Inherited Bleeding Disorders in Women

Preface to Second Edition

It has been a privilege to edit the second edition of Inherited Bleeding Disorders in Women.

The first edition was published in 2009, almost a decade ago, and during that time there has been enormous endeavor in the research, management, and education of inherited bleeding disorders in women. This is reflected in the contents of this new edition.

We have comprehensively updated the chapters covering the gynecological and obstetric issues for carriers of hemophilia, women with von Willebrand disease, rare bleeding disorders, and inherited platelet disorders to provide an evidence‐based, practical approach to management. The enormous developments in genetic analysis are included in the chapters on laboratory and antenatal diagnosis. New chapters include the use of bleeding assessment tools in the context of women's health, and a consideration of inherited bleeding disorders in different cultures and marriage within the family.

As before, the book is a collaboration, written by hematologists, obstetrician‐gynecologists, laboratory scientists, a nurse, and anesthetists who have expertise in the field. Our aspiration continues to be the high quality of care for women with inherited bleeding disorders worldwide and we hope this book will be useful for those providing care and for the affected women themselves.

January 2018

Rezan A. Kadir

Paula D. James

Christine A. Lee

Cover image: ‘Menorrhagia Healing’

© Barbara Bruch 1991

Preface to First Edition

In 1926, Erik von Willebrand described a large kindred from the Åland Islands, an archipelago in the Baltic Sea, many of whom had a bleeding disorder. The index case was a little girl called Hjordis, who presented with severe epistaxis and died at the onset of her fourth menstrual period. Her maternal grandmother died from hemorrhage after childbirth in her only pregnancy. Von Willebrand wrote that the condition was particularly prevalent in women. This first description of von Willebrand disease underlined the hemostatic challenges of menstruation and childbirth for those women with an inherited bleeding disorder.

Until recently, the predominant issue for men with hemophilia has been safe and effective treatment, and most effort has been directed to the resolution of transfusion‐transmitted disease. Furthermore, since hemophilia is a sex‐linked disorder, there has been a failure to recognize that women have inherited bleeding disorders. Thus, the substantial morbidity caused in women with inherited bleeding disorders has only recently been addressed in a comprehensive way. It is important that collaboration in the care and research of bleeding disorders in women continue as many challenges remain. The main task now is to identify those women who do not realize they may have a treatable condition. The patient advocacy organizations are crucial to this endeavor. There also remains the challenge of developing more effective, tolerable, and widely available therapies for controlling menorrhagia and postpartum hemorrhage.

This book is written by hematologists, obstetrician‐gynecologists, an anesthetist, and those involved in patient advocacy. It covers the gynecological and obstetric issues for carriers of hemophilia, women with von Willebrand disease, rare bleeding disorders, and inherited platelet disorders. We hope that this book is a modest step towards safe motherhood and provision of quality of care for women with bleeding disorders worldwide and that all those providing care for these women, as well as the women themselves, will find it useful.

December 2008

Christine A. Lee

Rezan A. Kadir

Peter A. Kouides

List of Contributors

Vanessa Bouskill, MN RN(EC)

