Congenital and acquired bleeding disorders in pregnancy

Delphi consensus recommendations for neuraxial anesthesia in adults with platelet disorders and coagulation defects: communication from the ISTH SSC Subcommittee on von Willebrand Factor

Neuraxial anesthesia is used for pain management in surgical and nonsurgical settings. Spinal/epidural hematomas likely occur in between 1:10 000 and 1:200 000 procedures. Risk is believed to be greater in patients with bleeding disorders/thrombocytopenia, and there are no existing comprehensive recommendations to guide neuraxial anesthesia in these patients. The study's objective was to develop recommendations to advise clinicians on treatment thresholds for neuraxial anesthesia in patients with platelet disorders/coagulation defects. A 4-round electronic modified Delphi consensus study was conducted. A steering committee generated the original Delphi statements and refined them based on panelist feedback. Consensus was achieved if ≥70% of participants agreed/strongly agreed or disagreed/strongly disagreed with a statement. This project was endorsed by the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on von Willebrand Factor. Forty-five experts participated (42% response rate) with an essentially equal number of hematologists and anesthesiologists. Thirty consensus statements were developed for 11 disorders ranging from various causes of thrombocytopenia, inherited platelet function disorders, and single or multiple coagulation defects in obstetrical and nonobstetrical patients. Risk of sampling bias is present due to a predominantly North American sample, attrition (common in Delphi studies), and steering committee participation in the Delphi rounds. This is the first set of consensus recommendations for neuraxial anesthesia in adult patients with an array of platelet disorders/coagulation defects. These recommendations, based on the best available evidence and expert opinion, provide a decision framework for clinicians when faced with this challenging scenario.

Von Willebrand disease (VWD) and pregnancy: a comprehensive overview

Von Willebrand disease (VWD) is a hereditary bleeding disorder characterized by a quantitative or qualitative deficiency of von Willebrand factor (VWF). Pregnancy significantly impacts hemostasis, leading to a hypercoagulable state. However, women with VWD experience unique challenges due to the interplay between pregnancy-related hormonal changes and VWF deficiencies. This review delves into the intricate relationship between VWD and pregnancy. We explored the physiological changes that occur during pregnancy, including hormonal fluctuations, hemodilution, and alterations in platelet-VWF interactions. We discuss how these changes can exacerbate bleeding tendencies in women with VWD, particularly during childbirth and the postpartum period. This review highlights the increased risk of postpartum hemorrhage (PPH) in women with VWD and the potential for severe maternal morbidity and mortality. We examine the various types of VWD and their specific implications for pregnancy outcomes. Additionally, we discuss the challenges associated with diagnosing and managing VWD during pregnancy, as well as the importance of prenatal counseling and careful monitoring. The management of VWD during pregnancy involves a multidisciplinary approach, including the use of prophylactic treatments, such as desmopressin and tranexamic acid, as well as factor replacement therapy when necessary. Careful planning of delivery, including the choice of delivery mode and the timing of interventions, is essential to minimize bleeding complications. By understanding the complexities of VWD during pregnancy and implementing appropriate management strategies, healthcare providers can significantly improve the outcomes for women with VWD and their offspring.

Recombinant von Willebrand factor use in obstetric anesthesia

Background

In pregnant patients with von Willebrand disease who have reduced von Willebrand factor (VWF) activity but normal factor VIII activity, recombinant VWF may be considered to supplement VWF.

Methods

All patients with known diagnosis of von Willebrand disease who were admitted for delivery and received recombinant VWF between October 2019 and March 2023 were included. Demographic data, peripartum course, laboratory data, neuraxial use, and bleeding complications were reviewed.

Results

There were 8 deliveries in 6 patients who had von Willebrand disease and received recombinant VWF during the study period. All patients received neuraxial analgesia or anesthesia after administration of recombinant VWF without complications. No patient required additional recombinant VWF supplementation at delivery.

Conclusion

Recombinant VWF may be an option for peripartum management in parturients with selective reduction in VWF activity and normal factor VIII activity.

Antepartum risk factors and outcomes of massive transfusion for elective cesarean section: a nationwide retrospective cohort study

BACKGROUND

Postpartum hemorrhage is one of the leading causes of maternal mortality and morbidity. The etiology of postpartum hemorrhage exhibits variations in relation to the mode of birth; consequently, risk factors for massive transfusion in elective cesarean section might diverge from those encountered in vaginal birth or emergency cesarean section. The main purpose of this study was to investigate antepartum risk factors of massive transfusion for elective cesarean section.

METHODS

We conducted a retrospective cohort study based on data from a nationwide system that collected inpatient medical records from tertiary hospitals in mainland China. We included women who had undergone elective cesarean section from January 2013 to August 2018. Primary outcome was massive transfusion defined as transfusion of more than eight units of red blood cells on the day of childbirth. Candidate risk factors were identified by the 10th revision of International Classification of Diseases Codes of admission diagnoses. The relationship between each factor and massive transfusion was assessed using multivariable logistic regression.

