (CAC). Data concerning CAC in pregnancy are limited. Better understanding of physician experiences is essential to identify current practice patterns and knowledge gaps. OBJECTIVES To determine physician experiences and practice patterns regarding CAC in pregnancy. METHODS Self-administered survey using the RedCap online platform; supported by the ISTH Subcommittee on Women's Health Issues in Thrombosis and Hemostasis. RESULTS Seventy-five respondents fully or partially completed the survey. Of 1546 reported cases, disease severity was specified in 1298. Sixty-four percent of COVID-19 infections were mild, whereas 4% were severe. Of all cases, 1% developed CAC, with 65% classified as severe. The most frequent abnormalities included thrombocytopenia, elevated C-reactive protein, D-dimer, and lymphopenia. Low molecular weight heparin was the anticoagulant of choice in CAC and was provided by 77% of respondents, with 60% using standard prophylactic dosing. Thrombosis occurred in seven anticoagulated patients who were receiving standard prophylactic (four) or weight-based (three) dosing. Disease severity and additional thrombosis risk factors dictated anticoagulation duration. CONCLUSION In the select population reported by our survey, CAC appears to be uncommon in pregnancy. Anticoagulation practices vary and may not reflect current guidelines. Venous thromboembolism was observed in some CAC patients despite prophylactic anticoagulation (including standard and weight-adjusted dosing). Urgent research is required to determine appropriate anticoagulant dosing and duration in pregnant women with COVID-19 infection.
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Affiliation(s)
- Stefan D Jevtic
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ann Kinga Malinowski
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, School of Baccalaureate Nursing, Kingston, ON, Canada
| | - Rezan A Abdul Kadir
- Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
- Institute for Women's Health, University College London, London, UK
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Weyand AC, Flood VH. Von Willebrand Disease: Current Status of Diagnosis and Management. Hematol Oncol Clin North Am 2021; 35:1085-1101. [PMID: 34400042 DOI: 10.1016/j.hoc.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Von Willebrand disease (VWD) is a common bleeding disorder, affecting male and female individuals equally, that often manifests in mucosal bleeding. VWD can be secondary to a quantitative (Type 1 and Type 3) or qualitative (Type 2) defects in Von Willebrand factor (VWF). Initial testing includes VWF antigen, as well as a platelet binding assay to differentiate between qualitative and quantitative defects. Further subtyping requires additional testing and is needed to ensure appropriate treatment. Desmopressin, antifibrinolytics, hormonal treatments for heavy menstrual bleeding, and VWF concentrates are commonly used in the treatment of VWD.
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Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, 1150 W. Medical Center Dr, MSRB III, Room 8220E, Ann Arbor, MI 48109, USA
| | - Veronica H Flood
- Department of Pediatrics, Medical College of Wisconsin and Versiti Blood Research Institute, Milwaukee, WI, USA; Comprehensive Center for Bleeding Disorders, 8739 Watertown Plank Road, PO Box 2178, Milwaukee, WI 53201-2178, USA.
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14
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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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Maternal and neonatal bleeding complications in relation to peripartum management in hemophilia carriers: A systematic review. Blood Rev 2021; 49:100826. [PMID: 33775466 DOI: 10.1016/j.blre.2021.100826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/20/2022]
Abstract
Currently, there is no consensus on the optimal management to prevent postpartum hemorrhage (PPH) in hemophilia carriers. We aimed to evaluate peripartum management strategies in relation to maternal and neonatal bleeding outcomes by performing an extensive database search up to August 2020. Seventeen case-reports/series and 11 cohort studies were identified of overall 'poor' quality describing 502 deliveries. The PPH incidence in the individual patient data was 63%; 44% for those women receiving prophylaxis to correct coagulation and 77% for those without (OR 0.23, CI 0.09-0.58) and in cohort data 20.3% (26.8% (11/41) vs. 19.4% (55/284) (OR: 1.53, 95% CI: 0.72-3.24), respectively. Peripartum management strategies mostly consisted of clotting factor concentrates, rarely of desmopressin or plasma. Tranexamic acid appears promising in preventing secondary PPH, but was not used consistently. Neonatal bleeding was described in 6 affected male neonates, mostly after instrumental delivery or emergency CS, but insufficient information was provided to reliably investigate neonatal outcome in relation to management. The high PPH risk seems apparent, at most mildly attenuated by prophylactic treatment. Prospective cohort studies are needed to determine the optimal perinatal management in hemophilia.
