How would you treat a pregnant patient with type 2A von Willebrand disease?

Here’s how readers responded to a You Make the Call question about treatment options for a pregnant patient with type 2A von Willebrand disease.

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I might consider daily infusions at home to keep her level up, should she go into labor beforehand, and 2,400 units is close to what I might choose as a daily dose. I would probably induce earlier than week 39 if all indicators suggest child is matured. Giving Humate-P, which has less FVIII than vWF, seems appropriate. Also, she has had this product previously. I agree with the dose before epidural and keeping vWF:RCo above 50 percent by bolus every 12 hours. I would give an additional dose proximal to parturition if the prior dose was more than six hours earlier. Postpartum, I would maintain vWF above 50 percent for three days. Beyond that, dosing depends on the non-pregnant baseline vWF and FVIII levels, as well as bleeding symptoms. I would prefer FVIII above 30 percent for at least a week to 10 days and use Humate-P to maintain vWF near 30 percent until day five.

Ken D. Friedman, MD
BloodCenter of Wisconsin‎
Milwaukee, WI

For major surgery or patients with bleeding history with vWD, I usually use 50 IU/kg  every 12 hours for three days and start 12 hours prior to a procedure.

William Caceres, MD
San Juan VA Medical Center
Río Piedras, Puerto Rico

Her body weight is approximately 80 kg. The recommended dose of Humate-P is 40 units per kg of body weight. The dose should be 3,200 units. As a personal observation, the desired effects of Humate-P can be achieved if the infusion begins earlier. I would recommend giving the first dose the night before the day of delivery. Continue giving it every 12 hours for three to five days.

Ahmed Hamandi, MD
Child Welfare Hospital
Baghdad, Iraq

I think the ideal dose of Humate-P for the weight of the patient is 3,000 units in a single dose with subsequent monitoring of vWF activity, maintaining an activity of 100 percent. The amount of factor is increased physiologically throughout pregnancy, especially during the third trimester. Maintain levels increased above 100 percent even during the first week postpartum.

Jesús Alcaraz Rubio Sr., MD
Hospital Quirónsalud Murcia
Murcia, Spain