APPROACH TO VAGINAL BLEEDING, APPROACH TO ELEVATED PT & PTT (NO MEMORIZATION NEEDED!)

AM Report Pearls: Approach to Vaginal Bleeding

  • First, rule-out pregnancy!
  • Secondly, determine whether patient is pre- or post-menopausal
  • Pre-menopausal Vaginal Bleeding Ddx:
    • Dysfunctional uterine bleeding from PCOS
    • Fibroids
    • Pelvic inflammatory disease
    • Ovarian torsion
    • Ruptured ovarian cyst
    • Disorders of coagulation – #1 most common is von Willebrand’s Disease – most common autosomal dominant disease ~1/100 people
  • Post-menopausal Vaginal Bleeding Ddx:
    • Must rule-out endometrial carcinoma
    • Also consider uterine cancer, cervical cancer as well
    • Endometrial hyperplasia
    • Disorders of coagulation also can present here, but less commonly, think about acquired causes of coagulopathy

AM Report Pearls: Approach to Elevated PT/PTT

  • Isolated elevated PT: Think of Vitamin K antagonists like warfarin, liver disease
  • Isolated elevated PTT: Think of heparin, hemophilias, APLS
  • Both PT & PTT elevated: Think of DIC, factor deficiencies (either acquired or congenital: must be very distal in the coagulation cascade or very proximal and affecting both intrinsic & extrinsic pathways), inhibitors (either acquired or congenital)
    • Next step is to do a mixing study with normal plasma
      • If it corrects – clotting factor deficiency – so do assays to identify deficiency
      • If it doesn’t correct – inhibitor – check for drug-induced inhibitor, specific factor inhibitors, or non-specific inhibitors like lupus anticoagulant

Approach to Test for Factors in a Rational Way: Nilay’s Table!

You could re-memorize the coagulation cascade again, or you could look at this nifty table that Nilay taught us on how to rationally approach how to think about the specific coagulation factor assays:

 

Disease

    V VII VIII X
DIC

Warfarin

Liver dz

Low

Normal

Low

Low

Low

Low

Low

Normal

Normal

Low

Low

Low

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