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He M, Mirzakhani H, Chen L, Wu R, Litonjua AA, Bacharier L, Weiss ST, Nelson DM. Vitamin D Sufficiency Has a Limited Effect on Placental Structure and Pathology: Placental Phenotypes in the VDAART Trial. Endocrinology 2020; 161:5818078. [PMID: 32270179 PMCID: PMC7528633 DOI: 10.1210/endocr/bqaa057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/06/2020] [Indexed: 11/19/2022]
Abstract
Vitamin D insufficiency during pregnancy is widespread. The effects of active vitamin D on the human placenta in vivo are unknown. We test the hypotheses that 25(OH)D sufficiency (arbitrarily defined as 25(OH)D ≥32 ng/mL) modulates placental structure and function in vivo in a population of women whose offspring are at risk for childhood asthma, and that placental pathology is more common in offspring that evolve asthma at age 3. Pregnant volunteers in the St. Louis, MO, cohort of the Vitamin D Antenatal Asthma Reduction Trial (VDAART, NIH grant #HL091528) participated in a nested case-control study and consented for the study of placentas after delivery. Maternal concentrations of 25(OH)D were measured at trial entry and in the third trimester. The histopathology of the placentas from women with sufficient 25(OH)D, versus insufficient, showed no clinically significant differences, but morphometry revealed villi of women with sufficient third-trimester 25(OH)D had a higher villous surface density. Notably, analyses of transcripts, extracted from formalin-fixed paraffin-embedded specimens, revealed higher expression of INTS9, vWF, MACC1, and ARMS2, and diminished expression of the CNTN5 genes in the insufficient group. A larger proportion of placentas showed chronic chorioamnionitis in offspring with versus without asthma at age 3. These findings suggest that maternal 25(OH)D insufficiency has a limited effect on human placental villous histopathology and morphometry, but attenuates a small number of placental gene expression profiles in this selected population. The association of placental chronic chorioamnionitis and offspring asthma is worthy of further study.
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Affiliation(s)
- Mai He
- Department of Pathology & Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Correspondence: Mai He, MD, PhD, Department of Pathology & Immunology, 660 South Euclid, Campus Box 8118, Washington University School of Medicine in St. Louis, St. Louis, MO 63110.
| | - Hooman Mirzakhani
- Channing Division of Network Medicine, Department of Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ling Chen
- Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Robert Wu
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Augusto A Litonjua
- Division of Pulmonary Medicine, Department of Pediatrics, University of Rochester, School of Medicine, Rochester, New York
| | - Leonard Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Scott T Weiss
- Channing Division of Network Medicine, Department of Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
| | - D Michael Nelson
- Department of Obstetrics & Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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17
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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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Allerkamp H, Lehner S, Ekhlasi-Hundrieser M, Detering C, von Depka Prondzinski M, Pfarrer C. Expression of angiogenic factors in the uteroplacental unit is altered at time of placentation in a porcine model of von Willebrand disease type 1. Reprod Biol 2019; 19:412-420. [PMID: 31806575 DOI: 10.1016/j.repbio.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/27/2019] [Accepted: 09/29/2019] [Indexed: 11/15/2022]
Abstract
Von Willebrand disease (VWD) affects blood coagulation and correlates with angiodysplasia. Data on VWD-affected women point to slightly increased miscarriage rates. We aimed to investigate the impact of VWD on angiogenesis in the uteroplacental unit of pregnant pigs of a model of VWD type 1 (T1). Uteri, placentae, and embryos were harvested at time of placentation (day 29 to 31) from four sows (two wildtype (WT) and two heterozygous for a von Willebrand factor (VWF) mutation diagnosed with T1). T1 sows were bred to a T1 boar creating embryos of three different genotypes: WT, T1 or homozygous for the VWF mutation corresponding with VWD type 3 (T3). Uteroplacental tissues were examined histologically. Embryos were genotyped. Gene expression of angiogenic factors possibly related to VWF was determined by quantitative real-time PCR. Corresponding protein expression was analyzed by immunohistochemistry. Genotyping revealed 35.3% WT, 52.9% T1 and 5.9% T3 embryos (5.9% not classified confidently). No histological alterations were found. Gene expression of VEGF was significantly increased in T1 placentae while expression of ANG1, ANG2, TIE2, and ITGB3 was significantly reduced, confirmed on protein level for different cell types. TIE2/TIE1 ratios were significantly lower in T1 placentae. Distribution of embryo genotypes indicates selection favoring the WT. Significant expression differences of angiogenic factors in placentae suggest influence of VWF on these factors during placentation, although angiodysplasia was not observed. The alterations concerning VEGF/VEGFR-2 signaling, integrin expression and the ANG/TIE system may influence angiogenesis and vascular adaptation during placentation and thus the overall outcome of pregnancy.
