bleeding

Bleeding tendency

Haemostasis describes the normal process of blood clotting. It takes place via a series of complex, tightly regulated interactions involving cellular and plasma factors.
There are five main components:
1-Blood vessels
2-Platelets
3-Coagulation factors
4-Coagulation inhibitors
5-Fibrinolysis

Screening tests for bleeding tendency:

full blood count and blood film
prothrombin time (PT) - measures the activity of factors II, V, VII and X
activated partial thromboplastin time (APTT) - measures the activity of factors II, V, VIII, IX, X, XI and XII
if PT or APTT is prolonged, a 50: 50 mix with normal plasma will distinguish between possible factor deficiency or presence of inhibitor
thrombin time - tests for deficiency or dysfunction of fibrinogen
quantitative fibrinogen assay
D-dimers
biochemical screen including renal and liver function tests
Bleeding time ? platelet function analyser.


Hemophila
The commonest severe inherited coagulation disorders are haemophilia A and haemophilia B. Both have X-linked recessive inheritance. In haemophila A, there is FVIII deficiency . Haemophilia B (FIX deficiency). Identifying female carriers requires:
1- a detailed family history.
2-analysis of coagulation factors.
3- DNA analysis.
Prenatal diagnosis is available using DNA analysis.

Clinical presentation:

The disorder is graded as mild(>5-40%), moderate(1-5%) or sever(<1%) depending on the FVIII:C (or IX:C in haemophilia B) level .
The hallmark of the disease is recurrent spontaneous bleeding into joints and muscles, which can lead to crippling arthritis if not properly treated. Most children present towards the end of the first year of life, when they start to crawl then walk (and fall over).
Almost 40% of cases with severe disease present in the neonatal period, particularly with intracranial hemorrhage, bleeding post-circumcision or prolonged oozing from heel stick and venepuncture sites. The severity remains constant within a family.

Investigations:

1- prolong aPTT
2- normal aPT
3- quantitative assessment of factor IIIV concentrate

Management :

Recombinant FVIII concentrate for haemophilia A( or recombinant FIX concentrate for haemophilia B) is given by intravenous infusion whenever there is any bleeding.
If recombinant products are unavailable, highly purified, virally inactivated plasma-derived products should be used. The quantity required depends on the site and nature of the bleeding. In general, raising the circulating level to 30% of normal is sufficient to treat minor and simple joint bleeding.


Major surgery or life-threatening bleeds require the level to be raised to 100% and then maintained at 30-50% for up to 2 weeks to prevent secondary hemorrhage. This can only be achieved by regular infusion of factor concentrate (usually 8- to 12-hourly for FVIII, 12- to 24-hourly for FIX, or by continuous infusion) .
Dose for f IIIV :
desired level (%) × weight (Kg) × 0.5
Dose for f IX :
desired level (%) × weight (Kg) × 1.5

Intramuscular injections, aspirin and non-steroidal anti-inflammatory drugs should be avoided in all patients with haemophilia.


Home treatment is encouraged to avoid delay in treatment which increases the risk of permanent damage, e.g. progressive arthropathy. FVIII/IX is given to all children with severe haemophilia to further reduce the risk of chronic joint damage by raising the baseline level above 2%. Primary prophylaxis usually begins at age 2-3 years, and is given two to three times per week.
Desmopressin (DDAVP) may allow mild haemophilia A to be managed without the use of blood products. It is ineffective in haemophila B.

von Willebrand's disease (vWD)

Von Willebrand disease is a common disorder (found in 1% of the population) caused by a deficiency of von Willebrand factor
Von Willebrand factor (vWF) has two major roles:
it facilitates platelet adhesion to damaged endothelium
it acts as the carrier protein for FVIII, protecting it from inactivation and clearance.
vWD results from either a quantitative or qualitative deficiency of von Willebrand factor (vWF). This causes defective platelet plug formation and, since vWF is a carrier protein for FVIII, patients with vWD also are deficient in FVIII.


vWD
Clinical features :
bruising
excessive, prolonged bleeding after surgery
mucosal bleeding such as epistaxis and menorrhagia.

