Pregnant with Von Willebrand Disease – The Consult

Back in November, I had a consult with my hematologist regarding the recommendations for the remainder of my pregnancy, the birth and the postpartum. It went really well.  They reviewed my blood results which had been taken shortly after 20 weeks and everything looked great.  My iron was great.  My ferritin was great.  And even my VWF levels were great.  Essentially, pregnancy hormones have rendered me hemodynamically normal!  I knew pregnancy hormones have the tendency to raise VWF levels, but I didn’t realize the degree to which they would do so.  I was beyond pleased.

The hematologist reassured me that for the delivery I am essentially at no higher risk than the general population.  Lovely! As a result, labour and delivery should be handled as per normal, with the exception that baby should be treated as also having Von Willebrands disease. What does that mean?  It means that anything that could potentially cause a bleed in the baby should be avoided, for example instrumental deliveries, fetal scalp monitors, breech vaginal delivery, circumcision, etc.  Aside from the avoidance of a breech vaginal delivery (baby is still not eager to turn upside down!), I’m not too bothered by those other contraindications.

I am, unfortunately, at a higher risk of a delayed postpartum hemorrhage as it’s expected that my VWF levels will begin to drop once the placenta is delivered.  Fortunately, breastfeeding is thought to have a protective effect against that sudden drop in VWF levels and this baby WILL be breastfed.

During the consult, the hematologist didn’t express any concerns with me receiving prenatal care from midwives as opposed to an obstetrician.  He simply told me he would forward them a letter with his recommendations and then he sent me on my way.

That was early in November.

A few midwifery appointments went by and they still did not receive that letter though they did receive my lab work.  They tried to contact the hematology clinic on a few occasions, with little success. I wasn’t too bothered.  After all, my blood results were fabulous, the hematologist expressed very few concerns during my appointment with him, and my midwives were aware of the recommendations regarding treating baby as VWD positive.  Not to mention that simply by having midwifery care, statistics have shown that the likelihood of experiencing indications for invasive interventions like fetal scalp monitoring are significantly lower.  Essentially, everything seemed great and I was actually considering having yet another homebirth.  Who wants to be traveling in labour, in the middle of the night, in a snow storm, in February anyways?  It’s Canada, afterall… February, blizzards and birth always seem to go hand in hand.

Then the Wednesday before Christmas I received THE PHONE CALL.

It was a rather unexpected phone call from my nurse practitioner. My doctor had just received the consult letter from the hematologist and while it plainly stated that  while I am to be considered hemodynamically normal during the birth and the immediate postpartum, the recommendation was that I leave midwifery care and switch to an obstetrician.  As such, my doctor felt compelled to have my nurse practitioner call me to recommend/strongly encourage me to do the same.  Strange considering the hematologist did not once vocalize any objections to  my receiving midwifery care during the consult I had with him so many many weeks prior.  Quite frankly, the recommendation made little sense to me.  If I had type II or type III Von Willebrands and if my risk of a primary postpartum hemorrhage were elevated, then yes, high risk obstetrical care would seem like the most logical choice.  But in this specific situation, it just seems  like the recommendations given emerged from the age old doctor vs midwife conflict as opposed to the relevant clinical information at hand.  I didn’t like that…

Conveniently, I already had a midwifery appointment scheduled for the following day.  They STILL had not received the consult letter, but I did inform them about the supposed contents.  We discussed it and in the end it was decided that despite the recommendations I would remain in midwifery care.

Fast forward a week, the midwives finally received the consult letter and while they still seem fine with keeping me in their care they requested that I have an obstetrical consult with one of the local obstetricians just to keep them in the loop should I require their assistance postpartum.  I’m cool with that, in fact, I think it’s a fabulous idea.  Essentially, that’s the gold standard of obstetrical care, is it not?  Having both midwives and obstetricians work together as a team to provide optimal care…  So now I just have to wait for them to call me with an appointment time.  Oh, how I love waiting!  

Grow! Baby! Grow!

Moving on from the Von Willebrands issue….  Fetal growth is still a bit of a concern.  The 32 week growth scan showed baby to be at the 7th percentile.  Slightly better than the 6th percentile baby was at during the 30 week scan, but still under the 10th: The arbitrary line of normal vs abnormal.  While I was hoping for a nice growth spurt, consistent growth is still much preferable to no growth at all.  Everything else is seeming to be normal. I had yet another ultrasound two days ago at 34 weeks and I am once again waiting for those results.  More waiting.  It seems like that is all I am doing these days!  Unfortunately, the ultrasound technicians at my local hospital refuse to reveal any measurements to you and should they catch you trying to look at the screen during their assessment they adjust it so that you can no longer see a thing.  It’s awful.  So here’s hoping there was furthered consistent growth!

It will be interesting to see what the obstetrician will say about baby’s small measurements.  Oftentimes, they won’t intervene unless growth halts or other abnormalities present itself like abnormal doppler readings or lowered amniotic fluid volumes, but I do know of some practitioners in some areas who recommend induction at 37 weeks if EFW appears to be below the 10th percentile. I suppose the content of the next ultrasound report will likely play the biggest role in any potential game plan that unveils.  Which again… leaves me waiting… waiting… waiting… waiting…