Chapter 059. Bleeding and Thrombosis (Part 5)

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Epistaxis is a common symptom, particularly in children and in dry climates, and may not reflect an underlying bleeding disorder. However, it is the most common symptom in hereditary hemorrhagic telangiectasia and in boys with vWD. Clues that epistaxis is a symptom of an underlying bleeding disorder include lack of seasonal variation and bleeding that requires medical evaluation or treatment, including cauterization. Bleeding with eruption of primary teeth is seen in children with more severe bleeding disorders, such as moderate and severe hemophilia. It is uncommon in children with mild bleeding disorders. Patients with disorders of primary hemostasis (platelet...

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Chapter 059. Bleeding and Thrombosis (Part 5) Epistaxis is a common symptom, particularly in children and in dry climates, and may not reflect an underlying bleeding disorder. However, it is the most common symptom in hereditary hemorrhagic telangiectasia and in boys with vWD. Clues that epistaxis is a symptom of an underlying bleeding disorder include lack of seasonal variation and bleeding that requires medical evaluation or treatment, including cauterization. Bleeding with eruption of primary teeth is seen in children with more severe bleeding disorders, such as moderate and severe hemophilia. It is uncommon in children with mild bleeding disorders. Patients with disorders of primary hemostasis (platelet adhesion) do have increased bleeding after dental cleanings and other procedures that involve gum manipulation. Menorrhagia is defined quantitatively as a loss of >80 cc of blood per cycle, based on blood loss required to produce iron-deficiency anemia. A complaint of heavy menses is subjective and has a poor correlation with excessive
blood loss. Predictors of menorrhagia include bleeding resulting in iron-deficiency anemia or a need for blood transfusion, excessive pad or tampon use, menses lasting longer than 8 days, passage of clots, bleeding through protection, or flooding at night. Menorrhagia is a common symptom in women with underlying bleeding disorders and is reported in the majority of women with vWD and factor XI deficiency and in symptomatic carriers of hemophilia A. Women with underlying bleeding disorders are more likely to have other bleeding symptoms, including bleeding after dental extractions, postoperative bleeding, and postpartum bleeding, and are much more likely to have menorrhagia beginning at menarche than women with menorrhagia due to other causes. Postpartum hemorrhage is a common symptom in women with underlying bleeding disorders. This occurs most commonly in the first 48 h after delivery, but it may also be manifest by prolonged or excessive bleeding after discharge from the hospital. Women with a history of postpartum hemorrhage have a high risk of recurrence with subsequent pregnancies. Rupture of ovarian cysts with intraabdominal hemorrhage has also been reported in women with underlying bleeding disorders. Tonsillectomy is a major hemostatic challenge, as intact hemostatic mechanisms are essential to prevent excessive bleeding from the tonsillar bed. Bleeding may occur early after surgery or after approximately 7 days postoperatively, with loss of the eschar at the operative site. Similar delayed
bleeding is seen after colonic polyp resection by cautery. Gastrointestinal (GI) bleeding and hematuria are usually due to underlying pathology and procedures to identify and treat the bleeding site should be undertaken, even in patients with known bleeding disorders. vWD, particularly types 2 and 3, has been associated with angiodysplasia of the bowel and GI bleeding. Hemarthroses and spontaneous muscle hematomas are characteristic of moderate or severe congenital factor VIII or IX deficiency. They can also be seen in moderate and severe deficiencies of fibrinogen, prothrombin, and of factors V, VII, and X. Spontaneous hemarthroses occur rarely in other bleeding disorders except for severe vWD, with associated FVIII levels
from another cause or even unmask a previously occult mild bleeding disorder such as vWD. All NSAIDs, however, can precipitate gastrointestinal bleeding, which may be more severe in patients with underlying bleeding disorders. The aspirin effect on platelet function as assessed by aggregometry can persist for up to 7 days, although it has frequently returned to normal by 3 days after the last dose. The effect of other NSAIDs is shorter, as the inhibitor effect is reversed when the drug is removed. Many herbal supplements can impair hemostatic function (Table 59-2). Some have been more convincingly associated with a bleeding risk than others. Fish oil or concentrated omega 3 fatty acid supplements impair platelet activation. They alter platelet biochemistry to produce more PGI3, a more potent platelet inhibitor than prostacyclin (PGI2), and more thromboxane A3, a less potent platelet activator than thromboxane A2. In fact, diets naturally rich in omega 3 fatty acids can result in a prolonged bleeding time and abnormal platelet aggregation studies, but the actual associated bleeding risk is unclear. Vitamin E appears to inhibit protein kinase C–mediated platelet aggregation and nitric oxide production. In patients with unexplained bruising or bleeding, it is prudent to review any new medications or supplements and discontinue those that may be associated with bleeding. Table 59-2 Herbal Supplements Associated with Increased Bleeding