CHAPTER An Approach to a Patient with Bleeding Disorder

62 Nidhi Sharma, Sandhya Gulati, Sudhir Mehta, Shaurya Mehta

ABSTRACT History taking: A good detailed comprehensive history is Hemorrhagic diathesis can be caused by disorders in the best predictor of a bleeding problem. primary hemostasis (von Willebrand disease, inherited NATURE OF BLEEDING platelet function disorders), secondary hemostasis If the bleeding involves the skin (cutaneous) and mucous (hemophilia A, B, other coagulant factor deficiencies) membranes i.e. petechiae, purpura bruises, epistaxis, and fibrinolysis, and in connective tissue or vascular gingival bleeding, menorrhagia and/or hematuria, it formation. This review summarizes the approach to would suggest a platelet and/or vascular abnormality. a bleeding patient starting from structured patient Bleeding into deep tissue, joints and muscles suggest a history, to applying bleeding assessment tools (BATs), coagulation factor defect4. the utilization of currently available diagnostic methods for bleeding disorders and finally investigating with HISTORY SUGGESTING CONGENITAL/ACQUIRED BLEEDING highly specialized tests. A comprehensive framework A history of easy bruising or exaggerated bleeding after for a genetic diagnostic work up to inherited bleeding injury suggests an inherited bleeding problem. There disorders is the need of the hour. The discovery of a wide should be questions on any childhood history of epistaxis, spectrum of mutations in the various genes associated umbilical stump bleeding, bleeding after circumcision with coagulation and their association with different hinting an inherited bleeding disorder. Any history of severity of the disease has allowed for the development blood transfusion or other blood components is very of a rational strategy for mutation detection in clinical important. Information on all surgeries including tooth settings. Characterization of the genetic defects is also extractions and any history of abnormal bleeding during required for carrier detection, antenatal testing, and or after surgery should be evaluated. The response to predicting risk of factor inhibitor development. trauma is an excellent screening test. Any significant injury KEYWORDS without abnormal bleeding is good evidence against the presence of an inherited haemorrhagic disorder. bleeding disorder, approach, investigations, genetics A very careful family history is critical; any family history INTRODUCTION of abnormal bleeding in parents, maternal grandparents, Hemostasis involves interactions between the blood aunts, uncles, and siblings as well as any history of vessels, platelets and coagulation factors1. A defect in any consanguineous marriage (or among relatives) should be of these phases of coagulation can result in a bleeding taken. However, a negative family history does not exclude problem which may be inherited or acquired. The aim of an inherited coagulation disorder. As an example, up to hemostasis is to prevent blood loss following injury by the 30-40% of patients with hemophilia A have a negative formation of a stable blood clot. Blood clots are eventually family history. A comprehensive history will guide the dissolved by the fibrinolytic system. A delicate balance direction and extent of the laboratory evaluation and also between formation and dissolution of a blood clot is help in determining management. maintained2,3. A disruption of this unique balance results in bleeding or thrombosis. The objectives of this review MEDICATION USE is to provide primary care physicians with a systematic A careful history of medication use is important, diagnostic approach in dealing with patients suffering including prescribed medications, over-the-counter from bleeding disorders, and demonstrate the importance medications and herbal products. Drugs cause bleeding of clinical and laboratory evaluation as highlighted in due to thrombocytopenia or platelet dysfunction, aplastic Table 1. anemia or vascular purpura. Table 1: Evaluation of a patient with bleeding disorder Bleeding scores (BSs) have been proposed for obtaining standardized quantitative histories5. Because symptoms Clinical History might be subtle, especially in younger children, a detailed evaluation Family history clinical history is crucial. In order to standardize this, Bleeding assessment tools (BATs) questionnaires have been drafted and are known as Physical examination bleeding assessment tools (BATs). The main advantages Laboratory First line investigations (screening tests) of using BATs are: evaluation Second line investigations (confirmatory 1. As a screening tool, particularly for mild bleeding test) disorders. Third line investigations (genetic workup) 340 2. To assess disease severity. occurring” platelet autoantibody directed against a 3. To address phenotypic heterogeneity and normally concealed epitope on the platelet membrane, correlations between clinical and laboratory which becomes exposed by EDTA. Use of alternative phenotype, and between genotype and phenotype anticoagulants (eg, citrate or heparin), may circumvent this technical problem. 