Department of Nursing

Hospital for Sick Children

Toronto

Canada

Anne‐Sophie Bouthors, MD

Department of Anesthesia and Intensive Care

Maternité Jeanne de Flandre

Academic Hospital

Lille

France

Manuel Carcao, MD FRCP(C) MSc

Division of Haematology/Oncology

Department of Paediatrics and Child Health Evaluative Sciences

Research Institute

Hospital for Sick Children

Toronto

Canada

Claudia Chi, MBBS MRCOG MD FAMS

Department of Obstetrics and Gynaecology

National University Hospital

Singapore

Hilary O.D. Critchley, MD FRCOG FMedSci FRSE

MRC Centre for Reproductive Health

University of Edinburgh

Edinburgh

UK

Joanna S. Davies, MB ChB MD

Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre

Royal Free Foundation Hospital

London

UK

Roseline d'Oiron, MD

Reference Centre for Hemophilia and Rare Congenital Bleeding Disorders

University Hospitals Paris Sud – Bicêtre Hospital – APHP

Le Kremlin‐Bicêtre

France

Adrian England, MBBS FRCA MD

Department of Anaesthesia

Royal Free Hospital

London

UK

Anne C. Goodeve, BSc PhD

Department of Infection

Immunity and Cardiovascular Disease

University of Sheffield Medical School

Sheffield

UK

Irena Hudecova, PhD

Cancer Research UK

Cambridge Institute

University of Cambridge

Li Ka Shing Centre

Cambridge

UK

Paula D. James, MD FRCPC

Department of Medicine

Queen's University

Kingston

Canada

Rezan A. Kadir, MB ChB MRCOG FRCS(Ed) MD

Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre

Royal Free Foundation Hospital

London

UK

and

Institute for Women's Health

University College London

London

UK

Christine A. Lee, MA MD DSc FRCP FRCPath FRCOG

University College London

London

UK

Mike Makris, MA MBBS MD FRCP FRCPath

Sheffield Haemophilia and Thrombosis Centre

Royal Hallamshire Hospital

Sheffield

UK

Jackie A. Maybin, MB ChB MRCOG PhD

MRC Centre for Reproductive Health

University of Edinburgh

Edinburgh

UK

Marzia Menegatti, BSc PhD

Luigi Villa Foundation and Angelo Bianchi Bonomi Hemophilia and Thrombosis Center

Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico

Milan

Italy

Danijela Mikovic, MD PhD

Haemostasis Department with Registry of Inherited Bleeding Disorders

Blood Transfusion Institute of Serbia

Belgrade

Serbia

Carolyn M. Millar, MD FRCP FRCPath

Centre for Haematology and Department of Experimental Medicine

Imperial College Healthcare NHS Trust

Imperial College London

UK

Fadi G. Mirza, MD FACOG

Faculty of Medicine and Medical Center

American University of Beirut

Beirut

Lebanon

and

Columbia University

New York

USA

Bethan Myers, MA FRCP FRCPath

Department of Haematology

University Hospitals of Leicester NHS Trust and Lincoln County Hospital

Lincoln

UK

Sarah H. O'Brien, MD

Division of Pediatric Hematology/Oncology

Nationwide Children's Hospital/The Ohio State University College of Medicine

Columbus

USA

Sue Pavord, MB ChB FRCP FRCPath

Department of Haematology

Oxford University Hospitals NHS Foundation Trust

Oxford

UK

Flora Peyvandi, MD PhD

Angelo Bianchi Bonomi Hemophilia and Thrombosis Center

Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation

University of Milan

Milan

Italy

Jane Reavey, MA BMBCh MRCOG

MRC Centre for Reproductive Health

University of Edinburgh

Edinburgh

UK

Clare Samuelson, MB ChB MA

Sheffield Haemophilia and Thrombosis Centre

Royal Hallamshire Hospital

Sheffield

UK

Jameela Sathar, MD MRCP FRCPath

Department of Haematology

Ampang Hospital

Malaysia

Ali T. Taher, MD PhD FRCP

American University of Beirut Medical Center

Beirut

Lebanon

and

Emory School of Medicine

Atlanta

USA

Henna Wong, MBBS MRCP FRCPath

Department of Haematology

Oxford University Hospitals NHS Foundation Trust

Oxford

UK

Tahira Zafar, MB DCP FRCPath

Haemophilia Treatment Centre

Rawalpindi Islamabad

Pakistan

and

Pakistan Haemophilia Patients Welfare Society

Rawalpindi Islamabad

Pakistan

1

Hematological Assessment of a Patient with an Inherited Bleeding Disorder

Sue Pavord and Henna Wong

Oxford University Hospitals NHS Foundation Trust, Oxford, UK

1.1 Introduction

The inherited bleeding disorders (IBDs) are a heterogeneous group of disorders affecting the hemostatic system. In individuals in whom the underlying abnormality has been identified, the majority of IBDs are due to von Willebrand disease (VWD) and disorders of coagulation factors; a small proportion are due to abnormalities in platelet count or function or defects in the fibrinolytic system [1]. Around 2% of patients registered with a bleeding disorder do not have a classifiable disorder [1].

