CSP

A REGULAR CASE-BASED SERIES ON PRACTICAL PATHOLOGY FOR GPs

MARCH 2008

Common Sense Pathology

CONTENTS

The importance of assessing the bleeding history Collection of samples and laboratory testing Case studies

A JOINT INITIATIVE OF

The Royal College of Pathologists of Australasia

Bleeding disorders - does this patient have an increased risk of bleeding?

Dr Huyen A M Tran,
staff haematologist, clinical haematology unit, Monash Medical Centre, Clayton, Victoria.

Introduction
We know it is important to determine a patients risk of bleeding, but clinically it can be a difficult thing to do. Current evidence does not support the indiscriminate use of coagulation screening tests to predict bleeding in unselected patients. Patients may present with a history of spontaneous bleeding or unexpectedly heavy bleeding after a minor trauma or procedure. Investigation to assess bleeding risk may be required before a procedure in the presence of a personal or family history of bleeding or the finding of an abnormal coagulation test. Inherited and acquired bleeding disorders can be associated with significant morbidity and mortality, so it is important to have a standardised diagnostic approach to assess for possible haemostatic defects.

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Bleeding disorders are divided into impaired primary or secondary haemostasis. Primary haemostatic disorders are most common and include von Willebrand disease (see box below), thrombocytopenia and platelet function disorders (See CSP Thrombophilia November 2004). Disorders of secondary haemostasis involve disorders of fibrin formation, the haemophilias (deficiencies of factors VIII and IX) and also deficiencies of factors V, VII and XI. There can be some overlap in bleeding symptomatology between primary and secondary haemostatic disorders, but spontaneous haemarthroses are usually indicative of coagulation factor deficiencies and are not seen in disorders of primary haemostasis. Figure 1 illustrates the process involved in normal coagulation and the causes of abnormal bleeding are listed in Table 1 (page 4).

The bleeding history

A detailed personal and family history using standardised criteria is an essential tool for correctly diagnosing a bleeding disorder. Table 2 (page 4) summarises the most important symptoms to ask about in order to assess the risk of bleeding. A personal history of bleeding is predictive of bleeding risk. There is increasing evidence that the bleeding history will be most discriminatory when a standardised and validated questionnaire is used to obtain this information. Such a questionnaire tested in patients with von Willebrand disease is available at www.med.unc.edu/ isth/ssc/collaboration/Bleeding_Type1_VWD.pdf? searchterm=questionnaire+von+willebrand+disease. This tool also provides a useful approach to other inherited and acquired bleeding disorders. If three or more symptoms are found, further investigation for a bleeding disorder is warranted.

Definition of von Willebrand disease

von Willebrand disease is an inherited disorder that impairs the bloods ability to clot properly as a result of a quantitative or qualitative defect of von Willebrand factor (vWF). In normal haemostasis, platelets adhere to the exposed subendothelium at the site of vascular injury to form a haemostatic plug. vWF has two important functions: Help platelets adhere to the subendothelium at the site of vascular injury. Protects coagulation factor VIII from degrading and delivers it to the site of vessel injury. von Willebrand disease is the most common inherited bleeding disorder, affecting as many as 1% of the population.

Figure 1. Overview of haemostasis extrinsic and intrinsic pathways.

PLATELET REACTION Vessel Injury COAGULATION CASCADE Contact with damaged vessels XI Subendothelial collagen exposure Tissue factor XIIa XIa VIIa Platelet adhesion (vWF) IXa VIIIa (vWF) Xa Va Adrenaline Thromboxane Adenosine diphosphate Platelet aggregation Prothrombin (factor II) Thrombin IX

Fibrinogen XIII

Fibrin

Stable haemostatic plug

Table 1: Causes of abnormal bleeding.

Congenital Disorders of primary haemostasis von Willebrand disease Thrombocytopenia Disorders of platelet function (eg, thrombocytopathies) Acquired Antiplatelet drugs Thrombocytopenia Renal failure Primary bone marrow diseases (eg, myelodysplasia, myeloproliferative disorders) Anticoagulants (eg, vitamin K antagonists) Liver failure Vitamin K deficiency Acquired factor inhibitors Scurvy

Disorders of secondary haemostasis

Deficiencies of coagulation factors: haemophilia A and B (factors VIII and IX) and deficiencies of factors XI, V and VII and, although rare, II and XIII Collagen disorders (eg, Ehler Danlos syndrome)

