1
|
Mauser‐Bunschoten EP, Kadir RA, Laan ETM, Elfvinge P, Haverman L, Teela L, Degenaar MEL, Fransen van de Putte DE, D'Oiron R, van Galen KPM. Managing women-specific bleeding in inherited bleeding disorders: A multidisciplinary approach. Haemophilia 2021; 27:463-469. [PMID: 33314402 PMCID: PMC8246991 DOI: 10.1111/hae.14221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/27/2020] [Accepted: 11/13/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Multidisciplinary management of women-specific bleeding is important to preserve quality of life, healthy reproduction and social participation of women and girls with bleeding disorders (WBD). AIM To support appropriate multidisciplinary care for WBD in haemophilia treatment centres. METHODS Two case examples are presented and management issues discussed from different health care perspectives, including the nurse, patient, psychologist, gynaecologist, geneticist, psychosexual therapist and haematologist. RESULTS Woman with bleeding disorders may experience heavy menstruation from menarche onwards. This has a physical and psychosocial impact requiring a multidisciplinary approach. If a woman with an inherited bleeding disorder desires to become pregnant, preconception counselling is essential, to discuss genetic diagnosis, state of the art treatment options for the bleeding disorder in question and possible choices to prevent having an affected child, as well as maternal bleeding risks during conception, delivery and the post-partum period. CONCLUSION Adequate management and good education of WBD requires a patient-centred multidisciplinary approach with experienced specialists in a haemophilia treatment centre.
Collapse
Affiliation(s)
| | - Rezan A. Kadir
- Katharine Dormandy Haemophilia and Thrombosis UnitDepartment of Obstetrics and GynaecologyRoyal Free Foundation Hospital and Insitiute for Women's HealthUniversity College LondonLondonUK
| | - Ellen T. M. Laan
- Department of Sexology and Psychosomatic GynaecologyAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - Petra Elfvinge
- Department of HaematologyKarolinska UniversityStockholmSweden
| | - Lotte Haverman
- Department of PsychologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lorynn Teela
- Department of PsychologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | | | | | - Roseline D'Oiron
- APHP Paris SaclayHôpital BicêtreINSERM U 1176Le Kremlin BicêtreFrance
| | - Karin P. M. van Galen
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| |
Collapse
|
2
|
Presky KO, Kadir RA. Women with inherited bleeding disorders – Challenges and strategies for improved care. Thromb Res 2020; 196:569-578. [DOI: 10.1016/j.thromres.2019.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/26/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
|
3
|
Noone D, Skouw-Rasmussen N, Lavin M, van Galen KPM, Kadir RA. Barriers and challenges faced by women with congenital bleeding disorders in Europe: Results of a patient survey conducted by the European Haemophilia Consortium. Haemophilia 2019; 25:468-474. [PMID: 31034126 DOI: 10.1111/hae.13722] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/28/2019] [Accepted: 02/12/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Historically, issues faced by women with bleeding disorders (WBD) have been underestimated. While advances in genetic testing have resulted in improvements, significant challenges remain in the initial recognition of abnormal bleeding and referral of WBD. METHODS The European Haemophilia Consortium (EHC) developed a questionnaire for WBD to provide insights into the barriers and challenges faced by WBD in Europe. RESULTS In total, 709 WBD responded to the survey from 32 countries, predominantly from western European countries (94%). A delay in ascertaining the diagnosis of a congenital bleeding disorders (CBD) remains, with a median age at diagnosis of 16 years. The presence of family history is strongly associated with a lower median age at diagnosis of 6 years. WBD reported significant disease impact on their day-to-day life, most evident for the rarer CBD. The bleeding symptom of biggest impact on daily life is heavy menstrual bleeding (HMB), reported by 55% of women. Importantly, 25% of WBD reports that their condition severely impacted their decision to have or has prevented them from having children. Respondents registered with Haemophilia Treatment Centres (HTC) are 2.2 times more likely to receive treatment compared to WBD in other hospital services. CONCLUSION Improved education for both patients and healthcare providers is essential to improve time to diagnosis, access to treatment and psychosocial supports for WBD in Europe.
Collapse
Affiliation(s)
- Declan Noone
- European Haemophilia Consortium, Brussels, Belgium
| | | | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,National Coagulation Centre, St. James' Hospital, Dublin 8, Ireland
| | | | | |
Collapse
|
4
|
Spiliopoulos D, Kadir RA. Congenital Factor X deficiency in women: A systematic review of the literature. Haemophilia 2019; 25:195-204. [DOI: 10.1111/hae.13729] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Dimitrios Spiliopoulos
- Katharine Dormandy Haemophilia Centre, Department of Obstetrics & Gynaecology Royal Free Hospital London UK
| | - Rezan A. Kadir
- Katharine Dormandy Haemophilia Centre, Department of Obstetrics & Gynaecology Royal Free Hospital London UK
| |
Collapse
|
5
|
Baithun M, Freeman-Wang T, Chowdary P, Kadir RA. Ligneous cervicitis and endometritis: A gynaecological presentation of congenital plasminogen deficiency. Haemophilia 2018; 24:359-365. [PMID: 29436075 DOI: 10.1111/hae.13418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congenital plasminogen deficiency is a rare autosomal recessive condition. Plasminogen deficiency is thought to result in an inability of fibrin breakdown and therefore accumulation of fibrin and formation of ligneous changes. Ligneous lesions can form on a number of mucosal membranes including the cervix and endometrium. METHODS We report the case of a 25-year-old woman with type 1 plasminogen deficiency with ligneous cervicitis and endometritis and her treatment and clinical course over the last few years. We then review the current literature of ligneous cases of the female genital tract and discuss available treatment options. KEY RESULTS We found 30 reported cases of ligneous lesions affecting the female genital tract, with the cervix being the most affected part. A number of treatment options have been tried by our patient and other cases in the literature. These include use of the combined oral contraceptive pill, fresh frozen plasma infusion, topical plasmin and plasminogen and trial use of plasminogen concentrate. CONCLUSIONS This is a chronic condition requiring a multidisciplinary approach. There is currently no definitive treatment for the condition, current trials with plasminogen concentrate replacement therapy may provide a promising option for these patients in the future.
Collapse
Affiliation(s)
- M Baithun
- Department of Obstetrics and Gynaecology, The Royal Free Foundation NHS Trust, London, UK
| | - T Freeman-Wang
- Department of Obstetrics and Gynaecology, The Whittington NHS Trust, London, UK
| | - P Chowdary
- Katharine Dormandy Haemophilia and thrombosis Centre, The Royal Free Foundation NHS Trust, London, UK
| | - R A Kadir
- Department of Obstetrics and Gynaecology, The Royal Free Foundation NHS Trust, London, UK.,Katharine Dormandy Haemophilia and thrombosis Centre, The Royal Free Foundation NHS Trust, London, UK
| |
Collapse
|
6
|
Hudecova I, Jiang P, Davies J, Lo YMD, Kadir RA, Chiu RWK. Noninvasive detection of F8 int22h-related inversions and sequence variants in maternal plasma of hemophilia carriers. Blood 2017; 130:340-347. [PMID: 28490568 PMCID: PMC5532756 DOI: 10.1182/blood-2016-12-755017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/19/2017] [Indexed: 12/15/2022] Open
Abstract
Direct detection of F8 and F9 sequence variants in maternal plasma of hemophilia carriers has been demonstrated by microfluidics digital PCR. Noninvasive prenatal assessment of the most clinically relevant group of sequence variants among patients with hemophilia, namely, those involving int22h-related inversions disrupting the F8 gene, poses additional challenges because of its molecular complexity. We investigated the use of droplet digital PCR (ddPCR) and targeted massively parallel sequencing (MPS) for maternal plasma DNA analysis to noninvasively determine fetal mutational status in pregnancies at risk for hemophilia. We designed family-specific ddPCR assays to detect causative sequence variants scattered across the F8 and F9 genes. A haplotype-based approach coupled with targeted MPS was applied to deduce fetal genotype by capturing a 7.6-Mb region spanning the F8 gene in carriers with int22h-related inversions. The ddPCR analysis correctly determined fetal hemophilia status in 15 at-risk pregnancies in samples obtained from 8 to 42 weeks of gestation. There were 3 unclassified samples, but no misclassification. Detailed fetal haplotype maps of the F8 gene region involving int22h-related inversions obtained through targeted MPS enabled correct diagnoses of fetal mutational status in 3 hemophilia families. Our data suggest it is feasible to apply targeted MPS to interrogate maternally inherited F8 int22h-related inversions, whereas ddPCR represents an affordable approach for the identification of F8 and F9 sequence variants in maternal plasma. These advancements may bring benefits for the pregnancy management for carriers of hemophilia sequence variants; in particular, the common F8 int22h-related inversions, associated with the most severe clinical phenotype.
