Evaluation of the patient with a bleeding tendency

Clinical assessment

An apparent bleeding tendency is a common clinical problem, with presentation varying from acute unexpected bleeding during or immediately after surgery, to spontaneous unusual or excessive bruising, purpura, epistaxis, or a chronic haemorrhagic tendency. The following are important aspects of the assessment of the patient.

Is haemostatic capacity reduced, or is there a nonhaematological cause for bleeding?—recurrent bleeding from a single site suggests a structural vascular abnormality, whereas bleeding at many different sites suggests a systemic haemostatic defect. Other elements of history or examination that suggest reduced haemostatic capacity include (1) after dental extraction—bleeding that lasted more than an hour, rebleeding, or late bleeding requiring suturing on more than one occasion; (2) after surgery—unusual or prolonged bleeding; (3) bleeding in unusual sites, e.g. into joints; (4) very extensive bruising, particularly over soft areas that are not likely to be traumatized, and bruises more than 5 cm in diameter in the absence of trauma. Ecchymoses suggest coagulation factor deficiencies (e.g. classical haemophilia, liver disease) and petechiae suggest thrombocytopenia or a vessel wall defect, but these distinctions are not invariable.

If haemostatic capacity is reduced, is it due to a heritable defect with late clinical presentation, or is it the result of a newly acquired defect?—long-standing bleeding symptoms suggest a lifelong condition, whereas recent-onset bleeding suggests an acquired disorder. If a bleeding disorder has been diagnosed and characterized in another family member, then the cause of bleeding may be easily identified, but the absence of a family history does not exclude a heritable disorder.

If the bleeding disorder is newly acquired, is it due to an anticoagulant drug?—the commonest cause of an acquired bleeding disorder is antithrombotic therapy.

Clinical investigation

The routine evaluation of many patients includes the full blood count (including platelet count), prothrombin time (PT) and activated partial thromboplastin time (APTT), but (1) the platelet count gives no indication of platelet function; (2) the PT and APTT are insensitive; hence (3) comprehensive laboratory assessment of haemostatic capacity is indicated if these are normal but the history is suggestive of an underlying bleeding disorder.

Investigations include (1) full blood count and film—severe bleeding rarely occurs in the absence of trauma with a platelet count of more than 20 to 30 × 10⁹/litre; automated machines may not count platelets reliably in some conditions, hence a blood film must be examined; (2) PT—the time taken in seconds for a fibrin clot to form after recalcification and addition of thromboplastin; (3) APTT—the time taken in seconds for a fibrin clot to form after recalcification and exposure to a contact factor activator; (4) fibrinogen level; (5) thrombin time—the time taken in seconds for a fibrin clot to form after addition of thrombin; (6) reptilase time—prolonged by low fibrinogen levels, but not by heparin, hence useful for determining if a prolonged APTT is due to heparin; (7) individual factor assays—useful in patients with a bleeding history and guided by PT and APTT results; (8) mixing studies—can indicate if prolongation of PT or APTT is likely due to a factor deficiency or an inhibitor; (9) platelet function analysis; (10) bleeding time—now rarely used.

Treatment of bleeding

Aside from general supportive care, specific therapy can be given when a defined haemostatic abnormality is identified. Drugs that cause bleeding should be stopped. Vitamin K should be given to critically ill patients and patients with liver disease. Early and sufficient blood product support should be given to those with massive blood loss and/or dilutional coagulopathy. Judicious use of fresh frozen plasma and platelets should be given to patients with severe coagulopathy such as disseminated intravascular coagulation while the underlying condition is being treated. Patients with overt haematological disorders will require specialist care.