How to take a bleeding history

Hemato update 2013

Hospital Ampang Toh See Guan

4 important points

4 important points I wish to obtain from history taking:

1. Establish the presence of bleeding disorder

2. Assess the severity of bleeding

3. Congenital vs acquired

4. Looking for clues associated with specific bleeding disorder

Point 1 : Establish the presence of bleeding disorder

• Does my patient really has bleeding disorder?

• Patients with haemorrhagic disorders always have significant abnormal bleeding histories

• Evaluate previous response to hemostatic challenge, e.g. dental extraction, surgery, trauma, childbirth, etc.

A significant bleeding history

• Epistaxis not stopped by 10 mins compression or requiring medical attention

• Cutaneous haemorrhage or bruising without apparent trauma (esp. multiple/ large)

• Prolonged (>15 mins) bleeding from trivial wounds, or in oral cavity or recurring spontaneously within 7 days

• Post-operative bleeding

A significant bleeding history

• Menorrhagia (esp. from menarche) – clots > 1 inch in diameter, changing a pad > frequent than 2hourly, or resulting in anemia.

• Bruising with minimal or no apparent trauma

• Heavy or prolonged bleeding after dental extraction that required medical attention

Point 2 : Assess severity of the bleeding

• Severe Spontaneous haemorrhage

Early onset, usually from infancy

Frequent spontaneous bleed required intervention

• Minor Haemorrhage

secondary to major trauma/ surgery

Rare spontaneous bleed

Point 3 : Congenital vs acquired

• Congenital Platelet disorder –

Glanzmann thrombasthenia, Bernard Soulier syndrome

Clotting factor deficiency – Haemophilia A & B

Von Willebrand disease

Herediatry haemorrhagic telangiectasia

• Acquired ITP APML/AA/MDS Acquired haemophilia Anticoagulant/

antiplatelet medication

Drug induced thrombocytopenia

Uraemia Liver disease DIC

Point 3 : Congenital vs acquired

• Congenital Family history – blood

relative with bleeding problem; consanguinous marriage; autosomal/X-linked inheritance

Onset since small/young

• Acquired Medication history –

on anticoagulant/ antiplatelet? medication/ traditional medicine a/w thrombocytopenia

Late/recent onset Underlying

lymphoproliferative d/o, CTD, HIV, HCV, CKD, liver disease, sepsis, etc

XH X

Carrier Woman Healthy Man

Carrier Girl Healthy Girl Haemophilic Boy Healthy Boy

XH

X

X X X XH Y X Y

Y

Inheritance : X-linked recessive

Point 4 : Looking for clues associated with specific bleeding disorder

• Mucocutaneous bleed – thrombocytopenias, plt dysfunction, vWd

• Cephalhematomas in newborns, hemarthroses, intramuscular, retroperitoneal hemorrhages –severe hemophilias A & B, severe FVII def, severe type 3 vWd, afibrinogenemia

Point 4 : Looking for clues associated with specific bleeding disorder

• Bleeding from stump of umbilical cord – FXIII def, afibrinogenemia

• Recurrent epistaxis & chronic iron def anemia –hereditary hemorrhagic telangiectasia

EC

Primary haemostasis

Platelets adhere to vWF-collagen

TF

platelets

vWF

M. Laffan

VIIa

EC TF

Xa

Secondary haemostasis

TF-VIIa triggers Xa productionThrombin generation proceeds on PL (platelet) surface

X

M. Laffan

Stable clot formation

fibrin platelets

Stable fibrin-platelet clot is formed

M. Laffan

Bleeding

• Immediate bleeding

– Defects in primary haemostasis

– Vascular abnormality

• Delayed bleeding

– Defects in secondary haemostasis

A good bleeding history is the best screening test

Bleeding disorders not detected by routine coagulation screen

• Mild factor deficiencies

• von Willebrand disease

• Factor XIII deficiency

• Platelet disorders

• Excessive fibrinolysis

• Vessel wall disorders

• Metabolic disorders (e.g. uraemia)

Case 1

• 1o year old boy with chronic tonsillitis

• Planned for tonsillectomy

• FBC, PT, APTT sent

• Mother c/o that son has easy bruising and recurrent epistaxis and she herself has menorrhagia

• Hb 12 Plt 243

• PT 12.5s (12- 16s) APTT 38s (30- 42s)