Collapse
Affiliation(s)
- Irena Hudecova
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Peiyong Jiang
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Joanna Davies
- Department of Obstetrics and Gynaecology and
- Katharine Dormandy Haemophilia and Thrombosis Center, Royal Free Hospital, London, United Kingdom
| | - Y M Dennis Lo
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| | - Rezan A Kadir
- Department of Obstetrics and Gynaecology and
- Katharine Dormandy Haemophilia and Thrombosis Center, Royal Free Hospital, London, United Kingdom
| | - Rossa W K Chiu
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, Hong Kong, China
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong, China; and
| |
Collapse
|
7
|
Orsini S, Noris P, Bury L, Heller PG, Santoro C, Kadir RA, Butta NC, Falcinelli E, Cid AR, Fabris F, Fouassier M, Miyazaki K, Lozano ML, Zúñiga P, Flaujac C, Podda GM, Bermejo N, Favier R, Henskens Y, De Maistre E, De Candia E, Mumford AD, Ozdemir GN, Eker I, Nurden P, Bayart S, Lambert MP, Bussel J, Zieger B, Tosetto A, Melazzini F, Glembotsky AC, Pecci A, Cattaneo M, Schlegel N, Gresele P. Bleeding risk of surgery and its prevention in patients with inherited platelet disorders. Haematologica 2017; 102:1192-1203. [PMID: 28385783 PMCID: PMC5566025 DOI: 10.3324/haematol.2016.160754] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 04/04/2017] [Indexed: 11/16/2022] Open
Abstract
Excessive bleeding at surgery is a feared complication in patients with inherited platelet disorders. However, very few studies have evaluated the frequency of surgical bleeding in these hemorrhagic disorders. We performed a worldwide, multicentric, retrospective study to assess the bleeding complications of surgery, the preventive and therapeutic approaches adopted, and their efficacy in patients with inherited platelet disorders: the Surgery in Platelet disorders And Therapeutic Approach (SPATA) study. We rated the outcome of 829 surgical procedures carried out in 423 patients with well-defined forms of inherited platelet disorders: 238 inherited platelet function disorders and 185 inherited platelet number disorders. Frequency of surgical bleeding was high in patients with inherited platelet disorders (19.7%), with a significantly higher bleeding incidence in inherited platelet function disorders (24.8%) than in inherited platelet number disorders (13.4%). The frequency of bleeding varied according to the type of inherited platelet disorder, with biallelic Bernard Soulier syndrome having the highest occurrence (44.4%). Frequency of bleeding was predicted by a pre-operative World Health Organization bleeding score of 2 or higher. Some types of surgery were associated with a higher bleeding incidence, like cardiovascular and urological surgery. The use of pre-operative pro-hemostatic treatments was associated with a lower bleeding frequency in patients with inherited platelet function disorders but not in inherited platelet number disorders. Desmopressin, alone or with antifibrinolytic agents, was the preventive treatment associated with the lowest bleedings. Platelet transfusions were used more frequently in patients at higher bleeding risk. Surgical bleeding risk in inherited platelet disorders is substantial, especially in inherited platelet function disorders, and bleeding history, type of disorder, type of surgery and female sex are associated with higher bleeding frequency. Prophylactic pre-operative pro-hemostatic treatments appear to be required and are associated with a lower bleeding incidence.
Collapse
Affiliation(s)
- Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Paula G Heller
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | | | - Rezan A Kadir
- Haemophilia Centre and Haemostasis Unit, Royal Free Hospital, London, UK
| | - Nora C Butta
- Unidad de Hematología, Hospital Universitario La Paz-IDIPaz, Madrid, Spain
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Ana Rosa Cid
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Fabrizio Fabris
- Clinica Medica 1 - Medicina Interna CLOPD, Dipartimento Assistenziale Integrato di Medicina, Azienda-Ospedale Università di Padova and Dipartimento di Medicina, Università di Padova, Italy
| | | | - Koji Miyazaki
- Department of Hematology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Maria Luisa Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia 30003 and Grupo de Investigación CB15/00055 del Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pamela Zúñiga
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claire Flaujac
- Service d'Hématologie Biologique Cochin Hospital, Paris, France
| | - Gian Marco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nuria Bermejo
- Department of Hematology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Remi Favier
- Assistance Publique-Hôpitaux de Paris, Armand Trousseau Children's Hospital, French Reference Centre for Inherited Platelet Disorders, Paris, France
| | - Yvonne Henskens
- Hematological Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Emmanuel De Maistre
- Department of Biology and Haematology, Centre Hospitalier Universitaire Dijon, France
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Institute of Internal Medicine, Policlinico Agostino Gemelli-Università Cattolica Sacro Cuore, Rome, Italy
| | | | - Gul Nihal Ozdemir
- Cerrahpasa Medical Faculty, Pediatric Hematology Department, Istanbul, Turkey
| | - Ibrahim Eker
- Gülhane Military Medical Faculty, Pediatric Hematology Department, Ankara, Turkey
| | - Paquita Nurden
- Reference Centre for Platelet Disorders, Bordeaux University Hospital Centre, Rythmology and Cardiac Modeling Institute (LIRYC), Xavier Arnozan Hospital, Pessac, France
| | - Sophie Bayart
- Centre Régional de Traitement des Hémophiles, Centre Hospitalier Universitaire de Rennes, France
| | - Michele P Lambert
- 1 Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PN, USA
| | - James Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | | | - Federica Melazzini
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Ana C Glembotsky
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Marco Cattaneo
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nicole Schlegel
- Centre de Référence des Pathologies Plaquettaires (CRPP), Service d'Hématologie Biologique, CHU Robert Debré, AP-HP, Paris, France
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | | |
Collapse
|
8
|
Hui WWI, Jiang P, Tong YK, Lee WS, Cheng YKY, New MI, Kadir RA, Chan KCA, Leung TY, Lo YMD, Chiu RWK. Universal Haplotype-Based Noninvasive Prenatal Testing for Single Gene Diseases. Clin Chem 2017; 63:513-524. [DOI: 10.1373/clinchem.2016.268375] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/17/2016] [Indexed: 01/02/2023]
Abstract
Abstract
BACKGROUND
Researchers have developed approaches for the noninvasive prenatal testing of single gene diseases. One approach that allows for the noninvasive assessment of both maternally and paternally inherited mutations involves the analysis of single nucleotide polymorphisms (SNPs) in maternal plasma DNA with reference to parental haplotype information. In the past, parental haplotypes were resolved by complex experimental methods or inferential approaches, such as through the analysis of DNA from other affected family members. Recently, microfluidics-based linked-read sequencing technology has become available and allows the direct haplotype phasing of the whole genome rapidly. We explored the feasibility of applying this direct haplotyping technology in noninvasive prenatal testing.
