Nov 18, 2020

A research abstract presented at the recent Thrombosis & Haemostasis Summit of North America 2020 Virtual Conference suggested that epidural analgesia may be a safe option for pregnant women with von Willebrand disease (VWD) type 1, provided clotting factors are maintained at certain levels. Epidural analgesia refers to the injection of a local anesthetic into the epidural space of the spine to prevent or eliminate pelvic pain during labor.

Findings such as these could begin to fill a knowledge gap as current recommendations relevant to the safe use of epidural analgesia during pregnancy in VWD patients are not well defined in the United States. Authors from the Tulane University School of Medicine conducted a small retrospective review study of medical records of eight VWD type 1 patients who, between 2008 and 2018, received medical care that included an epidural analgesia. All of these deliveries were conducted at Tulane University Hospital in New Orleans.

Their review showed that seven of the eight patients who received epidural analgesia received a factor VIII replacement therapy (Humate-P®) prior to delivery, targeting von Willebrand factor antigen level (VWF:Ag) and factor VIII (FVIII) levels of 100% to 150%. Only one patient received tranexamic acid.

While no bleeding related to the epidural anesthesia was reported, two patients did develop postpartum hemorrhage (PPH), one in a spontaneous vaginal delivery and the second in a caesarian section delivery (CS). These two patients had third trimester VWF levels of 29% and 24% and FVIII levels of 103% and 61%, respectively.

The CS patient with PPH also experienced placenta previa and preeclampsia. The former is a complication whereby the placenta grows in the lowest part of the uterus and covers all or part of the cervix, while preeclampsia is characterized by high blood pressure with potential for organ damage. Fortunately neither of these complications lead to severe features in this patient, who also received tranexamic acid prior to delivery. Bleeding resolved with medical treatment and did not require any surgical intervention.

The authors cite multiple limitations to this review related to sample size, the retrospective design and relatively limited data. They therefore encourage further investigation if researchers are to corroborate the findings of this promising, if modest study.

“In our study, patients were treated to higher peripartum target levels of VWF:Ag and FVIII than the current guidelines. None experienced bleeding related to the epidural analgesia, suggesting that epidural analgesia might be safe in this patient population,” stated the authors. They conclude that larger prospective studies that encompass additional hemostasis testing in these patients are needed to provide “high level data” on the feasibility and safety of epidural anesthesia in this patient population, plus the correlation between third trimester VWF:Ag and FVIII levels and the risk of developing PPH.  

Source: Hematology Advisor, October 29, 2020