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Women with Bleeding Disorders Obstetric and Gynaecological Complications

Rezan A Kadir. 21 June 2011. Brussels. Women with Bleeding Disorders Obstetric and Gynaecological Complications. Women - Haemostatic challenges. During their lifetime ~ 1000 episodes Menstrual periods – 450- 500 Ovulation- 400-450 Child birth - 1.5/woman Miscarriages – ¼ pregnancies

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Women with Bleeding Disorders Obstetric and Gynaecological Complications

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  1. Rezan A Kadir 21 June 2011 Brussels Women with Bleeding Disorders Obstetric and Gynaecological Complications

  2. Women - Haemostatic challenges During their lifetime ~ 1000 episodes • Menstrual periods – 450- 500 • Ovulation- 400-450 • Child birth - 1.5/woman • Miscarriages – ¼ pregnancies • Abortions - 1/5 woman Europe

  3. A world map showing countries by fertility rate (live children), 2005-2010 529 000 women die in relation to pregnancy each year 25% of deaths - due to haemorrhage Over 99% in resource-poor countries

  4. Post-partum haemorrhage • Primary PPH - 1st 24 hours • >500ml after NVD • >1000ml after C/S • Massive >1500 ml • Secondary PPH: 24 hr-6weeks • Excessive Lochia – aneamia Kadir 1998, Siboni 2009, Chi 2009 • Women with bleeding disorders • Massive PPH – requirement for blood transfusion • Recurrent risk for PPH • Perineal/vaginal haematoma Al-Zirqi 2008, Kominiarel 2007 Chi 2011

  5. Maternal death 4/4067 VWD - 10 times higher than other women James et al JTH 2009

  6. Risk of Miscarriage APH & Late Pregnancy Loss Siboni et al 2009 33% 21% Kadir et al 1998 • Strong association • FXIII deficiency • Fibrinogen deficiency Other Bleeding disorders Risk – Unknown

  7. Women with Bleeding Disorders Anovulatory cycles Anovulation IUCD Polyp Endometriosis Adenomyosis Ovulatory cycles OC pill Menarche Menopause Long standing menorrhagia Other associated symptoms Other gynaecological conditions Impaired QOL Adolescent menorrhagia

  8. Menorrhagia – Heavy Menstrual Loss Causes of menorrhagia • Excessive menstrual blood loss affecting quality of life: • Physical, emotional, Social • Affects ~ 880,000 women in England • 18 million women world wide • Bleeding disorders ~ 1/3 of cases – Majority undiagnosed Bleeding disorders

  9. Women with Bleeding Disorders Heavy menstrual bleeding Prolonged menstruation > 8 days 25% (control 4%) Iron deficiency anaemia 64% in women with bleeding disorders Vs 34% control Kadir et al 1999, Kouides et al 2000

  10. Inherited Bleeding Disorders - Menorrhagia Siboni et al 2009

  11. Women with Inherited Bleeding Disorders Other associated Gynaecological problems • Dysmenorrhea Affected women 51% Vs 18% control • Ovulation bleeding Mid-cycle pain (Mittlesmerz) Haemo-peritoneum Broad ligament haematoma • Midcycle bleeding Kadir 1999, Kulkarni 2011

  12. Other associated Gynaecological problems Kirtava et al 2003

  13. Inherited Bleeding Disorders – QOL in women QOL Bleeding disorders Control P value General Health (0-5) 2% poor 16% fair 0% poor 2% Fair 0.01 Physical activity 10 activities (0-2) 2(0-9) Median (range) 1(0-11) 0.07 Role Physical 35% 10% 0.004 Pain 51% 19% 0.001 Mental health & vitality 47 (27-60) 40 (15-60) 0.0001 Chi 2009

  14. Inherited Bleeding Disorders – QOL in women • QOL in VWD • Major difference between men and women (P> 0.09) • College/university education Female 5.5 % Vs Male 35% Barr et al 2003 • Increased prevalence of anxiety-depressive disorders - 28% (51/181) met criteria for anxiety disorder Roziek &Scharrer 1998 • 1/3 to 1/2 have lost time from work/school in the past year Kadir et al 1998

  15. Women and Bleeding Disorders Delay in Diagnosis • Average time from 1st symptom Dx 16 (range 10-39) years • Average bleeding symptom before Dx 6 (1-19) symptoms Kirtava et al 2004

  16. 8 yr old UK Menarche USA 35yr old UK Reprod. Age USA Bleeding history 65.3% (356) 47.2% (257) Clotting screen 30.4% 35.4% 13.0% 17.0% Test for VWD 12.1% 16.5% 2.0% 4.0% None of the above 24.8% 45.5% Women and Bleeding Disorders Delay in Diagnosis Survey of Gynaecologists (UK & USA) Chi et al 2005, Dilley et al 2002

  17. The last decade Increased research interest and increased publications Women issues – National and International societies Guidelines www.womenbleedtoo.org.uk www.haemophilia.org.uk www.hemophilia.org info@projectredflag.org barbforss@yahoo.com www.hemophilia.ca www.haemophilia.org.nz www.haemophilia.org.au www.womenshealth.about.com

  18. Women with Bleeding Disorders in HTCs: 1991-2006 Hemophilia Data Set Women advocacy programme – Increased awareness Multi-centre research – Increased knowledge Comprehensive care – Improve care and QOL

  19. Women and Bleeding Disorders • Under-diagnosed • Symptomatic - Frequent haemostatic challenges • Significant O&G complication • Early Dx and appropriate management • Improve QOL and reduce morbidity • Challenges • Increased awareness • Identification and diagnosis • Provision of comprehensive care Conclusions

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