Slide 1

Diagnosis of the bleeding patient

Diana Oelofse

Descriptions of bleeders date back a few centuries.The first modern description of haemophilia, as an example of a bleeding disorder likely came from the American physician John Otto in 1803.

This description is the first in which the inheritance pattern is clearly stated.And the first instance of what we now know as X-linked inheritance in any disorder.Otto clearly recognized both that the bleeding disorder was limited to males and the possibility of its transmission by healthy female relatives.

We know now however that bleeding disorders can be hereditary or acquired.And that females can also be affected by hereditary bleeding disorders, in some instances as often as males for e.g. VWD.

The evaluation of the patient with a suspected bleeding diathesis has the potential to provoke much diagnostic uncertainty. A severe bleeding disorder is generally a relatively straightforward diagnostic process.But in contrast the work-up for minor bleeding disorders can be complicated.

There is currently no test available that serves as a reliable screening test for global haemostasis. (that includes the bleeding time - which does not predict bleeding)In addition some patients have multiple acquired abnormalities in their haemostatic systems.This may also be the case in hereditary bleeding disorders where for e.g. VWD with Haemophilia A or B can co-occur, or concurrent Factor V deficiency and Haemophilia A.

Screening tests may point to the possible presence of defects in primary haemostasis or a factor deficiency. Specific diagnosis : requires more detailed testing.Laboratory studies have limitations including pre-analytical errors, false negatives, long distances to reference laboratories for tests that cannot be done locally and costs involved.

In Port Elizabeth we are able to do basic screening tests and some of the more specialized tests. (with Livingstone NHLS being our regional reference laboratory for urgent tests)Non-urgent specialized tests are often done in larger centralized labs.Some specialized tests are however only available on site at certain universities in South Africa (for e.g. LPA)

Pre-analytic errorsProblems with citrate vacutainersPartially filled tubesVacuum leak and citrate evaporation

Problems with phlebotomyHeparin contaminationWrong labelSlow fillUnder-fillToo vigorous shaking

Biological effectsHct 55 or 15Lipemia, hyperbilirubinemia, hemolysis

Divers laboratory errorsDelay in testingProlonged incubation at 37CFreeze/thaw deterioration

Aims when investigating a patient/family with suspected bleeding disorder / bleeding risk

Determine likelihood that patient (family) has a haemorrhagic disorder, using the medical history and then confirmed by laboratory investigations.

Is there implications for family members and potential offspring?

Attempt to estimate risk.Establish a management plan for future problems and/or to at least reduce risk for invasive procedures.

Stages in normal coagulationInitiation phase : vasconstriction, platelet adhere to site (VWF), exposed collagen interaction with platelets and interaction between TF and FVII = TF/FVIIa : activation X and IX.Amplification phase : thrombin activation of platelets and activation of procoagulant cofactors Va and VIIIa. (on a primed platelet surface)Propagation : Burst of thrombin generation on platelets through the more stable platelet surface generated Xa (via IXa ), + Va : Thrombin = leading to fibrin formation.Localization : TFPI, ATIII, Thrombomodulin, Prot C and C and fibrinolysis.

Reproduced with permission from Sysmex

http://www.healthcare.siemens.com/hemostasis/hemostasis-online-campus/interactive-hemostasis-cascade

The extent of laboratory investigations for an obvious, or possible bleeding diathesis is strongly informed by the bleeding history and also guided by clues from the physical investigation and context of the presentation.

Extensive work-up mandatory in major bleeds these patients are relatively few.

(Possible) Minor bleeders problematic.They may be normal or have mild to moderate bleeding disorders. (platelet secretion defects or mild VWD)

Tosetto et al. defines a bleeder as a patient with an increased bleeding rate. Number of bleeding episodes occurs within a defined time frame in the patients life.Bleeding rate = Number haemorrhages/time

Bleeding HistoryBleeding symptoms are often reported by otherwise healthy subjects.Trivial (non-relevant) is considered part of the human phenotype.Trivial bleeding never interferes with daily activities or requires medical attention.Minor bleeding severe enough to interfere with daily activities Major bleeding may cause permanent damage or be life -threatening.Various established scoring systems / Bleeding assessment tools available.

https://bh.rockefeller.edu/ISTH-BATR

Other indicators that may be derived from the history:Bleeding localized / diffuse.Spontaneous vs provoked.Mucocutaneous vs. joint bleeds.Delayed onset bleeding. Factor XIII deficiencyA2 antiplasmin deficiencyPlasminogen activator inhibitor-1 deficiencyBleeding in male and female members of a family.Consanguinity.

Physical examinationSkin : petechiae, ecchymoses, perifollicular haemorrhages, telangiectasia around mounth (HTS),distribution, oculocutaneous albinism, hepatosplenomegaly and lymphadenopathy,stigmata of liver diseaseJoint hypermobility and skin hyper-elasticity in Ehlers-Danlos SyndromeAortic Stenosis in acquired VWD. Large tongue, carpal tunnel syndrome peri-orbital purpura in amyloidosis several acquired factor deficiencies.

