Week 5- Prolonged heavy periods Flashcards
Sam, a 22-year-old female, presents to the GP with a history of prolonged heavy periods.
Take a history of this patient.
HPC:
• She occasionally has spotting between periods. This has gotten worse after birth of first child 2 years ago. ‘I thought things would get better but it isn’t’. Had a post partum haemorrhage and required blood transfusion of 2 units of blood ‘I have had a nose bleed this morning driving into appointment - I haven’t had one of those for age’.
• Often gum bleeds when bruising, had frequent nose bleeds as a child. (On examination, may find petechiae or purpura on skin or oral cavity).
• No SOB, recent fevers, infections, weight loss or nausea.
• No H/o liver, renal disease or taking drugs* (can also cause bleeding disorder).
• Mother easy bruising, hysterectomy for menorrhagia.
• No hepatosplenomegaly, no lymphadenopathy (exclude haematological malignancy e.g. leukaemia/lymphoma).
• Lab: Hb 136g/L, WBC 7.7x109/L (normal), Plt 270x109/L (normal).
• Coagulation studies - PT* 12 sec (normal). PTT* 38 sec (prolonged). Bleeding time* 13 mins (prolonged - normal ~10 mins). VWF: 28 IU/dL (low - most factors ~100 - deficiency causing bleeding <30).
HPC: • Onset - when did it first start? • Frequency - how often does it occur? • Character - volume of blood? • Alleviating factors? • Timing - experienced it before? How long does it usually last? Constant or intermittent? • Exacerbating factors? • Severity? • Associated symptoms? • Effect on lifestyle?
- Associated bleeding? i.e. gums, nose.
- Excessive bleeding from minor wounds?
- Easy/excessive bruising?
- Recent fever or infections?
- Weight loss or nausea?
- Recent overseas travel or illness?
- Dyspnoea or chest pain?
PMHx:
• Past history of any bleeding disorders, anaemia, liver disease, renal disease?
• Obs/gyn? i.e. menstrual history, childbirth.
PSHx:
• Any past surgeries or blood transfusions? Any complications?
Medications:
• Any regular medications? i.e. drugs that cause bleeding.
Allergies:
• Agent, reaction, treatment?
Immunisations:
• E.g. Fluvax, pneumococcal?
FHx:
• Family history of any bleeding disorders?
SHx: • Background? • Occupation? • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity?
Systems Review:
• General - weight change, fever, chills?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea?
• GI - bleeding? i.e. haematemesis, haematochezia/melaena.
• UG - haematuria?
• CNS - heachaches, nausea, bleeding?
• ENDO - heat/cold intolerance, swelling in throat/neck?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - joint bleeds (haemarthrosis)?
Perform an exam
- Introduction, explanation, consent, wash hands.
- General inspection: consciousness/orientation, distressed, anxious, pallor, bruising, bleeding.
3. Vitals signs: • HR - may be tachycardic. • RR - may be tachypnoeic. • BP • Temp - may be febrile.
4. Hands/arms: • Warm/cold, dry/sweaty, pallor. • Koilonychia, pallor of nail beds, CRT. • Arthropathy, petechiae/purpura. • Bruising. • Epitrochlear/axillary lymph nodes.
- Face:
• Eyes - conjunctival pallor.
• Nose - discharge/deformity, bleeding.
• Mouth - gum bleeding. - Neck:
• Cervical lymph nodes.
7. Abdomen: • Inspection - visible masses. • Palpation - hepatosplenomegaly, masses. • Percussion - fluid. • PR for bleeding. Genital examination.
8. Legs: • Bruising. • Purpura. • Pallor. • Oedema. • CRT. • Joint bleeding.
- CVS:
• Auscultation.
• Stigmata of liver disease - confused/drowsy, jaundice, cachetic/obese, muscle wasting, distended abdomen, erythema, Dupuytren’s contracture, tremor, hepatic flap, clubbing, leuconychia, Muehrcke’s lines, bruising/petechiae, scratch marks, icterus, parotid gland enlargement, angular stomatitis, fetor hepaticus, glossitis, gynaecomastia, spider naevi, prominent veins, hepatospenomegaly, ascites, oedema.
What is the patients primary presenting complaint
Menorrhagia - heavy periods (excessive blood loss with periods).
• Metrorrhagia - uterine bleeding at irregular intervals usually between menstrual periods (abnormal bleeding from uterus).
DDx - ectopic pregnancy, endometrial/gynaecological malignancy, endometrial polyps, liver or renal disease/failure, uterine fibroids, hyper/hypothyroidism, pelvic inflammatory disease.
What tx is needed
- Explanation and genetic testing - her daughter will require testing for this disorder. It can be inherited as a autosomal dominant or recessive gene. Affects approximately 1% of the population.
- Endometrial ablation - this will result in fibrosis of the endometrium. Important to consider if the patient has completed her family before deciding on endometrial ablation.
- Desmopressin is used in mild bleeding, VWF containing FVIII concentrate for surgery or major bleeds.
- Fresh frozen plasma/cryoprecipitate - contain VWF.
What other history is relevant
- History of liver disease: coagulopathy - due to impaired production of coagulation factors. The liver produces coagulation factors I (fibrinogen), II (prothrombin), V, VII, IX, X and XI as well as protein C, protein S and antithrombin.
- History of renal disease - renal impairment or failure.
- Medications - drugs that cause bleeding.
- Family history - genetic diseases that may cause bleeding e.g. haemophilia A/B, VWD.
What role does VWF play in haemostasis
- Brings platelets into contact with exposed subendothelium (connects the platelets to the sub-endothelium).
- Binds platelets to each other.
- Binds to FVIII, protecting it from destruction in the circulation.
*Revise intrinsic and extrinsic clotting pathways.
What is your provisional/ddx
Platelet dysfunction, immune thrombocytopenia.
• Provisional diagnosis: Von Willebrand Disease.
• DDx:
- Immune thrombocytopenia - primary autoimmune ITP accounts for around 85% of cases. Secondary causes include - SLE, viral infections, EBV, CMV, hepatitis C, HIV. Dengue and malaria may also cause thrombocytopenia.
- Haemophilia A/B.
- Bernard Soulier syndrome.
- Glanzmann’s thrombasthenia.
- DIC, TTP, HUS.
What ix is needed
- FBC - Hb, WCC, platelets.
- U+Es.
- LFTs.
- aPTT.
- PT/INR.
- Fibrinogen level.
- VWF antigen/function assay and FVIII activity - screen for the most common platelet dysfunction. These also need to be repeated as false negatives results are common. Can also be common in 40% of healthy people with type O blood.
