Pregnant women expecting a baby with hemophilia now have a stronger case for choosing a scheduled cesarean delivery rather than a vaginal birth.
A December 2009 article in the journal Haemophilia recommends cesarean section as the optimal mode of delivery for hemophilia carriers expecting a baby with hemophilia. The recommendation is based on new data from the US Centers for Disease Control and Prevention (CDC).
Physicians have long understood that although the vast majority of infants with hemophilia can be safely delivered vaginally, the outcome of natural labor is unpredictable. Abnormal labor that progresses to operative vaginal delivery or emergency cesarean can lead to higher rates of intracranial hemorrhages, or brain bleeds, which can be serious or even fatal to an infant with hemophilia.
The Haemophilia article was co-authored by W. Keith Hoots, MD, director of the Division of Blood Diseases and Resources at the National Heart, Lung, and Blood Institute, and Andra H. James, MD, director of the Women’s Hemostasis and Thrombosis Clinic and associate professor of obstetrics-gynecology, Division of Maternal-Fetal Medicine, at Duke University Medical Center. “Cesarean delivery reduces the risk of intracranial hemorrhage by an estimated 85 percent, and the risk can be nearly eliminated by performing elective cesarean delivery before labor begins,” the article states.
Further, the authors note, vaginal delivery is not necessarily safer for the mother who is a hemophilia carrier or has a bleeding disorder. Overall, maternal morbidity and mortality rates from planned vaginal delivery are about the same as for planned cesarean delivery. The National Hemophilia Foundation’s (NHF’s) Medical and Scientific Advisory Council (MASAC) concurs: “Obstetricians caring for women who are carriers of hemophilia should discuss with the woman the maternal and fetal risks of a vaginal delivery vs. a planned cesarean delivery; the option of a planned cesarean delivery should be recommended when an affected or potentially affected infant is anticipated.” (See “Learn More.”)
These findings are not new. However, the latest recommendations are based on newer CDC data from a larger and more complete sample of infants with hemophilia. “Since those numbers came out, even more data have been accumulated that continue to confirm the higher incidence of intracranial hemorrhage with vaginal delivery,” adds James, a MASAC member.
Still, this advice is not necessarily reflected in practice, James adds. “Ob/gyns may encounter only one pregnant hemophilia carrier in their practices over a lifetime, if that,” James says. “Typically they will look to a hematologist, who will consult the literature, much of it from Europe and containing statements that vaginal delivery is safe.”
However, the practice in Europe is changing. “At the Royal Free Hospital in London, cesarean delivery for carriers anticipating an affected infant is up to 50% now, from 20% 20 years ago,” says James.
In the Haemophilia article, Hoots and James concluded, “Therefore, after a discussion of the maternal and fetal risks with planned vaginal delivery versus planned cesarean delivery, hemophilia carriers should be offered the option of an elective cesarean delivery.”