METHODS
We first resolved the haplotypes of parental genomes with the use of linked-read sequencing technology. Then, we identified SNPs within and flanking the genes of interest in maternal plasma DNA by targeted sequencing. Finally, we applied relative haplotype dosage analysis to deduce the mutation inheritance status of the fetus.
RESULTS
Haplotype phasing and relative haplotype dosage analysis of 12 out of 13 families were successfully achieved. The mutational status of these 12 fetuses was correctly classified.
CONCLUSIONS
High-throughput linked-read sequencing followed by maternal plasma-based relative haplotype dosage analysis represents a streamlined approach for noninvasive prenatal testing of inherited single gene diseases. The approach bypasses the need for mutation-specific assays and is not dependent on the availability of DNA from other affected family members. Thus, the approach is universally applicable to pregnancies at risk for the inheritance of a single gene disease.
Collapse
Affiliation(s)
- Winnie W I Hui
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peiyong Jiang
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Yu K Tong
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wing-Shan Lee
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yvonne K Y Cheng
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Maria I New
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY
| | - Rezan A Kadir
- Department of Obstetrics and Gynaecology, Royal Free London NHS Foundation Trust, London, UK
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - K C Allen Chan
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Tak Y Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Y M Dennis Lo
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Rossa W K Chiu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| |
Collapse
|
9
|
Shreeve NE, Barry JA, Deutsch LR, Gomez K, Kadir RA. Changes in thromboelastography parameters in pregnancy, labor, and the immediate postpartum period. Int J Gynaecol Obstet 2016; 134:290-3. [DOI: 10.1016/j.ijgo.2016.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/23/2016] [Accepted: 05/16/2016] [Indexed: 11/28/2022]
|
10
|
Affiliation(s)
- R A Kadir
- University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
| | - D L Economides
- University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
| |
Collapse
|
11
|
Davies J, Kadir RA. Mode of delivery and cranial bleeding in newborns with haemophilia: a systematic review and meta-analysis of the literature. Haemophilia 2015; 22:32-8. [PMID: 25990680 DOI: 10.1111/hae.12726] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cranial bleeding at birth can result in significant neurological morbidity in newborns with haemophilia. The optimum mode of delivery (MOD) of a potentially affected foetus remains controversial. AIM The aim of this review is to ascertain overall incidence of cranial bleeding in newborns with haemophilia compared to the general population and the impact of MOD on rates of intracranial haemorrhage (ICH). METHOD An EMBASE/MEDLINE search using key terms revealed the relevant studies. Studies included report the incidence of cranial bleeding by MOD within a newborn population. The heterogenicity across studies was assessed using Cochrane's Q test and I(2) statistic and studies were assigned appropriate weight based on a fixed-effect model. Odds ratio (OR) is the primary effect measure. RESULTS Newborns with haemophilia are 44 times (95% CI: 34.7-57.1, P < 0.01) more likely to experience symptomatic ICH, and 8 times (95% CI: 5.38-12.6, P < 0.01) more likely to experience extracranial haemorrhage at birth, compared to the general population. In newborns with haemophilia the OR of experiencing ICH are 4.4 (95% CI: 1.46-13.7, P = 0.008) following an assisted vaginal delivery (AVD) and 0.34 (95% CI: 0.14-0.83, P = 0.018) following caesarean section (CS), compared to vaginal delivery. CONCLUSION Cranial bleeding occurs with a significantly higher frequency in newborns with haemophilia compared to the general population. In newborns with haemophilia, delivery by a CS is associated with the lowest risk of ICH. AVD significantly increases the risk of ICH and should be avoided.
Collapse
Affiliation(s)
- J Davies
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Department of Obstetrics and Gynaecology, Royal Free Hospital NHS Foundation Trust, London, UK
| | - R A Kadir
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Department of Obstetrics and Gynaecology, Royal Free Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
12
|
Chowdary P, Adamidou D, Riddell A, Aghighi S, Griffioen A, Priest P, Moghadam L, Kelaher N, Huq FY, Kadir RA, Tuddenham EG, Gatt A. Thrombin generation assay identifies individual variability in responses to low molecular weight heparin in pregnancy: implications for anticoagulant monitoring. Br J Haematol 2014; 168:719-27. [DOI: 10.1111/bjh.13193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/13/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Despoina Adamidou
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Saman Aghighi
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Anja Griffioen
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Paul Priest
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Lida Moghadam
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Nicholas Kelaher
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Farah Y. Huq
- Department of Obstetrics and Gynaecology; Royal Free Hospital; London UK
| | - Rezan A. Kadir
- Department of Obstetrics and Gynaecology; Royal Free Hospital; London UK
| | - Edward G. Tuddenham
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - Alex Gatt
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
- Department of Haemato-Oncology; Mater Dei Hospital; Msida Malta
| |
Collapse
|
13
|
Abstract
Factor XIII (FXIII) deficiency is a rare congenital bleeding disorder. There is a paucity of data in the literature about obstetrics and gynaecological problems in women affected by FXIII deficiency. The aim of this study was to examine gynaecological problems and obstetric complications and outcome in women with congenital FXIII deficiency. An electronic search was performed to identify the published literature on PUBMED, MEDLINE, EMBASE, Journals @OVID and CINAHL Plus databases using the following keywords: 'congenital factor XIII deficiency' AND 'women OR Pregnancy'. A total of 39 relevant articles were found and included in this systematic review; 27 case reports and 12 case series dating from 1964 to 2012. A total of 121 women were identified. Menorrhagia (26%) was the second most common bleeding reported after umbilical bleeding. Ovulation bleeding reported in 8% of women. Among 63 women, 192 pregnancies were reported; of these, 127 (66%) resulted in a miscarriage and 65 (34%) reached viability stage. In 136 pregnancies without prophylactic therapy, 124 (91%) resulted in a miscarriage and 12(9%) progressed to viability stage. Antepartum haemorrhage occurred in 5/65 (8%) pregnancies reaching viability stage while postpartum haemorrhage (PPH) seen in 16 (25%) cases. Women with congenital FXIII deficiency suffer significant bleeding complications. Menorrhagia and ovulation bleeding are common gynaecological problems and more prevalent than reported. Pregnancies in women with FXIII deficiency have a significant risk of miscarriage, placental abruption and PPH if not on prophylaxis treatment.
Collapse
Affiliation(s)
- L A T Sharief
- Obstetrics and Gynaecology Department, UCL, London, UK
| | | |
Collapse
|
14
|
Abstract
The past few decades have seen major advances in multidisciplinary obstetric care and management of gynecological conditions in women with bleeding disorders. Awareness of the impact of bleeding disorders has improved among the obstetric and gynecological community. Undiagnosed bleeding disorders can be the underlying cause for a significant proportion of women with heavy menstrual bleeding. They may also be the cause or a contributory factor for other gynecological problems, such as dysmenorrhea, intermenstrual bleeding, and endometriosis. Hemostatic assessment should be considered in women referred for menstrual abnormalities if they have a positive bleeding history as quantified by bleeding assessment tools. The reproductive choices and options for prenatal diagnosis are also expanding for families with hemophilia with a drive toward achieving a non-invasive approach. Current non-invasive prenatal diagnostic techniques are limited to identification of fetal gender. Research is ongoing to overcome the specific diagnostic challenges of identifying hemophilia mutations, utilizing free fetal DNA circulating in maternal plasma. The management of obstetric hemorrhage has recently evolved to include a greater focus on the identification of and early treatment for coagulation disorders. Deficiencies in certain hemostatic variables are associated with progression to more severe bleeding; therefore, specific interventions have been proposed to target this. Evidence is still lacking to support such strategy, and future research is required to assess the efficacy and the safety of these hemostatic interventions in women with persistent PPH.
