Bleeding disorder

BABYLON UNIVERSITY
COLLEGE OF DENTISTry

LECTURE1-3
Bleeding disorder
Bleeding disorder are conditions that alter the ability of blood vessel, platelets and coagulation factor to maintain homeostasis we have inherited bleeding disorder which are genetically transmitted and aquired bleeding disorders occur secondary to disease affecting vascular wall integrity, platelets , coagulation factors such as drugs ,radiation ,chemotherapy and cancer.

Normal control of bleeding
1-Vascular phase:
a- vasoconstriction in the area of the injury .
b- It begins immediately after injury.
2-platelets phase:
a- platelets and vessel wall will become sticky.
b- Mechanical plug of platelets seals off the opening of the vessel.
c- Begin seconds after injury.
3-Coagulation phase:
a- blood lost into surrounding area coagulates through extrinsic and common path way.
b- Take place more slowly than other phases.
4- Fibrinolytic phase:
a- release of antithrombotic agents b- Spleen and liver destroy the antithrombotic

Clinical presentation(sign&symptom)
Sign of bleeding may appear in the skin, mucous membrane, after trauma, invasive procedures, jaundice, acchymoses and may be hemathrosis due to bleeding in the joint.
Detection of patient who is bleeder:
1-History:
a-family history with hereditary bleeding diseases such as hemophilia.
b-bleedingproplems after operation and tooth extraction.
c- bleedingproplems after trauma.
d-spontaneous bleeding from nose, mouth, and ear.
e-Medication that cause bleeding problem:
1-Aspirin.2-Anticoagulant.3-Long term antibiotic therapy.
f-presence of illness that may have associated bleeding disorder:
1-Leukemia 2-Liver disease 3-Hemophilia 4-Congenital heart disease
5-Renal disease.
2-sreen lab test:
a-Bleeding time: normal 1-6min.It is increase in von will brand disease.
b-Platelet count: normal count is 150000-250000mm and there is bleeding disorder if less than 60000-80000mm.
c-Prothrombinetime:normal 11-15second and increase in patient with anticoagulant.
d-Partialthromboplastine time: normal 25-35second and increase if patienthave any defect in the intrinsic path way also increase in hemophilia andChristmas disease .
Types of bleeding
1-Primary bleeding: occur immediately after injury or during surgery.
2-Reactionary bleeding: occur after 6-8hr after surgery due to hypertention or slip suture .
3-Secondary bleeding: occur after 7days after surgery due to infection.
Management of bleeding :
1-Suture.2-pressure 3-local anesthesia 4-Hemostatic agent.5-heat application.
6-Freezing 7-Lagation 8-Cuttary 9-Lazer
10-Anterior and posterior nasal pack (in levortII).
Inherited coagulation disorders:
.Haemophilia A
This is an X-linked recessive disorder that thereforeaffects only males but which is transmitted by females.The prevalence is about 1:10000. Statistically, all the
daughters of haemophiliacs will carry the gene and noneof the sons will inherit the disease or transmit it. However,in the second generation, only 50% of the sons of
female carriers will inherit the disorder and only 50%of their daughters will inherit the gene.Haemophilia A can be caused by a number of geneticabnormalities, all of which result in decreased or absentfactor VIII:C. Deficiency of factor VIII:vWF results in
the closely related von Willebrand s disease (see below).Different affected individuals have a different level ofVIII in the blood and there is therefore a spectrum ofdisease. Factor VIII levels can be measured in the patient splasma and are expressed as a percentage of normal.Bleeding into joints causing arthritis is common and
produces clinically obvious joint deformities in manycases. Bleeding can also occur into body cavities andintracranially.Preoperative transfusion of factor VIII concentrate isaimed at raising factor VIII levels to nearer normal, forexample, 60% for dental extraction, and as near 100% aspossible for major surgery. These levels need to be
maintained postoperatively.
Haemophilia B
This is also known as Christmas disease. It is similar tohaemophilia A but the disorder is related to deficiencyof factor IX. The incidence is less common, with a
prevalence of around 1:100 000 and the defect can becorrected by the transfusion of fresh-frozen plasma(FFP).
vonWillebrand s disease
vonWillebrand s disease is not sex-linked and can occurvia a number of genetic abnormalities. It is usually due toautosomal dominant inheritance.abscence of chromosome 12.
Acquired coagulation disorders:
1-Warfarin therapy
Warfarin, a coumarin drug, is a vitamin K antagonist (itprevents conversion of vitamin K to an active form).Warfarin therapy is indicated in a number of commonconditions including atrial fibrillation, pulmonaryembolus and prosthetic heart valve replacement. Normalmedical practice for most conditions dictates thatwarfarin therapy should be administered to achieve anINR of around 3. Excessive bleeding will occur wherethe INR is greater than 2.The effects of warfarin are slow to reverse because,again, even if vitamin K is administered, the clottingfactors still have to be synthesised. When emergencysurgery is needed, vitamin-K-dependent factor concentratescan be administered intravenously, reducing theINR quickly, as noted above in obstructive jaundice. Thismust always be done with care. A balance needs to be
achieved between maintaining an acceptable level ofanticoagulation (e.g. to prevent thrombosis. of aprosthetic heart valve) and not exposing the patient to the
risk of haemorrhage during surgery. It is vital, therefore,that the administration of these concentrates is done inconsultation with a haematologist, and that the INR is
maintained well above 1. It is recommended that patientsundergoing elective surgical should have their warfarinstopped for 2-3 days before surgery and, depending on42
the procedure to be performed, are perhaps switchedperioperatively onto faster and more malleable anticoagulationtherapy with heparin. Coagulation tests
should always be performed on the morning beforeoperation. In most cases, an INR of 2 is acceptable. Indental procedures, an INR of less than 4 is acceptable
because local haemostatic measures can be used as anadjunct.
2-Heparin:natural short acting on the clotting stage.
3-Aspirin:antiplatelet, can acton the first stage so increase bleeding time.