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Affiliation(s)
- Hanna Allerkamp
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany.
| | - Stefanie Lehner
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Mahnaz Ekhlasi-Hundrieser
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Carsten Detering
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Mario von Depka Prondzinski
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Christiane Pfarrer
- University of Veterinary Medicine Hannover Foundation, Institute for Anatomy, Bischofsholer Damm 15, 30173 Hannover, Germany
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Fundamentals for a Systematic Approach to Mild and Moderate Inherited Bleeding Disorders: An EHA Consensus Report. Hemasphere 2019; 3:e286. [PMID: 31942541 PMCID: PMC6919472 DOI: 10.1097/hs9.0000000000000286] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023] Open
Abstract
Healthy subjects frequently report minor bleedings that are frequently ‘background noise’ of normality rather than a true disorder. Nevertheless, unexpected or unusual bleeding may be alarming. Thus, the distinction between normal and pathologic bleeding is critical. Understanding the underlying pathologic mechanism in patients with an excessive bleeding is essential for their counseling and treatment. Most of these patients with significant bleeding will result affected by non-severe inherited bleeding disorders (BD), collectively denominated mild or moderate BD for their relatively benign course. Unfortunately, practical recommendations for the management of these disorders are still lacking due to the current state of fragmented knowledge of pathophysiology and lack of a systematic diagnostic approach. To address this gap, an International Working Group (IWG) was established by the European Hematology Association (EHA) to develop consensus-based guidelines on these disorders. The IWG agreed that grouping these disorders by their clinical phenotype under the single category of mild-to-moderate bleeding disorders (MBD) reflects current clinical practice and will facilitate a systematic diagnostic approach. Based on standardized and harmonized definitions a conceptual unified framework is proposed to distinguish normal subjects from affected patients. The IWG proposes a provisional comprehensive patient-centered initial diagnostic approach that will result in classification of MBD into distinct clinical-pathological entities under the overarching principle of clinical utility for the individual patient. While we will present here a general overview of the global management of patients with MBD, this conceptual framework will be adopted and validated in the evidence-based, disease-specific guidelines under development by the IWG.
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Delbrück C, Miesbach W. The Course of von Willebrand Factor and Factor VIII Activity in Patients with von Willebrand Disease during Pregnancy. Acta Haematol 2019; 142:71-78. [PMID: 31085919 DOI: 10.1159/000496820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/09/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Women with von Willebrand disease (VWD) are at a higher risk of bleeding, which might affect the health of mother and child during pregnancy and the intra- and postpartum periods. This retrospective cohort study evaluates changes in the coagulation parameters von Willebrand factor antigen (VWF:Ag), von Willebrand ristocetin cofactor (VWF:RCo), and Factor VIII activity (FVIII:C) during pregnancy in patients with VWD. In total, 44 pregnancies of 38 patients were assessed (VWD type 1 n = 32, type 2A n = 3, type 2B n = 1, type 2 subtype unidentified n = 2). The patients' median age at childbirth was 32 years (range 22-40). RESULTS A significant increase in coagulation parameters was found in patients with VWD type 1 (VWF:Ag, VWF:RCo, and FVIII:C p = 0.000). In the third trimester, VWF:Ag and FVIII:C normalized in all patients with VWD type 1; in 3 patients VWF:RCo remained below the normal range. Patients with VWD type 2 showed a significant increase of VWF:Ag (p = 0.003) and FVIII:C (p = 0.011), and a non-significant increase of VWF:RCo (p = 0.097). In 4 of 9 pregnancies of patients with VWD type 2, all surveyed coagulation parameters normalized until the third trimester. CONCLUSION For the majority of the observed patients, the von Willebrand parameters increased during pregnancy.
