Von Willebrand's Factor. How To Understand What It Is, and What To Do About It.

Greta.
Looking a bit perplexed.

Greta is a six month old blue Doberman puppy. She was purchased by an older couple who wanted a doberman. Seems simple enough? BUT, there are so many things pet parents need to know before you go jumping into a life long relationship. 

Here's what her parents didn't know;

1. Dobermans are most common breed at risk for the most common inherited bleeding disorder in dogs, Von Willebrand's disease. They had never heard of this disease.

2. Greta has no paperwork. Therefore, we have no idea what her parents Von Willebrands status was? Were they ever tested? What were their results? Have any of Greta's siblings been tested, or had a bleeding disorder? History is such an important and over looked part of every case.

3. Without knowing the answers to number 2 her vet opted to address her spay as cautious as possible. So, Dr. Morgan called the referral hospital to inquire about having Greta spayed there? They quoted over $1,000 to do it. (At our clinic it is about $250). Big difference! Yes, her parents thought so too, and decided to forego the referral.

With a limited budget, a scant history, and her parents desire to have her spayed Dr. Morgan did her due diligence to fill in some of the blanks and help her parents make a safe, educated decision about how to proceed with Greta's elective surgery.

What an adorable face.

Here's what Dr. Morgan did:

1. Performed a through physical examination.

2. Based on Greta's dilute color, (she is what we call 'blue' an the perceived and tested links between autosomal recessive traits and incidence of disease) she performed a Von Willebrand's assay the week before her spay was scheduled.

3. Called for a consult about how to prepare for her surgery.

4. Gave Greta's parents lots of options and then helped them decide which were best for them.

Von Willebrand's disease is inherited. Dogs affected get it from their parents. Both males and females can have the disease or pass it along to offspring. The disorder occurs because of a deficiency or disorder of von Willebrand factor (vWF). Von Willebrand's factor is a plasma protein essential for the platelets in the blood to allow a clot to form and stop bleeding. If you have a breed commonly affected, like the Doberman pinscher, Scottish terrier, Shetland sheepdog, golden retriever, Pembroke Welsh Corgi, or standard poodle it is wise to suspect vWF if they ever have abnormal bleeding events. This can include nail trims, trauma, or problems with surgeries.

Greta's Von Willebrand's assay results were 22 (low).

• The normal values for canines are 70-180% (weird I know you can get a better score than 100%, but yes, you can). 
• 50-69% is considered "borderline normal" (reassuring isn't it? How do you interpret that when the lab notes it as " indeterminate range"
• <50 % abnormal carrier for vWF:AG

To make the testing more confusing, many experts will add that many dogs in the <20% range never show any signs of bleeding abnormalities. They also will tell you that the level of the vWF does not always correspond to the likelihood that they will bleed. OK, a little reassuring if you have a dog with say <20 %, but isn't the opposite true? Yes, you can have a dog previously tested and found to be "normal" who bleeds uncontrollably and life-threateningly. Terrific!

Good Girl!

DDAVP  (desmopressin) can be used pre-operatively (before surgery, just in case you do have a bleeding problem, you need to have this in the patient BEFORE surgery) as a prophylaxis. BUT it is not effective for severe Type 2 or 3 Von Willebrand dogs. (YIKES!! so confusing!) BUT, desmopressin is not commonly used in veterinary general practice clinics and it is very expensive. SO, when you mention it to a client, that MIGHT, or MIGHT NOT need it, OR MIGHT OR MIGHT NOT even benefit from it, it is a tough call. SO, there you are back at square one. Not really knowing what to advise OR what to do.

For Greta's spay her family opted to have her spayed with Dr. Morgan. Dr Morgan placed an i.v. catheter, paid very close attention to minimizing tissue trauma and maintained a high degree of surgical precision to minimize bleeding. IF the patients don't bleed significantly they don't need as many clotting factors. There are many cases of vWF pets doing very well under the most traumatic accidents and surgeries. For vWF pets they should have a physical exam, buccal mucosal bleeding time (BMBT), and careful precision in surgery. If the BMBT is abnormal they should be pre-treated with DDAVP and have fresh frozen plasma standing by should bleeding become a concern.

 

Thankfully, Greta had no surgical concerns or complications. But her family knows that any future surgeries need to be met with care and concern and any traumatic events monitored very closely.

I spoke to Dr. Morgan about Greta's case and we corroborated each others previous experiences with having doberman's with this disease, and the prevalence of seeing vWF positive dogs who are dilute blue's. If you have one of the breeds mentioned, or a dog with a dilute blue/silver coat thinking about this disease might be prudent to help avoid a medical emergency down the bumpy road of life. 

Dr. Morgan has a blue Cane Corso. He was tested, based on her color superstition and found 'normal' but has bled abnormally with each knee surgery he has had. 

That's disease for you, does what it wants and leaves you guessing in spite of 'being an expert."

Dr. Morgan and her boy, Cletus.
Recovering after his cruciate repair surgery.

If you have a question about this, or any other pet related item, you can find me chatting away, helping other people with their pets at Pawbly.com, or on Twitter @FreePetAdvice.