4. To improve communication in a clinical setting. Bleeding time — The bleeding time (BT) is a measure of PHYSICAL EXAMINATION the interaction of platelets with the blood vessel wall. A From the clinical assessment, one should be able to assess prolonged bleeding time may occur in thrombocytopenia whether: (1) the bleeding is the result of a local anatomic (platelet count usually below 50,000/microL), qualitative defect or part of a systemic defect in hemostasis, (2) the platelet abnormalities (eg, uremia), von Willebrand bleeding is due to a vascular defect, platelet abnormality disease (VWD), some cases of vascular purpura, and or coagulation disorder, or (3) the haemostatic defect is severe fibrinogen deficiency, in which it is probably inherited or acquired. the result of platelet dysfunction. Among patients with a normal platelet count who are not taking aspirin, the DISORDERS OF PLATELETS OR BLOOD VESSELS bleeding time is used primarily to screen patients for They are characteristically associated with mucosal inherited disorders of platelet function. An abnormal test HAEMATOLOGY (epistaxis, gingival) and cutaneous bleeding (petechiae, in a patient with mucocutaneous bleeding would justify ecchymoses). Patients with platelet abnormalities tend further testing for platelet dysfunction or specific tests for to bleed immediately after vascular trauma and rarely von Willebrand disease (VWD). However, a normal value experience delayed bleeding, which is more common in for the BT should not preclude testing for VWD. Platelet the coagulation disorders. Function Analyzer is more sensitive for detection of VWD COAGULATION DISORDERS than is the BT. The typical manifestations of bleeding in the coagulation A normal BT does not predict the safety of surgical disorders are large palpable ecchymoses and large procedures, nor does an abnormal BT predict for spreading deep soft tissue hematomas. Haemorrhage excessive bleeding. Since assessment of the BT is subject into synovial joints most often indicates a severe inherited to considerable variation due to technical factors in coagulation disorder such as hemophilia. executing the test, a normal range for the test varies LABORATORY INVESTIGATIONS from laboratory to laboratory, and cannot be generalized here. Of importance, the BT is not recommended as a For each phase of hemostasis, screening tests which help preoperative screening test. Because of considerable in distinguishing a platelet disorder from a coagulation variation due to technical factors in executing the test, the defect are available. The use of these tests are never a BT plays a limited role, if any, in evaluating hemostatic substitute for clinical assessment, as there is enough defects. evidence that screening tests are unhelpful in the prediction of a bleeding disorder especially when applied The Platelet Function Analyzer — The commercially- indiscriminately. The quality of the report issued from available Platelet Function Analyzer (PFA-100) is an the laboratory will depend on the quality of the sample. alternative technology that assesses platelet function with Clotted, hemolyzed and inappropriately collected sample greater sensitivity and reproducibility than the bleeding will lead to erroneous results. Sodium citrate is the anti- time (BT). Because the BT is insensitive, invasive, time coagulant of choice. consuming, and subject to variation due to technical factors, many centers have adopted the PFA-100 in place First line investigations (screening tests) include a of the BT as their screening test of platelet function. This complete blood count (CBC) to assess platelet count, test may be performed on citrated samples of whole peripheral blood smear examination, prothrombin time blood that have been stored at room temperature, and is (PT), activated partial thromboplastin time (APTT), a considerably faster to perform than platelet aggregation thrombin time (TT) and a bleeding time (BT) or platelet studies. Normal PFA-100 test results may obviate the need function analysis (PFA)6,7,8. Second line investigations for further expensive platelet function testing. Unlike the include mixing studies, factor levels, platelet aggregation in vivo BT, the PFA-100 test does not provide a measure studies and von Willebrand factor level. of vascular function. Platelet counting and the peripheral smear — Platelets Prothrombin time — The production of fibrin via the may be counted directly or with the use of fully automated extrinsic pathway and the final common pathway electronic methods. While some automated methods may (common to both extrinsic and intrinsic cascades) flag for the presence of unusually small or extremely large requires tissue thromboplastin (tissue factor), factor VII platelets, there is no substitute for direct examination of (extrinsic pathway), and factors X, V, prothrombin (factor the peripheral blood smear for detection of quantitative II), and fibrinogen. The functioning of these pathways as well as qualitative (ie, abnormalities of platelet size) is measured by the plasma prothrombin time. The test platelet abnormalities. Examination of the peripheral bypasses the intrinsic pathway and uses