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Affiliation(s)
- Christiane Delbrück
- Department of Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Haemostaseology and Haemophilia Centre, University Hospital Frankfurt, Frankfurt am Main, Germany,
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21
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Swystun LL, Lillicrap D. Genetic regulation of plasma von Willebrand factor levels in health and disease. J Thromb Haemost 2018; 16:2375-2390. [PMID: 30246494 PMCID: PMC7147242 DOI: 10.1111/jth.14304] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 02/06/2023]
Abstract
Plasma levels of the multimeric glycoprotein von Willebrand factor (VWF) constitute a complex quantitative trait with a continuous distribution and wide range in the normal population (50-200%). Quantitative deficiencies of VWF (< 50%) are associated with an increased risk of bleeding, whereas high plasma levels of VWF (> 150%) influence the risk of arterial and venous thromboembolism. Although environmental factors can strongly influence plasma VWF levels, it is estimated that approximately 65% of this variability is heritable. Interestingly, although variability in VWF can account for ~ 5% of the genetic influence on plasma VWF levels, other genetic loci also strongly modify plasma VWF levels. The identification of the additional sources of VWF heritability has been the focus of recent observational trait-mapping studies, including genome-wide association studies or linkage analyses, as well as hypothesis-driven research studies. Quantitative trait loci influencing VWF glycosylation, secretion and clearance have been associated with plasma VWF antigen levels in normal individuals, and may contribute to quantitative VWF abnormalities in patients with a thrombotic tendency or type 1 von Willebrand disease (VWD). The identification of genetic modifiers of plasma VWF levels may allow for better molecular diagnosis of type 1 VWD, and enable the identification of individuals at increased risk for thrombosis. Validation of trait-mapping studies with in vitro and in vivo methodologies has led to novel insights into the life cycle of VWF and the pathogenesis of quantitative VWF abnormalities.
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Affiliation(s)
- L L Swystun
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - D Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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22
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Rottenstreich A, Kleinstern G, Amsalem H, Kalish Y. The course of acquired von Willebrand syndrome during pregnancy among patients with essential thrombocytosis. J Thromb Thrombolysis 2018; 46:304-309. [PMID: 29654448 DOI: 10.1007/s11239-018-1663-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To investigate the course of acquired type 2A von Willebrand syndrome (AVWS) in relation to patient management and outcomes among pregnant patients with essential thrombocytosis (ET). A review of pregnant women with ET evaluated for AVWS at the beginning of pregnancy and at the third trimester. Eighteen women with 24 pregnancies were included in this study. A history of bleeding was noted in 8 (44%) patients. In 20 (83%) pregnancies AVWS was evident at the initial testing. Following initial testing, antithrombotic therapy was administered in 22 (92%) pregnancies (aspirin, n = 20 and low-molecular-weight heparin, n = 2). In the remaining two pregnancies, VWF:RCo levels were below 30%; thus, aspirin was given only after repeat testing at 14-16 weeks. At third trimester testing, median VWF:RCo levels were significantly higher than at the initial testing (86 vs. 48%, P < 0.001), with no evidence of AVWS in any of the patients. Significant increases were also observed in the VWF:Ag level (127 vs. 84%, P < 0.001), the VWF:RCo/VWF:Ag ratio (0.75 vs. 0.54, P < 0.001) and the FVIII level (103 vs. 68%, P < 0.001); while platelet count (359 vs. 701 × 109/l, P < 0.001) and hemoglobin level (11.6 vs. 13.4 g/dl, P < 0.001) decreased. Neuraxial anesthesia was safely performed in 17 (71%) pregnancies. No significant bleeding events occurred during pregnancy and delivery. AVWS-related abnormalities in women with ET mostly improved during pregnancy, with favorable maternal and fetal outcomes. VWF parameters should be tested at early pregnancy and repeated at the third trimester, to guide pregnancy and delivery management.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Geffen Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, Jerusalem, Israel.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Hagai Amsalem
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
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Within-subject biological variation of activated partial thromboplastin time, prothrombin time, fibrinogen, factor VIII and von Willebrand factor in pregnant women. ACTA ACUST UNITED AC 2018; 56:1297-1308. [DOI: 10.1515/cclm-2017-1220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/13/2018] [Indexed: 11/15/2022]
Abstract
