What are the risks of a Dilation and Curettage (D&C) procedure in a pregnant patient with unrecognized type 2B von Willebrand's disease?

Risks of D&C in Pregnant Patients with Unrecognized Type 2B von Willebrand Disease

A D&C procedure in a pregnant patient with unrecognized type 2B von Willebrand disease carries significant hemorrhage risk and requires prophylactic hemostatic management with VWF/FVIII concentrate and possibly platelet transfusions to prevent life-threatening bleeding.

Understanding the Specific Risks

Type 2B von Willebrand disease (VWD) presents unique challenges during pregnancy and invasive procedures due to:

• Enhanced binding of abnormal VWF to platelets, causing platelet aggregation and thrombocytopenia
• Paradoxical worsening of thrombocytopenia during pregnancy as VWF levels rise
• Deficiency of high molecular weight VWF multimers
• Unpredictable bleeding risk that may not correlate with laboratory values

Risk Assessment for D&C

The risk is particularly high because:

1. Unrecognized status: Without prior diagnosis, no prophylactic measures would be in place
2. Pregnancy-related changes: VWF levels typically increase during pregnancy, but in type 2B VWD this can worsen thrombocytopenia 1
3. Procedure-related bleeding: D&C is considered a procedure with moderate bleeding risk
4. Postpartum risk: Risk of delayed hemorrhage extends into the postpartum period

Management Recommendations

Pre-procedure (if diagnosis is made)

1. Laboratory assessment:

   • Measure VWF antigen, VWF activity, FVIII levels, and platelet count
   • Assess fibrinogen levels (target >150 mg/dL)

2. Hemostatic prophylaxis 2, 3:

   • Primary approach: VWF/FVIII concentrate to achieve VWF activity >50 IU/dL
   • Avoid desmopressin (DDAVP) as it is contraindicated in type 2B VWD due to risk of worsening thrombocytopenia 4, 5
   • Consider platelet transfusion if platelet count <50 × 10⁹/L 2
   • Add tranexamic acid (TXA) as adjunctive therapy 2, 3

During procedure

1. Maintain VWF levels >50 IU/dL throughout the procedure 2
2. Have platelets available for transfusion if needed
3. Monitor for excessive bleeding

Post-procedure

1. Continue VWF/FVIII concentrate for at least 3-5 days post-procedure
2. Maintain tranexamic acid for 7-14 days 3
3. Monitor for delayed bleeding for up to 2-3 weeks

Emergency Management if Diagnosis is Made During Bleeding

If type 2B VWD is diagnosed during a bleeding episode:

1. Immediate VWF/FVIII concentrate administration
2. Platelet transfusion if count <50 × 10⁹/L or ongoing bleeding despite VWF replacement
3. Tranexamic acid administration
4. Consider fibrinogen replacement if levels drop below 150 mg/dL 2

Special Considerations

• Regional anesthesia: If neuraxial anesthesia is considered, VWF activity should be ≥50 IU/dL and platelet count ≥70 × 10⁹/L 2
• Fetal risk: If the fetus inherits type 2B VWD, there is risk of neonatal bleeding complications 6
• Monitoring schedule: Close monitoring of VWF levels and platelet counts is required as rapid changes can occur during pregnancy 7

Common Pitfalls

• Misdiagnosis: Type 2B VWD may be misdiagnosed as immune thrombocytopenia, especially during pregnancy
• Inappropriate use of DDAVP: Can worsen thrombocytopenia in type 2B VWD 5
• Inadequate duration of treatment: Bleeding risk extends beyond the immediate post-procedure period
• Failure to monitor platelets: Thrombocytopenia may worsen rapidly during pregnancy in type 2B VWD
• Underestimating bleeding risk: The bleeding tendency may be more severe than laboratory values suggest

Without proper management, a D&C in an unrecognized type 2B VWD patient carries substantial risk of major hemorrhage that could lead to significant morbidity or mortality. Early recognition, multidisciplinary consultation, and appropriate hemostatic management are essential for safe outcomes.