Pregnancy with a Bleeding Disorder: Q&A with Dr. Andra James

Pregnancy and delivery are a time of increased anxiety for many women, and if you have an inherited bleeding disorder it might be worse. Let’s Talk Period conducted an interview with Dr. Andra James, OB-GYN and a specialist in maternal-fetal medicine, high-risk obstetrics and hematology at Duke University in North Carolina, USA about some common questions that a woman in this situation might have.

Are women with inherited bleeding disorders more likely to have bleeding during their pregnancy than women without a bleeding disorder? Is there any evidence there is an increased rate of miscarriage if so?

If it is a healthy pregnancy, and not counting delivery, I would say “no” in most cases. The exception being fibrinogen or FXIII deficiencies.  If there are bleeding complications during pregnancy, the bleeding is more likely to be heavier, of course, in patients with a bleeding disorder. 

There is no evidence that shows an increased rate of miscarriage for women with bleeding disorders, again with the exception of fibrinogen and FXIII deficiencies. The evidence [for an increased rate of miscarriage in women with fibrinogen and FXII deficiencies] is based on small numbers at a few centers, but if we do have women with a fibrinogen or FXIII deficiency we treat them prophylactically.

Are the treatments for bleeding safe during pregnancy?

Yes, there are treatments for bleeding disorders that are safe during pregnancy. If the bleeding is obstetrical (meaning the bleeding is from the uterus), it can’t be fixed by hematological means, but we can help with the bleeding. If it is a viable pregnancy, obstetrical bleeding is usually self-limited which is a good thing. 

Can women with an inherited bleeding disorder have an epidural during delivery?

Yes, in most cases. The American Society for Regional Anesthesia has guidelines for epidurals in patients with bleeding disorders. The general rule is it is ok for women with factor levels in the normal range at delivery and a normal PT/PTT.

Are there bleeding risks to the newborn during delivery?

If a fetus is known or suspected of having a bleeding disorder we always err on the side of caution. With the exception of Hemophilia, we assume the phenotype of the baby will be the same as the phenotype of the mother (i.e. no worse) as long as the mother’s partner is not affected with a bleeding disorder. If the baby is expected to be even mildly affected, we recommend avoiding forceps or vacuum delivery and the use of fetal scalp electrodes. However, in the case of suspected Hemophilia, we always assume the baby could be severely affected and in this case, we recommend cesarean delivery in order to reduce the risk of intracranial bleeding. 

In both cases, we recommend patients deliver at a centre where they have access to a pediatric hematologist, instead of at a community hospital.

What is the risk of postpartum hemorrhage in a woman with an inherited bleeding disorder?

Data in a prospective study done by us on 35 women with von Willebrand disease showed approximately a 50% higher risk of post-partum hemorrhage than the United States national average. The national average rate of post-partum hemorrhage is approximately 4%, so the rate in the women with VWD in our study was approximately 6%. It is generally estimated as being between 5-10% for women with bleeding disorders.

Any general advice for women with an inherited bleeding disorder contemplating a pregnancy?

Yes. Talk to a knowledgeable hematologist, one who has access to a high-risk obstetrician. At best, they are working together and familiar with each other’s areas of practice. Genetic counseling is also important for discussing inheritance risks but the involvement of a hematologist and high-risk obstetrician helps to inform the patient of the potential bleeding risks for themselves and their offspring. 

Thanks so much for talking with us, Dr. James!

My pleasure! 

