Conditions

Question 1

Describe Von Willebrand’s Disease

Answer 1

• Commonest coagulopathy - autosomal dominant
• Mucocutaneous bleeding
• 15% of women with menorrhagia have it
• Can be difficult to diagnose

Question 2

What are the types of VW disease?

Answer 2

Type 1 - reduced amount of normal VW protein
Type 2 - abnormal VW protein (IIb overactive)
Type 3 - little or no VW (undetectable levels) and decreased VIII

Question 3

Describe type 1 VW disease

Answer 3

• Autosomal dominant
• Mild
• Bruising/mucosal bleeding
• Menorrhagia
• Operations/dental extraction
• Treat with DDAVP (24 hrs half-life)

Question 4

Describe type 2 VW disease

Answer 4

• Autosomal dominant
• Indistinguishable from type 1 based off symptoms
• Watch for type 2: overactive protein, can result in thrombocytopenia (abnormal level of platelets), avoid DDAVP (releases VWF causing further overactivation), use VWF concentrate

Question 5

Describe type 3 VW disease

Answer 5

• Autosomal recessive
• Severe illness
• Serious mucosal bleeding
• Operative treatment will cause severe bleeding

Question 6

What patients need to be considered at risk for a venous thromboembolism?

Answer 6

• Over 18
• Immobile i.e. in bed, after surgery
• Often hypercoagulable - acute phase reactant proteins include fibrinogen, factor VIII + VWF
• Endothelial injury - obvious if leg or pelvic operation or needs post-operative plaster cast but even stasis itself will cause some endothelial damage

Question 7

Why is surgery a risk for thromboembolism?

Answer 7

• Knee and hip replacement
• Anaesthesia leads to immobility, stasis and reduced blood flow in legs
• Post-operative period with bed rest - increased risk with increased duration
• Acute reactants post surgery
• Open surgery greater risk than laparoscopic

Question 8

What is a DVT?

Answer 8

Formation of thrombus in deep veins (usually leg). This can travel to heart > RA > RV > pulmonary arteries and cause a PE > cardiac arrest.

Question 9

How is PE defined?

Answer 9

Massive PE is classified by the presence of arterial hypotension (systolic BP < 100mmHg) or cardiogenic shock/cardiac arrest. This is an emergency and requires urgent thrombolysis.

Question 10

What are the risk factors for DVT?

Answer 10

• Immobility > 3days (or major surgery within 12 weeks)
• FH DVT
• Age (>60yrs)
• Active cancer (includes treatment within the last 6 months)
• Previous DVT

Question 11

What is thrombophilia?

Answer 11

A condition that increases the risk of blood clots - usually only treated when a clot develops (DVT or PE). Occurs in 25-55% of surgery patients.

Question 12

What are differentials of DVT?

Answer 12

• Cellulitis
• A ruptured baker’s cyst
• Muscle haematoma

Question 13

What is haemarthrosis?

Answer 13

Bleeding in joints

Question 14

What does haemodynamically unstable mean?

Answer 14

Low BP so organs in the body aren’t being sufficiently perfused. Give patients thrombolysis (altaplase) to break down clot.

Question 15

What are the 3 processes after injury that halt bleeding?

Answer 15

1. Vasoconstriction
2. Gap-plugging by platelets
3. Coagulation cascade

Question 16

What do vascular and platelet disorder cause?

Answer 16

They lead to prolonged bleeding from cuts, bleeding into the skin (e.g. easy bruising, purpura) and bleeding from mucous membranes (e.g. epistaxis, bleeding from gums, menorrhagia).

Question 17

What do coagulation disorders cause?

Answer 17

Delayed bleeding into joints and muscle - haemophilia, VW disease.

Question 18

Describe haemophilia A

Answer 18

X-linked recessive pattern in 1:10,000 male births (30% have no FH).

Question 19

What are the risk factors for PE?

Answer 19

• Malignancy, myeloproliferative disorder, anti-phospholipid syndrome
• Surgery: especially pelvic and lower limb
• Immobility, active inflammation e.g. infection, IBD
• Pregnancy, combined OCP, HRT
• Previous thromboembolism and inherited thrombophilia