thromboplastins blood smear is essential in patients with low platelet counts to substitute for platelets. Within this combined pathway, to exclude the presence of pseudothrombocytopenia due factors VII, X, and prothrombin are vitamin-K dependent to in vitro platelet agglutination in the presence of EDTA. and are altered by warfarin. For this reason, the PT is used This phenomenon is thought to result from a “naturally CHAPTER 62 341 Fibrin and fibrinogen degradation degradation fibrinogen and Fibrin — normal plasma to the test reaction tube. This is normally is normally This tube. test reaction to the plasma normal of mixture 1:1 a on aPTT or PT a by performing done factor Specific study). (mixing plasma normal and patient deficiencies are then determined by assessing the PT or with of test plasma aPTT in mixes available commercially plasmas deficient in known factors. Factor levels can be to standard test results by comparing assessed functionally by generated normal of serially diluted mixtures curves plasma and factor-deficient plasma. Immunologic assays Immunologic to measure factor levels. can also be used results equivalent give should assays functional and when a factor deficiency is present. On the otherassay but a low functional normal immunologic assay hand, of a functionally abnormal factor. indicates the presence factor inhibitor The presence of a the is suspected when not correct, or only partially abnormal test does corrects, assay of a 1:1 mixture of patient following an immediate In some cases, such as acquired factor and normal plasma. after immediately correct may aPTT VIII antibodies, the after 60 to 120 minutes prolonged mixing, but becomes of incubation at 37º. In addition to factor inhibitors, lupus not that is aPTT prolonged a result in anticoagulants can of effect The plasma. normal of addition the by correctable by adding overcome these antibodies on the aPTT can be excess platelet phospholipid (particularly a hexagonal the diluted Russell’s phase phospholipid) or by assessing the antiphospholipid Paradoxically, time. venom viper with a tendency to syndrome is usually associated is aPTT rather than bleeding; the prolonged thrombosis an artifact of the antiphospholipid phenomenon. fibrinolysis for Tests resulting from the products (FDP) are protein fragments action of plasmin on fibrin or Elevated levels fibrinogen, are respectively. seen in states of fibrinolysis such coagulation (DIC). FDP assays as intravascular disseminated do not differentiate between fibrin degradation products and fibrinogen degradation products. accurately measure the It concentration of fibrin D-dimers, is possible to The fibrin. cross-linked of products degradation are which immunosorbent the enzyme-linked is of choice method assay (ELISA). When fibrinolysis exceeds thrombin generation, thereby hemorrhage rather than thrombosis the risk of increasing coagulation associated (eg, disseminated intravascular FDP leukemia), quantitative with acute promyelocytic an as than D-dimer levels may be more sensitive levels indication of the degree of fibrinolytic activity. Because D-dimers specifically reflect fibrinolysis of cross-linked fibrin (ie, the fibrin clot), assessmentAs an example, in suggests thrombosis more reliably. of levels D-dimer a low pretest probability of deep vein patients who have is D-dimers of value predictive the negative thrombosis, high. overall The euglobulin lysis time, which assesses fibrinolysis is less useful, since results from this test may concentrations ion calcium to relation in significantly vary and of tissue plasminogen activator as plasma levels as well Alpha-2 antiplasmin, inhibitor-1. plasminogen activator an inhibitor of fibrinolysis, is not measured in this test. The activated activated The /cmm 3 — A prolonged aPTT — Normal range 10 150-450 x Size and clumps Size and Good 10-14 seconds 25-38 seconds 15-19 seconds Insoluble Platelet count Platelet Test Test Table 2: Screening coagulogram for a patient with bleeding with bleeding a patient 2: Screening for coagulogram Table disorder Platelet morphology Platelet study Clot retraction Prothrombin time partial Activated thromboplastin time Thrombin time Clot solubility test as a measure of the anticoagulant activity of warfarin and anticoagulant activity of warfarin as a measure of the other vitamin K antagonists. partial thromboplastin time Activated can be due to a deficiency (or absence) of a coagulation factor or the presence of a coagulation factor inhibitor. A factor deficiency should be correctable by addition of partial time (aPTT) measures the intrinsic thromboplastin of coagulation. It is called and common pathways partial since platelet substitutes are used which are only partial thromboplastins; they are incapable of activating tissue which requires complete the extrinsic pathway, factor).thromboplastin (tissue a method, In the original the However, activation. contact glass test tube provided or particulate such as ellagic acid addition of activators silicates provided better and more standardized contact is now (aPTT) of the PTT version This activated activation. intrinsic coagulation to