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Bleeding Disorders May Cause Menorrhagia and Postpartum Hemorrhage

A consensus meeting aimed to improve recognition of bleeding disorders as a cause of menorrhagia and postpartum hemorrhage so that effective disease-specific treatment can be provided.
"In those women who do have a bleeding disorder such as von Willebrand disease (VWD), there is an increased incidence of pathologic bleeding....The lack of a clinical tool for the objective assessment of abnormal reproductive tract bleeding and the lack of awareness of the potential of bleeding disorders to exacerbate or even cause abnormal bleeding leads to the underdiagnosis and suboptimal treatment of women with bleeding disorders."
Although menorrhagia or postpartum hemorrhage may result in considerable, clinically significant blood loss, congenital bleeding disorders exacerbating these conditions historically tend to be underdiagnosed, presumably because of lower awareness among obstetricians and gynecologists vs hematologists.
Clues suggesting the possibility of an underlying bleeding disorder include a family or personal history of bleeding events. Recognizing these clues should improve collaboration among obstetrician-gynecologists and hematologists, reduce diagnosis of "idiopathic" menorrhagia, and result in better management of reproductive tract bleeding events. Women who have these conditions should thereby have improved quality of life and school and work performance indicators.

Questions and Answers Addressed
1. What is menorrhagia?
Although menorrhagia is typically defined as more than 80 mL of blood loss per menstrual cycle, other indicative features are soaking through a pad or tampon within 1 hour, soaking through bed clothes, below normal ferritin levels, anemia, and pictorial blood assessment chart score of more than 100.
2. When should a gynecologist or obstetrician suspect a bleeding disorder and pursue a diagnosis?
Indicators suggesting an underlying bleeding disorder include menorrhagia since menarche, a family history of a bleeding disorder, or failed response to conventional management of menorrhagia.
Other indicators are a personal history of 1 or more of the following: epistaxis; notable bruising without injury; minor wound bleeding; bleeding of oral cavity or gastrointestinal tract without an obvious anatomic lesion; prolonged or excessive bleeding after dental extraction; unexpected postsurgical bleeding; hemorrhage from ovarian cysts or corpus luteum; hemorrhage requiring blood transfusion; and PPH, especially delayed PPH.
Even in the presence of gynecologic disease such as uterine fibroids, a bleeding disorder may contribute to menorrhagia.
3. What hematologic evaluations should be ordered, and when should they be repeated?
Platelet number and function and specific coagulation factor profile should be evaluated in consultation with a hematologist. Other tests should include complete blood cell count, activated partial thromboplastin time, prothrombin time, VW factor (VWF) measured with ristocetin cofactor activity and antigen, coagulation factor VIII, and fibrinogen.
If results of these tests are normal, women should undergo testing of platelet aggregation and platelet release. Although testing should not be delayed to coincide with menstruation, subsequent testing during menses should be considered if the first set of VWF levels is at the lower limit of normal.
Hormonal contraception should not be interrupted to permit testing.
4. How should menorrhagia be managed in women with bleeding disorders?
Tranexamic acid (1 - 1.5 g, 3 - 4 times/day) may be given before hematologic testing, although management is optimally started once the diagnosis is made. Nonsteroidal anti-inflammatory drugs should be avoided. Further management strategies differ based on whether future fertility and/or becoming pregnant soon are desired. A combination of therapies is often needed, and consultation with a hematologist is essential. Hemostatic treatment should start on the first or second day of menses.
5. How can PPH be prevented in women with bleeding disorders?
Hematology consultation and collaborative care are recommended. VWF levels should be determined. If the coagulation factor profile is not in the normal range by the third trimester, delivery should take place at a specialized center. If third-trimester VWF levels are 50 IU/dL or more, epidural analgesia/anesthesia may be considered safe for delivery; otherwise, appropriate hemostatic cover is required. Adequate venous access is needed during labor, and the third stage of labor should be actively managed.
6. What do we know about menorrhagia and RBDs?
Tranexamic acid and aminocaproic acid or desmopressin (DDAVP) is useful for the treatment of menorrhagia in combined factor V or factor VIII deficiency, but additional research is needed to determine its role in other RBDs. Patients should be treated with antifibrinolytic treatment and appropriate factor replacement when available.
"An awareness of bleeding disorders (such as VWD, RBDs, and platelet disorders) is an important asset for obstetricians and gynecologists," the consensus authors write. "These disorders remain underdiagnosed in women with menorrhagia and potentially in other cases of abnormal bleeding (such as PPH)....The authors of this consensus believe that these recommendations will aid obstetricians and gynecologists to better anticipate, prepare for, and manage cases of abnormal reproductive tract bleeding in women with bleeding disorders."

Clinical Context
RBDs are inherited autosomally, with prevalence ranging from 1 in 2 million for factor II and factor XIII deficiencies to 1 in 500,000 for factor XI and factor VII deficiencies. The number affected by RBDs around the world has reached approximately 7000, with the most common being factor XI deficiency. VWD affects menstruation and childbirth and may lead to unacceptable blood loss. Because of menses and childbirth, VWD is more likely to present in women vs men, although the prevalence is similar between the sexes.
This is a consensus panel review constructed by obstetricians and gynecologists with hematologists based on a 2007 meeting of the literature on VWD in women focusing on presentation, diagnosis, and treatment strategies.

Clinical Implications
• The prevalence of VWD in adult women with menorrhagia is 13%, increasing to 33% in adolescents, and diagnosis is made by assessing risk factors and performing hematologic evaluation.
• In women with VWD who desire fertility, medical management is recommended, and VWF level should be at least 50 IU/dL to prevent PPH.

