BLEEDING DISORDERS

A bleeding disorder is suspected if a patient has unexplained bruising and bleeding (i.e. no history of trauma). Prolonged bleeding or oozing can also occur after injury or surgery (e.g., tooth extraction, small cut).

Causes

  • Blood vessel defect
    • Acquired: age, side effects of steroids, NSAIDS (e.g. easy bruising)
    • Genetic e.g. hereditary telangiectasia
  • Platelet defect
    • Decreased platelet number/function e.g., blood cancer, viruses, aplastic anaemia
    • Increased destruction e.g., in hypersplenism, autoimmune disease, massive blood transfusion
  • Coagulation defect
    • Hereditary e.g., haemophilia A or B, von willebrand disease
    • Acquired e.g., anticoagulant treatment, liver disease, alcoholism
  • Infections: meningococcal sepsis, haemorrhagic fevers (causing widespread endothelial damage and disseminated intravascular coagulation)

Clinical features

  • Platelet disorder: mucosal bleeding (gingivitis, nose bleeds), superficial ecchymoses, excessive bleeding after
    minor injury, petechiae, heavy menstrual bleeding
  • Coagulation disorder: large, deep haematomas or haemathrosis

Investigations

  • Complete blood count, and platelet count (can be estimated using a peripheral smear if an auto-analyser is
    not available)
  • Bleeding time (time required for bleeding to stop). It is normal with coagulation factor deficiencies (except Von
    Willebrand disease), and abnormal in thrombocytopenia and qualitative platelet defects
  • Coagulation tests
    • Prothrombin time (PT): prolonged in factor VII, X, V, II deficiencies, liver disease, warfarin treatment
    • International normalised ratio (INR) to monitor anticoagulation therapy
    • Partial thromboplastin time (aPTT): prolonged in factor VIII, XII, XI, IX, X, V and I deficiencies
  • Blood smear
  • If acute, consider if haemorrhagic fevers are the cause

Management

Patients with acute bleeding disorders should be referred to hospital for appropriate investigations and treatment.

Patients with chronic bleeding disorders should be referred to a specialist.

  • Identify and treat root cause of bleeding disorder
  • Give phytomenadione (vitamin K) injection to: Newborn: 1 mg for full-term baby; 500 mcg for a
    pre-term baby IM or IV. Repeat every 8 hours if necessary
  • In patients on warfarin with acute bleeding, give vitamin K 5 mg slow IV to reverse warfarin effect.
    If patient has severe or active bleeding, give fresh frozen plasma
  • Discontinue any medications that will interfere with coagulation or platelet function, e.g.,
    cephalosporins, dipyridazole, thiazide, alcohol, chloropromazine, sulfonamides, rifampicin,
    methyldopa, phenytoin, barbiturates, quinidine, isoniazid, NSAIDs, and aspirin
  • If fresh frozen plasma or platelets are not available, transfuse fresh, whole blood to replace
    some of coagulation factors and replenish any significant blood losses

Referral criteria

  • Refer patient to hospital if any of the following signs are present
    • If cause cannot be determined locally
    • Spontaneous bleeding
    • Bleeding into muscles or joints, GIT, or CNS
    • Bleeding patients who are on warafrin
    • Postpartum bleeding
    • Family history of bleeding

Health education

  • Advise the patient with chronic bleeding disorder to:
    • Prevent injury
    • Avoid injections and unnecessary surgery
    • Visit the clinic immediately if symptoms occur
    • Continue all medication as prescribed
  • All haemophiliacs should have prophylactic treatment before traumatic procedures, e.g., tooth extractions, or
    surgery