Laboratory InvestigationsFBC, U/E and Creatinin, LFTsClotting ScreenProthrombin time : Extrinsic ( F 2 5 10 + 7 ) liver pathology, warfarin therapy PTT Intrinsic ( F12 11 9 8 + 2 5 10)Trombin Time and Fibrinogen (Common path) DIC , Heparin therapy and dysfirbinogenaemia Bleeding time : Result depends on integrity of blood vessels, platelet function, VWD. Not standardised. Ivy template method 3 8minPFA - 100D-Dimers :DICCorrections studies and Factor assaysVon Willebrand Disease screen(often needs to be repeat and can be complex)LTA (light transmission aggregometry)Electron microscopy plateletsEvaluation of fibrinolysis

Two stage approachFirst StageFBCPTPTTFibrinogenTTBT / PFA-100VWF assaysFVIIIABO blood groupSecond Stage(Depending on results of first stage)Specific coagulation factorsMixing testsVW:Collagen binding assayVWFMLTAFXIIIAntiplasminFibrinolysis exploration

Coagulation tests in context of simplified clotting cascadeF10Thrombin (F 2)Fibrinogen FibrinF5F8PTTPT/INRClauss FibrinogenThrombin timeClot lysis time, 2 antiplasminD-DimersFDPsCorrection studiesCorrection studiesF13

A quick and accurate method for measuring fibrinogen in plasma J. Lab. Clin. Med. 1961 Sep; 58; 477-88 Ellis BC, Stransky A.

Coagulation factor disordersInherited bleeding disordersHemophilia A and BvonWillebrands diseaseOther factor deficienciesAcquired bleeding disordersLiver diseaseVitamin K deficiency/warfarin overdoseDICAcquired inhibitors to factors

Platelet problems can be congenital or acquired platelet abnormalities,and quantitative and qualitative

Blood Vessels in Hemostasis:Initial phase of hemostasis.Simple easy bruising womenSenile purpura atrophy, Scurvy vit C deficiency, collagen def.Steroid induced purpura

Henoch-Schonlein purpura children. ( *Acquired F 13 deficiency)

Patient - 1Abnormal PTAbnormal PTTTest for factor deficiency: Isolated deficiency in common pathway: Factors V, X, Prothrombin, Fibrinogen Multiple factor deficiencies (common) (Liver disease, vitamin K deficiency, warfarin, DIC)

Repeatwith50:50mix

50:50 mix is normal50:50 mix is abnormalTest for inhibitor activity: Specific : Factors V, X, Prothrombin, fibrinogen (rare) Non-specific: anti-phospholipid (common)

Patient - 2Normal PT Abnormal PTTTest for factor deficiency: Isolated deficiency in intrinsic pathway (factors VIII, IX, XI) Multiple factor deficiencies (rare)

Repeatwith50:50mix

50:50 mix is normal50:50 mix is abnormalTest for inhibitor activity: Specific factors: VIII,IX, XI Non-specific (anti-phospholipid Ab)

Patient - 3Abnormal PTNormal PTTTest for factor deficiency: Isolated deficiency of factor VII (rare) Multiple factor deficiencies (common) (Liver disease, vitamin K deficiency, warfarin, DIC)

Repeatwith50:50mix

50:50 mix is normal50:50 mix is abnormalTest for inhibitor activity: Specific: Factor VII (rare) Non-specific: Anti-phospholipid (rare)

Evaluation of a Bleeding Patient 4 normal PT normal PTT UreasolubilityNormalAbnormalFactor XIII deficiencyConsider evaluating for:Mild factor deficiency Monoclonal gammopathy Abnormal fibrinolysisPlatelet disorder (a2 anti-plasmin def)Vascular disorder Elevated FDPs

To conclude with Dr Otto:

And now 210 years later..

Thank you !

ReferencesKey,Makris et al. Practical Haemostasis and Thrombosis, Second edition. Pg1 Hayward, Moffat 2013. Laboratory testing for bleeding disorders, uses of high and low-yield tests IJLHTosetto, Castaman et al. 2013. Bleeders, bleeding rates and bleeding score. JTHSchulman, Angeras et al.2010.Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. JTHRedeghiero, Michel et al. 2013. Standardization of bleeding assessment in ITP from the IWG. Blood.The Medical Research Council`s General Pratice Research Framework. Thrombosis prevention trial. 1998 LansetRidker,Cook et al . A Randomised trial of low dose aspirin in the primary prevention of CVD in women. 2005. NEMJhttp://www.genmedhist.info/articles-and-papers/https://bh.rockefeller.edu/ISTH-BATRDe Moerloose et al. Diagnosis of mild bleeding disorders.Diagnosis and management of mild bleeding disorders.Hayward. ASH