The inheritance is usually autosomal dominant.
In contrast to haemophilia, spontaneous soft tissue bleeding such as large haematomas and haemarthroses are rare.

vWD
Investigations :
1- vWF testing involves measurement of the amount of protein, usually measured immunologically as the vWF antigen (vWF:Ag).
2-vWF activity (vWF:Act) is measured functionally in the ristocetin cofactor assay (vWFR:Co), which uses the antibiotic ristocetin to induce vWF to bind to platelets.
3- aPTT mildly prolonged.
4- bleeding time is prolonged.

vWD
Management :
1- Mild vWD can usually be treated with DDAVP, which causes secretion of both FVIII and vWF into plasma.
2- More severe types of vWD have to be treated with vWF- FVIII concentrate.
3- Cryoprecipitate is no longer used to treat vWD as it has not undergone viral inactivation.
4-Intramuscular injections, aspirin and non-steroidal anti-inflammatory drugs should be avoided in all patients with vWD.


Acquired disorders of coagulation
The main acquired disorders of coagulation affecting children are those secondary to:
haemorrhagic disease of the newborn due to vitamin K deficiency .
liver disease
ITP (immune thrombocytopenia)
DIC (disseminated intravascular coagulation).

Immune thrombocytopenia (ITP)

Thrombocytopenia is a platelet count <150 × 109/L.
The risk of bleeding depends on the level of the platelet count: severe thrombocytopenia (platelets <20 × 109/L - risk of spontaneous bleeding
moderate thrombocytopenia (platelets 20-50 × 109/L) - at risk of excess bleeding during operations or trauma but low risk of spontaneous bleeding
mild thrombocytopenia (platelets 50-150 × 109/L) - low risk of bleeding during operations or trauma

ITP
Childhood ITP is a common disorder in children that usually follows an acute viral infection. Childhood ITP is caused by an antibody (IgG or IgM) that binds to the platelet membrane. The condition results in Fc receptor-mediated splenic destruction of antibody-coated platelets. Rarely, ITP may be the presenting symptom of an autoimmune disease, such as systemic lupus erythematosus.
The reduced platelet count is accompanied by a compensatory increase of megakaryocytes in the bone marrow.

ITP
Clinical picture
Most children present between the ages of 2 and 10 years, with onset often 1-2 weeks after a viral infection. Affected children develop petechiae and purpura and superficial bruising . It can cause epistaxis and other mucosal bleeding but profuse bleeding is uncommon.
Intracranial bleeding is a serious but rare complication, occurring in 0.1-0.5%, mainly in those with a long period of severe thrombocytopenia.


ITP
Diagnosis
1- History and examination.
2- CBC and blood film.
3- Bone marrow examination ??

ITP
Management
1- steroid .
2- IV IG.
3- anti D immunoglobulin to patient with Rh +ve bl gp.
4-Platelet transfusions are reserved for life-threatening haemorrhage as they raise the platelet count only for a few hours.
5- Splenectomy is indicated in acute ITP only for life-threatening bleeding
In about 80% of children, the disease is acute, benign and self-limiting, usually remitting spontaneously within 6-8 weeks. Most children can be managed at home and do not require hospital admission.

ITP
Chronic ITP: In 20% of children the platelet count remains low 6 months after diagnosis; this is known as chronic ITP.
No treatment is given unless there is major bleeding, treatment is mainly supportive, the child should avoid contact sports but be encouraged to continue normal activities, including schooling.
Splenectomy may benefit patient with significant bleeding, but has significant morbidity and may be unsuccessful in up to 25% of cases.
If ITP in a child becomes chronic, regular screening for SLE should be performed, as the thrombocytopenia may predate the development of autoantibodies.