|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 49-50
Anesthesia for cesarean section in a patient with von willebrand's disease
Nitu Puthenveettil, Juby Mathew, Sunil Rajan, Lakshmi Kumar
Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||24-Jun-2020|
|Date of Acceptance||21-Dec-2020|
|Date of Web Publication||16-Apr-2021|
Dr. Nitu Puthenveettil
Department of Anaesthesia and Critical Care, Amrita Vishwa Vidyapeetham, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Puthenveettil N, Mathew J, Rajan S, Kumar L. Anesthesia for cesarean section in a patient with von willebrand's disease. J Obstet Anaesth Crit Care 2021;11:49-50
|How to cite this URL:|
Puthenveettil N, Mathew J, Rajan S, Kumar L. Anesthesia for cesarean section in a patient with von willebrand's disease. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Jun 14];11:49-50. Available from: https://www.joacc.com/text.asp?2021/11/1/49/313912
Von Willebrand's disease (vWD) is an autosomal dominant hereditary coagulation disorder, affecting up to 1% of the population. It is characterized by a deficiency or defect of von Willebrand's factor (vWF). vWF aids in platelet adhesion and preventing degradation of coagulation factor VIII., There are three types of vWD. Type 1 with quantitative deficiency, type 2 with a qualitative defect, and type 3 with a total absence of VWF. Type 2 is further subdivided into 2A, 2B, 2M, and 2N., Women face hemostatic challenges during menstruation and childbirth. Preoperatively hemoglobin, prothrombin time, thromboplastin time, bleeding time, factor VIII, and vWF antigen levels should be evaluated. A multidisciplinary team including obstetricians, hematologist, and anesthetists are required for a good obstetric outcome. We present two cases of von Willibrand's disease that were referred to our obstetric department for further management.
A 29-year-old G2P1L1, at 37 weeks of gestation, a known case of von Willibrand's disease type 2B was admitted for safe confinement. She gave a history of multiple platelet transfusions in her previous pregnancy. On the day of surgery, her platelet count was 32,000/μL. One unit of single donor platelet (SDP), 2000 U of factor VIII, and vWF concentrate were transfused before the surgery. In the operation theatre, in addition to standard monitors, an invasive arterial line and two large-bore IV access were secured. General anesthesia with rapid sequence induction was performed, and a live baby was extracted. Oxytocin infusion was started. However, she had a bout of atonic bleeding, which was managed with additional oxytocin, prostaglandin F2α, tranexamic acid, bilateral uterine artery ligation, and per rectal prostaglandin E1 (PGE1). A point of care thromboelastogram was performed (R = 3.5 min, k = 2.7 min, Angle = 58.9, MA = 61.6 mm, CI = 0.9). Two units of packed red blood cells, 10 units of cryoprecipitate, 1 unit of SDP, 2 units of fresh frozen plasma, and 2000 U of factor VIII were transfused. The postoperative period was uneventful.
A 28-year-old G2P1A1, at 37 weeks of gestation, a known case of vWD Type 2 was admitted for safe confinement. The investigations showed normal factor VIII and vWF antigen levels, but the platelet count was 45,000/μL. On the day of surgery, a half unit of SDP was transfused. General anesthesia with rapid sequence induction was performed. She was given intravenous oxytocin, tranexamic acid, and per rectal PGE1. The uterus was well contracted, and the postoperative period was uneventful.
Patients with vWD have an increased risk of postpartum hemorrhage due to uterine atonicity., Caesarean sections are performed for obstetric indications. Successful use of regional anesthesia has been reported. But general anesthesia is safer when coagulation parameters are deranged. A platelet count below 50,000 has to be corrected before the caesarean section. Desmopressin, which raises plasma levels of endogenous vWF is preferred in type 1 vWD and factor concentrates in type 2 and 3. Tranexamic acid is used as it inhibits fibrinolysis. Intraoperative bleeding can be managed with blood transfusion, fresh frozen plasma, and cryoprecipitate. Cryoprecipitate has 5 to 10 times more factor VIII and vWF than fresh frozen plasma. Factor VIII and vWF are preferred to avoid viral transmission. A thromboelastogram can be used to guide transfusion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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