Dr. McLintock presents her talk “Prevention and
Treatment of Postpartum Hemorrhage.”
As a self-proclaimed “shematologist” who loves all things “shemostasis,” I found the Education Program session “Selected Hemostasis and Thrombosis Topics in Women” (live Q&A Sunday, December 6, at 12:00 noon Pacific time) to be just my cup of tea. The same way we do not treat children as if they are just “small adults,” we also cannot care for women as if they are just “small men.” Menstruation, pregnancy, and childbirth all present their own hemostatic and thrombotic challenges that are often overlooked, underestimated, and underdiagnosed. There has been increasing attention to these unique issues in recent years, and that is truly a cause for celebration. However, significant work remains in providing women with bleeding and clotting disorders the care they deserve, and attending this session is a great first step!
In this session, Dr. Paula James, a pioneer in advocacy for the treatment of women with bleeding disorders, starts out exploring the significant barriers in the care of these women. Unfortunately, these barriers start even prior to diagnosis. Women with bleeding disorders wait up to 15 years from onset of symptoms to diagnosis. Stigmatization leads to under-recognition of gynecologic and obstetrical bleeding as abnormal, causing many women to go undiagnosed and therefore, without access to appropriate treatment. Lack of access to appropriate diagnostic testing as well as challenges in disease classification and nomenclature further complicate diagnosis. Looking forward, Dr. James also discusses the advances that have been made, including much-needed changes in nomenclature, as well as ongoing initiatives focused on improving the care of these women. With leaders like Dr. James, I’m confident we can do better!
In addition to unique bleeding considerations, women with venous thromboembolism (VTE) also present specific challenges. Dr. Bethany Samuelson Bannow discusses an often ignored, but not infrequent, complication of anticoagulation: heavy menstrual bleeding. Approximately 70 percent of women on anticoagulation report heavy menstrual bleeding, with some anticoagulants (rivaroxaban) more commonly implicated. Women with thrombosis history and significant bleeding can be particularly challenging to treat, and there are now data showing that women on rivaroxaban who develop heavy menstrual bleeding face a high risk of recurrent VTE. Dr. Bannow reviews the role of hormonal therapy (including safety data on the use of combined hormonal contraceptions in patients on treatment anticoagulation), procedural interventions, and supportive care, along with the importance of screening for and treating iron deficiency, a common complication. She discusses considerations in using antifibrinolytics, recommending avoidance in the acute VTE period. Balancing bleeding and thrombotic risk, she elaborates on anticoagulant modification as well as the utility of switching anticoagulants. (One may want to try apixaban or dabigatran!)
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, accounting for 25 percent of deaths, but this unfortunately represents just the tip of the iceberg, as it also causes 75 percent of severe maternal morbidity cases. Dr. Claire McLintock discusses this important issue, reviewing the risk factors, prevalence, and management. Importantly, most women with PPH have no identified risk factors. With increased uterine blood flow, increased cardiac output, and lack of physiologic signs up to a loss of 25 percent of blood volume, it’s no wonder PPH is so scary. Fibrinogen, which is normally elevated in pregnancy, is an important biomarker because low levels portend significant risk and replacement is critical. Dr. McLintock covers the importance of rapid identification as well as optimal treatment of these patients starting with the treatment of antenatal anemia, as a decrease of 15 percent in hematocrit can lead to 60 percent prolongation of bleed time. Later, don’t forget your four “Ts” (not to be confused with those used in heparin-induced thrombocytopenia): tone, tissues, trauma, and thrombin. She also reviews the evidence for the use of tranexamic acid (TXA). TXA decreases cases of death due to bleeding by 20 percent, or 40 percent if given within one to three hours. I’m with Dr. McLintock, TXA deserves to be the fifth T!
And for hot-off-the-presses data on peripartum use of tranexamic acid in women with bleeding disorders, check out the poster session “A Retrospective Cohort Study Evaluating the Safety and Efficacy of Peri-Partum Tranexamic Acid for Women With Inherited Bleeding Disorders,” on Saturday, December 5 (7:00 a.m. to 3:00 p.m. Pacific time). Women with bleeding and clotting disorders have been neglected for too long, and we as hematologists have the knowledge and power to change this!
Dr. Weyand indicated no relevant conflicts of interest.