Pregnancy

Bleeding disorders, pregnancy and birth

Bleeding disorders are surprisingly common, although many women are not aware of the signs and symptoms. However, it is vitally important that we do know, because there may be a risk of prolonged bleeding during childbirth, surgery or dentistry for women living with undiagnosed bleeding disorders. 

Most bleeding disorders are inherited, meaning that they are caused by a gene alteration that is passed down through the generations.  New cases can however arise with no previous family history, either because the gene alteration has occurred spontaneously, or because previous generations have never been diagnosed.


All about bleeding

Blood is continuously flowing through the body’s system of blood vessels: the veins, arteries and capillaries. Bleeding occurs when one of these blood vessels is damaged, and blood flows out. At this point, the body’s clotting system gets to work to stop the bleeding. Special blood proteins called clotting factors work with platelets to form a clot that covers the area where the blood vessel is damaged so that bleeding stops and the vessel can recover. When someone has a bleeding disorder, it means that there is a problem with body’s clotting system, so that blood takes longer to clot, bleeding takes longer to stop and they will bleed for longer than normal.


Von Willebrand’s disease

This is the most common bleeding disorder, and affects men and women in equal numbers. Von Willebrand’s may not be very well-known, but it is surprisingly common, and the milder forms are thought to affect over 1% of the population. Von Willebrand factor is one of the proteins for blood clotting, and helps blood platelets to stick together to form a clot. When someone has von Willebrand’s disease, they will either have lower levels of von Willebrand factor, or factor that does not work properly. 

Although von Willebrand’s disease is fairly common, many people are still undiagnosed, mainly because they do not realise that their symptoms may be a sign that something is wrong.  Anyone with an untreated bleeding disorder can be at risk of bleeding after surgery or dental treatment, and any woman who is pregnant is at risk of complications, including severe bleeding during and after childbirth. Effective treatments are available, and although there is no cure, the condition can be well managed. 

The signs of a bleeding disorder:
  • Heavy menstrual flow
  • Previous postpartum haemorrhage
  • Previous bleeding problems following surgery or dentistry
  • Easy bruising
  • Frequent nosebleeds
  • Prolonged bleeding from minor injuries

What to do next
If you have one or more of the common symptoms, the first step is to see your GP, who can arrange an outpatient referral to a haematologist for testing. Proper diagnosis is essential, even in the mildest of cases, because of the risk of bleeding. Bleeding disorders are diagnosed with specialist blood tests, and this is the reason that a referral is recommended. 

When a bleeding disorder is diagnosed, effective treatments to control bleeding symptoms are available. If you have, or think you may have a bleeding disorder, tell your midwife at your first ante-natal appointment. Pregnancies will usually be classed as high-risk, but it can still be possible to have a natural delivery, with care managed jointly by teams from obstetrics and haematology. Levels of blood clotting factors including von Willebrand factor can rise during pregnancy and then fall immediately after the baby is delivered, increasing the risk of post-partum haemorrhage. Expert care is essential to ensure that the right treatment is given to manage the risk of life-threatening complications. An epidural may not be an option because of the risk of bleeding in the spine, so discuss this with your midwife and haematology nurse so that you can plan your delivery well in advance.

Finally, it is essential that a mother with a bleeding disorder does not have an assisted delivery using forceps or a ventouse. Most bleeding disorders are inherited, so there is a chance that the baby may also be affected, and could be at risk of bleeding in the head if instruments are used. Talk to your midwife or haemologist about genetic counselling, as there is a great deal of information and support available throughout conception, pregnancy and beyond. 




 
by Helena, mum to Amalia and Luca


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