von Willebrand factor (VWF) multimers in plasma and very low factor VIII ..... Pregnancy in women with von Willebrand's disease or factor XI deficiency. Br J.
Journal of Thrombosis and Haemostasis, 4: 357–360
ORIGINAL ARTICLE
Factor VIII and von Willebrand factor changes after desmopressin and during pregnancy in type 2M von Willebrand disease Vicenza: a prospective study comparing patients with single (R1205H) and double (R1205H-M740I) defect G. CASTAMAN,* A. B. FEDERICI, M. BERNARDI,* B. MORONI, K. BERTONCELLO* and F. R O D E G H I E R O * *Department of Hematology and Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza; and Department of Internal Medicine and Dermatology, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Mangiagalli, Regina Elena and University of Milan, Foundation IRCCS Policlinico Maggiore Hospital, Milan, Italy
To cite this article: Castaman G, Federici AB, Bernardi M, Moroni B, Bertoncello K, Rodeghiero F. Factor VIII and von Willebrand factor changes after desmopressin and during pregnancy in type 2M von Willebrand disease Vicenza: a prospective study comparing patients with single (R1205H) and double (R1205H-M740I) defect. J Thromb Haemost 2006; 4: 357–60.
Summary. Background: Type 2M von Willebrand disease (VWD) Vicenza is characterized by the presence of ultra-large von Willebrand factor (VWF) multimers in plasma and very low factor VIII (FVIII)/VWF measurements. So far, R1205H mutation, alone or associated with M740I defect, has been constantly detected in these patients. No data on FVIII/VWF changes after desmopressin and during pregnancy in patients with phenotypic VWD Vicenza has been reported. Objective: To evaluate biological responsiveness to desmopressin, the FVIII/ VWF changes during pregnancy and the clinical outcome in pregnancies and deliveries of six primipara with type 2M VWD Vicenza prospectively followed. Patients and methods: Three women with single (R1205H) and three with double (R1205H and M740I) mutation in the VWF gene were enrolled in the study. Prior to pregnancy, all patients had undergone desmopressin test-infusion to assess biological responsiveness and its possible clinical usefulness. Results: The results of test-infusion with desmopressin showed the full normalization of FVIII/ VWF measurements, with rapid clearance of all moieties postinfusion. However, FVIII/VWF measurements in patients with double defect remained greater after 4 h than those of patients with single defect. The severely reduced basal FVIII/ VWF measurements did not change during pregnancy, although somewhat higher VWF levels were observed in patients with double defect. Five out of six women underwent successful delivery under desmopressin prophylaxis, without immediate or delayed bleeding and only one was given a Correspondence: G. Castaman, Department of Hematology, San Bortolo Hospital, I-36100 Vicenza, Italy. Tel.: +39 444 753679; fax: +39 444 753922; e-mail: castaman@ hemato.ven.it Received 30 June 2005, accepted 1 October 2005 2006 International Society on Thrombosis and Haemostasis
FVIII/VWF concentrate because of a cesarean section. Conclusions: Delivery in women with VWD type 2M Vicenza is safely managed by using desmopressin, despite the fact that basal low FVIII/VWF is not significantly increased during the pregnancy. Keywords: desmopressin, inherited bleeding disorders, pregnancy, von Willebrand disease. Introduction Pregnancy and delivery represent an important hemostatic challenge for women with von Willebrand disease (VWD) [1]. Factor VIII (FVIII) and von Willebrand factor (VWF) deficiencies in the majority of type 1 VWD patients are usually corrected by the end of pregnancy and treatment is rarely required to manage delivery [2]. Usually, patients with dysfunctional (type 2) or severe (type 3) VWD require replacement treatment to avoid immediate or delayed bleeding, even though FVIII procoagulant activity (FVIII:C) is corrected by the end of pregnancy in type 2 [3,4]. However, information on the possible correlation of specific mutations with laboratory changes during pregnancy is still meagre. We have recently reported a favorable clinical outcome at delivery using desmopressin in some women with type 1 VWD associated with C1130F mutation [5], despite the lack of FVIII/VWF increase during pregnancy. On the contrary, patients with type 2N VWD R854Q show good correction of FVIII:C deficiency during pregnancy and no treatment is usually required at delivery [6]. Type 2M VWD Vicenza is a peculiar VWD variant characterized by very low FVIII/VWF measurements, normal to slightly prolonged BT, normal VWF platelet content and the presence of supranormal multimers in plasma [7]. The disease appears to be mostly associated with R1205H VWF mutation
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Patients and methods Six primipara women belonging to six different families with VWD Vicenza, previously diagnosed and regularly followed up at the Hemophilia Thrombosis Centers of Vicenza and Milan, were included in this study. Three carried the single (R1205H) and three the double (R1205H and M740I) VWF mutation. Over a period of 5 years, the six women have been prospectively followed during pregnancy, with FVIII/VWF measurements serially assessed. A test-infusion with desmopressin was also previously carried out in the patients and the biological response was evaluated by testing the bleeding time (BT) and FVIII/VWF measurements according to a protocol previously reported [10]. FVIII:C, VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), multimeric pattern of VWF and platelet VWF content were assessed as previously described [10–12]. As the VWF:RCo levels were very low, at the limit of sensitivity of the aggregometric assay, VWF:RCo data were also confirmed by the new sensitive ELISA test [13]. Bleeding time was measured with the Simplate II device (General Diagnostics, Morris Plains, NJ, USA). Results Phenotypic results
The baseline characteristics of the six patients enrolled in the prospective trial are summarized in Table 1. There were no differences as to FVIII/VWF basal measurements and BT between the two groups of women. Normal VWF content was present in platelets (data not shown).
