How everyone handles Von Willebrand dz?

[neuroride]

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We have had a few roll through in the last year and the question always comes up in regards to labor epidurals on what labs and when to draw? 1 of them had factor levels drawn appropriately just before the labor started and then 1 only had labs drawn early like at 18wks, none following.

 

[Hork Bajir]

IIRC the management (including when to check levels/activity) depends on the subtype and whether they are DDaVP responders... I think if it’s a quantitative deficiency the levels increase at term, so if your second trimester check is good then no need to recheck.

But it’s one of those confusing things I need to look up every time

 

[DM27]

Yeah, it is 100% dependent on the sub-type. Some will require DDaVP, some will require recombinant Factor VIII:vWF combo, some you don't need to do anything, and some you can do nothing.

The most commonly encountered scenarios are either DDaVP or Factor VIII:vWF, if you need the VIII:vWF and your hospital doesn't carry it, you can use cryo.

 

[getdown]

If you have enough time and the OBs are smart enough, they'd consult heme-onc prior to pt presenting in labor or for elective c/s.

 

[Gern Blansten]

I am handling it just fine, though it can be depressing at times. Thank you for asking.

 

[bobow98]

Please send these patients to us in hematology clinic before they bleed on the table k thnx bye 😉

 

[pjl]

We make all of them have a defined subtype at some point in their life, or sent to hematologists during the 9 MONTHS of pregnancy.
The OBs were all whiny about organizing that until we got in their face about how freaking long pregnancy is.

Them: “You can’t expect us to always figure this out, sometimes we can’t get them in or don’t know what labs to order”
Me: 9
Them: What?
Me: ****ing
Them: huh?
Me: Months

 

[dchz]

Does anyone go ahead with the epidural/spinal if the TEG is normal?

 

[deleted875186]

Standard TEG does not accurately diagnosis VWD i believe.

I think I would only go ahead with neuraxial if VW levels weee normal checked close to delivery.

 

[vector2]

Standard TEG does not accurately diagnosis VWD i believe.

I think I would only go ahead with neuraxial if VW levels weee normal checked close to delivery.

That was my understanding as well but then I ran across this study: A prospective diagnostic accuracy study evaluating rotational thromboelastometry and thromboelastography in 100 patients with von Willebrand disease. - PubMed - NCBI

 

[deleted875186]

That was my understanding as well but then I ran across this study: A prospective diagnostic accuracy study evaluating rotational thromboelastometry and thromboelastography in 100 patients with von Willebrand disease. - PubMed - NCBI

Interesting.

From the looks of that study, very low negative predictive value with TEG. So I would not use a normal TEG to justify placing an epidural.