Minnie's Menacing Gracile Grimace

When I bought JVC about 6 years ago there were quite a few breeders who used our clinic. One of the breeders I met back then bred and raised Dobermans, Ms. White. Ms. White would breed and raise several litters a year. She cared about her puppies but she wasn’t very familiar with the breed. I really feel that one of the most important aspects of a Veterinarians job is to educate. I do a lot of talking to my clients about their pets. Shoot, I think I do a lot of talking period. I love to hear about my clients family, their pets, their hobbies, how their pets got their names, how their pets are doing in every aspect of their lives, everything. I feel compelled to talk about diet, exercise, preventative care, breed specific concerns, the whole gamut of every aspect of my pets, and much of my client’s life. I wear the hat of veterinarian, therapist, behaviorist, psychologist, nutritionist, etc, etc. I have some strong suits and some weaker suits. For example I really enjoy surgery, but I am not so great in reproductive medicine. My predecessor was what we “newbies” call an ”old timer”. Back 30 plus years ago we Vets did a lot of reproductive medicine. Remember 30 plus years ago Vets saw just as many cows, pigs, and horses as they did dogs, and honestly, they probably didn’t see many cats. They could teach me a thing or two, (probably a million) things about reproduction.

Well, Ms. White came in one day with her newest litter of Dobie pups. Now I have already admitted to you that I LOVE the puppy visits. Nothing in the world makes me happier than a puppy. I devote a huge block of my schedule when I see a “litter exam” coming in. I need extra time to hug, kiss, cuddle, smother, smell, and coo over puppies. When we entered the exam room Ms. White pointed out that one of the pups (they were about 6 weeks old) had an odd quizzical look. This little female puppy had a pretty severe head tilt. It was definitely noticeable, but she still had all of the charm, joy, and happiness of the rest of her littermates. Ms. White asked me if I thought that she would “out grow this condition?” I told her that “I couldn’t be sure, but I thought that there was a good possibility that she might.” I asked her if she “thought that the puppy had improved over the last few weeks?” She replied “no, I don’t think so.” I gave the puppy a thorough exam, to make sure that if this was a congenital defect that there weren’t any others we didn’t know about. I didn’t find anything but a sweet, exuberant, playful puppy who just had a crooked neck. I kissed all of the puppies goodbye and told Ms. White to call me if she had any questions or concerns.

4 weeks later I saw that Ms. White was on the appointment record to see another doctor for a euthanasia. I made sure that I stuck around until she got there to see who she was bringing in to euthanize. My greatest fears came true when she came in with her crooked necked puppy.

I interjected and brought her and the puppy immediately into an exam room. She began to explain to me that she had sold the rest of the puppies but couldn’t sell this one because of her head tilt. She also told me that her husband would not let her keep this puppy. So now comes the hard part for me. I have in the past jumped in to try to save a pet from being euthanized by its owner only to have the following happen; 1. I get really angry clients yelling at me, because I have "intervened in an already difficult decision" and “they have MADE THEIR MINDS UP AND SAID THEIR GOODBYES!” 2. I have had clients tell me to “mind my own business” like this clinic isn’t my business? I remind them it is. 3. they say to me “I work for them and I will do what they tell me to do.” That’s my favorite one so far. “Buddy,” I sarcastically replied, “I don’t work for you, and my conscious is not for sale.” He left, he reported me to the State Medical Board, and I still think he is an A-Hole. He can report me to the State Board for that too. 4. I have had some clients cry, and thank me for giving them an option that saves their pets life, because they didn’t think anyone could help them. 5. I have had clients march out, drive down the street to the neighbor vet in my town and have their pet euthanized there. So I took a deep breath and told Ms. White that we do not euthanize healthy pets at this practice. I then very quickly, before she could get a word in, followed up my statement with “you can sign her over to us and we will find her a home.”

I waited on the edge of my seat, and braced myself for an attack. She looked, paused, and then handed over the puppy. I think that she was relieved to have the offer on the table.

We named her “Minnie”. She stayed with us at the front desk for a week or two. During that time, Dr. Wilson, the previous JVC owner, came in and saw her. He immediately looked at me and said, ”You know that dog will be perfectly normal and outgrow that, don’t you?” I replied, “I hope so.”

Within two weeks one of our favorite friends and clients, CB, came in. She saw Minnie and immediately fell in love with her. She announced to all of us that she was “going home right now to tell her husband that she was bringing her home.” I think she wanted it to sound like she was being respectful and considerate in asking for his blessing, but in reality we all, husband included, knew she had made up her mind, and the matter was not up for discussion. She came in the next day and brought Minnie home.

2011 Pets With Santa, Murray on the left and Minnie on the right.

Over the next few months, we received photos, phone calls, and the funniest stories I have ever heard. She told me that Murray, her dog, was having a tough time convincing himself that he was happy to have a puppy in the house. Minnie would play, and pester, and bite, jump, romp, and annoy him until he snipped back as recourse to dissuade her. Problem is, all puppies just think they are playing back; finally. So they continue the annoyances until the play resumes again. Then there was the whole pool fiasco. See, Murray the lab loves to swim, so he jumps into the pool all the time, for a quick cool off dip. Of course, Minnie thinks that whatever her big brother can do, she can do. Labs float, Dobes don’t. So down to the bottom she went, and into the water her mom went after her. After re-learning that same lesson over and over again, CB finally decided she had to do something. So she bought her a child’s wading pool. Minnie loves her pool! She lays in it all day and avoids the deep section.

Within 4 months Minnies head tilt disappeared completely. She remains one of the happiest, sweetest, gentlest girl I have ever met. She truly is one of my favorite patients. And her mom, well, we all love CB too. We are really lucky to have such great clients who help us make happy endings.

Minnie in her 2011 costume, with Murray