Diagnosis and treatment discussion of congenital factor VII deficiency in pregnancy: A case report

Bleeding Symptoms in Pediatric Patients with Congenital FVII Deficiency and Correlation to Thrombin Generation Assay Parameters: A Single-Center Retrospective Analysis

Inherited factor VII deficiency is the most common rare bleeding disorder, affecting about 1/500,000 individuals without gender predilection. Most of the patients with FVII 20-50% are asymptomatic, but post-traumatic or post-surgical bleeding may often occur since there is not an exact correlation between FVII plasma levels and the bleeding phenotype. We enrolled 19 children and adolescents with FVII levels of 20-35% and 33 controls. Laboratory data collected included thrombin generation, prothrombin time, activated partial thromboplastin time, fibrinogen, and FVII levels. In our study, we found a statistical difference in the lag time ratio (p < 0.01) and tt-peak ratio (p < 0.05) between patients and controls but no difference in the other parameters, such as the endogenous thrombin potential (ETP). However, when we categorized patients, regardless of their bleeding scores, as presenting symptoms and having no symptoms, both the lag time ratio (p = 0.01) and tt-peak ratio (p < 0.05) were significantly different, and the vel. index % showed increased levels in patients without symptoms (p < 0.05). This study shows that thrombin generation may be a useful tool in assessing the risk of bleeding symptoms in children with an FVII deficiency categorized in the mild category (20-35%), although we cannot predict the severity of the bleeding.

Feto-Maternal Outcomes in Pregnancy With Factor VII Deficiency in a Tertiary Care Institution

This paper aims to study antepartum and postpartum bleeding manifestations of patients with factor VII (FVII) deficiency, their management, and feto-maternal outcomes, to establish danger signs and management protocols. We describe a case series of nine pregnancies in four patients with FVII deficiency diagnosed at a tertiary care referral center in India between 2012 and 2023. Out of nine pregnancies, six had cesarean deliveries, two had vaginal deliveries, and one had dilatation and curettage for unwanted pregnancies. One out of nine pregnancies (11.11%) with an unknown FVII deficiency had antepartum hemorrhage (abruption) necessitating multiple transfusions, ICU stay, and neonatal loss. Three patients with no prior history of obstetric hemorrhage were diagnosed with severe deficiencies and received prophylactic recombinant FVII preoperatively, averting the potential loss of lives. In patients with no history of bleeding, no hemorrhage was reported with or without prophylaxis while 33.33% of hemorrhage was reported in patients with a history of bleeding. Factors like the history of bleeding, FVII levels, mode of delivery, and other risk factors for hemorrhage should all be considered to predict the risk of bleeding in delivery. Cesarean is a surgical procedure, and prophylactic use of recombinant FVII concentrate (rFVIIa) should be considered.

Thromboelastometry as an Ancillary Tool for Evaluation of Coagulation Status after rFVIIa Therapy in a Pregnant Woman with Severe Hypoproconvertinemia-A Case Series and Review of the Literature

Introduction: Factor VII (FVII) deficiency is a rare hemorrhagic diathesis. In females, heavy menstrual and postpartum bleeding can appear as a consequence of its deficiency. Supplementation of the recombinant FVIIa is widely accepted. The supplementation effect in FVII-deficient subjects is difficult to predict, and severe hemorrhage has been described even when FVII levels after supplementation were within normal ranges. The aim of this report is to present the application of thromboelastometry to control the coagulation status in a patient with severe FVII deficiency during pregnancy and delivery, supplemented by rFVIIa per protocol complicated with life-threatening venous thromboembolism. Methods: Rotational thromboelastometry (ROTEM) was performed in 16 pregnant women: in one 28 year old primigravida at 35 weeks of pregnancy with congenital FVII deficiency after rFVIIa administration and 15 healthy women at 38 gestational weeks. The results were compared. Results: The thromboelastometry results showed significant shortening of the clotting time in the extrinsic and the intrinsic pathway in the hypoproconvertinemia patient after rFVIIa administration in relation to healthy pregnant women. A significant reduction in maximum lysis of the clot after FVII supplementation was observed. Conclusions: The thromboelastometry results showed a significant hypercoagulable state with hypoproconvertinemia. Thrombotic complications after delivery might be prevented by the reduction in rFVIIa guided by thromboelastometry. Thromboelastometry performed on a pregnant woman with factor VII deficiency during the supplementation of rFVIIa in peripartum time might be helpful in order to determine an individual, effective dosage regimen of rFVIIa to ensure full correction of clotting disorders without the tendency to develop thrombosis, but further studies are needed.