Individuals with IBDs may give a life‐long history of excessive bruising or bleeding, but many only manifest when faced with a hemostatic challenge or are picked up incidentally by abnormal coagulation tests. Indeed some, such as certain cases of factor XI (FXI) deficiency, may not have a bleeding phenotype at all, even when exposed to hemostatic challenges. IBDs can affect all genders, but women with IBDs face added challenges related to menstruation, pregnancy, and childbirth. Undiagnosed bleeding disorders can often be the cause of heavy menstrual bleeding and also the cause of or a contributory factor for other gynecological problems, such as bleeding from the corpus luteum [2].

Women with IBDs may present with a positive bleeding history or have a known family history. Manifestations of bleeding can vary, even within the same type of disorder, because of the influence of concomitant inherited and acquired factors. An integrated clinical and laboratory assessment is therefore essential in the diagnostic work‐up.

This chapter will cover the mechanisms of normal hemostasis and an approach to the clinical and laboratory hematological assessment of a patient with a suspected IBD.

1.2 Normal Hemostasis

After damage to the lining of the blood vessel wall, the body responds with physiological mechanisms to stop bleeding and maintain hemostasis, without causing more widespread thrombosis. This co‐ordinated process involves components of the blood, including platelets and clotting factors, with the overall aim of forming a stable blood clot (Figure 1.1). Hemostasis is achieved through a delicate balance of pro‐ and anticoagulant factors to stop bleeding while simultaneously avoiding development of pathological thrombi [3].

Figure 1.1 Overview of hemostasis and key components. A vascular injury exposes collagen that allows platelets to adhere via VWF to the subendothelium. Activation of platelets occurs and platelets aggregate together via VWF and fibrinogen. Primary hemostasis results in the formation of the initial platelet plug. Tissue factor activates the coagulation pathway in parallel with platelet activation; both pathways enhance each other. Fibrinolysis prevents excessive thrombus formation, through the generation of plasmin followed by the digestion of fibrin.

Source: Modified from www.thrombocyte.com/hemostasis‐definition.

1.2.1 Primary Hemostasis

In the early stages after vessel injury, interactions between platelets, the subendothelium, and adhesive proteins lead to the formation of a platelet plug (primary hemostasis). The three main steps of primary hemostasis are as follows.

Platelet adhesion: following vessel injury, von Willebrand factor (VWF) binds to specific sites on exposed collagen. Platelets adhere to the exposed subendothelial matrix (directly or indirectly via VWF). This is mediated through binding of VWF with the platelet glycoprotein GP1b, while GPVI interacts with collagen, and platelet β1 integrin with laminin, collagen, and fibronectin. These interactions enable firm adhesion of platelets to the exposed subendothelial matrix [3].

Platelet activation: platelet adhesion to the subendothelium triggers shape change and release of platelet α and dense granule contents. This activation recruits and activates additional platelets to the injured site. (Thrombin, produced by the coagulation pathway, adds to the activation of platelets.)

Platelet aggregation and platelet plug formation: thrombin cleaves fibrinogen and the resulting fibrin monomers form a bridge between activated platelets, causing platelets to aggregate together, forming a platelet plug. The GPIIb/IIIa platelet receptor is converted into its high‐affinity conformation, allowing for stable interactions between the receptor and fibrin, VWF, and fibronectin.

1.2.2 Secondary Hemostasis

Secondary hemostasis usually occurs simultaneously with primary hemostasis. After endothelial damage, tissue factor (TF) is exposed, which binds to and activates FVII. The TF‐FVIIa complex then stimulates generation of small amounts of thrombin and FXIa through the extrinsic pathway. Thrombin generation is amplified through the intrinsic pathway starting with FXI and through the downstream cascade including co‐factors FVIII and FV (Figure 1.2). These enzymatic reactions occur on the surface of platelets and other cell surfaces. This leads to the formation of FXa on the platelet surface which, aided by its co‐factor, FVa, generates an explosive burst of thrombin. Thrombin catalyzes the conversion of fibrinogen to fibrin. Fibrin polymers form a fibrin network, which is stabilized by FXIII. As the clot forms, circulating red blood cells, white blood cells, and platelets become incorporated into its structure.

