Safety of von Willebrand factor substitution for neuraxial anesthesia in women with persistent von Willebrand deficiency at delivery.

BACKGROUND

Neuraxial anesthesia (NA) constitutes a risk for patients with bleeding disorders, the main hemorrhagic adverse effect being spinal epidural hematoma. No clear recommendation has been issued concerning NA use for delivery in patients with von Willebrand disease (VWD) whose von Willebrand factor (VWF) levels have not been spontaneously corrected by the end of pregnancy.

OBJECTIVES

This study describes the experience of 8 French hospital centers with NA use during delivery in these patients.

METHODS

Patients included in this study manifested still uncorrected VWF levels at the end of pregnancy and received NA for delivery together with VWF substitution to avoid the risk of hemorrhage associated with this type of anesthesia. Thirty-two patients participated in the study, accounting for 40 pregnancies in total. All VWD types were represented except for type 3. VWF, factor (F)VIII, fibrinogen and platelet levels were recorded before and at the end of pregnancy. The monitoring of VWF levels, the type of VWF ± FVIII substitution, and the doses administered were also noted. We additionally reviewed the literature concerning NA use at delivery in patients with VWD.

RESULTS

No spinal epidural hematoma or ecchymosis related to NA was observed in any of the 32 patients during the 40 deliveries.

CONCLUSION

In conclusion, our results suggest that patients with VWD manifesting VWF levels not spontaneously corrected by the end of pregnancy could safely benefit from NA with closely monitored VWF substitution. Based on these results and national and international recommendations, we formulated proposals on how to manage these patients.