AbstractBackground:During pregnancy, interpretation of results from coagulation parameters can be difficult as the physiological changes that occur may affect the biochemical parameters. The aim of this study was to describe the normal course of five coagulation parameters in healthy pregnancies, and to estimate the within-subject biological variation (CVI).Methods:Blood samples were obtained every 4th week during pregnancy and three samples after delivery in 20 healthy women and every 4th week during a 40-week period in 19 healthy non-pregnant women. Activated partial thromboplastin time (APTT), prothrombin time (PT), PT International Normalized Ratio (INR), fibrinogen, factor VIII clot (FVIII:C) and von Willebrand factor antigen (vWF:Ag) were analyzed. The physiological changes during pregnancy were compensated by transformation into multiples of the median (MoM) and it is natural logarithm (lnMoM) in order to establish a kind of steady state, and CVIwas calculated from the standard deviation.Results:During pregnancy, APTT, PT and INR remained unchanged or decreased, depending upon the reagent used, while fibrinogen, FVIII:C and vWF:Ag increased gradually until delivery. The CVIin pregnancy were 2.2 and 3.0% for APTT, 2.3 and 2.6% for PT, 2.2 and 2.3% for INR, 7.2% for fibrinogen, 12.2% for FVIII:C and 11.3% for vWF:Ag, and corresponded with the CVIin non-pregnant women.Conclusions:Transformation of coagulation parameters in healthy pregnancies to MoM is a tool to establish a kind of steady state. Although there is a physiological change in these coagulation parameters during pregnancy, the CVIafter lnMoM transformation was comparable with the CVIof non-pregnant women.
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Favaloro EJ, Bonar R, Hollestelle MJ, Jennings I, Mohammed S, Meijer P, Woods T, Meiring M. Differential sensitivity of von Willebrand factor activity assays to reduced VWF molecular weight forms: A large international cross-laboratory study. Thromb Res 2018; 166:96-105. [DOI: 10.1016/j.thromres.2018.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/22/2018] [Accepted: 04/16/2018] [Indexed: 12/17/2022]
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25
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Plastini T, Henry D, Dunleavy K. Ovarian vein thrombus: to treat or not to treat? Blood Adv 2017; 1:1120-1123. [PMID: 29296754 PMCID: PMC5728322 DOI: 10.1182/bloodadvances.2017006577] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/17/2017] [Indexed: 11/20/2022] Open
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26
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Evaluation of a von Willebrand factor three test panel and chemiluminescent-based assay system for identification of, and therapy monitoring in, von Willebrand disease. Thromb Res 2016; 141:202-11. [DOI: 10.1016/j.thromres.2015.12.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/06/2015] [Accepted: 12/12/2015] [Indexed: 01/31/2023]
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Favaloro EJ, Bonar RA, Mohammed S, Arbelaez A, Niemann J, Freney R, Meiring M, Sioufi J, Marsden K. Type 2M von Willebrand disease – more often misidentified than correctly identified. Haemophilia 2016; 22:e145-55. [PMID: 27029718 DOI: 10.1111/hae.12903] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 12/24/2022]
Affiliation(s)
- E. J. Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis Institute of Clinical Pathology and Medical Research (ICPMR) Pathology West NSW Health Pathology Westmead Hospital Westmead NSW Australia
| | - R. A. Bonar
- RCPAQAP Haematology St Leonards NSW Australia
| | - S. Mohammed
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis Institute of Clinical Pathology and Medical Research (ICPMR) Pathology West NSW Health Pathology Westmead Hospital Westmead NSW Australia
| | - A. Arbelaez
- Mater Pathology Mater Health Services Brisbane Qld Australia
| | - J. Niemann
- Mater Pathology Mater Health Services Brisbane Qld Australia
| | - R. Freney
- Mater Pathology Mater Health Services Brisbane Qld Australia
| | - M. Meiring
- Department of Haematology and Cell Biology Faculty of Health Sciences University of the Free State Bloemfontein South Africa
| | - J. Sioufi
- RCPAQAP Haematology St Leonards NSW Australia
| | - K. Marsden
- RCPAQAP Haematology St Leonards NSW Australia
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28
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De Jong A, Eikenboom J. Developments in the diagnostic procedures for von Willebrand disease. J Thromb Haemost 2016; 14:449-60. [PMID: 26714181 DOI: 10.1111/jth.13243] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 12/28/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder but its diagnosis can be challenging due to the heterogeneity of the disease. VWD is mainly associated with mild mucocutaneous bleeding, although there are more severe phenotypes with bleeding from the gastrointestinal tract or even the joints. Also, surgical interventions and trauma may lead to critical bleeding events. These bleeding episodes are all related to quantitative or qualitative defects of von Willebrand factor (VWF), a multimeric glycoprotein produced by endothelial cells and megakaryocytes, which mediates platelet adhesion and aggregation and binds factor VIII (FVIII) in the circulation. This review describes the diagnostic procedures required for correct diagnosis. Accurate diagnosis and classification is required for proper treatment and counseling. Assessment of bleeding starts with the medical history. After a positive bleeding or family history, subsequent laboratory investigations will start with a panel of standard screening tests for hemostatic defects. Patients suspected of having VWD will be tested for plasma VWF antigen levels, the ability of VWF to bind platelets and FVIII activity. When VWD is confirmed, a set of subtyping tests can classify the patients as VWD types 1, 2 (A, B, M or N) or 3. The performance of some additional assays and analyses, such as VWF propeptide measurement or genetic analysis, may help in identifying the pathological mechanism behind certain defects or can guide in the choice of treatment.
