Successful Perioperative Management of Acquired Hemophilia B in a Pregnant Patient Refusing Blood Transfusion Due to Religious Beliefs
Rogermar D Villanueva* and Ma Angelina L Mirasol
Rationale and Objectives
Acquired hemophilia B (AHB) is an ultra-rare, potentially life-threatening bleeding disorder, with pregnancy-associated cases and transfusion-free management scarcely documented worldwide.
Case Report
This report describes the perioperative management of a 33-year-old pregnant Filipino woman with AHB and concomitant iron deficiency anemia who categorically refused allogeneic blood products on religious grounds. Comprehensive work-up revealed a variably prolonged activated partial thromboplastin time, normal factor VIII and von Willebrand factor levels, and a high-titer factor IX inhibitor (10 Bethesda units), confirming acquired hemophilia B. Preoperative optimization followed patient blood management principles, including intravenous iron, subcutaneous erythropoietin, cessation of aspirin and low molecular weight heparin at appropriate gestational intervals, and formulation of a bloodless cesarean section plan with multidisciplinary input from hematology, obstetrics, anesthesia, allergy-immunology, neurology, and psychiatry. At term, the patient underwent urgent repeat cesarean section with bilateral tubal ligation under spinal anesthesia, using tranexamic acid, meticulous surgical technique, and vigilant hemodynamic monitoring; estimated blood loss was 400 mL, and no blood products, factor concentrates, or bypassing agents were administered. The postoperative course was uneventful, with stable hemoglobin, absence of hemorrhagic or thrombotic complications, and healthy maternal and neonatal discharge.
Discussion and Summary
This case demonstrates that, even in a resource-limited setting, pregnancy-complicated AHB can be managed safely without transfusion through early recognition, structured multidisciplinary planning, and rigorous application of blood conservation strategies, and it adds novel data to the sparse global literature on bloodless management of acquired hemophilia B in pregnancy.
