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risk for hemorrhage; hemorrhagic diathesis; bleeding disorder

An inherited or acquired tendency to bleed, including: 1) coagulation disorders 2) platelet disorders Etiology: - coagulation disorders - liver disease - increased risk of bleeding & thrombosis - decreased coagulation factors, vitamin K - decreased protein C, protein S & antithrombin - diminished & dysfunctional fibrinogen - coagulation factor deficiency - hemophilia A, hemophilia B - coagulation factor inhibitor - pregnancy, post partum, systemic lupus erythematosus, malignancy - disseminated intravascular coagulation - prolonged PT & aPTT, low plasma fibrinogen, high plasma D-dimer, schistocytes on peripheral smear - platelet disorders - thrombocytopenia - von Willebrand disease - thrombotic thrombocytopenic purpura - hemolytic uremic syndrome - heparin-induced thrombocytopenia Pathology: - primary or secondary defect in hemostasis - primary hemostasis involves formation of platelet plug at the site of vascular injury - secondary hemostasis occurs from exposure of tissue factor at the site of vascular injury with initiation of the coagulation cascade Clinical manifestations: - failure of primary hemostasis (platelet disorder) - mucocutaneous bleeding - epistaxis, gingival bleeding, easy bruising, menorrhagia - failure of secondary hemostasis (coagulation disorder) - bleeding into muscles & joints - delayed bleeding Laboratory: - prothrombin time (PT) & activated partial thromboplastin time (aPTT)* - mixing study if prolonged aPTT to distinguish coagulation factor deficiency from coagulation factor inhibitor (deficiency completely corrects) - bleeding time identifies platelet disorders & vascular integrity - platelet function testing as indicated - thrombin time: conversion of fibrinogen to fibrin - D-dimer in plasma identifies disseminated intravascular coagulation associated with excessive fibrinolysis [1] * see prothrombin time, activated partial thromboplastin time or coagulation disorder for differential diagnosis of PT & aPTT values Complications: - excessive bleeding after childbirth, surgery or trauma can occur from failure of primary or secondary [1]hemostasis

Specific

coagulation disorder; coagulopathy hereditary bleeding disorder platelet disorder; thromboasthenia

General

health risk factor(s)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14,16. American College of Physicians, Philadelphia 2006, 2012 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Stine KC, Becton DL. Bleeding disorders: when is normal bleeding not normal? J Ark Med Soc. 2009 Aug;106(2):40-2. PMID: 19715248
  3. Sallah S, Kato G. Evaluation of bleeding disorders. A detailed history and laboratory tests provide clues. Postgrad Med. 1998 Apr;103(4):209-10, 215-8. PMID: 9553596