von Willebrand’s Disease The Diagnosis of von Willebrand’s Disease Among Iranian Women with Gynaecological Bleeding Baghaipour Mohammad Reza, MD, Pediatrician, Hemophilia Fellow

history The patient who led to the discovery of a hereditary bleeding disorder that we now call VWD was a 5-year-old girl who lived on the Åland Islands and was brought to Deaconess Hospital in Helsinki, Finland, in 1924 to be seen by Dr. Erik von Willebrand.

Dr Erik von Willebrand history 1870-1949 The patient who led to the discovery of a hereditary bleeding disorder that we now call VWD was a 5-year-old girl who lived on the fogolo Åland Islands and was brought to Deaconess Hospital in Helsinki, Finland, in 1924 to be seen by Dr. Erik von Willebrand. 1870-1949

history

history He ultimately assessed 66 members of her family and reported in 1926 that this was a previously undescribed bleeding disorder that differed from hemophilia and exhibited

Bleeding from mucosal tissues Significant bleeding in women history Bleeding from mucosal tissues Significant bleeding in women Prolonged BT No X linked inheritance

history 1926 1928 1951 1964 1971 1973 1977 First description by Erik von Willebrand 5 patients described in Boston by Minot Cross transfusion by HA plasma in vWD Pool’s cryoprecipitate in vWD Immunologic difference of HA and vWD Synthesis of vWF by cultured EC First report on the use of DDAVP in vWD

history Introduction of Haemate P in the market 1981 1982 1984 1985 1992 1994 2002 2007 Introduction of Haemate P in the market Epidemiology of vWD in general population 1st classification based on multimer Discovery of vWF gene by four laboratories First PK trials with FVIII/vWF concentrates 2nd Classification based on pathogenesis National guidelines for vWD management Molecular & clinical markers of vWD type 1

Genetics vWF gene is located near the tip of the short arm of chromosome 12, at 12p13.3 approximately 178 kb of DNA and contains 52 exons. Mutations causing vWD have been identified throughout the vWF gene ( >500 mutations) good correlation between the location of mutations in the vWF gene and the subtype of vWD 186 for fviii

Genetics ↑ Adams13 The von Willebrand factor (vWF) protein sequence (amino acid 1–2813) is aligned with the cDNA sequence (nucleic acid 1–8439). The vWF signal peptide is the first 22 aa, the propeptide (vWFpp) aa 23–763, and mature vWF aa 764–2800. Type 2 mutations are primarily located in specific domains (regions) along the vWF protein. Types 2A, 2B, and 2M vWF mutations are primarily located within exon 28 that encodes for the A1 and A2 domains of vWF. The two different types of 2A are those that have increased proteolysis (2A2) and those with abnormal multimer synthesis (2A1). Type 2N mutations are located within the D’ and D3 domains. Ligands that bind to certain vWF domains are identified, including FVIII, heparin, GPIb (platelet glycoprotein Ib complex), collagen, and GPIIb/IIIa (platelet glycoprotein IIb/IIIa complex that binds to the RGD [arginine-glycine-aspartate] amino acid sequence in vWF).

Genetics

Genetics Type Inheritance 1 Autosomal Dominant 2A Autosomal Dominant (recessive) 2B Autosomal Dominant 2M Autosomal Dominant (recessive) 2N Autosomal Recessive 3 Autosomal Recessive

vWF Molecule Vascular endothelium Endoplasmic Reticulum Dimerization Stored in secretory granules (Weibel-Palade bodies) Released by stress or DDAVP Bone marrow megakaryocyte Stored in alpha-granules Released by platelet activation. DDAVP does not release platelet vWF Endoplasmic Reticulum Dimerization Golgi Apparatus Multimerization

vWF Molecule Endoplasmic reticulom

vWF Molecule Plasma vWF has a half-life of approximately 12 hours (range 9–15 hours). vWF is present as very large multimers that are subjected to physiologic degradation by ADAMTS13 ADAMTS13 TTP ADAMTS13 Type 2A

vWF blood level vWF Molecule Blood type O (25%) Hypothyroidism Valproate Old age African-American black Exercises, Surgery, Trauma Pregnancy Hyperthyroidism Renal failure Diabetes Liver disease Atherosclerosis Inflammatory state and cancer

Function Hemostasis (1) Vascular factors (2) Platelet factors vWF Molecule Function Hemostasis (1) Vascular factors (2) Platelet factors (3) Plasma factors

