Epidural analgesia in pregnant women with von Willebrand disease (VWD) type 1 appears to be safe with von Willebrand factor (VWF) and Factor VIII levels of 80% or more in the third trimester, according to the results of a study presented at the Thrombosis & Hemostasis Summit of North America (THSNA) 2020 Virtual Conference.
As current recommendations for the safety of administering epidural analgesia during pregnancy in patients with VWD are not well defined, the investigators conducted a retrospective review of the management of pregnant women with VWD.
Medical records of 8 patients with VWD type 1 who received medical care, including epidural analgesia, and delivered at Tulane University Hospital in New Orleans, Louisiana, from 2008 to 2018 were reviewed.
All 8 patients received epidural analgesia, and 7 of the 8 received Humate-P prior to delivery (targeting VWF:Ag and FVIII levels of 100% to 150%). Only 1 patient received tranexamic acid. No patients experienced bleeding related to the epidural anesthesia, suggesting this procedure may be safe in this patient population.
Postpartum hemorrhage (defined as >500 cc in spontaneous vaginal delivery [SVD] or >1000 cc in caesarian section [CS] delivery) developed in 2 patients (1 SVD and 1 CS). In the third trimester, the VWF:Ag and FVIII levels were 29% and 103%, respectively, in the patient with SVD, and 24% and 61%, respectively, in the patient with CS. The patient with CS and postpartum hemorrhage (PPH) also had placenta previa and preeclampsia and had received tranexamic acid. Bleeding in these patients resolved with medical treatment.
“Epidural analgesia is safe in [VWD] type 1 patients as long as VWF levels and FVIII levels in the third trimester are at least ≥80[%],” concluded the authors.
Limitations of this study included the retrospective nature, limited data, and small sample size.
The authors suggested that larger prospective studies of the feasibility and safety of epidural anesthesia that include other testing of the hemostasis in pregnant patients with VWD are needed and should assess the correlation between third trimester VWF:Ag and FVIII levels and the risk of developing PPH.
Janbain M, Ksayer R, Swigert A. Von Willebrand disease in pregnancy and the use of epidural analgesia. Abstract presented at: THSNA 2020 Thrombosis & Hemostasis Summit of North America; October 27-30, 2020. Abstract 66.