Yes. For most women with VWD, conception is not a problem. Of course, hormone therapy to control menorrhagia interferes with conception.
For many women with VWD, pregnancy is a time of few bleeding problems. Fortunately, the level of VWF in the blood for women with Type 1 VWD goes up during pregnancy and at the time of childbirth. However, after childbirth, VWF levels fall quickly and bleeding can continue for many weeks. Treatment may be required to prevent it.
Breastfeeding can help to keep VWF levels raised after childbirth in women with Type 1 VWD.
Women with Types 2 and 3 VWD can also have children. However, more precautions may be necessary.
It is very important for a woman with VWD to have confidence in a team of physicians to help her through her pregnancy. This team should include:
- an obstetrician (who specializes in caring for a woman during pregnancy and at delivery)
- a hematologist (who can make sure the woman’s bleeding problem is under control).
The anesthesiologist who will be present at the birth needs to know the special needs of a woman with a bleeding disorder. He/she should check with the hematologist before performing invasive procedures like epidural anesthesia.
Women with Type 3 von Willebrand disease seem to have more frequent miscarriages (spontaneous abortions), especially during the first trimester. It may also be that these miscarriages, rather than being more frequent, are simply more noticeable because they are accompanied by heavier bleeding.
In addition, bleeding after a miscarriage may be severe for a woman with VWD.
Yes. Plasma-derived factor concentrates can transmit parvovirus. This common virus is not normally dangerous to people. This is because most people have already been exposed to it. However, in rare cases, it can cause miscarriage (spontaneous abortion). Therefore, pregnant women, or women who might become pregnant, should raise this question with their doctors.
No. In fact, for women with Type 1 VWD the opposite is true. They have less bleeding than they normally do. This is because high hormone levels during pregnancy stimulate the production of blood clotting proteins. As a result, levels of von Willebrand factor and factor VIII rise closer to normal. Most women with Type 1 VWD have few bleeding problems during pregnancy, or during childbirth.
Nevertheless, clotting levels should be monitored, especially as the date of delivery approaches. This way, doctors will know whether to prepare treatments. Some of the clotting factors needed by women with bleeding disorders are rarely used. The hospital blood bank will have to be alerted so that the factor concentrates are on hand if needed.
Desmopressin can also be prescribed to raise VWF and factor VIII levels during delivery for women with Type 1 VWD.
In Type 2 VWD, the levels of VWF will rise during pregnancy. However, because the structure of this increased VWF is still not normal, the bleeding disorder will not be corrected. The levels of VWF will not rise for women with Type 3 VWD because they do not make any VWF.
If tests have shown that a woman is likely to suffer from bleeding during or after delivery, preventive treatments should be given. These include:
- desmopressin, if effective
- antifibrinolytics (Cyklokapron and Amicar)
- FVIII/VWF concentrates.
It should be assumed, unless prenatal testing has shown the opposite, that the fetus is also affected by a bleeding disorder. As a result, delivery should be as gentle as possible for both the woman and the baby. Natural childbirth without the use of instruments is the goal for a woman with a bleeding disorder.
In order to prevent bleeding, the following should be avoided, when possible:
- suction extraction of the baby
- deep intramuscular injections
- episiotomy (cutting of the skin near the vagina to avoid tearing)
- the use of forceps
- scalp electrodes.
An epidural (freezing of the lower body by means of a needle in the spine) may cause bleeding in women with Types 2 and 3 VWD. Before using epidural anesthesia, the anesthesiologist should consult an experienced hematologist. Treatment with FVIII/VWF concentrate may be necessary.
If a Caesarean section is necessary, prior treatment with FVIII/VWF concentrate is necessary.
Postpartum bleeding in women with VWD is more common than in the general population. Therefore, all women should be watched carefully for bleeding in the hours, days and weeks following delivery. The following blood tests need to be done:
- VWF and factor VIII levels
- hemoglobin (iron level in the blood).
If a woman feels her bleeding is excessive, she should immediately notify her obstetrician or hematologist.
Women with Type 1 VWD who breastfeed keep the high hormone levels they had during pregnancy. This may protect them from bleeding in the weeks following delivery (postpartum). Women who do not breastfeed see their hormone levels fall. This can lower the levels of clotting factors. They can have bleeding problems in the weeks after giving birth.
Transfusions of factor concentrates, and even red blood cells, may be necessary.
Babies with VWD rarely bleed at birth. Babies with Type 3 VWD, however, may bleed if they undergo surgery, including circumcision.
No, not usually. Because the symptoms of VWD can be so easily managed, prenatal testing of the fetus is not recommended. However, if an older child has already been diagnosed with Type 3 VWD, parents may choose prenatal testing. This can be done starting 10 weeks into the pregnancy.
The diagnosis of severe VWD in a newborn can be made starting one week after birth. It can be difficult to diagnose milder forms of VWD in babies, therefore, most doctors prefer to wait until the child is older – 4-5 years of age – before testing.