Function Hemostasis (1) Vasoconstriction (2) Platelet plug formation vWF Molecule Function Hemostasis (1) Vasoconstriction (2) Platelet plug formation (3) Coagulation

vWF Molecule Function

Function vWF Molecule A3 Collagen A1 Gp I b C1 Gp II b III a A2 ADAMS 13 Fibrinogen Gp II b

Function vWF Molecule Platelet to exposed sub-endothelium (collagen & GPIb ) Platelet to platelet ( GP IIb/IIIa ) Carry FVIII ( protect from proteolysis) Exposed sub- endothelium Collagen vWF GPIb GPIIb/IIIa Platelet

Classification 1984 ( Multimer Based ) Term Definition Type I All sizes multimer, decreased Quan. Type II Absent of large multimer in plasma Type II A Absent of large multimers from Plt and plasma, no DDAVP response Type II B Largest multimers present in Plt, Appear in plasma after DDAVP Type III No multimers Platelet Type - vWD Largest multimers absent from plasma

Classification 1994 , 2006 ( Pathogenesis Based ) Term Definition Type 1 ( platelet nor/ low, IA,I-1,I-3) Partial quantitative deficiency of vWF Type 2 Qualitative vWF defect Type 2A ( IIA, IB, I platelet discor, IIC,IID, IIE, IIF, IIG, IIH, II-1, IIA-1, IIA-2, IIA-3 ) Decreased vWF-dependent platelet adhesion with selective deficiency of high-molecular-weight Multimers Type 2B ( IIB, I New york, Malmo ) Increased affinity for platelet GPIb Type 2M ( IC, ID, B, Vicenza ) Decreased vWF-dependent platelet adhesion without selective deficiency of high-molecular-weight multimers Type 2N ( Normandy ) Markedly decreased binding affinity for FVIII Type 3 Virtually complete deficiency of vWF Pseudo- vWD ( not vWF defect ) Increased affinity of platelet GPIb for vWF

Type 1 Classification Level of vWF in plasma is low. vWF mediates platelet adhesion and binding FVIII normally. FVIII is normal or mildly decreased. vWF multimer gels are normal.

Classification Type 2 A Platelet adhesion is decreased because the proportion of large vWF multimers is decreased. Levels of vWF:Ag and FVIII may be normal or modestly decreased. vWF:Rco is markedly decreased.

Classification Type 2 B Mutations increase platelet–vWF binding and leads to the proteolytic degradation and depletion of large vWF multimers. Patients have thrombocytopenia that is exacerbated by surgery, pregnancy, or other stress. RIPA is increased at low concentrations of ristocetin.

Classification Type 2 M Reduced interaction of vWF with platelet GPIb or with connective tissue. Screening laboratory results are similar with type 2A vWD and the distinction between them depends on multimer gel electrophoresis.

Classification Type 2 N Impaired binding to FVIII, lowering FVIII levels. Type 2 N masquerade as an autosomal recessive H.A. The FVIII level is low but vWF:Ag and vWF:Rco are normal. Discrimination from hemophilia A needs FVIII–vWF binding assay.

Classification Type 3 Type 3 vWD is characterized by undetectable vWF protein and activity, and FVIII levels usually are very low.

1% of General population Epidemiology vWD , the most frequent inherited bleeding disorder. 1% of General population Clinically significant patients = 100-200 / milion Mild form thought to be healthy

Epidemiology vWD sub/type prevalence: Type 1 , 55- 75 % Type 3 , 5 – 20 % ( 0.5 – 6 / million ) 2A 2B 2M 2N France 30 28 8 34 Italy 17 14 66 3 Germany 74 10 13 Average

Epidemiology Non X-linked Disorder ( F ═ M ) Type 1, 60% F

Diagnosis Family History Patient medical history Physical exam Laboratory findings Genetics

Family History Diagnosis Although a positive family history of documented vWF is useful for diagnosis of vWD, such a history is frequently not present. But a family history of bleeding symptoms is not helpful. The presence of a documented bleeding disorder in a family member is extremely helpful in deciding which persons to evaluate further, whereas a family history of bleeding symptoms is less helpful.

Physical exam Diagnosis Ecchymoses, Haematomas, Petechiae Evidence of liver disease (e.g. jaundice), Splenomegaly Arthropathy Joint and skin laxity (e.g. Ehlers-Danlos syndrome), Telangiectasia (e.g. hereditary haemorrhagic telangiectasia), Signs of anemia Gynaecological examination.