Collapse
Affiliation(s)
- R A Kadir
- The Haemophilia Centre and Thrombosis Unit, The Royal Free Hospital, London, UK.
| | | |
Collapse
|
15
|
Abstract
Under normal physiological circumstances menstruation is a highly regulated, complex process that is under strict hormonal control. During normal menstruation, progesterone withdrawal initiates menstruation. The cessation of menstrual bleeding is achieved by endometrial haemostasis via platelet aggregation, fibrin deposition and thrombus formation. Local endocrine, immunological and haemostatic factors interact at a molecular level to control endometrial haemostasis. Tissue factor and thrombin play a key role locally in the cessation of menstrual bleeding through instigation of the coagulation factors. On the other hand, fibrinolysis prevents clot organisation within the uterine cavity while plasminogen activator inhibitors (PAI) and thrombin-activatable fibrinolysis inhibitors control plasminogen activators and plasmin activity. Abnormalities of uterine bleeding can result from imbalance of the haemostatic factors. The most common abnormality of uterine bleeding is heavy menstrual bleeding (HMB). Modern research has shown that an undiagnosed bleeding disorder, in particular von Willebrand disease (VWD) and platelet function disorders, can be an underlying cause of HMB. This has led to a change in the approach to the management of HMB. While full haemostatic assessment is not required for all women presenting with HMB, menstrual score and bleeding score can help to discriminate women who are more likely to have a bleeding disorder and benefit from laboratory haemostatic evaluation. Haemostatic agents (tranexamic acid and DDAVP) enhance systemic and endometrial haemostasis and are effective in reducing menstrual blood loss in women with or without bleeding disorders. Further research is required to enhance our understanding of the complex interactions of haemostatic factors in general, and specifically within the endometrium. This will lead to the development of more targeted interventions for the management of abnormal uterine bleeding in the future.
Collapse
Affiliation(s)
- Joanna Davies
- The Haemophilia Centre and Thrombosis Unit, The Royal Free Hospital, Hampstead, London, UK
| | | |
Collapse
|
16
|
Sharief L, Pollard D, Mathias M, Kadir RA. Mayer-Rokitansky-Kuster-Hauser syndrome with type 3 von Willebrand's disease: a case report and review of literature. Haemophilia 2012; 19:e57-9. [PMID: 23167253 DOI: 10.1111/hae.12060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2012] [Indexed: 11/26/2022]
|
17
|
|
18
|
Abstract
Women with inherited bleeding disorders may face several haemostatic challenges during pregnancy and childbirth. Pregnancy in these women requires specialised and individualised care. Prenatal diagnosis is primarily considered in families affected by severe bleeding disorder such as haemophilia. Non-invasive fetal sex determination by analysis of free fetal DNA in maternal blood offers carriers of haemophilia a means of avoiding invasive testing and its associated risks in female pregnancies. With the exception of fibrinogen and factor XIII deficiencies, it is currently unclear whether women with inherited bleeding disorders are at increased risk of miscarriage or antepartum haemorrhage. However, they are at increased risk of primary and secondary postpartum haemorrhage. The fetus, if severely affected, is at risk of cranial bleeding during labour and delivery. Appropriate haemostatic cover during labour and delivery, avoidance of prolonged labour and traumatic delivery, and active management of third stage of labour can minimise the risk of bleeding complications for the mother and her fetus.
Collapse
Affiliation(s)
- Claudia Chi
- Department of Obstetrics and Gynaecology, Royal Free Hospital, Pond Street, London, UK
| | | |
Collapse
|
19
|
Abstract
To determine changes in Factor VIII (FVIII) and von Willebrand Factor (VWF) in the first 3 days of the puerperium. A prospective study assessing FVIII clotting activity, VWF activity and antigen levels in 95 women (with singleton uncomplicated pregnancies) during labour and on days 1, 2 and 3 of the puerperium. There were no significant differences in FVIII, VWF:Ag and VWF:CB on days 1 and 2 of the puerperium compared with levels during labour. There was a significant decrease in VWF:Ag (P = 0.009) and VWF:CB (P = 0.04) on day 3. Age, ethnicity, duration of labour and mode of delivery did not have any significant effect on the changes in FVIII and VWF levels. The pregnancy induced increase in FVIII and VWF is maintained in the first 48 h after delivery. VWF levels start to decline on day 3 postdelivery.
Collapse
Affiliation(s)
- F Y Huq
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK
| | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Huq FY, Tvarkova K, Arafa A, Kadir RA. Menstrual problems and contraception in women of reproductive age receiving oral anticoagulation. Contraception 2011; 84:128-32. [PMID: 21757053 DOI: 10.1016/j.contraception.2010.12.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/15/2010] [Accepted: 12/28/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Oral anticoagulation is associated with increased bleeding complications. The aim of this study was to assess the changes in menstrual loss and pattern in women taking anticoagulant treatment. STUDY DESIGN Women on oral anticoagulant (OA) treatment at the Royal Free Hospital were interviewed and completed a questionnaire about their menstrual cycle before and after commencing oral anticoagulation treatment. They were then asked to complete a pictorial bleeding assessment chart (PBAC) during their next menstrual bleeding episode. RESULTS Fifty-three women between the ages of 20 and 50 years participated in the study. Of these, 47 women completed a PBAC. The mean duration of menstruation increased from 5 days before starting OA therapy to 7 days after the commencement of treatment. Thirty-one (66%) of the 47 women who completed the PBAC had a score that was greater than 100. The number of women who experienced flooding or clots during menstruation and intermenstrual or postcoital bleeding also increased. In total, 29 (54.7%) women changed their method of contraception during OA treatment. Seventeen women who did not want to become pregnant were not using contraception, including 10 women who were on hormonal contraception prior to starting anticoagulant therapy. CONCLUSION Women of reproductive age experience heavy and prolonged menstrual bleeding whilst on OA therapy. Women of reproductive age on OA therapy should be monitored for menstrual disorders to ensure that prompt and appropriate treatment is instituted. Advice about appropriate contraception should also be part of the medical care provided for these women. Barrier contraception, sterilization and progestin-only contraception are all suitable methods of contraception in this patient group.
Collapse
Affiliation(s)
- Farah Yasmine Huq
- Hemophilia Centre, Haemostasis Unit, Royal Free Hospital, London, UK
| | | | | | | |
Collapse
|
22
|
Abstract
OBJECTIVE The aim of this study is critically to review the available evidence regarding the use, efficacy and safety of tranexamic acid in the management of hemorrhage during pregnancy and for prevention and treatment of postpartum hemorrhage. RESEARCH DESIGN AND METHODS We performed a systematic search of electronic literature (PubMed, Embase, CINAHL, Scopus, Cochrane, DARE) to review all studies looking at the use of tranexamic acid during pregnancy and puerperium. We did a meta-analysis on three randomized controlled trials that evaluated reduction in blood loss in women undergoing cesarean sections with the use of tranexamic acid. RESULTS An electronic search yielded 34 articles, the studies dating from 1976 to 2010, five randomized controlled trials, seven observational studies, and twenty-two case reports. Meta-analysis showed that the estimate of the combined effect of tranexamic acid compared with placebo was a difference of 32.5 ml reduction in blood loss (95% CI -4.1-69.13; p = 0.08). Tranexamic acid was also used successfully to prevent and treat bleeding in observation studies and case reports. Pulmonary embolism was reported in two cases; however, the possible involvement of tranexamic acid in these thrombotic episodes could neither be confirmed nor excluded. CONCLUSIONS The clinical studies suggest that tranexamic acid reduces the amount of blood loss after delivery during cesarean sections and vaginal deliveries, and reduces the requirement for blood transfusion. Tranexamic acid seems to be safe and effective in the prevention and management of bleeding during pregnancy. Further investigation and larger clinical trials with better design and methodological quality are required to confirm these findings.