Other

By adopting this approach, the GP will have a good idea as to whether: A bleeding disorder is present. The disorder is inherited or acquired. The disorder involves primary or secondary haemostasis as suggested by the type of bleeding (mucosal vs non-mucosal bleeding) and timing (immediate vs delayed). The underlying bleeding tendency has been aggravated by drugs or acquired inhibitors interfering with haemostasis. A tendency to epistaxis, menorrhagia, easy skin bruising or mild increased bleeding associated with minor surgery or minor trauma may suggest a defect in primary haemostasis, such as von Willebrand disease. The bleeding can be difficult to define as abnormal because there is usually a subjective component. Spontaneous haemarthroses and spontaneous haematomas are usually indicative of moderate to severe coagulation factor deficiency, in particular factor VIII and IX (haemophilia A and B, respectively). The exception is patients with factor XI deficiency where mucosal bleeding symptoms predominate. The symptoms and presentations of haemophilia A and B are the same, but haemophilia A is much more common. Recurrent painful joint bleeding and muscle haematomas can dominate the clinical course of severely affected patients leading to progressive joint deformity. Such patients may also have a history of profuse post-circumcision haemorrhage, extensive ecchymoses in childhood, previous life-

threatening operative and post-traumatic bleeding, and spontaneous intracerebral haemorrhage. A family history of a bleeding disorder (transmitted in an X-linked fashion) is expected but not always present. Up to 30% of new cases of haemophilia are due to new gene mutations. Patients with mild haemophilia may present in adulthood with unusual postoperative bleeding. Carriers of haemophilia A or B may or may not have bleeding symptoms, depending on their baseline factor level, which may be variable because of random X chromosome inactivation. These clinical features can also be seen in moderate and severe deficiencies of factors II, V, VII and X and, rarely, fibrinogen. With the exception of severe

Table 2. Symptoms suggestive of a bleeding disorder.

Epistaxis Cutaneous bleeding Minor bleeding wounds Oral cavity bleeding Gastrointestinal bleeding Postpartum haemorrhage Muscle haematomas or haemarthrosis Tooth extraction Surgery Menorrhagia

Adapted from Rodeghiero F. Journal of Thrombosis and Haemostasis 2005; 3:2619-26.

von Willebrand disease with associated factor VIII of less than 5%, haemarthroses are rarely seen with other disorders of primary haemostasis.

Laboratory testing
Blood samples must be taken and handled correctly to be confident of obtaining valid coagulation test results. Difficult venepuncture, an excess citrate-to-plasma ratio because of erythrocytosis, incorrect filling of collection tubes, undisclosed drug contamination (eg, heparin or antiplatelet drugs) or the time elapsed from sample collection to analysis can all effect results. Therefore, testing should only be undertaken by specialised laboratories. When abnormal results are identified, the tests should be repeated to confirm the diagnosis. In patients with a suspicious clinical history, coagulation testing should be used to confirm the presence of and determine the precise type of bleeding disorder (abnormality in primary or secondary haemostasis). History and clinical examination should dictate the tests ordered. The laboratory work-up (figure 2, page 6) should be organised to identify the specific defect in haemostasis. Start with screening studies to find the abnormal phase of haemostasis involved: a full blood count and film, activated partial thromboplastin time (aPTT), international normalised ratio (INR) and thrombin time (TT) provide an initial assessment of platelet numbers and morphology and a screen for defects in coagulation. Patients who have a prolonged aPTT or INR should have mixing studies performed to differentiate between a factor deficiency and the presence of a factor inhibitor. In this assay, plasma from the patient and normal plasma are mixed in a 1:1 ratio and the aPTT or INR is calculated at 37C immediately after incubation and at varying times, typically at 30, 60 and 120 minutes. When the disorder is a factor deficiency, the initially abnormal aPTT or INR will correct to normal after mixing and remain corrected with prolonged incubation. If a prolonged aPTT is due to a lupus (non-specific) inhibitor, the immediate mixing and incubation will show no correction because the inhibitor remains present in the mixed plasma. In the presence of an acquired neutralising factor antibody, such as an acquired factor VIII inhibitor,

the aPTT will be prolonged before mixing and may or may not correct itself immediately on mixing, but will be prolonged or remain prolonged with incubation. Acquired factor VIII inhibitor occurs most commonly in the elderly, but has also been described in postpartum women and children. Extensive ecchymoses and soft tissue bleeding are more common among these patients than in those with inherited haemophilia. Patients with haemophilia A and B can develop inhibitors to factor VIII and IX, respectively. Patients with acquired von Willebrand disease may also have a prolonged aPTT, if the level of von Willebrand factor antigen (vWF:Ag) is low, thereby reducing factor VIII levels. Acquired von Willebrand disease is usually associated with lymphoproliferative disorders but can be seen in other conditions including autoimmune disease, myeloproliferative disorders and valvular disease. There has been much interest in the possibility that global tests, such as the PFA-100 test (an in vitro platelet function assay), could be used to assess overall haemostatic potential. While this may be of value in further investigating platelet function in vitro, this test is not widely available and is best performed in consultation with a haematologist. Beyond the initial screening tests, second-level tests should take into account the features of the bleeding history and focus on the specific factors of haemostasis found to be abnormal in screening. For example, a female with easy bruising and excessive bleeding after dental extraction should have specific tests for von Willebrand disease and platelet function disorders performed. Similarly, a male with a personal history of spontaneous joint bleeding and a family history of bleeding should be tested for both haemophilia A and B. The ability of laboratory testing using the aPTT to detect single factor deficiencies involved in the intrinsic coagulation pathway (factors VIII, IX, XI and XII) varies depending on the coagulometer and test reagent being used. In general, the aPTT will not be prolonged if a single factor level is reduced in the range of 30%-50%. Therefore, specific testing for factors VIII, IX and XI must be performed to adequately evaluate for the diagnostic possibilities of haemophilia A and B and factor XI

