Protocols - Hemorio

TREATMENT OF BLEEDING SITUATIONS
SITUATIONS CONDUCTION FVIII FREQUENCY DURATION
NASAL OR ORAL - Locals (topical thrombin,
- - -
MUCOSA
cauterization, solution to rinse the
BLEEDING
mouth with)
- antifibrinolytic
- DDAVP
DENTAL
- DDAVP only dose + 20 IU/Kg Only dose -
EXTRACTION antifibrinolytic (when indicated) When indicated
MENOMETRORRH - Contraceptive
20 IU/Kg Only dose -
AGIA
- Antifibrinolytic
- NOR-etisteron
10mg 2x/day during10d, after
-10mg/day for 10d
- DDAVP
PREGNANCY
- DDAVP
- - -
VWD TYPE 1 - antifibrinolytic is not indicated
(4-5d, after
childbirth, it might
have some bleeding)
- Normal birth
PREGNANCY
30 - 50 IU/kg 24/24h
Until
VWD TYPE 2
(thrombocytopenia
Normal birth
In cases of
Severe
Thrombocytopenia is
corrected and until
may occur)
Thrombocytopeni
a
scarring
PREGNANCY
VWD TYPE 3
Normal birth or Cesarean section 40 - 60 IU/Kg 24/24h During 7 days
MINOR
SURGERIES
Keep FVIII> 50U/dL until scarring 30 IU/Kg
Once a Day in
alternate days
Until scarring
MAJOR
SURGERIES
Keep FVII > 50U/dl 50 IU/Kg
Once a day 1st to 4th In alternate days
day
5th until scarring
AUXILLIARY DRUGS
Epsilon Amino Caproic Acid (EACA, 50 mg/kg/dose, 4 times a day, P.O.) and tranexamic acid (15-20
mg/kg/dose, 3 times a day, P.O.) are most frequently applied antifibrinolytics. The antifibrinolytics are very
effective to control oral mucosa bleeding, epistaxis, menorrhages and after dental extraction. They may be
used as only treatment, in minor severity bleeding in these sites, or associated to desmopressin, or factor
concentrate, for more severe bleeding in pre- or post-operatory. Although they are more commonly used
orally, antifibrinolytics can also be given through intravenous and topic routes. They are counter-indicated
in cases of hematuria and present risk to anticipate vessel-occlusion events in post-thrombotic patients.
Estrogen-progesterone associations increase FVW plasma levels, but with variable and not-predictable
response pattern, are not applied with therapy purposes, although, they are useful to reduce intensity of
menorrhages in women with VWD. Even in low doses, the combined tablets of estrogen-progesterone
decrease endometrial proliferation and may be enough to control mild bleeding. Combination with higher
doses may be used where there is no control with lower doses. Tablets can be continuously administered
during several months to reduce menstruation frequency, The use of intravenous estrogen, such
Premarin® 25 mg every 4 hours for up to 6 doses, maybe administered to stop one severe menorrhage.
Intravaginal rings or IUD with estrogen + progesterone release or progesterone release alone are welltolerated
in more mature women. Hysterectomy may be indicated for women with persistent menorrhage
and to which completed family planning.
NOTES:
A – Pregnancy and Childbirth: As of 10 th week of pregnancy, FVIII and FVW levels increase
spontaneously in VWD types 1 and 2, being able to achieve normal levels. Pregnant patients with VWD
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