Collapse
Affiliation(s)
- Panagiotis Peitsidis
- The Royal Free Hospital, Haemophilia Centre & Thrombosis Unit, Department of Obstetrics and Gynaecology, Pond Street, London, UK.
| | | |
Collapse
|
23
|
|
24
|
Abstract
Hemostasis in women is influenced by physiological changes in hormone status associated with the menstrual cycle, pregnancy and hormone-based contraceptives, and hormone replacement therapy (HRT) preparations. These hormonal influences can lead to an increase in the risk of venous thromboembolism (VTE) due to altered levels of clotting factors and an acquired resistance to the actions of activated protein C. This articles reviews recent evidence for these changes. During the menstrual cycle, changes are observed in levels of von Willebrand factor (VWF), fibrinogen, and activated factor VII. No such effect has been demonstrated in protein S or protein C levels or activated protein C resistance. Pregnancy is a procoagulant state with progressive increase in levels of factors VII, VIII, X, and XII, fibrinogen, and VWF, as well as increased resistance to activated protein C. Hormonal contraceptives and HRT are widely used and have undergone many changes over the years. Recent modifications to the preparations used in combined oral contraceptives (COC) aimed at improving side-effect profiles have also been shown to increase the risk of VTE for third- and fourth-generation COC compared with second-generation COC. This has been shown to be due to changes in activated protein C resistance. This risk of VTE represents a significant public health issue, but increased awareness and further research may allow development of safer future therapies leading to improvements in women's health.
Collapse
|
25
|
Affiliation(s)
- Jeffrey P Wilkinson
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
| | | |
Collapse
|
26
|
Agarwal U, El Sheikh S, Kulkarni A, Baff D, Kadir RA. Von Willebrand factor expression in endometrial endothelial cells in women with menorrhagia. Fertil Steril 2010; 94:2335-7. [DOI: 10.1016/j.fertnstert.2010.02.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Revised: 02/23/2010] [Accepted: 02/23/2010] [Indexed: 11/28/2022]
|
27
|
Chi C, Pollard D, Tuddenham EGD, Kadir RA. Menorrhagia in adolescents with inherited bleeding disorders. J Pediatr Adolesc Gynecol 2010; 23:215-22. [PMID: 20471874 DOI: 10.1016/j.jpag.2009.11.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 11/15/2009] [Accepted: 11/19/2009] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVES We reviewed the management and treatment outcomes of menorrhagia in adolescents with inherited bleeding disorders and assessed the impact of menorrhagia on their quality of life. DESIGN Retrospective review of case notes and a questionnaire study. SETTING Comprehensive-care hemophilia treatment center. PARTICIPANTS Adolescents with inherited bleeding disorders who had registered at the center and were attending the multidisciplinary hemophilia and gynecology clinic for management of menorrhagia. INTERVENTIONS Review of medical records and assessment of menstrual blood loss using the pictorial blood assessment chart and quality of life measurements during menstruation using a questionnaire. MAIN OUTCOME MEASURES Scores on pictorial blood assessment charts and quality of life measurements before and after treatment. RESULTS Of 153 girls aged 12 to 19 years who had registered at the center and had an inherited bleeding disorder, 42 (27%) attended the multidisciplinary clinic for management of menorrhagia. The majority (38/42; 90%) had experienced menorrhagia since menarche. Of the group, 5 (12%) required hospital admission for acute menorrhagia and severe anemia. Treatment options for menorrhagia included tranexamic acid, desmopressin, combined oral contraceptive pills, clotting factor concentrate, and the levonorgestrel intrauterine system. These treatment modalities, alone or in combination, were associated with a reduction in menstrual blood loss (median pre- and posttreatment pictorial blood assessment chart scores were 215 and 88, respectively) and improvement in quality of life scores (median pre- and posttreatment were 26 and 44, respectively). CONCLUSIONS Menorrhagia is a common symptom in adolescents with inherited bleeding disorders. It can present acutely, and it adversely affects quality of life. Treatment options include hemostatic and/or hormonal therapies and can improve the quality of life of affected girls.
Collapse
Affiliation(s)
- Claudia Chi
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK
| | | | | | | |
Collapse
|
28
|
Chi C, Bapir M, Lee CA, Kadir RA. Puerperal loss (lochia) in women with or without inherited bleeding disorders. Am J Obstet Gynecol 2010; 203:56.e1-5. [PMID: 20417483 DOI: 10.1016/j.ajog.2010.02.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 11/15/2009] [Accepted: 02/16/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the quantity and duration of lochia in women with or without inherited bleeding disorders and to identify factors that influence lochial loss. STUDY DESIGN Pictorial blood assessment chart was completed by 115 pregnant women (21 with or carriers of inherited bleeding disorder and 94 without bleeding disorder) using standardized sanitary products. RESULTS The median duration of lochia was significantly longer in women with (or carriers of) inherited bleeding disorder (39 days; range 21-58) compared with women without bleeding disorder (31 days; range, 10-62; P = .03); however, the median lochial loss were similar (441 mL; range, 135-1290 vs 429 mL; range, 112-1295; P = .59). Long labor and instrumental delivery were associated with heavier lochia. CONCLUSION Pictorial blood assessment chart is potentially a useful tool in the assessment of lochia. Women with inherited bleeding disorders experience longer period of lochia compared with women without bleeding disorder. Labor duration and mode of delivery influence lochial loss.
Collapse
|
29
|
Abstract
SUMMARY Menorrhagia, heavy menstrual bleeding, is a common condition that has a substantial impact on the lives of many women. The objective measurement of menorrhagia is often impractical; therefore diagnosis and treatment are usually based on the direct perception of the woman. Menstrual problems are likely to be worse in women with bleeding disorders, as they are more likely to have heavy and painful menstrual periods and ovulation bleeding and pain. These can have a major impact on the quality of women's lives, especially those who suffer heavy menstruation. These problems can also lead to limitations at work and school and hinder educational and academic achievements. Only few studies describe how quality of life (QOL) changes in women with an underlying haemostatic defect; poorer QOL being associated with more frequent bleeding symptoms. Early recognition, accurate diagnosis and appropriate management of bleeding disorders should improve not only the quality of care for affected women but also their QOL. Increased awareness of the high prevalence of menstrual problems especially menorrhagia is essential for early diagnosis and provision of appropriate treatments without any delay. Accurate knowledge of the impact of menorrhagia on health-related quality of life (HRQOL) and its adequate assessment help individualize treatment and assess the magnitude of changes in HRQOL. An ideal situation would be to use a generic and a disease-specific measure together so that comparisons can be made on a general and disease-specific level.
Collapse
Affiliation(s)
- R A Kadir
- Haemophilia Centre and Haemostasis Unit, Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK.
| | | | | |
Collapse
|
30
|
Abstract
Bernard Soulier syndrome (BSS) is a rare disorder of platelets, inherited mainly as an autosomal recessive trait. It is characterised by qualitative and quantitative defects of the platelet membrane glycoprotein (GP) Ib-IX-V complex. The main clinical characteristics are thrombocytopenia, prolonged bleeding time and the presence of giant platelets. Data on the clinical course and outcome of pregnancy in women with Bernard Soulier syndrome is scattered in individual case reports. In this paper, we performed a systematic review of literature and identified 16 relevant articles; all case reports that included 30 pregnancies among 18 women. Primary postpartum haemorrhage was reported in 10 (33%) and secondary in 12 (40%) of pregnancies, requiring blood transfusion in 15 pregnancies. Two women had an emergency obstetric hysterectomy. Alloimmune thrombocytopenia was reported in 6 neonates, with one intrauterine death and one neonatal death. Bernard Soulier syndrome in pregnancy is associated with a high risk of serious bleeding for the mother and the neonate. A multidisciplinary team approach and individualised management plan for such women are required to minimise these risks. An international registry is recommended to obtain further knowledge in managing women with this rare disorder.