Figure 2. Laboratory testing for a patient with a positive bleeding history. Initial screening tests
Full blood count including platelet morphology and liver function tests Activated partial thromboplastin time (aPTT) International normalised ratio (INR) Thrombin time (TT) PFA-100

Disorders of primary haemostasis von Willebrand disease testing

Disorders of secondary haemostasis

Coagulation factor deficiencies

Platelet disorders

Prolonged aPTT
Intrinsic pathway factors Factor VIII Factor IX Factor XI

von Willebrand factor antigen assay Ristocetin co-factor activity or collagen binding assay If abnormal von Willebrand disease test, repeat with multimer studies to confirm. If high clinical suspicion, repeat testing

Platelet morphology and number Platelet aggregation (arachadonic acid, collagen, adenosine diphosphate, ristocetin) Repeat abnormal platelet aggregation studies

Prolonged INR
Extrinsic pathway factors Factor VII Factor X Factor V Factor II

Prolonged TT

Ristocetin is an antibiotic that causes agglutination in normal blood. In von Willebrand disease, abnormal agglutination occurs.

Fibrinogen If all initial screening tests are normal consider factor XIII screening

deficiency. Deficiencies of coagulation factors involved in the extrinsic and common pathways of haemostasis (factors VII, X, V and II) are less common than defects of primary haemostasis or haemophilias. Prolongation of the INR alone or in addition to a prolonged aPTT depends on the specific factor that is deficient. The diagnosis of each condition will require specific factor assays for confirmation. In disorders of primary haemostasis, all screening coagulation test results can be normal. If the bleeding history is suspicious a targeted set of studies must be

performed to comprehensively evaluate platelet function. Platelet morphology, aggregometry and, if necessary, platelet secretion and the enumeration of dense granules should be requested. Look for von Willebrand disease, the most common bleeding disorder, by assaying vWF:Ag, ristocetin co-factor activity, collagen binding and factor VIII concentrations. vWF:Ag concentration can be affected by several pre-analytical variables. It may be increased above baseline by vigorous exercise, stress and inflammation, and varies with menses, being lowest in the first 1-3 days of the menstrual cycle.

Hormonal therapy may increase vWF:Ag levels, but the lower doses of oestrogen in second- and third-generation oral contraceptive pills tend not to cause this affect. Individuals with a type O blood group generally have lower vWF:Ag levels. Therefore, testing on 2-3 occasions should be performed before confirming or ruling out the diagnosis of von Willebrand disease in a woman with excessive mucocutaneous bleeding. If there is laboratory evidence of von Willebrand disease, additional testing is necessary to identify the sub-type of the disease, including von Willebrand factor multimer assay, ristocetininduced platelet aggregation assay and factor VIII-binding assay if type 2N von Willebrand disease (a factor VIII deficiency caused by a decreased affinity of vWF for factor VIII) is suspected. These latter tests require expertise and experience to produce reliable results and are only available in a few laboratories. Any patient identified with a bleeding disorder should be referred to a haematologist to assess the appropriate long-term treatment plan.

be identified with this presentation are von Willebrand disease, platelet function disorders and, less commonly, factor XI deficiency. Carriers of haemophilia A and B uncommonly present with menorrhagia. What coagulation tests would you order? Initial screening tests should be ordered to identify the abnormal phase of haemostasis. This history of mucocutaneous bleeding is more likely to be a disorder of primary haemostasis, although it is not specific to any particular disorder of primary haemostasis. Perform all of the further tests to investigate for defects of primary haemostasis. Patients with von Willebrand disease typically have a normal aPTT and INR, and specific testing for von Willebrand disease should be performed. Similarly, platelet function disorders can only be detected by studies assessing primary haemostasis, such as PFA-100, and platelet aggregometry assays. An abnormality in either the aPTT or INR requires specific coagulation testing for haemophilia A and B, and factor XI deficiency, respectively.