Common Bleedings Diagnosis Nose 60% ( common in kids ) Gyn/Obs 60% ( 15% have vWD ) Teeth 50% Ecchymosis 50% Post surgical 25% GI Tract 15% Musculoskeletal 10% ( type 3 )

Diagnosis Mild bleeding symptoms are very common in healthy populations. Menorrhagia has good sensitivity but low specificity. Three findings that predict abnormal menstrual blood loss of >80 mL include: Clots greater than approximately 1 inch in diameter Low serum ferritin Changing a pad or tampon more than hourly. The clinical evaluation of bleeding symptoms is a challenge, because

Bleeding Score Diagnosis The bleeding symptoms are very Important. The bleeding score (BS) is a quantitative index summarizing both the number of episodes and their severity. The BS has shown good sensitivity and specificity for the diagnosis of type 1 VWD.

Bleeding Score Diagnosis Rodeghiero et al,2005 A score of >3 in a male or >5 in a female is 99% specific and 64% sensitive in identifying obligate carriers of VWD.

Diagnosis Bleeding Score Tosetto A,et al,2006

Bleeding Score Diagnosis Tosetto A,et al,2006 Positive BS (4 or more) has a sensitivity of 100% and a specificity of 87%. The positive predictive value is 0.20 and the negative predictive value is 1.

Diagnosis

Treatment DDAVP : release endogenous VWF stores through stimulation of endothelial cells Plasma-derived, viral-inactivated concentrates. Agents that promote hemostasis and wound healing but do not substantially alter the plasma concentration of VWF.

Treatment DDAVP: 0.3 µg/kg , IV, (30–50 mL of N/S) over 30 min, peak increments of FVIII and VWF 30 to 90 min post infusion. Sub cutaneous way is usually identical to IV. Nasal DDAVP ( Simate, 150 micro/g / dose ) >50 kg: 2 puffs nasal absorption is variable all patients who have VWD and are responsive to intravenous DDAVP should undergo a trial of Stimate® to measure FVIII and VWF response before using it When used for epistaxis, Stimate® ideally is delivered into the nonbleeding nostril Minerin 10 micro is not good

Treatment DDAVP: Use with caution: Under 3 years vWD type1 with low PLT vWD type 3 vWD type 2B ( some physicians recommend DDAVP) Pseudo platelet vWD Older age with atherosclerosis Uremia Major surgery ( long term prophylaxis is needed ) Several doses Brain, ocular, and coronary artery surgeries

Treatment DDAVP: Complications: Headache Flushing Tachycardia Water intoxication ( only maintenance fluid for 24h) DVT MI Release of tPA ( anti fibrinolytic agents ?)

Treatment Cryoprecipitate Each bag contains about 100 IU vWF Virally non safe Volume overload Not available always Immunological reaction Not reliable response

Replacement Therapy Treatment

Replacement Therapy Treatment

Treatment Other Therapies Fibrin sealant Antifiibrinolytic agents Aminocaproic acid (25-50 mg/kg/dose QID )and Tranexamic acid (5-10 mg/kg/dose TDS), PO or IV or topically in oral cavity. DIC and U.T bleeding are contraindications. Topical agents Topical bovine thrombin Fibrin sealant Topical collagen sponges Women Bleedings OCP, IUD, hysterectomy

Treatment Other therapies Platelet transfusion : may control bleeding that is non- or poorly responsive to replacement therapy with VWF concentrate.

Menorrhagia in women with bleeding disorders

Pictorial Blood Assessment Chart score 100 = 80ml blood

Women with inherited bleeding disorders 116 women studied at Royal Free Hospital 66 vWd 30 carriers of hemophilia 20 with factor XI deficiency

Prevalence rates of von Willebrand disease in 988 women presenting with menorrhagia 13% (5-24%)

Frequency of inherited bleeding disorders in women with menorrhagia 12% general gynecology referrals are for menorrhagia 150 women with PBAC score > 100 Frequency of VWD 13% compared with 0.1 to 1% in the normal population

The frequency of bleeding symptoms in the normal population compared with 264 Scandinavian patients with VWD

Predictive value of bleeding symptoms in diagnosis of type 1 VWD

RCof: Type 3 Type 2 Type 1 VWD – 0.82% (480.000 patients?) < 10% 10-30% 30-50% Type 1 Type 2 Type 3 RCof: VWD – 0.82% (480.000 patients?)

Please Reffer : Thank you for your attention! Women with menorrhagia whom surgical and Endocrinal abnormalities have been ruled out. تقاطع زرتشت – فلسطین ، مرکز جامع هموفیلی Thank you for your attention!