Background: Pregnancy and delivery are considered an important hemostatic challenge for women with von Willebrand disease (VWD). Treatment is rarely required to manage delivery in type 1 VWD patients. Usually, patients with dysfunctional (type 2) or severe (type 3) VWD require replacement treatment to avoid immediate or delayed bleeding, even though FVIII procoagulant activity (FVIII:C) is corrected by the end of pregnancy in type 2. We present the case of a primigravida with type 2M VWDin whom a combined spinal epidural was safely performed.
Case Report: A 29 year old pregnant patient, ASA II, with VWD familiar history, was referred to immunohemotherapy at 14 weeks of pregnancy. Her laboratory results were as follows: VWF functional (VWFf) 11%, FVIII 51% and VWF antigen (VWF:Ag) 48%. She was diagnosed with VWD type 2M by genetic study. At 38 weeks gestation, she was admitted to our hospital ín active labor. She was managed under a multidisciplinary team which included obstetricians, immunohemotherapist, anaesthetists and neonatologists. The laboratory results on admission were: VWFf 44%, FVIII 156% and VWF:Ag 151%. The immunohemotherapist proposed administration of VWF Wilate® for bleeding prevention and confirmation of
laboratory results before performing neuroaxial anesthesia. After Wilate® administration, the results were: VWFf 67%, FVIII 165% and VWF:Ag 166%. According to the immunohemotherapist the technique could be performed safely as the risk of bleeding into the epidural space was minimal. She had a forceps delivery for fetal bradycardia without complications. The patient was discharged on the 6th day of puerperium without complications. The laboratory results stand at normal levels (VWFf>42%; FVIII>80%; VWF:Ag >42%). 
Discussion: VWD is the most common inherited bleeding disorder that may result in various bleeding complications in a parturient because of hemostatic challenges during pregnancy. There are no studies defining guidelines for the use of regional anesthesia during labor and delivery in women with VWD and there is no consensus on safe VWF and FVIII levels for placement of an epidural catheter. The current
evidence is limited to case reports of women with VWD who received epidural anesthesia without bleeding complications.
Learning points: Our case report highlights the importance of advanced planning, careful patient assessment and multidisciplinary approach for the successful regional anesthesia based on clinical experience.

09 / Von Willebrand disease in pregnancy: Is it neuraxial anesthesia safe? - A case report