Collapse
Affiliation(s)
- P Peitsidis
- Royal Free Hospital, Obstetrics and Gynaecology, London, UK
| | | | | | | | | | | |
Collapse
|
31
|
Abstract
We wanted to evaluate the efficacy, safety and acceptability of misoprostol for outpatient management of missed miscarriage. This was a prospective observational study conducted in the early pregnancy unit of a university teaching hospital involving women attending the unit with a diagnosis of missed miscarriage. All women with a missed miscarriage of <12 weeks' gestation and opting to have medical management were eligible for inclusion. Women who consented to take part were given 800 microg of misoprostol in the unit and advised to take two further doses of 400 microg of misoprostol, orally, 3 h apart, the following day at home. Outcome measures included success rates, emergency admission rates, blood transfusion rates, pain scores, satisfaction scores, incidence rates of side-effects and number of women who would choose medical management in future. Of the 268 women diagnosed as having a missed miscarriage during the study period, 75 (28.0%) opted to have medical management. Over three-quarters (n = 58, 77.3%, 95% confidence interval (CI) 66.2 - 86.2) of the women achieved successful complete medical evacuation. Overall, five (6.7%; 95% CI 2.2 - 14.8) women presented for emergency admission. The mean visual analogue scale (VAS) score of all women was 6.7 (SD = 2.8) and the mean satisfaction score was 8.6 (SD = 2.1). Two-thirds of women (n = 50, 66.7%) said that they would choose to have medical evacuation in a future miscarriage, while seven (9.3%) were unsure. A total of 70 (93.3%) women said they preferred to have the treatment at home rather than in the hospital. We conclude that medical evacuation of missed miscarriage is efficacious, safe and acceptable in the outpatient setting.
Collapse
Affiliation(s)
- M Shankar
- Early Pregnancy Unit, Royal Freeand UC Medical School, London, UK.
| | | | | | | | | |
Collapse
|
32
|
Kadir RA, Pepera T, Economides DL. Second trimester maternal serum biochemical screening for Down's syndrome: experience of a single obstetric unit. J OBSTET GYNAECOL 2009; 19:373-6. [PMID: 15512334 DOI: 10.1080/01443619964670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The objective of this study was to assess the effects of mid-trimester biochemical screening on the prenatal diagnosis of Down's syndrome. All patients booked for antenatal care at the Royal Free Hospital are offered a double marker biochemical screening test (alpha-fetoprotein and free beta human chorionic gonadotrophin). The results of double marker screening tests and the notes of all cases of trisomy 21 from 1 April 1993 to 31 March 1995 were reviewed. Of the 6170 women booked in the antenatal clinic during this 2-year period 4427 (71.8%) took up the offer of biochemical screening. Four hundred and twenty-nine (9.7% of those screened) were reported positive and 293 karyotypes were performed in this group (68.3% uptake) and 253 karyotypes were also performed for other indications. Thirteen of 21 affected pregnancies had biochemical screening. The detection rate of biochemical screening in women aged <37 years was 0% (0/2) with a 8.4% false positive rate. In women aged 37 years the detection rate was 100% (11/11) with a false positive rate of 23%. The overall detection rate for Down's syndrome was 84.6% and the false positive rate was 9.5%. In conclusion, biochemical screening successfully targeted affected pregnancies in women aged 37 years and was useful in reducing the fetal karyotyping rate. However, it was disappointing in the prenatal diagnosis of trisomy 21 in women <37 years old.
Collapse
Affiliation(s)
- R A Kadir
- Department of Obstetrics and Gynaecology, The Royal Free Hospital, London, UK
| | | | | |
Collapse
|
33
|
Wilcock FM, Kadir RA. Fetomaternal haemorrhage—a cause for unexplained neonatal death, presenting with reduced fetal movements and non-reactive fetal heart trace. J OBSTET GYNAECOL 2009; 24:456-7. [PMID: 15203594 DOI: 10.1080/01443610410001696888] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- F M Wilcock
- Department of Obstetrics and Gynaecology, The Royal Free Hospital School of Medicine, London, UK
| | | |
Collapse
|
34
|
Chi C, Lee CA, England A, Hingorani J, Paintsil J, Kadir RA. Obstetric analgesia and anaesthesia in women with inherited bleeding disorders. Thromb Haemost 2009; 101:1104-1111. [PMID: 19492155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A retrospective review was carried out on the methods of obstetric analgesia/anesthesia used in 80 pregnancies amongst 63 women with inherited bleeding disorders (19 factor XI deficiency, 16 carriers of haemophilia, 15 von Willebrand disease, seven platelet function disorders, four factor VII deficiency, one factor VII and XI deficiency and one factor X deficiency). In 72 pregnancies, the woman was seen antenatally in a multidisciplinary clinic to discuss and plan pain relief options. Regional block was performed for 41 pregnancies. The mothers were known to have a bleeding disorder in 35 of these pregnancies. Prophylactic cover was given in 10 pregnancies prior to the insertion of regional block but not required in the remaining 25 pregnancies because the coagulation defects had spontaneously normalised at term. There were six reported adverse effects from regional block similar to that found in the general population: inadequate anesthesia/analgesia (2), bloody tap (2), hypotension and a possible dural puncture which was treated conservatively. There were no reports of long-term complications. The findings show that it is possible to offer women with inherited bleeding disorders the option of regional block provided their coagulation defects have normalised, either spontaneously during pregnancy or following adequate haemostatic cover.
Collapse
MESH Headings
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthesia, Epidural/adverse effects
- Anesthesia, Obstetrical/adverse effects
- Anesthesia, Obstetrical/methods
- Anesthetics, Combined/administration & dosage
- Anesthetics, Combined/adverse effects
- Blood Coagulation Disorders, Inherited/drug therapy
- Blood Coagulation Factors/genetics
- Blood Coagulation Factors/metabolism
- Cesarean Section
- Female
- Hematoma, Epidural, Spinal/chemically induced
- Hematoma, Epidural, Spinal/prevention & control
- Hemorrhage/chemically induced
- Hemorrhage/prevention & control
- Humans
- Labor Pain
- Labor, Obstetric
- Nitrous Oxide/administration & dosage
- Nitrous Oxide/adverse effects
- Oxygen/administration & dosage
- Oxygen/adverse effects
- Pregnancy
- Pregnancy Complications, Hematologic/drug therapy
- Retrospective Studies
- Treatment Outcome
Collapse
Affiliation(s)
- Claudia Chi
- Department of Obstetrics and Gynaecology, Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
| | | | | | | | | | | |
Collapse
|
35
|
Arafa A, Peitsidis P, Kadir RA. Unusual case of congenital chylothorax. J OBSTET GYNAECOL 2009; 29:59-60. [PMID: 19280501 DOI: 10.1080/01443610802484062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A Arafa
- Department of Obstetrics and Gynaecology, Royal Free Hospital NHS Trust, London, UK
| | | | | |
Collapse
|
36
|
|
37
|
Anastasakis E, Kingman CE, Lee CA, Economides DL, Kadir RA. Menstrual problems in university students: an electronic mail survey. In Vivo 2008; 22:617-620. [PMID: 18853757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To establish the prevalence of menstrual-related problems among university students. MATERIALS AND METHODS A questionnaire regarding gynecological, bleeding and family history was sent by electronic mail (e-mail) to all female students attending University College London (UCL). RESULTS A total of 767 students aged 18-39 years replied; 71% had a regular menstrual cycle. One in three (n = 264) had received some treatment for their menstrual periods (such as the combined oral contraceptive pill or simple analgesia). Those with heavy or painful periods were more likely to feel that their menstrual problems had a substantial impact on their academic and social life; however, even among those with light periods, one in every four females felt that their life was considerably affected. CONCLUSION A considerable prevalence of menstrual-related problems was demonstrated among this young healthy population. Additionally, the use of e-mail could present potential benefits as a research medium for this kind of study.
