A staged approach to diagnostic testing for mild bleeding problems.If von Willebrand factor and platelet problems are not suspected, tests for these disorders can be omitted. If complete testing is not available, consider referral to a center that can complete the investigations.
| First assessment: . |
|---|
| Complete blood count with blood film evaluation |
| ABO blood group |
| Ferritin |
| PT, PTT |
| if abnormal, investigate for factor deficiencies |
| if hemophilia or other factor deficiencies strongly suspected, do factor VIII, IX, XI assays |
| Thrombin clotting time and clottable fibrinogen |
| if abnormal, evaluate reptilase time and measure fibrinogen antigen |
| Von Willebrand disease screen |
| factor VIII, von Willebrand factor antigen and ristocetin cofactor levels |
| multimers if screen is abnormal |
| Platelet aggregation with the full panel of agonists |
| Our practice: testing done with the agonists ADP, collagen (two concentrations), arachidonic acid, thromboxane analogue, epinephrine and ristocetin |
| Some centers may test platelet secretion with aggregation |
| Evaluate for platelet dense granule deficiency (first or subsequent assessment) |
| Consider tests for renal problems, liver or thyroid disease, if appropriate |
| Subsequent assessments: |
| Confirm and further evaluate abnormalities identified on the first assessment |
| Evaluate platelet secretion (or dense granules) if a platelet-type bleeding disorder is suspected but not diagnosed by initial tests, or if the aggregation abnormalities suggested a secretion or dense granule problem. Consider tests for rarer disorders (e.g., Scott’s syndrome) if no abnormalities are found |
| If the history suggests delayed bleeding problems, and no diagnosis was established, exclude mild deficiencies (factors VIII, IX, XI first) by factor assays and consider other tests (e.g., partial alpha2 plasmin inhibitor deficiency) |
| First assessment: . |
|---|
| Complete blood count with blood film evaluation |
| ABO blood group |
| Ferritin |
| PT, PTT |
| if abnormal, investigate for factor deficiencies |
| if hemophilia or other factor deficiencies strongly suspected, do factor VIII, IX, XI assays |
| Thrombin clotting time and clottable fibrinogen |
| if abnormal, evaluate reptilase time and measure fibrinogen antigen |
| Von Willebrand disease screen |
| factor VIII, von Willebrand factor antigen and ristocetin cofactor levels |
| multimers if screen is abnormal |
| Platelet aggregation with the full panel of agonists |
| Our practice: testing done with the agonists ADP, collagen (two concentrations), arachidonic acid, thromboxane analogue, epinephrine and ristocetin |
| Some centers may test platelet secretion with aggregation |
| Evaluate for platelet dense granule deficiency (first or subsequent assessment) |
| Consider tests for renal problems, liver or thyroid disease, if appropriate |
| Subsequent assessments: |
| Confirm and further evaluate abnormalities identified on the first assessment |
| Evaluate platelet secretion (or dense granules) if a platelet-type bleeding disorder is suspected but not diagnosed by initial tests, or if the aggregation abnormalities suggested a secretion or dense granule problem. Consider tests for rarer disorders (e.g., Scott’s syndrome) if no abnormalities are found |
| If the history suggests delayed bleeding problems, and no diagnosis was established, exclude mild deficiencies (factors VIII, IX, XI first) by factor assays and consider other tests (e.g., partial alpha2 plasmin inhibitor deficiency) |