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Affiliation(s)
- A De Jong
- Department of Thrombosis and Haemostasis, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - J Eikenboom
- Department of Thrombosis and Haemostasis, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
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29
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Abstract
Antiphospholipid syndrome (APS) is characterized by vascular thrombosis and/or obstetric complications associated with presence of antiphospholipid antibodies (aPL) but additional factors would also induce thrombosis. ABO (H) blood groups are known to be closely related to thrombosis, especially non-O blood type with venous events. The aim of this study was to investigate possible role of ABO (H) blood types in the thrombotic events in primary APS (PAPS). Seventy PAPS patients were selected for the study and were divided according to ABO blood group in: O PAPS (n = 26) and non-O PAPS (n = 44). ABO blood group phenotyping was performed by indirect technique. aPL anticardiolipin (aCL) and anti-βeta2 glycoprotein-1 (aβ2GPI) and the concentrations and activities of von Willebrand factor (VWF) were measured with ELISA. Lupus anticoagulant (LA) was detected by coagulation assays. A significant higher frequency of venous events was observed in non-O PAPS group (72.7 vs. 46.2 %, p = 0.040). In contrast, the frequency of arterial events was significantly higher in the O PAPS compared to the non-O PAPS group (69.2 vs. 36.4 %, respectively; p = 0.013). Frequencies of aCL, LA, aβ2GPI and triple aPL positivity were similar in both groups (p > 0.05). VWF antigen (75.54 ± 8.68 vs. 79.51 ± 7.07 IU/dl, p = 0.041) and activity (70.23 ± 11.96 vs. 77.92 ± 13.67 %, p = 0.020) were decreased in O PAPS compared to non-O blood group. VWF:CB/VWF:Ag ratio was similar among groups (p > 0.05). This is the first report that confirms the role of ABO blood system in thrombosis of PAPS and suggests that non-O blood group was related with venous events and O blood group with arterial thrombosis.
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Baouahi H, Zerqouni Y, Doumiri M, Oudghiri N, Saoud AT. [The role of the anesthesiologist in the care of the pregnant woman with Von Willebrand Disease]. Pan Afr Med J 2015; 22:335. [PMID: 26977242 PMCID: PMC4773058 DOI: 10.11604/pamj.2015.22.335.7997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/12/2015] [Indexed: 11/23/2022] Open
Abstract
La maladie de Von Willebrand (VWD) est la maladie hémorragique constitutionnelle de l'hémostase la plus fréquente. Elle est liée à un déficit, soit quantitatif, soit qualitatif en facteur willebrand (VWF). Elle se caractérise par son extrême hétérogénéité sur les plans clinique, phénotypique et génotypique. La grossesse et surtout le péri-partum représente une période à risque hémorragique pour ces femmes. Nous rapportons le cas d'une parturiente présentant une maladie de Von Willebrand de type 1 documentée, la difficulté du choix du mode d'accouchement et de la technique anesthésique a été revue.
