Hemostasis for Primary Care, ENT, and OB/GYN Amber M. Federizo, - - PowerPoint PPT Presentation

Hemostasis for Primary Care, ENT, and OB/GYN

Amber M. Federizo, APRN, FNP-BC Hemostasis Board Certified

Pre-Questionnaire Link

• https://goo.gl/forms/MGUJAM5GRyjt0eqO2

Introduction

• Hemostasis and Thrombosis Center of

Nevada

• Nevada’s only federally recognized

treatment center.

• Comprehensive care
• CDC studies
• Background

Primary Care/ENT/OB/GYN

• Forefront of encounters for easy bruising,

epistaxis, and uterine bleeding. 16 years

Hemophilia

• Inheritance
• Spontaneous
• Acquired
• Reduced clotting factors – levels can be

discordant with phenotypic expression

Diagnosis

• PT, PTT (if prolonged) Factor activity

testing.

• Problematic for females

– Definitive testing. Activity levels and genetics

FVII (7) PT About 12 seconds PTT Factor 8, 9,11,12 About 25-39 seconds Prolongation of both Factor 1, 2, 5, 10

Treatment

• Infusions of clotting factors 100%

Case #1

• 8 year old male, history of easy bruising and occasional nosebleeds
• Presented to PCP with left knee swelling/warmth and pain.
• Despite conservative methods pain and swelling worsened
• Referred to orthopedics
• Orthopedics pursued needle aspiration of the knee – fluid and blood
• Discharged. Knee worsened in 48 hours. PT, PTT slightly prolonged.

Hematologist/Oncologist consult notes as not significantly delayed. Orthopedics completes second needle aspiration of the knee.

• Discharged again. Presented in 24 hours without ability to walk.

Knee swollen to 2-3 times normal hot to the touch and extremely

• painful. PT, PTT on admission slightly prolonged federally

designated hemophilia treatment center consulted. Diagnosed with Mild Hemophilia A. Treated with daily factor for one month and PT.

Case #2

• 28 year old female G1P0 develops bleeding at 28 weeks gestation.
• Family history of Hemophilia (father)
• Bleeding increases over the next few hours.
• Patient provides family history and assured bleeding could not be

due to hemophilia since she is female.

• Bleeding becomes perfuse, miscarries and requires 5 units of

PRBC

• Family self refers to HTC
• Determined to have Hemophilia a 17%.
• Given plan for factor as she is non-responsive to DDAVP

von Willebrand Disorder

• Most common
• Mucocutaneous bleeding
• Delays in diagnosis

– Female gender – Initiation of hormones prior to testing – Cautery of nasal mucosa prior to testing

Von willebrand

Platelet GpIIb/IIIA VWF GpIb CR Endothelium

Von willebrand

Platelet GpIIb/IIIA VWF GpIb

CR

Endothelium

Diagnosis

• A complete von Willebrand Panel includes

– VWF antigen – VWF ristocetin cofactor activity – FVIII (8) activity – Multimeric analysis 1.Pre-analytic variables

– Processing, anxiety (fear of needles), prescribed hormones,

Von Willebrand Type 1

Platelet GpIb CR Endothelium

Treatment

• Anti-fibrinolytics – preferred

– Lysteda 25mg/kg per dose average adult 650mg PO TID – Amicar 50mg/kg/dose PO every 6 hours.

• Hormones
• DDAVP

– 2B/3/Non-responsive Type 1

• VW Factor concentrate

Case #4

32 year old family and personal history of heavy menstrual periods

• started on hormones with some improvement but still with heavier

periods.

• Anemia with some improvement
• Discontinues hormones to become pregnant. Symptoms improve

dramatically.

• Delivers without complications but experiences a postpartum

hemorrhage and develops a delayed perineal hematoma. PT, PTT normal.

• Referred to hematology. VWF ag 10% VWF Rco 10% FVIII 55%

Case #5

• 15 year old male
• Epistaxis 2-3 times a week between 10-30 minutes in duration x 2

years

• Denies picking
• Referred to ENT for epistaxis
• Cauterized x 8
• Episodes worsened
• Presented to ER with 4 hour profuse bleeding.
• PT, PTT normal. Hemoglobin 8. Consult with HTC patient found to

have VWD type 2M. Started on intranasal amicar, personal lubricant, and on demand treatment with VWF concentrate with improved control of epistgaxis

Case #6

• 50 year old female
• History of epistaxis, easy bruising, heavy periods until

menopause at age 45

• Complains of occasional epistaxis
• Undergoes colonoscopy with biopsy and polyp removal.

Does well and is discharged.

• 4 days later presents with GI bleed. Further testing

reveals Type 1 VWD. Patient is treated with VWF concentrates and pre-treated for all future procedures.

Case #7

• 3 year old with epistaxis
• Tested for VWD comes back WNL
• Undergoes cautery with some improvement
• Undergoes clearance for Tonsillectomy and Adenoidectomy. PT PTT

normal platelet count on CBC normal

• Undergoes surgery. Day 10 has perfuse bleeding. Attributed to

sloughing of eschar. Continues to ooze for 21 days.

• Seen by HTC initial work-up negative. Platelet aggregation

consistent with Bernard solier.

What can be done

• Obtain testing at presentation before

intervention

– VWD Quest – VWD LabCorp Strong clinical suspicion beyond normal levels warrants a referral. POC for remote patients yearly with interimn follow-up and management with PCP.

Post Questionnaire Link

• https://goo.gl/forms/6QkGglp64kbPeTV72