Haematology Watch



Approach to the patient with an unusual bleeding

Dr. Mehmood

Unusual bleeding means either relatively excessive bleeding after minor trauma or spontaneous bleed without any trauma



Differential diagnosis:

Hereditary à     - Haemophilia 

                        - von Willebrand’s disease

                        - Bernard-Soulier syndrome

                        - Platelet storage disorder

Acquired à   - Liver disease

                    - Vitamin K deficiency (Haemorrhagic disease of the newborn, Obstructive jaundice, malabsorption)

                    - Drugs (Heparin, Warfarin, thrombolytic therapy overdosage)

                    - Disseminated intravascular coagulation

                    - Massive transfusion of stored blood

                    - Thrombocytoenia

                    - Vasculitis

                    - Vitamin C deficiency





1.       Confirm that the patient bleeds unusually!

2.       Age: Neonate (Haemorrhagic disease of the newborn likely)

         Young patient (Congenital cause likely)

         Middle age to Old (Acquired cause likely)

3.       Gender: Male (X-linked cause likely)

              Female (Autosomal cause likely;Lyonisation)

4.       Duration: Acute (Acquired cause likely)

                Chronic (Congenital cause likely)

5.       Onset: Spontaneous (Coagulopathy likely)

           Traumatic (Coagulopathy/Platelet disorders)

           Delayed (FXIII deficiency likely)

6.       Location of bleed: Epithelial (Platelet disorders more likely than coagulation defect)

                             Joint spaces/muscle (Clotting factor deficiency likely)

                             Umbilical stump bleed (Afibrinogenemia, Hypo-/Dysfibrinogenemia, Factor XIII deficiency)

                             Facial purpura in neonate (Glanzmann thrombasthenia, severe thrombocytopenia)

7.       Past Hx: Excessive Bleeding after Tooth extraction/Tonsillectomy /Major surgery (Coagulation defect likely)                      

              Ch. Hepatitis (Liver disease likely)

              Snake bite (DIC likely)

              Malignancy of Gastrointestinal tract (Liver metastasis likely)

              Chronic diarrhea (Malabsorption of Fat-soluble vitamins likely)

              Gall stones (Obstructive jaundice/Fat-soluble vitamin deficiency likely)

              Fever/repeated infections (Pancytopenia due to aplasia or leukemia likely)

              Burns (DIC possible)                   

              Renal stones/Uremia (Platelet function defect likely)

              Leukaemia (Relapse)

8.       Treatment Hx: Warfarin, Heparin, Thrombolytics, Aspirin (Overdosage likely)

                        Operation (Delayed bleeding/ peroperative continuous bleeding)

                        Massive transfusion of stored blood (Dilutional thrombocytopenia and coagulopathy likely)

                        Cholecystectomy (deficiency of vitamin K due to malabsorption)

9.       Family Hx: Males from maternal side affected (X-linked cause likely)

                  Consanguinity (Autosomal recessive disease likely)

10.   Obstetric Hx: Complicated labour (DIC likely)

11.   Gynaecologic Hx: No. of pads used (Shows extent of bleed)


1. Look: Normal/Toxic

2. Consciousness: Grade it. (Poor in DIC, Intracranial bleed, Fulminant hepatic failure)

3. Pulse: For severity of bleed

4. Temp.: For fever (DIC likely)

5. B.P.: Hypotension (DIC)

6. Skin: Petechiae (Platelet disorder likely)

             Bruises (Platelet disorder/coagulopathy likely)

             Snake bite mark (DIC likely)

7. Joint: Swollen (Haemarthrosis: Coagulopathy likely)

8. Muscle: Swollen (Coagulopathy likely)

8. Operation/trauma site: Poorly healing scab on umbilical stump (FXIII deficiency)

9. Cannula sites: Continuous ooz (DIC likely)

10. Spleen: Massively enlarged (Sequestration of cells)

11. Percussion on abdomen: Ascites in Cirrhosis

12. Liver: Reduced dull note on percussion in cirrhosis



Laboratory Investigation

1. Screening tests:

               i. CBC:  Thrombocytopenia (Quantitative disorder)

                            Normal platelet count (Qualitative disorder)

                            Pancytopenia (Marrow aplasia/Leukaemia)

               ii. Peripheral blood morphology: Schistocytes (DIC), Reticulocytosis (DIC), MP (DIC), Blasts,

                                                              Giant platelets (BSS)

              Coagulation screen

               iii. PT: Monitoring of Warfarin. Deficiency of Factor VII, X, V, II, I

               iv. aPTT: Monitoring of Heparin. Deficiency of Factor VIII, IX, XII, XI, X, V, II, I

               v. Fibrinogen level: Reduced in DIC, A-/Hypo-fibrinogenemi; normal in Dysfibrinogenemia.

               vi. TT: Prolonged in Heparin therapy, Fibrinogen defects

               vii. CT: Bedside monitoring of Heparin therapy (Obsolete now; replaced by PT & APTT)

               viii. BT: Prolonged in reduced Platelet count/function, von Willebrand disease, Factor I defects

               ix. FDP: DIC, thrombolysis

               x. Hess’s test: Vessel wall defect, thrombocytopenia, platelet function defects

               xi. Mixing studies (for detecting most likely coagulation factor deficiency and inhibitors)

               xii. Euglobulin clot lysis time

2. Confirmatory tests:

               i. Platelet function tests

               ii. Factor assays (for confirmation of plasma levels of coagulation factors)

               iii. Liver Function Tests

iv. Renal Function Tests

               v. Urea solubility test (FXIII deficiency)

3. Additional tests:

           Rule out other causes of bleeding which are not considered a bleeding disorder e.g. carcinomas (colon, lung, prostate), peptic ulcer, urinary stones, repeated trauma at wounds, iatrogenic (instrumentation), schistosomiasis.