Table 1 Main baseline laboratory data for the six women Bleeding FVIII:C VWF:Ag VWF:RCo time (BT) Case (IU dL)1) (IU dL)1) (IU dL)1) (min, range) Mutation 1 2 3 4 5 6
14 11 13 9 12 10
6 6 7 8 7 6
4 3 4 5 4 5
6–9 7–10.5 8 5–11 6.5 5.5–9
R1205H R1205H R1205H R1205H-M740I R1205H-M740I R1205H-M740I
For FVIII:C, VWF:Ag and VWF:RCo the values represent the median of at least five separate determinations; the lower limit of normal range for BT is 7.5 min.
VWF:RCO
160
VWF:AG
FVIII:C
120
IU dL–1
[8]. However, patients coming from Vicenza area, including those belonging to the originally reported families, share a second nucleotide change (G2470A), leading to aminoacid change M740I, on the same allele carrying R1205H mutation [9]. Thus far, it is still not clear whether these patients behave differently with regard to desmopressin responsiveness. Furthermore, no data have been reported as far as FVIII and VWF changes during pregnancy are specifically concerned. We report here on FVIII/VWF changes after desmopressin and during pregnancy along with clinical outcome in a series of women with type 2M VWD Vicenza associated with both single (R1205H) and double (R1205H and M740I) VWF mutations [8,9].
80
40
0
0
1
2
4 0
1 2 Time (h)
4 0
1
2
4
Fig. 1. Factor VIII/VWF measurements before and after desmopressin infusion (0.3 lg kg)1 bw) in women with VWD type 2M and R1205H mutation (closed circles) compared with women with R1205H-M740I mutations (open circles).
variation in individual response was observed in these relatively few cases. Influence of pregnancy on FVIII/VWF measurements and multimeric pattern
Factor VIII/VWF measurements during pregnancy until delivery are reported in Fig. 2. FVIII:C always remained below 25 IU dL)1 and VWF below 20 IU dL)1 even at the end of pregnancy. However, a relatively milder phenotype was observed in women with double mutations, minimal variations being present at various time points. No significant changes of the ultra-large VWF multimers were observed in both groups, as tested at 12, 24 and 36 weeks of pregnancy (Fig. 3). Delivery outcome
Desmopressin test-infusion
The results of the FVIII/VWF levels before and 1, 2, 4 h after desmopressin are shown in Fig. 1. FVIII/VWF measurements increased very efficiently after 1 h and remained relatively high also 2 h later with values higher than baseline up to 4 h in all cases. However, women with double mutation seemed to show a more prolonged increase of the measurements in comparison to those with single R1205H mutation, even though large
Five women were given desmopressin immediately after the vaginal delivery and umbilical cord section. Midline episiotomy was carried out in one instance, without complications and wound healing was normal. A second infusion of desmopressin was administered 24 h later. No excessive bleeding was observed and the measured blood losses were approximately £300 mL. The patients were discharged from hospital on the postpartum day 5. No excessive bleeding was observed in the late puerperium 2006 International Society on Thrombosis and Haemostasis
Desmopressin and pregnancy in type 2M VWD Vicenza 359 Pregnancies in 2M Vicenza VWF:RCo
160
VWF:Ag
FVIII:C
IU dL–1
120 80 40 0 0
12
24
36 0
12
24
36 0
12
24
36
Time (weeks)
Fig. 2. Factor VIII/VWF changes during 12, 24 and 36 weeks of pregnancy in three women carrying heterozygous R1205H (closed circles) and R1205H-M740I mutations (open circles).