Case 1 – cont’d

• Since platelet count and PT, APTT all normal

• Mother reassured and proceeded with tonsillectomy

• During surgery, excessive bleeding noted but controlled with local measures

• 2 hours post-op, further significant bleeding

Case 1 – cont’d

• Returned to OT, cauterization done

• 2 Packed RBC and 2 FFP transfused; bleeding controlled

• Repeat PT, APTT the following day- normal

• Refer hematologist

Case 1 – cont’d

• Further bleeding history taken

• Mother’s blood sample sent

• FBC normal PT 13s (12-16) APTT 40s (30-42)

• FVIII 34% (40-150) vWF 30% (50-150)

• Son’s results similar to mum’s (on f/u)

• Diagnosis: von Willebrand disease type 1

Limited investigation of a patient with a bleeding history

is as inappropriate as

Extensive investigation of a patient with no bleeding history

Limitations of PT, APTT

• Lack sensitivity and specificity

• Tests a very limited portion of haemostasis

• Can only detect factor levels below 30%

Case 2

• 11 year-old boy

• Blunt abdominal trauma by bicycle handle

bar on 30th June 2013

• 3 days later on 3rd July – abdominal pain

• Hospitalised on 5th July 2013

S. Krishnan 2013

Case 2 – cont’d

• In pain

• Stable circulation

• Tender LHC

• Bicycle handle bar

impression

S. Krishnan 2013

CT scan 05/07/13 S. Krishnan 2013

CT scan 05/07/13 S. Krishnan 2013

CT scan 05/07/13 S. Krishnan 2013

Case 2 – cont’d

• Hb 11.6 TW 11.8 Plt 208

• PT 12 s APTT 38.7 s TT 15.7 s

• Fibrinogen 2.6 g/L

• D-Dimers detected

• Serum amylase: not elevated

• RP, LFT normal

Case 2 – cont’d

• 48 hours later …

• Increasing abdominal

distension and pain

• Hb 6.4 g/dL

S. Krishnan 2013

CT scan 07/07/13 S. Krishnan 2013

CT scan 07/07/13S. Krishnan 2013

CT scan 07/07/13 S. Krishnan 2013

CT scan 07/07/13 S. Krishnan 2013

Case 2 – further tests

• Repeat tests on 8th July

• PT 14 s

• APTT 43.4 s

• Fibrinogen 4 g/L

• Platelet 106

Case 2 – clinical suspicion

• Diagnosis: DIC

• Rx: Transfusions

– Packed red cells

– FFP

– Platelets and

– Cryoprecipitate

Case 2 – bleeding history

• Normal SVD

• No umbilical stump bleeding

• Vaccinations – OK

• No mucocutaneous bleeds

Case 2 – bleeding history

• Age 6 years old

– delayed expanding haematoma R shin after hit by a

stone

– Had some tests to investigate bleeding tendency but no

abnormalities detected

– Surgical evacuation done. No specific therapy

– Wound healing by secondary intention

Arrows mark the linear surgical scar resulting from operative evacuation of an expanding traumatic right shin haematoma

at the age of 6 years at Hospital Sultanah Aminah JB

S. Krishnan 2013

Case 2 – family history

• 3rd of 5 children; 1 sister and 3 brothers

• Non-consanguinous parents

• No family history of easy bruising or h/o

haemophilia

Case 2 – specific factor assays

• Factor VIII 13%

• Factor IX 150%

• vWF Ag 144%

• Diagnosis: mild haemophilia A

Case 2 – progress

• Factor replacement: 100%

• Double J stent inserted in L ureter

• Planned for evacuation of haematoma

Case 3

• 5 year-old boy

• Admitted for upper GI haemorrhage

• h/o recurrent epistaxis and easy bruising

• No f/h of bleeding

• Hb 4.5 g/dL TW 4.5 Plt 398

Case 3 – cont’d

• PT 12.o (11.5- 14.4) sec

• APTT 102.0 (36.9- 45.5) sec

• 4 PRBC & 4 FFP transfused

• Factor VIII 2.5%

• Diagnosis: Moderate Haemophilia A

Case 3 – cont’d

• Bleeding stopped with FFP x 3 doses

• OGDS: pangastritis

• Switched to hemofil M (high purity FVIII)

• 3 days later, re-bled

• Hb fell from 11.o to 5.0 g/dL

• APTT 98 sec Mixing studies 48 sec

Case 3 - cont’d

• Suspected inhibitor; switched to PCC

• Unable to do inhibitor assay

• Sample sent to reference laboratory

– FVIII 3% No inhibitor detected

– vWF Ag < 1%

• Diagnosis: severe type 3 vWD

A good bleeding history is the best screening test

Thank you