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Bleeding disorders in pregnancy

Bleeding disorders and pregnancy


Genetic counselling and pre-pregnancy care

§       Assessment of the genetic risk

§       X-linked v. others

§       Reproductive options

§       Conceive naturally, have prenatal diagnosis and terminate if foetus affected

§       Accept risk of having an affected child

§       Not have a child

§       Adopt

§       Assisted conception with donor egg or sperm

§       Preimplantation genetic diagnosis

§       IVF to create embryos

§       Tests 1 or 2 cells from each embryo

§       Selects unaffected embryos for implantation

§       Success rates much lower than for natural conception

§       Prenatal testing

§       Invasive

§       CVS

§       11-14 weeks – not before 10 weeks due to risk of limb defects

§       Better than amnio (>15 weeks) as can be performed in first trimester – when termination likely to be more acceptable

§       Miscarriage risk 1-2%

§       As amnio as later, foetal sex can be accurately determined, excluding females from the risk

§       Cordocentesis

§       Factor levels on cord blood

§       Rarely done, but may be useful if genetic mutation cannot be identified

§       Need to exclude maternal blood contamination as this will affect results

§       May need to give mum factor prior to the invasive procedure, as her levels are unlikely to have risen this early in pregnancy

§       Remember anti-D

§       Non-invasive

§       Ultrasound

§       In 2nd trimester and beyond, foetal sex can be accurately determined, and if female can reassure

§       Free foetal DNA in maternal circulation

§       To look for presence or absence of Y chromosome

§       Choices if foetus found to be affected


Antenatal management

§       Factor VIII levels usually rise during pregnancy

§       Factor IX levels don’t usually rise

§       Management

§       Levels should be checked at booking, 28 and 34 weeks.

§       Recombinant products should be used

§       Virally inactivated products still have risk of transmitting parvo and hep A, and parvo may be life threatening to the foetus

§       DDAVP controversial

·       Risks of placental insufficiency, miscarriage, preterm labour

·       Doesn’t pass into breast milk, therefore may be used in labour/ post-partum

·       Can be used in vWD, but repeated administrations / use in pre-eclampsia should be avoided. Monitor closely for water retention.


Intrapartum management

§       Delivery plan should be made in advance, planned at a unit with the necessary expertise


Labour management

§       Check factors and send group and save

§       If levels <50, treatment likely to be needed.

§       Spontaneous labour should be allowed where possible

§       If induced, greater risk of prolonged labour or instrumentation and elective section should be considered

§       Analgesia

§       Should be discussed with anaesthetist in advance

§       If coag screen normal and levels >50, regional block is not contraindicated

§       Should be performed by an expert anaesthetist

§       Levels should be checked prior to removal as factor levels may fall quickly after delivery


Foetal monitoring

§       Foetal scalp electrodes or blood sampling should be avoided



§       Vacuum extraction, forceps and prolonged labour should be avoided


Post partum

§       Levels fall rapidly after delivery

§       Increased risk of primary and secondary PPHs

§       Factor levels should be maintained >50 for at least 3 days or 5 days if C/S

§       Active management of 3rd stage and minimize perineal trauma

§       DDAVP and TA can be considered



§       IM injections and venepuncture should be avoided

§       Vit K should be given orally

§       Immunisations should be given subcut

§       Circumcision should be delayed until diagnosis known

§       Cord blood should be checked on all male babies

§       Cranial USS/ CT. Consider prophylaxis.






§       Pictorial blood assessment charts should be considered in the assessment of menorrhagia

§       A significant number of people with menorrhagia have an underlying bleeding disorder (usually vWD) and testing should be considered.

§       Remember hypothyroidism

§       Treatment options include

§       Tranexamic acid

§       COCs

§       DDAVP

§       POP

§       Mirena