Mild factor XI deficiency linked to higher risk for postpartum hemorrhage after cesarean delivery
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ORLANDO — Giving birth via cesarean section appeared to be associated with twice the risk for postpartum hemorrhage among women with mild factor XI deficiency compared with controls, according to results of a retrospective study presented at ASH Annual Meeting and Exposition.
Women with a bleeding history demonstrated nearly 10 times the risk for postpartum hemorrhage after cesarean delivery compared with women without a bleeding history.
Prophylactic measures should be taken before childbirth for this high-risk group of women, researchers noted.
“Factor XI is being tested for a little bit more these days because women are getting their genome tested before giving birth,” Thomas Bogue, BS, clinical research coordinator at Beth Israel Deaconess Medical Center, told Healio. “It used to be that a patient would have a bleeding event and they would look at a whole panel of things to figure out what’s wrong. Now we have genetic testing and if someone gets pinged for having the gene ... they would then get their factor level measured.”
Factor XI deficiency is a rare bleeding disorder that occurs in approximately one in 1 million people. It is more prevalent in the Ashkenazi Jewish community, 10% of which is heterozygous with mild deficiency.
Factor XI levels usually do not correlate with bleeding severity, and limited data exists on how to appropriately manage a woman with mild deficiency during childbirth. Because postpartum hemorrhage accounts for about 10% of maternal mortality, Bogue and colleagues retrospectively studied delivery outcomes among women with mild factor XI deficiency.
The matched, case-control, single-institution analyses included 40 women with mild factory XI deficiency, defined as levels between 20% and 70%, among whom 71 deliveries occurred between 2016 and 2018. Researchers compared outcomes with 200 deliveries among a control population of women, identified through successive medical record numbering, who did not have factor XI deficiency.
The investigators defined primary postpartum hemorrhage as estimated blood loss greater than 1,000 mL or blood loss accompanied by symptoms of hypovolemia within 24 hours of giving birth.
Median estimated blood loss was 300 mL among both factor XI-deficient women and controls following vaginal delivery and 800 mL in both groups following cesarean delivery. Researchers observed no postpartum hemorrhages among the 45 vaginal deliveries by women with factor XI deficiency compared with one hemorrhage among 125 births in the control group.
However, women with mild factor XI deficiency who underwent a cesarean section had more than twice the risk for postpartum hemorrhage than controls (OR = 2.73; 95% CI, 1.02-7.26).
The overall rate of postpartum hemorrhage among women with factor XI deficiency who had a cesarean section was 38.4%, compared with 18.7% for the control group (P = .04).
No women who had factor XI deficiency required a red blood cell transfusion, compared with three women in the control group.
Researchers identified prior history of hemorrhage as the best predictor of postpartum hemorrhage following cesarean section. Seven of the 10 women who experienced postpartum hemorrhage after cesarean delivery had a history of hemorrhage. Two of them received prophylactic treatment before delivery.
Significantly fewer women with factor XI deficiency who did not experience postpartum hemorrhage after cesarean delivery had a history of bleeding (n = 3 of 16; P = .015).
“I think the big takeaway from this is that there were no postpartum hemorrhages in the vaginal delivery cohort,” Bogue said. “If you are going into delivery and you know that you have factor XI deficiency, it’s probably good to mention it because it’s associated with a high risk for bleeding. But it’s not something to be too stressed out about.” – by John DeRosier
Reference:
Bogue T, et al. Abstract 629. Presented at: ASH Annual Meeting and Exposition; Dec. 7-10, 2019; Orlando.
Disclosures: Bogue reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.