Case study 1
A 35-year-old female presents with a history of menorrhagia. Gynaecological causes have been excluded. Menorrhagia is a loss of more than 80mL of blood per menstrual cycle, usually the amount required to cause iron-deficiency anaemia. Although a complaint of heavy menstrual loss can be subjective, predictors of menorrhagia include menses lasting more than eight days, passage of clots, flooding at night, iron-deficiency anaemia or a need for blood transfusion or iron infusion. What other aspects of the patients history are important to evaluate? Unexplained menorrhagia is a common presenting symptom in women with congenital bleeding disorders. Ask them about a family history of bleeding disorders and a personal history of excessive bleeding with tooth extraction, delivery, miscarriage or surgery because a positive response increases the likelihood of an underlying bleeding disorder being present. Bleeding disorders that are most likely to

Case study 2
An 18-year-old male presents with a spontaneous left knee haemarthrosis seven days after elective knee arthroscopy. What other aspects of the patients history are important to evaluate? If haemarthrosis occurs after a minor surgical procedure the possibility of a coagulation factor deficiency, in particular haemophilia A and B, should be considered. Ask about previous major and minor bleeding episodes, such as spontaneous muscle haematomas, profuse bleeding after circumcision or extensive ecchymoses in childhood. A family history of a diagnosed bleeding disorder, especially where only males are affected (X-linked), increases the likelihood of haemophilia A and B being diagnosed. What coagulation tests would you order? Initial screening tests should be undertaken paying particular attention to the aPTT and INR levels. If

either is prolonged, mixing studies should be performed. It is expected that this patient has a prolonged aPTT that corrects with mixing studies, and coagulation factors VIII, IX and XI should be assessed. This patient is more likely to have factor VIII or IX deficiency, because factor XI patients rarely have delayed, deep tissue bleeding. In this patient, if the aPTT is prolonged and does not normalise with mixing studies the presence of a neutralising factor antibody to factor VIII or IX, and rarely XI, is likely. This is considered to be a haematological emergency and the patient should be referred urgently to a haematologist for further assessment.

Case study 3
A 60-year-old male requires coronary artery bypass surgery. He has no personal or family history of bleeding but his aPTT is prolonged. You need to assess if the patient is at increased risk of perioperative bleeding. What further coagulation tests would you order? This is a common scenario. Mixing studies should be performed for all patients with prolonged aPTTs after heparin exposure has been excluded. Normalisation of the aPTT with mixing studies suggests a deficiency of factors VIII, IX, XI or XII. Factor XII deficiency classically prolongs the aPTT but is not associated with bleeding. Similarly, patients with factor XI deficiency may present with this scenario since bleeding symptoms among such patients are variable, and even patients with severely low levels may not bleed with trauma. Patients with factor VIII or IX deficiency might not have a history of bleeding because the deficiency is mild or they have not encountered any haemostatic challenges in the

past. Regardless of the severity, all patients identified with factor VIII, IX or XI deficiency should be referred to a haematologist for further assessment before surgical procedures. Patients with an aPTT that does not correct with mixing studies usually have a lupus inhibitor. Patients with a lupus inhibitor typically have a prolonged aPTT but the INR usually remains normal. Specific testing showing phospholipid dependence is necessary to confirm the presence of a lupus inhibitor. Patients with a lupus inhibitor are at increased risk of venous and arterial thrombosis and should receive thromboprophylaxis during high-risk periods, such as surgery. Patients with a prolonged aPTT that does not normalise with mixing studies and is not identified with a lupus inhibitor might have a neutralising factor antibody and should be referred to a haematologist for further assessment. An isolated prolonged INR that normalises with mixing studies is usually due to factor VII deficiency (especially if it is mild), and uncommonly a deficiency of factor II, V or X. Factor VII levels more than 10%-15% are not usually associated with clinical bleeding while patients with levels below this range have a variable bleeding history. Liver function tests should be checked in a patient with an isolated prolonged INR because factor VII is usually affected early on in liver disease and bleeding symptoms are uncommon.

Practice points
Patients with a suspected bleeding disorder require a careful history and examination. First, order screening tests, then direct specialised coagulation tests according to your findings.

Further reading
Rodeghiero F et al. How to estimate bleeding risk in mild bleeding disorders. Journal of Thrombosis and Haemostasis 2007; 5 (suppl 1):157-66. Greaves M, Watson HG. Approach to the diagnosis and management of mild bleeding disorders. Journal of Thrombosis and Haemostasis 2007; 5 (suppl 1): 167-74. Kouides PA, Kadir RA. Menorrhagia associated with laboratory abnormalities of hemostasis: epidemiological, diagnostic and therapeutic aspects. Journal of Thrombosis and Haemostasis 2007; 5 (suppl 1): 175-82.