Here’s how readers responded to a You Make the Call question about a bleeding diathesis in a 65-year-old woman with newly diagnosed breast cancer.
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I would work her up for von Willebrand disease. This would include the usual tests: prothrombin time, partial thromboplastin time, platelet count, factor VIII antigen and activity, von Willebrand factor antigen and activity, and von Willebrand factor multimers. I would conduct further coagulation tests depending on whether those gave an answer. Also, I would collect a detailed family history.
Richard Lind, MD
I would do a complete blood count test to look at platelet count, a peripheral smear to look at the morphology of the platelets, and a coagulation profile: prothrombin time (PT)/activated partial thromboplastin time (aPTT)/fibrinogen. If PT/aPTT are normal, I would test platelet function, von Willebrand factor antigen levels, ristocetin cofactor activity levels, and do further typing.
Ummay Farwa Naqvi, FCPS
I would offer genetic testing for fibrinogen disorders to the patient. If this is approved by the patient and her health insurance, identifying an abnormal variant would be helpful in testing and counseling the family. If this is not feasible, it may be worth screening her offspring with fibrinogen activity testing, especially if they have bleeding symptoms or prior to a hemostatic challenge such as surgery or a dental procedure. For management, the patient may benefit from anti-fibrinolytic agents for minor mucosal procedures and supplementation of fibrinogen for moderate-to-major surgeries.
Lakshmi Srivaths, MD
This might be von Willebrand disease.
Tiziano Barbui, MD
I would be sure to have 10 units of cryoprecipitate on call to operating room. I would also monitor and re-dose as needed to maintain fibrinogen >200 mg/dl for 10 days post-op. Tranexamic acid or aminocaproic acid post-op can be used for minor surgery. First-degree relatives need to be tested.
Kelty R. Baker, MD