[Factor X deficiency and pregnancy]

Rare case of combined factor V and factor X deficiency in pregnancy: presenting as secondary postpartum haemorrhage in first pregnancy and successful outcome in second pregnancy

Isolated factor V and factor X deficiency is a very rare condition affecting 1 in 500,000-1,000,000 persons worldwide. We present a rare first reported case of combined deficiency of factor V and factor X where the patient developed secondary postpartum haemorrhage in first pregnancy, after which she was diagnosed to have this rare disorder and her subsequent pregnancy was then successfully managed.

Factor deficiencies in pregnancy

Pregnancy, childbirth, and the puerperium are hemostatically challenging to women with bleeding disorders. This article provides general recommendations for the management of pregnant women with inherited coagulation disorders. Each factor deficiency is discussed, providing an up-to-date review of the literature and, where possible, guidance about how to manage patients throughout pregnancy, delivery, and the puerperium. The factor deficiencies covered are inherited abnormalities of fibrinogen; deficiencies of prothrombin, factor (F)V, FVII, FX, FXI, FXIII; combined deficiencies of FV and FVIII; and the inherited deficiency of vitamin K-dependent clotting factors. The management of carriers of hemophilia A and B is also discussed.

Blood product support for delivery in severe factor X deficiency: the use of thrombin generation to guide therapy

BACKGROUND

Severe FX deficiency is a rare disorder with a variable bleeding tendency but spontaneous life threatening haemorrhage can occur. Treatment for invasive procedures and spontaneous bleeding is with prothrombin complex concentrates (PCC). When used in large or repetitive doses these are associated with a thrombotic tendency. FX:C levels of 0.15 - 0.30 IU/ mL are thought to be haemostatic during surgery . There is only limited information on the outcome and management of pregnancy in severe FX deficiency. Caesarean section is suggested as delivery mode to reduce the risk of intracranial/abdominal neonatal haemorrhage, but successful vaginal deliveries are also described. The calibrated automated thrombin generation assay (CAT) is a global coagulation test that measures the time course of thrombin generation. It has been reported to correlate with prothrombotic states and the severity of bleeding in rare coagulation disorders. The variability in phenotype, the uncertainty of the minimal haemostatic FX:C concentration and the association of PCC's with thrombosis make thrombin generation of interest in the management of FX deficient patients.

PATIENT

We describe the use of CAT as a possible means to monitor treatment with PCC (Beriplex) in a patient with severe FX deficiency (FX:C < 0.01 IU/mL) during successful vaginal delivery and epidural anaesthesia.

RESULTS

Thrombin generation was normal at FX:C 0.80 IU/mL but only borderline normal at FX:C 0.25 IU/mL. Repetitive doses over 3 days increased thrombin generation to the upper limit of normal at FX:C 0.25 IU/mL consistent with a prothrombotic tendency after multiple doses. The increase in thrombin generation was not related to prothrombin levels.

CONCLUSION

The data suggest that CAT may be used to monitor treatment with PCC in FX deficiency. Higher levels than previously thought may be needed to normalize thrombin generation. Further studies into the correlation with bleeding or thrombosis are needed before the approach can be accepted in clinical practice.

Severe factor X deficiency in pregnancy: case report and review of the literature

Isolate factor X deficiency is an extremely rare clotting factor disorder inherited in autosomal recessive fashion and pregnancy in a homozygous patient is frequently complicated by recurrent miscarriage, uterine bleeding and premature labour. Eleven pregnancies in seven patients affected by FX deficiency have been reported in the literature. Two additional pregnancies have been reported in a FX variant (FX Friuli). We present a new case of successful at term pregnancy in a homozygous patient.