ulVWF
NP
NP 12 24 36 DDAVP R1205H
NP
12 24 36 R1205H-M740I
NP
Fig. 3. Multimeric analysis of plasma VWF obtained in SDS–agarose (0.9% low gelling temperature) gel electrophoresis in representative patients with single (R1205H) and double (R1205H-M740I) mutations as tested at 12, 24, and 36 weeks of pregnancy. As comparison, plasma multimeric pattern from a normal individual before and after DDAVP is also shown in lanes 1 and 2 from the left to right: two additional normal plasmas are reported in lanes 6 and 10. Note that the patients shows ultralarge VWF multimers throughout the entire pregnancy similar to those observed after DDAVP (parenthesis).
and no further treatment had to be administered. The sixth woman underwent cesarean section under coverage with Hemate-P without mishap. A daily dose of 40 IU kg)1 of FVIII was given before surgery and on postsurgical days 1 and 2; then Hemate-P was given every other day until discharge. Discussion In this study, six pregnancies in six primipara women with VWD 2M Vicenza have been prospectively followed. All the women had median FVIII:C basal levels ranging from 9 to 14 IU dL)1 and VWF:Ag and VWF:RCo below 10 IU dL)1 (Table 1). Thus, the baseline laboratory phenotype in our women is somewhat severer in comparison with that commonly reported in mild type 1 VWD. In the latter case, normalization of FVIII/VWF levels at the end of pregnancy is usually observed and prophylactic treatment is seldom required [1,2]. All our patients had significant, albeit short-lived, increase of their measurements after desmopressin, in keeping with the 2006 International Society on Thrombosis and Haemostasis
data previously reported [7,14]. However, patients with double mutation have on the average higher levels after 4 h, but individual variation was wide. Notwithstanding this apparent discrepancy, desmopressin had been similarly successful in the past for the treatment or prevention of bleeding episodes. This useful response to desmopressin and the normal VWF:RCo/ Ag ratio observed after infusion has been suggested as possible criteria to consider type 2M Vicenza as a true type 1 [15]. However, these criteria have never been considered previously as a tool to assign patients with VWD to a subtype and the current, officially recognized classification includes VWD Vicenza among type 2M cases [16]. No significant changes of FVIII/VWF levels were observed during pregnancy, even though a somewhat milder phenotype, especially as to FVIII:C levels, was evident throughout pregnancy in women with double defect. R1205H mutation is located in the D3 domain of VWF [8]. As previously observed in patients with C1130F mutation [17] similarly located in the D3 domain, it appears that patients with mutations in this domain have marked, albeit short-lived, increase of FVIII/VWF measurements after desmopressin. The short half-lives of some VWF mutants within this domain (including R1205H) have been recently evaluated also in animal models [18]. The M740I change is located in the propeptide region of VWF, but so far no data obtained by expression experiments are available to speculate about its possible pathophysiological role. In clinical practice, the decision for using prophylaxis with desmopressin (or VWF concentrates) in women with VWD without a definite VWF gene defect relies on FVIII/VWF monitoring during pregnancy. Our data demonstrate that no significant FVIII/VWF changes occur in women with R1205H and C1130F mutation. In VWD patients with these VWF defects, prophylaxis with desmopressin should be planned in advance because this drug was proven to be successful in raising FVIII/VWF and in preventing bleeding in all such patients, as usually observed in patients with normal VWF platelet content [11]. Interestingly, despite the fact that FVIII/VWF did not correct at the end of pregnancy, no late bleeding was observed, as reported in other cases of type 1 VWD with similar behavior during pregnancy [3]. Even though the precise pathophysiological mechanism underlying VWD Vicenza remains to be identified [15], it appears that possible impairment of endothelial constitutive release pathway, previously hypothesized as responsible for the peculiar laboratory phenotype [8], is not modified by pregnancy. Whatever the explanation, shortened VWF survival remains unaffected during pregnancy [14]. In conclusion, we show that FVIII/VWF levels do not correct during pregnancy in women with type 2M Vicenza VWD either because of single (R1205H) or double (R1205 and M740I) mutation. These relatively low FVIII/VWF levels, which remain similar to baseline also during the third trimester of pregnancy, are not accompanied with any increased risk of bleeding. Finally, despite these relatively low levels during pregnancy, desmopressin is effective and safe in preventing major bleeding during delivery in most of these patients.
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