October 15 2021 Disclosures None Objectives To understand current prenatal screening options To provide appropriate counseling for method of delivery including maternal and fetal risks To review modifications to intrapartum management to minimize maternal and neonatal morbidity ID: 1048401
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1. Obstetric ConcernsLaura Merrill, MD, MAOctober 15, 2021
2. DisclosuresNone
3. ObjectivesTo understand current prenatal screening optionsTo provide appropriate counseling for method of delivery, including maternal and fetal risksTo review modifications to intrapartum management to minimize maternal and neonatal morbidity
4. Patient Case37 yo G3P2002 at 38+2 wks presents in spontaneous labor, SVE 6cmPatient is a know carrier for Hemophilia A with multiple affected male family membersIn G1, referred to MFM, who stated as a carrier, she had no further concerns. Fetus was female, no changes to delivery. Patient has never seen Hematology. No further high-risk follow-up. Uncomplicated SVDG2 – no MFM or Heme referral given recommendations in G1, another female fetus. Uncomplicated SVD
5. Patient Case, cont.Current pregnancy – again no referrals given prior recs. Male fetus. Was counseled that only difference was to avoid instrumentation during laborPeds notified of patient’s presence upon admission. Peds Heme notified OB team of preference for primary CS for fetal concernsPatient declined CS immediately, however fetus was asynclitic and she ultimately underwent CS for arrest of dilation at 8 cmEBL 2L due to surgical bleeding. No atony or extensions were noted
6. Maternal DiagnosisIdeally made prior to pregnancy given normal physiologic changes in multiple coagulation factorsvWF, fibrinogen and Factors II, VII, VIII & X all increaseGet Hematology involved in pregnancy, even if not following long-term
7. Fetal DiagnosisCurrently no non-invasive means of evaluating fetus in uteroCVS or amnio can allow for sequencing of factor genes, but generally risk outweighs benefit if no other genetic concernsSequencing not recommended in vWD due to complexity of mutationsIn one algorithm, CVS only recommended if pregnancy termination of affected child is considered
8. Delivery Planning - MaternalMain maternal risk is hemorrhageHigher rates of delayed PPH in vWDConsider prolonged postpartum admission, especially in patients who live remote from referral centersVaginal delivery preferable to minimize bleeding risks if at all possibleNo randomized studies regarding risks of neuraxial anesthesiaMulti-disciplinary planning is keyHave factor replacement and/or medical prophylaxis plan in placeConfirm availability of factor with blood bank
9. Delivery Planning – Fetal/NeonatalHemophilia carriersFemale fetus – no changes in routine OB management, but should be screened postnatally for carrier statusMale fetus – avoid intra-partum proceduresIf OVD unavoidable, forceps preferable to vacuumSeveral small studies suggest pre-labor CS has lower neonatal riskOther guidelines prefer SVD with low threshold for CS prior to far advancement into second stageNO postpartum procedures/IM injections until evaluation is completedAll others really nothing changes
10. Delivery PlanningVisual abstract from Leebeek FWG, Duvekot J, Kruip MJHA. “How I manage pregnancy in carriers of hemophilia and patient with von Willebrand disease.” Blood. 2020;136(19):2143-2148