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Case History

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Image not available. A 28-year-old woman is referred by her General Practitioner as she is complaining of easy bruising and menorrhagia.

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Background

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Initial management

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Image not available. A thorough, detailed history of the bleeding is vital in the assessment of patients with potential haemostatic defects, and it will impact on the extent of investigation.

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The duration of bleeding/bruising is important when considering whether the patient is likely to have a congenital or acquired haemostatic disorder. Bleeding since childhood, such as menorrhagia since menarche, would usually suggest a congenital disorder; however, mild congenital disorders of coagulation may present in adult life.1 A family history of abnormal bleeding clearly would also support the presence of a congenital defect.

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It is useful to establish the details of bruising, in particular whether it is spontaneous, occurs after minimal trauma or after surgery, and its extent.

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Tonsillectomy and dental extraction in particular pose significant haemostatic challenges and if these have not been associated with significant bleeding, a congenital disorder of haemostasis is much less likely.

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Bleeding or bruising on multiple occasions and from different sites merits more extensive investigation as this suggests a systemic haemostatic defect. Repeatedly bleeding from one site, such as epistaxis from the same nostril, suggests a structural abnormality.

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Mucocutaneous bleeding (epistaxis, bruising, menorrhagia, gastrointestinal bleeding) as in this case suggests a disorder of platelet function.

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Coagulation factor deficiencies are more likely to be associated with haemarthrosis, muscle haematoma and post-operative bleeding.

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Although menorrhagia is a common gynaecological symptom, a specific cause is identified in less than 50% of affected women.2 Studies have shown that bleeding disorders are found in a substantial proportion of women with menorrhagia and a normal pelvis examination. Inherited bleeding disorders have been diagnosed in 17% of such patients, with von Willebrand’s disease being the most common abnormality.2

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Systemic illness, in particular uraemia and liver disease, may cause abnormalities of haemostasis (Table 4.1).

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Table Graphic Jump Location
Table 4.1Causes of platelet disorders
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A detailed drug history is clearly relevant; aspirin and non-steroidal anti-inflammatory agents are common culprits causing platelet function defects, but many drugs are implicated (Table 4.2).

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Table Graphic Jump Location
Table 4.2Drugs and other agents known to interfere with platelet function

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