Collapse
Affiliation(s)
- E Anastasakis
- Department of Obstetrics and Gynecology, the Royal Free Hospital and Royal Free Medical School, University College London (UCL), London, UK.
| | | | | | | | | |
Collapse
|
38
|
Abstract
The objectives of this study were to identify the impact of menorrhagia on the health-related quality of life (HRQOL) of women in general and those with inherited bleeding disorders and to identify the commonly used tools in assessing quality of life. A review of studies evaluating quality of life in women suffering from menorrhagia was conducted. Data sources used included electronic databases Medline and Embase. Reference lists and bibliographies of the relevant papers and books were hand-searched for additional studies. Eighteen of the 53 studies identified measured quality of life prior to treatment of menorrhagia. Ten of the studies used a validated measure of quality of life. Five studies involving a total of 1171 women with menorrhagia in general and using SF-36 were considered for further review. The mean SF-36 scores in women with menorrhagia were worse in all the eight scales when compared with normative scores from a general population of women. Three studies, involving 187 women, assessed the quality of life in women with menorrhagia and inherited bleeding disorders. None of these studies used a validated HRQOL score making it difficult for comparison. However, all reported poorer scores in study women compared to the controls. In conclusion, HRQOL is adversely affected in women with menorrhagia in general and in those with inherited bleeding disorders. HRQOL evaluation is useful in the management of women with menorrhagia for assessment of treatment efficacy.
Collapse
Affiliation(s)
- M Shankar
- Department of Obstetrics & Gynaecology, Royal Free Hospital, London, UK
| | | | | |
Collapse
|
39
|
Abstract
The aim of the study was to review the complications, management and outcome of pregnancy in carriers of haemophilia over a 10-year period following the introduction of a multidisciplinary management guideline. Comparison was made to a 10-year cohort prior to implementation of the guidelines. A retrospective review of case notes of carriers of haemophilia (41 haemophilia A, 12 haemophilia B) who had received obstetric care at the Royal Free Hospital between 1995 and 2005 was conducted. There were 90 pregnancies (65 live births, 13 miscarriages, 12 terminations). Prenatal testing was taken up in 97% (63/65) of pregnancies where the mother was known to be a carrier of haemophilia. The majority (71%; 46/65) chose only to have non-invasive fetal sex determination. Seventeen (26%) had invasive testing (13 primarily for haemophilia and four primarily for chromosomal abnormalities). Termination of pregnancy was opted for in 67% (6/9) of pregnancies affected with haemophilia. Pregnancy was accompanied by a marked rise in factor VIII levels compared to only a small rise in factor IX levels. Invasive intrapartum monitoring techniques and instrumental deliveries were avoided in all pregnancies known to be at risk of haemophilia. Regional block was performed in 25 pregnancies for labour/delivery with no complications. The caesarean section rate was 47%. The incidence of primary and secondary postpartum haemorrhage was 19% and 2%, respectively. There were two neonatal head bleeding complications associated with prolonged labour or instrumental delivery. Availability of management guideline and care provided in a multidisciplinary approach can help to minimize bleeding complications in carriers of haemophilia and their newborns.
Collapse
Affiliation(s)
- C Chi
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK
| | | | | | | | | | | |
Collapse
|
40
|
Anastasakis E, Zhang EG, Bates AW, Abdel-Aal MAE, Kadir RA. Parapagus dicephalus dibrachius tripus: an unusual case of conjoined twins. Prenat Diagn 2007; 27:1165-6. [PMID: 17787023 DOI: 10.1002/pd.1842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
41
|
Chi C, Lee CA, Kadir RA. Women bleed too. Acta Obstet Gynecol Scand 2007; 86:772-3. [PMID: 17611819 DOI: 10.1080/00016340701417042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- C Chi
- Department of Obstetric and Gynaecology, Royal Free Hospital, London, UK
| | | | | |
Collapse
|
42
|
Abstract
Historically, the pathogenesis of menorrhagia has focused on anatomic and hormonal etiologies. However, in the past decade, numerous epidemiological studies have confirmed an association of von Willebrand factor (VWF) deficiency and menorrhagia with an incidence of VWF deficiency of 13% (95% CI, 11%, 16%). Such patients have a reduced quality of life and incur a high rate of seemingly unnecessary gynecological interventions. In addition, it appears that platelet function abnormalities are c. 3- to 4-fold more common than VWF deficiency in association with menorrhagia. The management of menorrhagia with an underlying disorder of hemostasis involves consideration of the patient's age, childbearing status and preference in terms of several options: hemostatic (oral tranexamic acid, intranasal desmopressin), hormonal (oral contraceptive, levonorgestrel intrauterine system) and surgical (endometrial ablation, hysterectomy). Pending ongoing comparative trials in bleeding disorder-related menorrhagia of intranasal desmopressin (DDAVP), tranexamic acid and further study of the levonorgestrel intrauterine device, specific recommendations cannot be made at present regarding whether one intervention is superior to the other. It should also be noted that the dose and schedule and combination of intranasal DDAVP and tranexamic acid have not been well established and warrant further study. It is imperative to establish algorithms of effective menorrhagia interventions in order to justify widespread hemostasis screening of the menorrhagia patient.
Collapse
Affiliation(s)
- P A Kouides
- Mary M. Gooley Hemophilia Treatment Center, and the Rochester General Hospital, Rochester, NY 14621, USA.
| | | |
Collapse
|
43
|
Abstract
Hemostatic disorders in women are frequently associated with long-standing menorrhagia. This leads to significant morbidity and adversely affects quality of life. Management of these women poses a particular challenge; medical treatments may be contraindicated, and surgery carries additional risks. The levonorgestrel intrauterine system (LNG-IUS) has been shown to be highly efficacy in reducing menstrual blood loss in women with normal coagulation. It is also a reliable and reversible contraceptive. Data on the use of this system in women with bleeding disorders or those receiving anticoagulant therapy are limited. Analysis of data from four reported studies suggests that LNG-IUS is a viable and safe option for the management of menorrhagia in these women. Whether the underlying hemostatic disorders lead to a shorter duration of action or prolonged irregular bleeding/spotting post insertion is unknown and requires large prospective studies. Proper counselling remains crucial for patients' satisfaction.
Collapse
Affiliation(s)
- Rezan A Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia Center and Haemostasis Unit, Royal Free Hospital, NW3 2QG London, UK.
| | | |
Collapse
|
44
|
Kadir RA, Kingman CEC, Chi C, O'connell NM, Riddell A, Lee CA, Economides DL. Screening for factor XI deficiency amongst pregnant women of Ashkenazi Jewish origin. Haemophilia 2007; 12:625-8. [PMID: 17083513 DOI: 10.1111/j.1365-2516.2006.01347.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A pilot study was conducted over a 6-month period to evaluate antenatal screening for factor XI (FXI) deficiency amongst Ashkenazi Jewish women booking for their pregnancy in a single obstetric unit. Fifty-four women of Ashkenazi Jewish origin were recruited during their visit for the routine first trimester ultrasound scan. They completed a questionnaire about their personal bleeding symptoms and had blood taken for FXI levels (FXI:C). Seven (13%) women had partial FXI deficiency. Five (9%) were newly diagnosed, and in the remaining two, the diagnosis was known previously. One infant with severe FXI deficiency was identified as a result of maternal testing. This study has shown that FXI deficiency is common amongst women of Ashkenazi Jewish origin and supports its antenatal screening in this population. However, further studies are required to evaluate its cost-effectiveness and the effect on pregnancy outcome.
