Acquired factor VIII deficiency in a nulliparous patient undergoing induction of labor

Abstract

Objectives: To present a case of acquired factor VIII deficiency in the setting of labor and describe the challenges of its diagnosis and treatment.

Case presentation: A 31-year-old woman was diagnosed with acquired factor VIII deficiency while undergoing induction of labor. Her labor and post operative course were complicated by epidural hematoma formation, prolonged postoperative surgical site bleeding, and subcutaneous hematoma. Management included blood products, human Factor VII, rituximab, and a steroid taper.

Conclusions: Acquired factor VIII deficiency can be challenging to diagnose and should be considered in the differential diagnosis in patients with prolonged bleeding accompanied by a prolonged activated partial thromboplastin time (aPTT).

Keywords: acquired hemophilia A; epidural hematoma; perinatal medicine; subcutaneous hematoma.

Figure 1:

Sagittal MRI of the thoracic and lumbar spine on postoperative day 0. The image reveals a posterior epidural hematoma extending from T12/L1–L4, measuring 1.0 cm anteroposteriorly, 1.1 cm transversely, and 11.5 cm craniocaudally. Significant mass effect on the cauda equina and conus medullaris is evident.

Figure 2:

Postoperative day nine CT scan of the abdomen and pelvis following cesarean delivery. Two subcutaneous hematomas visible anterior to the lower rectus musculature at the cesarean skin incision site.

Figure 3:

Comprehensive treatment approach for acquired hemophilia A. This figure illustrates the dual strategy in managing AHA, highlighting both hemostatic treatments to address acute bleeding episodes and immunosuppressive therapies aimed at eradicating the underlying autoantibodies. (A) Treatment guidelines for hemostasis in patients with AHA as per International Guidelines (rFVIIa, recombinant activated factor VII; aPCC, activated prothrombin complex concentrate; rpFVIII, recombinant porcine factor VIII; hFVIII, human (plasma-derived or recombinant) factor VIII; h, hour; d, day). (B) Immunosuppressive recommendations for patients with AHA as per International Guidelines (FVIII, factor VIII activity; BU, Bethseda unit; CTX, cyclophosphamide).