Figure 1.2 Pathways of coagulation: the intrinsic (in vitro) pathway as measured by the activated partial thromboplastin time (APTT) and the extrinsic (in vivo) pathway as measured by the prothrombin time (PT). Both intrinsic and extrinsic pathways share a common final pathway.

1.2.3 Fibrinolysis

Fibrinolysis is tightly regulated by the fibrinolytic system. Fibrinolysis is initiated by the proteases tissue plasminogen activator (tPA) or urokinase‐like plasminogen activator (uPA), which convert plasminogen to the active plasmin. Plasmin cleaves fibrin and fibrinogen, leading to clot breakdown.

1.2.4 Cell‐Based Model of Hemostasis

The importance of cells and cell surfaces in hemostasis is reflected in the cell‐based model of hemostasis described by Hoffman and Monroe [4]. It is more representative of in vivo coagulation than the traditional cascade model. There are three main phases in the cell‐based model (Figure 1.3). The initiation phase occurs on the TF‐bearing cell. Injury exposes the TF‐bearing cell to flowing blood and plasma‐based VIIa. The TF‐VIIa complex results in the generation of a small amount of FIXa, Xa, and thrombin. In the second phase, amplification, the small amount of thrombin activates platelets, releases VWF, and leads to generation of FVa, FVIIIa, and FXIa. The propagation phase is characterized by the migration of large numbers of platelets to the site of injury and the production of the tenase complex, which results in FXa generation on the platelet surface. The FXa generated on platelets rapidly binds to Va and converts prothrombin to thrombin. Large amounts of thrombin are generated, converting fibrinogen to fibrin. The fibrin clot is stabilized by activation of thrombin‐activatable fibrinolysis inhibitor (TAFI) and FXIII.

Figure 1.3 Cell‐based model of hemostasis. The cell‐based model comprises three overlapping stages: (a) initiation, (b) amplification, and (c) propagation. (a) Initiation phase: this occurs on the TF‐expressing cell and is initiated when injury exposes the TF‐bearing cell to the flowing blood. A small amount of FIXa, Xa, and thrombin is formed. (b) Amplification phase: the small amount of thrombin generated from the initiation phase activates platelets, releases VWF, and leads to generation of activated forms of FV, FVIII, and FXI. (c) Propagation phase: activated coagulation factors from the previous phases aggregate on the platelet surface. FVIII complexes with FIX to form the tenase complex, resulting in FXa generation on the platelet surface. The prothrombinase complex forms and results in large amounts of thrombin generation. This thrombin burst leads to fibrin formation and also activates FXIII and TAFI. FXIIIa cross‐links fibrin strands to form a stable fibrin network, and TAFI protects the clot from plasmin‐mediated fibrinolysis.

Source: Adapted from Hoffman and Monroe [5] and Kessler [6].

Although the intrinsic and extrinsic pathways may be less representative of in vivo coagulation, an appreciation of the components of each pathway is helpful when interpreting abnormalities in the activated partial thromboplastin time (APTT) and prothrombin time (PT). Deficiencies of clotting factor may prolong the APTT (tests the intrinsic pathway) and PT (extrinsic pathway) (see Figure 1.2).

1.3 Defects of Hemostasis

The ability to achieve hemostasis and stop bleeding depends on the integrity of all components of the pathway [7] and knowledge of the underlying hemostatic defect can help with categorization of the bleeding disorder. For a patient with an undiagnosed disorder, it may be possible to predict whether the defect affects primary or secondary hemostasis from the type and pattern of bleeding elicited in the history.

The main IBDs can be categorized according to the underlying defect.