Collapse
Affiliation(s)
- R A Kadir
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK.
| | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
A study was conducted to evaluate the value of screening for inherited bleeding disorders in women with primary postpartum haemorrhage (PPH). Over a 2-year period, women identified to have PPH (defined as >500 mL blood loss for spontaneous vaginal delivery, >700 mL for instrumental deliveries and >1000 mL for caesarean sections within 24 h of delivery) were invited to participate in this study testing for a possible underlying bleeding disorder at 3-9 months post-delivery. Women known to have an inherited bleeding disorder were excluded. Of the 5744 deliveries in our unit during the study period, 152 (3%) fulfilled the criteria for primary PPH and 50 women agreed to participate in the study. Of these, 25 (50%) had a spontaneous vaginal delivery, 8 (16%) had an instrumental delivery and 17 (34%) had a caesarean section. Half of the women were multiparous and five (20%) had PPH in their previous pregnancy. Nineteen (38%) and 12 (24%) reported at least one significant personal and family bleeding history, respectively. One (2%) woman was identified to have von Willebrand disease. In conclusion, primary PPH does not appear to be a strong predictor of inherited bleeding disorders. Further studies are required to assess the prevalence of inherited bleeding disorders among these women.
Collapse
Affiliation(s)
- R A Kadir
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK.
| | | | | | | | | |
Collapse
|
46
|
Abstract
The aim was to review the pregnancy and obstetric outcome in women with factor VII (FVII) deficiency. The study group contained women with FVII deficiency, registered with Haemophilia centre and Haemostasis Unit at the Royal Free Hospital, London. The women were interviewed and case notes were reviewed. The main outcome measures were changes in FVII levels in pregnancy, maternal and perinatal outcome. The FVII levels ranged from 7-36 IU dL(-1) in the 13 women included in the study. There were a total of 14 pregnancies in seven women. Ten pregnancies in four women were prior to the diagnosis of FVII deficiency. Following the diagnosis of FVII deficiency, there were four pregnancies in three women. There was an increase in the FVII level during pregnancy in these women from a mean baseline level of 33 IU dL(-1) to a mean of 73 IU dL(-1). These women received recombinant FVIIa replacement during labour and delivery. There were two early pregnancy losses, both associated with excessive haemorrhage. There was only one postpartum haemorrhage in the study. There is a significant increase in FVII levels in pregnancy in women with heterozygous FVII deficiency. The risk of bleeding in early pregnancy might be higher than that at term, due to inadequate rise in the FVII level in early pregnancy.
Collapse
Affiliation(s)
- A A Kulkarni
- Haemophilia Centre and Haemostasis Unit, Royal Free Hopital, London, UK.
| | | | | |
Collapse
|
47
|
Sarris I, Arafa A, Konaris L, Kadir RA. Topical use of tranexamic acid to control perioperative local bleeding in gynaecology patients with clotting disorders: two cases. Haemophilia 2007; 13:115-6. [PMID: 17212738 DOI: 10.1111/j.1365-2516.2006.01386.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Operating on patients with abnormal coagulation is a challenge frequently faced by surgeons. Achieving haemostasis perioperatively can involve bleeding points that would not ordinarily present a problem with intact clotting function. Here we present two women with localised wound bleeding following a gynaecological surgery in the presence of a clotting disorder. Haemostasis was successfully achieved with tropical use of tranexamic acid. These two cases illustrate a novel use for this antifibrinolytic agent. We suggest that there is a role for topical use of tranexamic acid in perioperative haemostasis in patients with clotting disorders.
Collapse
Affiliation(s)
- I Sarris
- Royal Free Hospital NHS Trust, Department of Obstetrics and Gynaecology, London, UK
| | | | | | | |
Collapse
|
48
|
Abstract
BACKGROUND [corrected] Puerperal hemorrhage associated with disseminated intravascular coagulation is a life-threatening obstetric emergency. Recombinant factor VIIa is a novel hemostatic agent, but more information concerning its dosage, efficacy, and safety is required. CASE A primigravida developed preeclampsia complicated by disseminated intravascular coagulation and severe puerperal hemorrhage after an emergency cesarean at 35(+5) weeks of gestation. Two doses of recombinant factor VIIa controlled the hemorrhage without any thrombotic complications. CONCLUSION Recombinant factor VIIa should be considered when conventional methods fail to control puerperal hemorrhage complicated by disseminated intravascular coagulation. A review of 17 similar cases treated with this hemostatic agent revealed that in 76% a single dose ranging from 16.7 to 120 microg/kg controlled bleeding. Guidelines are needed to help obstetricians use recombinant factor VIIa effectively in such emergencies.
Collapse
Affiliation(s)
- Litha P Pepas
- Department of Obstetrics and Gynecology, Royal Free Hospital, Hampstead, London, UK.
| | | | | |
Collapse
|
49
|
Abstract
von Willebrand disease (vWD) is the commonest bleeding disorder in women. More than 70% of women with vWD suffer from menorrhagia and half of them suffer from dysmenorrhea. There is also the risk of hemorrhage with ovulation and mid-cycle pain. These have a significant effect on all aspects of quality of life. vWD also can be the underlying cause of menorrhagia in a small but significant proportion of women. There are still several unanswered issues in the diagnosis and management of menorrhagia in these women. There is no consensus whether testing for vWD should be part of the routine investigations in menorrhagia. Diagnosis of vWD is difficult. There are intraindividual variations in von Willebrand factor and factor VIII levels influenced by age, race, and blood group. This is further complicated in women because of the fluctuation of these factor levels during the menstrual cycle and possibly with hormonal therapy. The diagnosis of menorrhagia is also difficult due to the lack of a simple objective tool for the assessment of menstrual blood loss. In vWD, the treatment of menorrhagia is usually medical, but there is lack of prospective data on the efficacy of commonly used medical therapies in these women. The levonorgestrel intrauterine system, Mirena, is effective and should be considered prior to surgical management. Surgical interventions may be required in patients unresponsive to medical treatments. These procedures can be complicated by hemorrhage in these women. A multidisciplinary approach in the management of these women is essential in ensuring an optimal outcome. Multicenter clinical trials are required to answer the controversial issues in the management of women with vWD.
Collapse
Affiliation(s)
- Rezan A Kadir
- Department of Obstetrics Gynaecology, Royal Free Hospital, London, UK.
| | | |
Collapse
|
50
|
Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the rectus sheath necessary during Pfannenstiel incision for lower segment Caesarean section? A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2006; 128:262-6. [PMID: 16621227 DOI: 10.1016/j.ejogrb.2006.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Revised: 11/30/2005] [Accepted: 02/08/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective was to determine the benefit of non-dissection of the rectus sheath inferiorly in a Pfannenstiel incision during an elective Caesarean section with regard to operative blood loss and post-operative pain. DESIGN A randomised controlled trial. SETTING The Royal Free Teaching Hospital in London. POPULATION One hundred and twenty women who underwent elective Caesarean section delivery. METHOD Women were randomised to have dissection or non-dissection of the rectus sheath inferiorly during an elective Caesarean section. MAIN OUTCOME MEASURES Estimated blood loss during the operation, as well as the difference between pre- and post-operative haemoglobin levels. Post-operative pain was assessed by the visual analogue scale, a verbal rating scale and the use of post-operative analgesia. Patient satisfaction was assessed by a verbal rating scale. RESULTS There was no significant difference in the estimated blood loss during the procedure between the two groups; however, the mean difference between the pre-operative and post-operative haemoglobin was significantly smaller in the study group (p=0.05). There was a statistically significant difference in both the visual analogue scale (p-value=0.03) and the verbal rating scale scores (p-value=0.02) for pain between the two groups, with lower scores for the study group. There was no overall difference in the verbal rating scale scores for patient satisfaction. CONCLUSION Non-dissection of the rectus sheath inferiorly in Pfannenstiel incisions during Caesarean section procedures is associated with a significant reduction in the post-operative pain as well as a smaller drop in post-operative haemoglobin.
Collapse
Affiliation(s)
- Rezan A Kadir
- Department of Obstetrics and Gynaecology, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, United Kingdom.
| | | | | | | |
Collapse
|