evaluate the routine assay used and the degree of heparin anticoagulation. inhibitors such as heparin and to The aPTT is sensitive VII factors except factors coagulation all of deficiencies to and XIII. It is less sensitive than the PT to deficiencies of and prothrombin, V, (factors X and pathway the common fibrinogen). High levels of a single factor (eg, factor VIII) an association between However, can shorten the aPTT. state remains a short aPTT and a hypercoagulable controversial. thrombin time time — The reptilase time and Thrombin of conversion (TT) and reptilase time (RT) measure initial of formation the and monomers fibrin to fibrinogen Reptilase, clot by thrombin and reptilase, respectively. a thrombin-like snake enzyme, by differsgenerating fibrinopeptide A from but not fibrinopeptide thrombin B from fibrinogen and by resisting inhibitionvia antithrombin. Fibrin strand cross-linking, which is heparin by mediated by factor XIII, is not measured by these assays. due may be and reptilase times thrombin times Prolonged fibrinogens abnormal structurally hypofibrinogenemia, to (dysfibrinogens), or increased fibrin split products. Since the RT is useful heparin prolongs the TT but not the RT, a prolonged of the cause determining if heparin is for its heparin activity via test for can one Alternatively, TT. anti-factor Xa activity, or with the use of a commercial heparinase. Factor deficiencies and inhibitors 342 Table 3: Screening test results in various bleeding disorders Platelet count Prothrombin time Activated partial Differential diagnosis thromboplastin time Normal Increased Normal Factor VII deficiency(early liver disease, early vitamin K deficiency, early warfarin therapy) Dysfibrinogenemia Factor VII inhibitor Some cases of DIC Normal Normal Increased Factor VIII, IX, XI deficiency Inhibitors to Factor VIII, IX, XI VWD Heparin Lupus inhibitor Normal Increased Increased Vitamin K deficiency Liver disease HAEMATOLOGY Warfarin Heparin Factor V,X, deficiency Decreased Increased Increased DIC Liver disease HIT Decreased Normal Normal Increased platelet destruction Decreased platelet production Hypersplenism Increased Normal Normal Myeloproliferative disorders Normal Normal Normal Mild VWD Qualitative platelet defects Factor XIII deficiency

More specific tests of the fibrinolytic system include assays blood vessel wall abnormalities. A vessel wall defect can for plasminogen, tissue plasminogen activator (t-PA), result in abnormal bleeding despite an otherwise normal alpha-2 antiplasmin, plasminogen activator inhibitor-1 coagulation system. Since there are no reliable clinical (PAI-1), and thrombin-activatable fibrinolysis inhibitor tests of vascular integrity, diagnosis depends on a high (TAFI). Assays for alpha-2 antiplasmin are used clinically level of suspicion, when all laboratory tests are normal. to identify patients with alpha-2 antiplasmin deficiency, an inherited disorder associated with delayed bleeding. BLEEDING DISORDERS WITH NORMAL SCREENING However, specific assays for t-PA, PAI-1 and TAFI are of COAGULOGRAM uncertain use clinically. There can be scenarios in which the coagulation disorders leading to a bleeding diathesis may be associated with The screening coagulogram is tabulated in Table 2. normal screening coagulation tests (i) if the factor is not The aim of the screening tests is thus, to reveal broadly involved in the steps in coagulation measured by in vitro the source of problem, and accordingly request further tests or (ii) if the degree of deficiency is mild. The most investigations. Interpretation of screening tests is common amongst these rare clinical disorders is factor tabulated in Table 3. XIII deficiency9. Factor XIII stabilizes and cross-links The second line investigations include mixing studies in fibrin strands. Factor XIII deficiency may present with the case of abnormal PT or aPTT for further information delayed bleeding, usually 24 to 36 hours after surgery or on the nature of the defect; coagulation factor assays trauma. Coagulation testing shows normal values for the to confirm and assess the severity of the coagulation PT, aPTT and TT. The diagnosis is made by measurement factor deficiency such as in Hemophilia A or B; platelet of reduced plasma factor XIII activity; an immunoassay aggregation studies to confirm platelet qualitative defects for factor XIII or demonstration of clot dissolution in 5 and investigations for Von Willebrand disease. If all molar urea or monochloroacetic acid. Rare abnormalities baseline-screening tests are normal then investigations for in regulators of plasminogen activation or plasmin factor XIII deficiency and alpha 2-antiplasmin deficiency degradation have been reported as causes of familial which are not detectable by the routine screening tests are bleeding disorders (eg, alpha-2 antiplasmin deficiency, warranted. Factor XIII deficiency may be diagnosed by a plasminogen activator inhibitor-1 deficiency). Mild clot solubility test, and the alpha 2-antiplasmin activity can hemophiliac patients with factor activity levels above be measured by a chromogenic assay. If all investigations approximately 15 to 20 percent are often sufficient to are found normal, the patient should be investigated for prevent spontaneous bleeding and to produce a normal PT and aPTT. However, patients with mild deficiency of CHAPTER 62 343 2002; Coller Henry’s 2012; 87: S45-50. ISTH/SSC bleeding ISTH/SSC Arnold DM, Arnold 2000; 46:1260-9. degree female relatives of degree female relatives st Abshire T, Abshire Lillicrap D. Tosetto A, Neunert C, 2006; 12:137-42. International journal of human genetics 2006; 6:27. . J Thromb Haemost 2010; 8:2063–5. James P, James B, assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders diagnosis and management by laboratory methods. clinical Elsevier Health Sciences, 2016. 