RESULTS

A total of 294,695 women were included and 572 of them received massive transfusion (incidence: 194 per 100,000 elective cesarean sections). Maternal age [adjusted odds ratio (aOR) 1.22; 95% confidence interval (CI) 1.10-1.48], anemia (aOR 1.66; 95% CI 1.34-2.05), thrombocytopenia (aOR 3.54; 95% CI 2.39-5.05), coagulopathy (aOR 25.92; 95% CI 8.59-69.50), hypoalbuminemia (aOR 2.97; 95% CI 1.86-4.53), hepatic dysfunction (aOR 1.65; 95% CI 1.04-2.47), uterine scar (aOR 1.39; 95% CI 1.15-1.67), multiple pregnancy (aOR 2.84; 95% CI 1.74-4.38), polyhydramnios (aOR 2.52; 95% CI 1.19-4.68) and placenta previa (aOR 25.03; 95% CI 21.04-29.77) were associated with massive blood transfusion for elective cesarean section. Among the women receiving massive blood transfusion, 7 (1.2%) died during hospitalization, 126 (22.0%) needed hysterectomy, 25 (4.4%) uterine packing and 57 (10.0%) uterine artery ligation.

CONCLUSIONS

Ten risk factors of massive transfusion were identified in women undergoing elective cesarean section. Our findings may facilitate blood products preparation and provide opportunities for applying prophylactic strategies prior to cesarean section for women at high risk of massive transfusion.

Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas)

Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.

Pregnancy, childbirth and neonatal outcomes of women with rare inherited coagulation disorders

Background

We aimed to describe the characteristics and the pregnancy outcomes of women with rare inherited coagulation factor disorders managed at a tertiary obstetric-haematology unit in the United Kingdom.

Methods

A retrospective service evaluation was conducted using routinely collected medical records. Descriptive analyses were applied to investigate pregnancy, childbirth and neonatal management and outcomes.

Results

Overall, 20 patients with rare inherited coagulation disorders were included who birthed 30 live infants from 29 pregnancies. Regarding maternal bleeding outcomes, 3% experienced antepartum haemorrhage, 38% of pregnancies experienced primary post-partum haemorrhage, and none experienced secondary post-partum haemorrhage. Five (17%) neonates had cranial ultrasound scans for imaging to investigate for a neonatal haemorrhage, which were all normal.

Conclusions

Although women with rare inherited coagulation disorders may be more susceptible to complications in pregnancy, within this cohort there was no evidence that the condition led to increased morbidity or mortality when best practices were observed.

Pregnancy and childbirth in women with bleeding disorders: A retrospective cohort study

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.

Recurrent miscarriage in a woman with congenital factor V deficiency: a case report

BACKGROUND

Factor V deficiency is a rare bleeding disorder that can be either congenital or acquired. Factor V deficiency mostly present with mucosal bleeding. Coagulation factor V does not increase considerably during normal gestation. Since pregnancy can be threatened by blood clotting disorders, abnormal changes in coagulation factors level can pose challenges to pregnant women.

CASE PRESENTATION

We report a 40-year-old pregnant woman with prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy. Her past medical history included two unexplained abortions. Physical examination was unremarkable, but the blood test showed elevated PT and PTT with a considerable decrease in factor V activity, while other factors were within normal range. Subsequently, the patient was diagnosed with congenital factor V deficiency. After treatment with fresh frozen plasma, she underwent vaginal delivery and a baby with factor V deficiency was born.

CONCLUSIONS

This is the second report of recurrent miscarriage in congenital factor V deficiency patients. Clinicians should consider the possibility of factor V deficiency in women with a history of idiopathic miscarriage even in patients without any symptoms.

Eltrombopag treatment for severe immune thrombocytopenia during pregnancy: a case report

Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia (platelet count <100 × 109/l) in the absence of other causes or disorders associated. The incidence of ITP in pregnancy is one to two cases per 1000 gestations. ITP could be diagnosed before or during pregnancy; sometimes a relapse of a previously diagnosed ITP can occur. Intravenous immune globulins (IVIg) and corticosteroids are the standard frontline therapy because of their well known safety profile either for the mother or for the neonate. Treatments for refractory patients are limited by potential fetal risk. We report the case of a patient with ITP along pregnancy, refractory to corticosteroids and IVIg, successfully treated with, the thrombopoietin receptor agonist (TPO-RA) eltrombopag. Patient received this compound for almost the whole pregnancy and in particular for the whole first trimester, without any complication for the mother and the neonate. Although transient administration of TPO-RAs in pregnancy seems to be well tolerated, their use during the whole gestation is still controversial; this is the reason of the description of this case, which did not show any complications, and thus it could add useful information on this field.

Hematologic Findings in Pregnancy: A Guide for the Internist

Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.

Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review

The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.

Thrombocytopenia in pregnancy: Diagnosis and approach to management

Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.