The Comprehensive Hemophilia Treatment Center (HTC) at the Newark Beth Israel Medical Center in New Jersey published results of a retrospective review of female von Willebrand disease (VWD) patients who had undergone epidural anesthesia (EA) during the delivery of a full-term babies in the November 2007 issue of the journal Haemophilia. EA, a type of regional anesthesia that prevents pain in a particular part of the body, is often used during childbirth. It blocks nerve impulses from the lower spine, diminishing sensation in the lower half of the body.
The review, which was conducted at the HTC, included female VWD patients registered between 1999 and 2004. Of the 36 women known to have carried at least one pregnancy to full term, 34 (94%) were type 1 VWD patients; two (5%) were type 2A VWD patients.
In all, 64 full-term pregnancies occurred in this group of 36 women--47 (73%) had normal spontaneous vaginal deliveries and 17 (26%) had Cesarean sections. Postpartum hemorrhaging occurred in 24 (37%) of the deliveries. The mode of delivery did not predict postpartum bleeding. Hemorrhaging occurred in three of the 17 (17%) C sections and 21 of the 47 (44%) vaginal deliveries.
Fifteen women had EA during 17 deliveries; 14 of them (93%) had type 1 VWD. During the other 47 deliveries EA was not used for several reasons, including patient refusal, anaesthesiologist’s objection due to the presence of VWD or an obstetrician not providing the EA option, in light of their VWD. None of the 17 patients undergoing EA during delivery received DDAVP (desmopressin acetate), plasma-derived factor VIII (FVIII) or von Willebrand factor (VWF)-containing concentrates prior to the procedure.
The review showed that in all 17 deliveries, EA was administered successfully via catheter, with no bleeding complications. Postpartum hemorrhage occurred in eight deliveries; three of the women needed transfusions of packed red blood cells. Of the women in this group, 16 had type 1 VWD. A single type 2A VWD patient who received EA was among the women who experienced postpartum bleeding.
FVIII and VWF levels tend to rise during pregnancy and then often fall abruptly following delivery. This accounts, in part, for the bleeding patterns observed in the group. Despite the relatively small size of the study, investigators were still encouraged by the results, suggesting that EA can be administered in patients with VWD if certain precautions are taken. “Our patient group does suggest that EA can be safely administered to women with mild type 1 VWD in whom coagulation defects have normalized,” said Jay Varughese, MD, the lead author of the study. “Coagulation parameters should be obtained in the third trimester to evaluate for safety prior to administration of EA. A larger prospective study with baseline, late term and postdelivery coagulation factor levels should be performed to confirm the safety of EA in women with vWD.”
The report, “Experience with Epidural Anesthesia in Pregnant Women with Von Willebrand Disease,” was published in the November 2007 issue of Haemophilia.
Source: Pharma Law Weekly, December 11, 2007