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Affiliation(s)
- Hanane Baouahi
- Service d'Anesthésie-Réanimation, Hôpital Maternité Souissi, Centre Hospitalier Universitaire, Université Mohamed V Rabat, Maroc
| | - Yassine Zerqouni
- Service d'Anesthésie-Réanimation, Hôpital Maternité Souissi, Centre Hospitalier Universitaire, Université Mohamed V Rabat, Maroc
| | - Mouhcine Doumiri
- Service d'Anesthésie-Réanimation, Hôpital Maternité Souissi, Centre Hospitalier Universitaire, Université Mohamed V Rabat, Maroc
| | - Nezha Oudghiri
- Service d'Anesthésie-Réanimation, Hôpital Maternité Souissi, Centre Hospitalier Universitaire, Université Mohamed V Rabat, Maroc
| | - Anas Tazi Saoud
- Service d'Anesthésie-Réanimation, Hôpital Maternité Souissi, Centre Hospitalier Universitaire, Université Mohamed V Rabat, Maroc
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Abstract
PURPOSE OF REVIEW Anesthesiologists frequently care for patients with altered hemostasis and coagulation. Where a clear history of familial and personal bleeding exists, a thoughtful plan can be developed in advance to manage the issue perioperatively. However, in some cases, it may not be known that the patient has a disorder until excessive bleeding is noted during or after surgery. Recognition of the issue and appropriate targeted therapy are the keys to successful management. RECENT FINDINGS With an estimated prevalence approaching 1% of the population, von Willebrand disease (vWD) is the most common hereditary bleeding diathesis, but the estimated prevalence of acquired vWD (often termed von Willebrand syndrome or vWS) is now believed to be significantly higher, especially in patients with malignancies, autoimmune diseases, cardiac valvular lesions, and in patients on mechanical circulatory support devices. Acquired vWD may also occur with certain medications. SUMMARY The mainstay of the diagnosis of vWD is laboratory testing. Preoperative clinical assessment and a high level of suspicion are often effective to alert the anesthesiologist to the possibility of vWS, thus allowing for appropriate testing and potential prophylaxis in elective situations, as well as appropriately targeted therapy of unexpected bleeding when a hemostatic derangement was not anticipated preoperatively.
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Drury-Stewart DN, Lannert KW, Chung DW, Teramura GT, Zimring JC, Konkle BA, Gammill HS, Johnsen JM. Complex changes in von Willebrand factor-associated parameters are acquired during uncomplicated pregnancy. PLoS One 2014; 9:e112935. [PMID: 25409031 PMCID: PMC4237360 DOI: 10.1371/journal.pone.0112935] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Background The coagulation protein von Willebrand Factor (VWF) is known to be elevated in pregnancy. However, the timing and nature of changes in VWF and associated parameters throughout pregnancy are not well understood. Objectives To better understand the changes in VWF provoked by pregnancy, we studied VWF-associated parameters in samples collected over the course of healthy pregnancies. Methods We measured VWF antigen (VWF:Ag), VWF propeptide (VWFpp), Factor VIII (FVIII), and ADAMTS13 activity in samples collected from 46 women during pregnancy and at non-pregnant baseline. We also characterized pregnant vs. non-pregnant VWF multimer structure in 21 pregnancies, and performed isoelectric focusing (IEF) of VWF in two pregnancies which had samples from multiple trimesters. Results VWF:Ag and FVIII levels were significantly increased during pregnancy. ADAMTS13 activity was unchanged. VWFpp levels increased much later in pregnancy than VWF:Ag, resulting in a progressive decrease in VWFpp:Ag ratios. FVIII:VWF ratios also decreased in pregnancy. Most pregnancies exhibited a clear loss of larger VWF multimers and altered VWF triplet structure. Further evidence of acquired VWF qualitative changes in pregnancy was found in progressive, reversible shifts in VWF IEF patterns over gestation. Conclusions These data support a new view of pregnancy in which VWF can acquire qualitative changes associated with advancing gestational age. Modeling supports a scenario in which both increased VWF production and doubling of the VWF half-life would account for the data observed. We propose that gestation induces a prolongation in VWF survival, which likely contributes to increased total VWF levels and altered VWF structure.
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Affiliation(s)
| | - Kerry W. Lannert
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Dominic W. Chung
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Gayle T. Teramura
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
| | - James C. Zimring
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Barbara A. Konkle
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Hilary S. Gammill
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Jill M. Johnsen
- Research Institute, Puget Sound Blood Center, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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