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Transcript of Women and bleeding Dr. Nita Radhakrishnan Sir Ganga Ram Hospital, New Delhi, India Annual Meet WG...
Women and bleeding
Dr. Nita RadhakrishnanSir Ganga Ram Hospital,
New Delhi, India
Annual Meet WG HFI 6 Dec 2014
Woman
• Challenges in the life of a woman – Many
• Hemostatic challenges in the life of a woman
– Menstruation (Menorrhagia = Heavy menstrual bleeding)– Pregnancy – Childbirth
Bleeding disorders in women
Hemophilia A, B carrier state
Von Willebrand disease
Rare bleeding disorders
Inherited platelet disorders
Royal disease
• Queen Victoria • Had no ancestors with hemophilia • 9 children • Disease appeared in her 8th child Leopold who was
“very delicate” • “We must have some strong blood”
• Spread to the royal family of England • Spread to German, Russian and Spanish royal families
Von Willebrand disease
• Most common bleeding disorder • 1% of the population • Eric von Willebrand
• Index case: 5 year old died eight years later following menstrual bleeding
• 23 affected family members • Her grandmother died following delivery
Menstrual Cycle is a Vital Sign• American College of Obstetricians and Gynecologists• American Academy of Pediatrics
• Normal menstruation – Begins at 11 to 14 years of age– Normal interval is is 21 to 45 days– Normal length of menstrual flow is 7 days or less – Not more than 3-6 pads/ tampons per day
• What is not normal? – Heavy menstrual bleeding
• >7 days • Loss of more than 80 ml per menstrual cycle
– Ovarian cysts with bleeding – Endometriosis – Bleeding following delivery lasting > 24hours
Ovarian cysts with bleeding
• Ovulation with bleeding is never normal• 7% of VWD reported to have bleeding ovarian cysts
• Can bleed into the abdominal cavity• Increases risk of endometriosis
Pregnancy and bleeding
• 4067 deliveries in women with vWd • 2000-2003 (USA)
• Risk of bleeding before delivery 10.2• Risk of bleeding following delivery 1.5• Risk of receiving blood transfusion 4.7 • Risk of death in mother low (but still high than
normal women)
James A 2007
• Childbirth in women with inherited bleeding disorders
Primary PPH Secondary PPH
Normal 5 0.7%
Hemophilia carriers
22% 11%
VWD 19% 29%
It is also not normal
• Prolonged bleeding from cuts• Following surgery• Bruising without any trauma• Nose bleeds• Following tooth extraction• Blood in stools • Anemia requiring blood transfusion
• 7/75 women with menorrhagia had underlying bleeding disorder
N Sherif 2014
• 53% had underlying bleeding disorder Rosa Diaz 2014
• 47.8% had some underlying hemostatic disorder– 17.7% platelet dysfunction – 13.3% Von Willebrand disease – 12.4% factor deficiency
V Serevalli 2013• 14.5% had bleeding disorders– 6.5% von Willebrand disease in five – 5.2% platelet function disorder
Turkiz Gursel 2014
• 120 women with menorrhagia – 19.16% had bleeding disorder – 11.6% VWD – 3.3% Glanzmann thrombasthenia
Sucheta Trasi 2005
Testing for bleeding disorders is a must for
Adolescent girls who present with menorrhagia Adult women with chronic menorrhagia who
have no other cause Women who are about to undergo hysterectomy
for menorrhagia ACOG 2002
• HTCs were originally created to treat men with hemophilia
• Since 1990s almost 9000 women have sought medical care in HTCs across USA
• Indian data?
• 70-100% of those with vWD• 10-70% of those with other inherited disorders • 5-98% with inherited platelet disorders
• Significantly longer, heavier menstruation• Significantly more hysterectomies for
menorrhagia
Health related QOL in VWD
• Women with VWD significantly worse than those of men with VWD
• Almost as low as that of severe hemophilia
• More school absenteeism • Less women likely to undergo secondary
education than men (5.5% vs 35%)
Health related QOL in VWD
• 39% cut down their activities due to menorrhagia
• 39% had to cut down the work that they do• 47% felt they had accomplished less
• 19.3% felt that dysmenorrhea affected their lives• 22.6% did not go to school/work during periods• 48.4% were hospitalized for a heavy menstrual
bleeding Fadhlaoui A 2012
Survey of health related QOL study
• SF 36 v2 survey • 30 subjects
• 3 groups
• Girls (Indian) with bleeding disorders • Girls with leukemia undergoing chemotherapy• Normal age matched controls
Radhakrishnan N (unpublished)
Does health limit you in your activities?1: A lot 2: Little 3: Not at all
FBD
Leukemia
Normal
0 0.5 1 1.5 2 2.5 3
Has you health interfered with social activities?
1:No 5:Very much
FBD
Leukemia
Normal
0 0.5 1 1.5 2 2.5 3
Factors that determined QOL
• Underlying bleeding disorder
• Being female
• Bleeding disorder (VWD) and being female
Surveying gynecologists
• 983 ACOG members surveyed in 1996• 8% of their patients complained about
menorrhagia • 74% patients presumed to have anovulatory cycles • 4% doctors considered VWD as a cause of
menorrhagia • 3% considered referring them to specialists• <1% of women should have a bleeding disorder
VR Byams 2007
Surveying gynecologists
• Repeated the survey in 2009 – 1200 gynecologist interviewed by mail – 42.4% (503) responded to the survey
• >70% enquired about other sites of bleeding • >60% enquired about a family history of bleeding • 77% said they would consider VWD as a cause
• What caused this change?Efforts by hematology providers, community based organizations, government to raise awareness
VR Byams 2012
Surveying gynecologists UK
• > 80% of the respondents considered the prevalence of VWD in women with menorrhagia to be <1%
• 12% and 2% of the respondents would consider testing for VWD in an 18 and a 35 year old
Chi C 2006
Total Score >100 is equivalent to >80ml blood loss per cycle
Total score:
PICTORIAL BLEEDING ASSESSMENT CALENDAR Higham JM, O’Brien PM, Shaw RWAssessment of menstrual blood loss using a pictorial chartBr J Obstet Gynecol 1990; 97:734-9
DayPad 1 2 3 4 5 6 7 8
1
5
20
Daily score
Day Tampone1 2 3 4 5 6 7 8
1
5
20
Daily score
International efforts to raise awareness
• Women bleed too (UK)
• Project Red Flag (USA)
• MyGirlsBlood
• WG HFI
To conclude
• Lets protect girls with any bleeding disorder • Collaborative efforts
Look after menstrual hygieneHeavy menstrual bleeding
Identify potential bleeders from the populationPrevent complications