Hemophilia – deficiency of clotting factors FVIII (hemophilia A) or FIX (hemophilia B). Patients lack amplification of the coagulation cascade by FIX with co‐factor VIII [7].

VWD, where there is deficiency of VWF and therefore impaired platelet adhesion and aggregation.

Platelet function disorders, for example affecting the platelet receptor or platelet signaling pathways.

Rare coagulation disorders, such as deficiency of factors V, VII, IX, and XIII or fibrinogen disorders.

1.4 Clinical Presentation of Bleeding

Inherited bleeding disorders may manifest with a variety of bleeding symptoms. There may be considerable variability in symptom severity even in patients affected by the same disorder. Acquired defects in the hemostatic system, for example caused by antiplatelet or antithrombotic medication, may exacerbate any underlying inherited disorder. Disorders of primary hemostasis often present with mucocutaneous bleeding and the early onset of bleeding after injury or trauma, compared with more delayed bleeding or overt bleeding with disorders of secondary hemostasis (abnormalities with clotting factors or fibrinolysis).

Bleeding symptoms are common in healthy individuals; over 20% of the general population report at least one bleeding symptom [8]. In addition, by chance alone, 1 in 20 people will have a result outside the normal reference range. Under‐ and overdiagnosis of bleeding disorders can have serious sequelae. Underdiagnosis will lead to inappropriate or inadequate medical treatment, but with overdiagnosis, healthy individuals can be needlessly exposed to hemostatic therapy and potential complications [9].

Menstruation, pregnancy, and childbirth present recurrent hemostatic challenges to females with and without IBDs. Menorrhagia is the most common symptom experienced by women with an IBD (up to 80% of women with IBD report menorrhagia) [10]. However, it is also common in the general population; 5–10% of women of reproductive age will seek medical attention for menorrhagia [11]. Menorrhagia may be due to endocrine, inherited bleeding or gynecological disorders but prior to comprehensive hemostatic testing, the underlying etiology was only found in ~50% of cases [12]. An IBD is found in up to 20% of women with menorrhagia and a normal pelvic examination [9, 13–15], the most common being VWD [15]. Laboratory abnormalities of hemostasis, especially platelet function defects, are common among women with unexplained menorrhagia, but their clinical significance requires further study, especially if the abnormality is mild [14].

1.5 Diagnosis

Making a diagnosis of an IBD has life‐long consequences. An accurate diagnosis is important as the impact is far‐reaching, especially with precautions that affect perioperative management, work, and lifestyle activities as well as implications for screening and investigation of family members. Despite the development and use of standardized bleeding assessment tools, distinguishing how to further investigate patients with bleeding symptoms can be challenging. Joint input from gynecology and hemostasis specialists is recommended to ensure the bleeding status has been thoroughly investigated in women with suspected IBD [16, 17].

1.6 Approach to a Female with a Bleeding History

1.6.1 History

A woman may present for consultation with positive bleeding symptoms related to the gynecological system or additional bleeding symptoms, or she may have a family history of a bleeding disorder. Assessment should include a history of bleeding symptoms and the site, duration, frequency, and severity of bleeding (Table 1.1). Particular enquiry should include a history of mucosal bleeding, menorrhagia, epistaxis, easy bruising, and any bleeding episodes after a hemostatic challenge such as surgery, dental extraction, childbirth (postpartum hemorrhage (PPH)), and treatment required for any bleeding episodes. Bleeding that required blood transfusion, use of hemostatic adjuncts, and antifibrinolytic agents, such as tranexamic acid, may indicate a significant or severe bleed.

Table 1.1 Bleeding history and salient features indicating non‐trivial bleed.

Source: Modified from [18, 19].

Bleeding history may be subjective and specific tools have been developed to provide a more objective and standardized assessment of bleeding symptoms, for example the International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool and pictorial bleeding assessment chart for menorrhagia (see Chapter 2 for bleeding assessment tools). These standardized tools should be used wherever possible.

