Week 6 - 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 a physical examination on this patient.
- 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 your provisional diagnosis and differential diagnoses?
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 investigations would you carry out on this patient?
- 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.
What treatment does this patient require?
- 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 is the patient’s 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 other history is relevant in this patient?
- 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.
- See additional case.
