Von Willebrand Disease and Pregnancy: A Review of Evidence and Expert Opinion.

von Willebrand disease (VWD) is a common, inherited bleeding disorder. There are three main types of VWD, which result in a quantitative or qualitative deficiency in von Willebrand factor (VWF) and in severe cases, also Factor VIII (FVIII). The severity of bleeding depends on the underlying pathophysiology. Type 1 VWD is usually mild, while types 2 or 3 VWD can be associated with moderate or significant bleeding. Managing pregnant women with VWD requires a multidisciplinary approach. Such patients are at increased risk of postpartum hemorrhage. Whether women with VWD are at increased risk of spontaneous abortion remains unclear. Because of increased risk of bleeding, there are special considerations for delivery and obstetrical analgesia. There is a lack of high-quality evidence supporting monitoring and treatment of VWD in pregnancy. Most experts recommend that FVIII and VWF levels be monitored prior to delivery and treatment initiated when levels remain below 0.50 IU/mL. Some experts consider desmopressin (DDAVP) to be the preferred initial treatment in type 1 and most type 2 VWD. DDAVP is relatively contraindicated in type 2B disease. Plasma-derived FVIII and VWF replacements are the treatment of choice in type 2B and 3 VWD and in type 1 or 2 VWD when patients do not respond to DDAVP.