Although women with IBDs are more likely to experience menorrhagia, they are also at risk of other problems that may present with increased bleeding such as hemorrhagic ovarian cysts, bleeding from the corpus luteum, endometriosis, hyperplasia, polyps, fibroids, pregnancy, and childbirth [20, 21]. In women with an IBD, especially VWD, the risk of PPH is increased [22, 23] but primary PPH alone is not a good predictor of IBDs [24].

1.6.1.1 Past Medical History and Family History

Any other medical problems and pregnancy history should also be established. A family history of a bleeding disorder may be useful but a negative family history does not exclude the presence of an IBD, especially if the underlying genetic abnormality has incomplete penetrance or if a de novo mutation is present.

1.6.1.2 Medication History

Drug history should also include the use of contraceptive medication, antiplatelet drugs, or other anticoagulants, as this may affect the results of hemostatic assays. Platelet function tests can be affected by high concentrations of alcohol and caffeine and other food (for a list of drugs and food interfering with platelet function see [25]).

1.6.2 Physical Assessment

In addition to a general systemic examination, a number of physical signs may be particularly relevant in the physical assessment of a patient with a bleeding disorder. Careful inspection of the skin, mouth, and nose may reveal bruising or petechiae. Joint examination may reveal swelling or evidence of contractures. Other inherited disorders that cause a bleeding tendency due to a connective tissue disorder, such as Ehlers–Danlos, should also be considered. Signs of a connective tissue disorder may include hypermobility of joints and loose joints. Although occurring very rarely, some inherited platelet disorders may present with other syndromic features such as ocular albinism with late‐onset sensorineural deafness.

1.6.3 Investigations

The specificity of bleeding symptoms may be poor and accurate laboratory assessment of the hematological and coagulation system (Table 1.2) is important [7].

Table 1.2 Laboratory assessment of hematological and coagulation system.

RiCoF, ristocetin co‐factor; ROTEM, rotational thromboelastometry; TEG, thromboelastography; VWD, von Willebrand disease; VWF, von Willebrand factor.

A first‐line set of investigations includes the full blood count, blood film, and standard coagulation screen (PT, APTT, Clauss fibrinogen, and thrombin time). In the full blood count, it is particularly important to know if the platelet count is within the normal range, elevated or low, as this can help direct further investigations (see Table 1.2). Although the PT and APTT are used widely, they were not designed to be used as screening tools and only assess part of the hemostatic system (see Fig ure 1.2). If prolonged, they may indicate the presence of an inhibitor or a clotting factor deficiency. An inhibitor could be due to either an antibody that inhibits the activity of a specific clotting factor or a non‐specific inhibitor, such as a lupus anticoagulant (a lupus anticoagulant is associated with increased risk of thrombosis rather than bleeding). However, a PT or APTT in the normal range does not preclude the diagnosis of a bleeding disorder. They will not pick up platelet defects or mild VWD. Therefore, laboratory results should always be interpreted in light of the clinical history.

If the PT or APTT is prolonged, the next step is to do a mixing study (50:50 mix). Here, normal plasma containing normal levels of clotting factor are mixed with the patient's sample. If, after mixing, there is no correction of the prolonged APTT or PT, this suggests the presence of an inhibitor in the patient's blood. If there is correction, this suggests a factor deficiency and specific factor assays are performed to identify the deficiency.

The Clauss fibrinogen should be measured, rather than the PT‐based fibrinogen. The Clauss fibrinogen is a quantitative, functional assay which measures the ability of fibrinogen to form a fibrin clot after being exposed to a high concentration of purified thrombin. For suspected dysfibrinogenemia, there will be a discrepancy between functional activity and antigen level (measured by an enzyme‐linked immunosorbent assay (ELISA)‐based immunological test). The thrombin time can also be used to assess fibrinogen, although it has mostly been superseded by the Clauss fibrinogen. A prolonged thrombin time may indicate low fibrinogen level (hypofibrinogenemia or afibrinogenemia) and/or abnormal fibrinogen function (dysfibrinogenemia). Thrombin time may also be prolonged if there is heparin present, or if the D‐dimers are elevated.