Evidence-Based Catheter-Care Procedures May Reduce Bloodstream Infection Rate

Evidence-based catheter-care procedures regarding hand hygiene may significantly reduce the rate of catheter-related bloodstream infections (CRBSIs),
"...CRBSI are a well recognized problem in the intensive care unit (ICU)," write Walter Zingg, MD, from the University Hospitals of Geneva in Geneva, Switzerland, and colleagues. "A recent study, in the neonatal setting, found hand hygiene successful as a single intervention measure in reducing CRBSI when its promotion was guided by healthcare workers' perceptions and combined with organization at the workplace. On the basis of high incidence rates of CRBSI in previous surveys of the ICUs in our institution, we decided to conduct an interventional study using an educational campaign focusing on hand hygiene and catheter care."

"Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention," the study authors write. "Infection control efforts to improve the quality of hand hygiene and catheter care are essential elements for patient safety, not only for the reduction of CRBSI but also for other health care-associated infections."

Clinical Context
Risk factors for CRBSIs include long duration of CVC use, insertion site other than subclavian, overmanipulation of the CVC system, and heavy cutaneous colonization, as well as patient factors of illness severity and immunodeficiency. Strategies such as handwashing and the use of CVCs coated with antimicrobials have been examined as methods to reduce CRBSIs.
This is a study of the effect of an educational intervention on hand hygiene practice in ICUs and its impact on CRBSI rates and predictors of CRBSIs among patients in the ICU.

Clinical Implications
• Predictors of risk for CRBSIs in ICUs are hospitalization in a medical ICU, male sex, and baseline period.
• An educational intervention for ICU nurses and medical staff is associated with improved hand hygiene and reduced CRBSI rates.

Screening at 2 Months Identifies Most Women With Postpartum Depression

Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.

No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
The purpose of the study was to assess the feasibility of using electronically generated reminders to detect and refer at-risk women and to look at the prevalence and incidence of maternal depression assessed at well-child visits during the first 6 months after birth.
The study included 204 mothers and 413 electronic depression–screening cues. These prompts appeared automatically when the medical records of children 0 to 6 months old were opened and reminded medical staff to administer the 10-item Edinburgh Postpartum Depression Scale (EPDS) to new mothers.
Providers were unable to close the children's medical records until they had entered the EPDS score or 1 of the precoded reasons for not administering the EPDS.
An EPDS of 10 or greater was considered a positive result, and providers could not close the medical record until a management plan or referral was recorded.
The providers administered the EPDS 98% of the time and always referred mothers with positive scores. Overall, 20.1% of the women who completed the EPDS at 2 weeks, 2 months, 4 months, or 6 months had positive scores.
EPDS scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.

Screening Before 2 Months Not Useful The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months. However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
If women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.

Clinical ContextAll new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
This is a study of a screening program using electronic cues to providers of well-child visits in a pediatric clinic to examine the efficacy of the cue on screening for postpartum depression and the prevalence of postpartum depression in adolescent new mothers in the first 6 months after delivery.

Study Highlights
• The Colorado Adolescent Maternity Program is a comprehensive prenatal delivery and postnatal care program for 12- to 21-year-old mothers in 1 US state located in an urban hospital, serving a low-income population.
• Providers of well-child care were a pediatrician and 2 mid-level providers with training in adolescent medicine.
• An electronic medical record system is used for practice improvement, and all child health records were flagged electronically with prompts to providers to administer the EPDS to mothers of children at well-child visits.
• The EPDS is a 10-item validated and reliable scale with a score of 10 or higher reliably identifying 90% of cases in other studies.
• Responses were on a 4-point scale with a score range from 0 to 30, with higher scores indicating higher depressive symptoms.
• Mothers were given a pencil-and-paper version of the EPDS to complete while waiting for their child to be seen.
• Providers collected and scored the EPDS forms, discussed results with mothers, and recorded the scores in the children's electronic medical records.
• After 5 months, providers were unable to close the children's electronic records unless they had administered the EPDS at least once or given a reason why it was not administered.
• During the study period, providers saw 418 electronic screening cues for the EPDS associated with 204 mothers.
• In 5 cases, mothers were not with the child; of the remaining cues, providers responded to 99%.
• None of the mothers refused to complete the EPDS.
• Mean age of mothers was 18 years, 36% were black and 44% were Hispanic, 87% were Medicaid recipients, mean parity was 1.4, and 51% were living with a biological parent.
• Overall, 20.1% of mothers who completed the EPDS at 2 weeks and at 2, 4, and 6-month well-child visits met the referral criteria of a score of 10 or higher on the EPDS.
• The prevalence of depressive symptoms ranged from 17.0% at 2 weeks to 16.5% at 2 months to 10.3% at 4 months and 18.5% at 6 months.
• Although the prevalence was highest at the 2-week visit, this was the least reliable measurement because only 12% of mothers met depression referral criteria at 2 visits, and 8% resolved the symptoms at the following visit.
• The incidence of depressive symptoms decreased from 16.5% at 2 months to 5.7% at 4 months and 1.9% at 6 months, with only 2 cases that would have been missed if the mothers had been screened only once.
• 94.5% of the mothers who met the referral criteria did so at the first screening.
• The authors recommended that screening at 2 months identifies most mothers who develop postpartum depression and that screening at 6 months was preferable to screening at 4 months.
• Of 40 mothers who met referral criterion, 8.6% were 22 years or older.
• They were referred for further evaluation and treatment.
• The authors concluded that screening of mothers at the well-child visit in the first 6 months was feasible and was associated with an accurate diagnosis of postpartum depressive symptoms.

Clinical Implications
• Use of an electronic cue to providers for screening for postpartum depression using the EPDS in mothers at well-child visits is associated with high compliance by providers and mothers.
• The EPDS used at the well-child visit at 2 and 6 months is helpful for diagnosing depressive symptoms in new mothers.