In a case-based discussion as part of this year’s Education Program, Andra James, MD, MPH, and Margaret Ragni, MD, MPH, will answer challenging questions about hemostasis and thrombosis in women of childbearing age – from managing thrombotic risks in women undergoing in vitro fertilization to reducing bleeding risks in pregnant women with congenital bleeding disorders. Here, session chair Saskia Middeldorp, MD, PhD, previews the conversation, which features insight from a hematologist and an obstetrician/gynecologist.
Why is it important to bring the perspective of a non-hematologist to this topic?
This is a multifaceted patient population, with many angles to consider. Dr. James, a maternal-fetal medicine specialist, and Dr. Ragni, a nonmalignant hematologist, are both experienced in treating young women of childbearing age who have bleeding or clotting tendencies. The case review format of this session will offer a good opportunity to see how dedicated specialists have different, but complementary, approaches to a specific patient. I also hope that the nontraditional structure of the event will encourage more interaction.
Can you give us a taste of what the speakers will discuss?
The first patient scenario is a woman with von Willebrand disease (vWD) and menorrhagia, or heavy menstrual bleeding. Each participant will be discussing the cause of the bleeding – looking at the patient’s clotting factor levels and whether the vWD is hereditary but undiagnosed – and its management.
We also will discuss the management of bleeding risk in a woman with a bleeding disorder who wants to become pregnant. There are several possible approaches and factors to consider here, such as how bleeding history will affect pregnancy and delivery and whether “normal” clotting factor levels will be high enough during pregnancy.
The final patient is a woman with thrombophilia who wants to undergo in vitro fertilization (IVF), which requires her to receive exogenous hormones. The question here is whether to anticoagulate the patient, which will include a discussion about whether anticoagulation improves IVF success rates – as some in the IVF field have argued. IVF specialists may give women heparin because it is thought to prevent thrombosis at the implantation site and to enhance pregnancy success. In the Netherlands, where I practice, IVF often is performed without consultation with a coagulation specialist.
What are the gaps in the knowledge about managing bleeding and clotting disorders in young women who are pregnant or wish to become pregnant?
We have guidelines for the management of this patient population, but they are generally based on low-quality evidence. The number of trials specifically in pregnant women is extremely small, because pregnant women or women who are breastfeeding are typically excluded from clinical trials. So, most of the guideline recommendations are conditional. Treatment decisions are rarely cut and dried; there are numerous ways of approaching a certain patient, as I think we will see from this discussion.
That’s why I’d rather perform one trial in this particular patient population, even if it takes 10 years, than to do 10 trials in an overall population. We have made progress, but it’s slow. We might not ever be able to say, “We have a randomized trial of 13,000 patients and this is the way to do it.” There are nuances, and what might be “right” for one patient is not right for another. We hope to eventually gather more evidence to inform our decisions but, for now, we can learn from each other and our colleagues in other specialties about optimal approaches.