1.6.3.1 Preanalytical Factors in Coagulation Testing

Preanalytical factors are the leading cause of error in coagulation testing [26, 27]. The preanalytical phase describes all actions and aspects of the medical laboratory diagnostic pathway, from when the test is requested up until the analytical phase.

Several preanalytical factors are particularly relevant in women. There have been some reports of lower VWF levels in the first few days of the menstrual cycle. Combined oral contraceptive pills (COCPs) and hormone replacement therapy (HRT) may also affect VWF levels. The elevated VWF levels can mask an underlying VWD [28], although the newer combination OCs (which are of lower dose potency than the estrogen preparations used in the initial case reports) do not appear to have the same effect. Contraceptives can also interfere with other tests of coagulation. They have been reported to lead to increased concentrations of fibrinogen, prothrombin, and factors VII, VIII, and X, and reduction in some coagulation inhibitors [27, 29, 30]. A practical approach would be to test women prior to starting the OC, if possible, but to obtain VWF testing if OCs have already been started. It is also important to consider the effect of pregnancy where factor levels, particularly of VWF, FVIII, and fibrinogen, rise and reach peak levels in the third trimester and continue to be elevated to a lesser degree postpartum.

When performing tests of coagulation, the following factors are important to note and steps should be taken to control for these conditions [26].

Avoid intense physical exercise for at least 24 hours prior to venepuncture.

For the diagnosis of VWD in fertile women, blood samples should be obtained on days 1–4 of the menstrual cycle. This may aid in the diagnosis in women with borderline values obtained at other times.

Test women before starting combined oral contraceptives and HRT if possible.

For the diagnosis of inherited disorders of hemostasis (particularly VWD and FVIII deficiency), samples should be obtained when normal menstrual cycles have returned or at least two months postpartum. All abnormal values obtained in connection with pregnancy should be verified with repeat blood sampling.

Avoid long transport times from venepuncture to hemostasis testing. Cold storage of whole blood can lead to artificially low VWF levels.

1.6.3.2 Specialized Tests of Coagulation

Specialized coagulation assays should be performed in a hemostasis laboratory with internal and external quality assurance, in conjunction with other tests of hemostasis and interpreted in light of the clinical history. One of the limitations with current standard coagulation tests is that they look at individual components of the hemostatic pathway. This may be a useful starting point in the diagnostic pathway but they do not give an overall measure of global hemostasis. Tests evaluating global hemostatic capacity (thrombin generation and viscoelastic hemostatic assays, e.g. thromboelastography (TEG) or rotational thromboelastometry (ROTEM)) may provide more accurate evaluation of in vivo hemostasis, as they more effectively assess rate/total thrombin generated and whole‐blood clot formation. Generally, there seems to be a very poor correlation between laboratory findings and bleeding genotype‐phenotype in the rare bleeding disorders such as deficiencies of fibrinogen, prothrombin, FV, combined FV and FVIII, FVII, FX, FXI, and FXIII. TEG and ROTEM show particular promise in the evaluation of hemostasis in patients with rare bleeding disorders where they may be clinically informative [31, 32]. Further work is required for validation in IBDs before widespread clinical use.

Advances in genetic and molecular diagnostics have also been seen in the field of hemostasis. Next‐generation sequencing (NGS) has transformed the scale and cost‐effectiveness of genetic testing and has emerged as a valuable tool, particularly for the diagnosis of inherited platelet disorders [33]. This is an evolving field and these tests are already becoming more widely available in the diagnostic work‐up of an inherited platelet defect (IPD) [1].

1.6.4 Interpretation of Hemostatic Assays

Abnormalities should be interpreted in light of the clinical history and taking into account any preanalytical factors. When assessing low VWF and FVIII levels, it is particularly important to consider whether the patient has blood group O as patients with this blood group have lower levels. Any abnormalities in hemostatic assays should be repeated.

1.7 Summary

The evaluation of bleeding symptoms can be challenging. Definitive diagnosis depends on a unified approach to clinical and laboratory assessment, using objective bleeding assessment tools where possible and considering the potential limitations of tests when interpreting results.

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