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M, Palla Haemophilia of bleeding S. Genetics Agarwal A, Pradhan M, Dalal disorders. Manisha M, Ghosh K, Shetty S, Nair S, Khare A, Kulkarni B, Kulkarni A, Khare S, Nair S, Shetty K, Ghosh M, Manisha Baindur S, Mohanty D. Spectrum of inherited AV, Pathare India. Haematologia from Western bleeding disorders 32:39-47. REFERENCES CONCLUSION 8. 4. 5. 1. 2. 3. The approach to a patient with a bleeding disorder needs patient with a bleeding disorder The approach to a physical detailed history and thorough a comprehensive must be a logical systematic approach examination. There to reach use of laboratory investigations and a discriminate emphasis Particular severity. the diagnosis and assess simple A drug history. family and on be placed should approach to detect the cause is to look at the hemostatic platelets vessels, system as three compartments- blood workup should be and coagulation proteins. Genetic personalize the management feasible to done whenever of the patient. severe and moderate hemophilia must get factor assays hemophilia must get factor assays and moderate severe of them may be vulnerable done because some to post- bleeding. procedural or post-traumatic disorder followed by Bernard-Soulier syndrome (12.5%). (12.5%). syndrome by Bernard-Soulier followed disorder 4 Table summarises the common bleeding disorders and genetic basis. their been have screening methods of mutation number A denaturing which include detecting mutations, used for strand (DGGE), single gel electrophoresis gradient (SSCP), conformational polymorphism conformational chemical (CSGE) and electrophoresis gel sensitive result in a mutational (CMC). These mismatch cleavage All 1 to 90%. detection rate up 6. 7. 9. 10. 11. Genetics Genetics recessive Sex-linked Xq28 recessive Sex-linked Xq27.1-27.2 Autosomal dominant, X -linked recessive, Autosomal recessive Autosomal 1q21-25 recessive Autosomal 13q34 recessive Autosomal 4q23-34 recessive . A study from western part of India reported part of India A study from western . . Amongst these, 598 (95%) patients had a Amongst . 10,11 12 Hemophilia A (Factor VIII A (Factor Hemophilia deficiency B Christmas Disease Hemophilia deficiency) (Factor IX (Most Disease Von Willebrand of platelet common disorder (Type function, many variants manifestations I-III, Pseudo, etc.) mild to severe Thrombasthenia (Impaired Glanzmann, platelet function) Bernard-Soulier disease Owren’s disease / (Factor-V Parahemophilia deficiency) Factor-VII (Proconvertin (Factor I deficiency) Afibrinogenemia/ Hypofibrinogenemia/ Dysfibrinogenemia Table 4: Genetics of common bleeding disorder bleeding of common 4: Genetics Table Disorder GENETICS OF BLEEDING DISORDERS BLEEDING OF GENETICS Ever Ever since the cloning and characterization of progress coagulation factor gene in 1982, considerable the first has been made in the use of molecular genetic strategies Working up of bleeding disorders. in diagnosis to assist in knowing the helps on the mutational data base also genetic basis of the coagulation disorders within a region and helps in determining management and prevention strategies a coagulation factor may have increased bleeding with a coagulation factor may have surgical bleeding, hemostatic challenges (eg, excessive menorrhagia). This may be in an individual who is seen a as such factor defect, a coagulation heterozygous for hemophilia carrier. to structural resulting due hemostatic disorders Lastly, telangiectasia), abnormalities (eg, hereditary hemorrhagic tissue (eg, Ehlers- of connective hereditary disorders osteogenesis imperfecta), acquired Danlos disease, steroid-induced (eg, scurvy, tissue disorders connective associated and purpura vasculitis, purpura), small vessel a normal have will also paraproteins of with the presence screening coagulogram. Some patients Abuse, bleeding history for which there is no explanation. are encountered occasionally self-inflicted, should be considered. with a significant on 630 patients, diagnosed to have hereditary bleeding to have on 630 patients, diagnosed diathesis coagulation disorder and 32 (5%) patients had a platelet and 32 (5%) patients coagulation disorder function abnormality. In a group of coagulation disorders, disorder the most common A (70.5%) was hemophilia followed by hemophilia B (14%) Glanzman’s thrombasthenia disease (10.8%). However function and platelet common most von the be Willebrand to found was (84.3%)