Bleeding monitoring in patients with acquired haemophilia: Consensus Statement

A group of 36 experts have released new consensus statements. The statements published in the Haemophilia journal, provide specific recommendations related to monitoring bleeding and assessing the efficacy of treatment in patients with acquired haemophilia.

The key areas outlined include the initial management of bleeding, and management of location-specific bleeding, including urological, gastrointestinal, muscle, and pharyngeal bleeds, as well as intracranial and postpartum haemorrhage.

Initial management

• Advice on management should be sought from an expert haematologist as soon as possible.


• The non‐expert treating physician should consider commencing treatment for serious bleeds in acquired haemophilia if specialist consultation is not available.


• If specialist consultation is not immediately available, and the condition is life‐threatening, Emergency Department doctors should commence treatment for AH in line with local or national recommendations until an expert haematologist becomes available. If there are no local or national recommendations available, published recommendations should be sought.


• All AH patients should be referred to an expert centre as soon as possible.

Urological bleeds/haematuria

• The following may be indicators of treatment effectiveness:
  
  
  
  • Decrease in haematuria
  
  
  • Increase/stabilization in haemoglobin
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Increase in haematuria
  
  
  • Decrease in haemoglobin
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6‐12 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 6‐12 h.

Gastrointestinal bleeds

• The following may be indicators of treatment effectiveness:
  
  
  
  • Increase/stabilization in haemoglobin
  
  
  • Improvement in vital signs
  
  
  • Resolution of melaena/haematemesis
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Decrease in haemoglobin
  
  
  • Deterioration/no improvement in vital signs
  
  
  • Worsening melaena/haematemesis
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after the withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 6‐12 h.

Muscle bleeds

• The following may be indicators of treatment effectiveness:
  
  
  
  • Decrease in swelling/pain
  
  
  • Improvement in neurological/vascular function
  
  
  • Increased range of motion/power
  
  
  • Softening of the muscles
  
  
  • Increase/stabilization in haemoglobin
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Increase in swelling/pain
  
  
  • Decrease in haemoglobin
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6‐12 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 12 h.

Skin bleeds

• The following may be indicators of treatment effectiveness:
  
  
  
  • No fresh bleeding
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Extension of symptomatic subcutaneous bleed
  
  
  • Decrease in haemoglobin
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 12‐24 h.


• A complete response to haemostatic treatment will be defined as the cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after the withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 24 h.

Joint bleeds

• The following may be indicators of treatment effectiveness:
  
  
  
  • Decrease in pain
  
  
  • Increased range of motion
  
  
  • Reduction in swelling
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Increase in pain
  
  
  • Decrease in range of motion
  
  
  • Increase in swelling
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6‐12 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 12 h.

Head and neck bleeds (nosebleed)

• The following may be indicators of treatment effectiveness:
  
  
  
  • No fresh bleeding
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Continued bleeding
  
  
  • Decrease in haemoglobin
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 after withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, it is appropriate to consider a different/more intensive treatment every 6‐12 h.

Intracranial haemorrhage

• The following may be indicators of treatment effectiveness:
  
  
  
  • Improving score in neurological scoring systems (GCS, NIH Stroke Scale etc)
  
  
  • Reduction in intracranial pressure
  
  
  • Reduction in haematoma size on CT scan
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Worsening score in neurological scoring systems (GCS, NIH Stroke Scale etc)
  
  
  • Increase in intracranial pressure
  
  
  • Increase in haematoma size on CT scan.
  
  
  
  


• Assessment intervals depend on the clinical situation and may vary from every 2 h (e.g. for clinical assessment) to every 24 hours (e.g. for imaging studies).


• A complete response to haemostatic treatment will be defined as a cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after the withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, a different/more intensive treatment should be considered every 6 h.

Postpartum haemorrhage–female genital tract bleeding

• The following may be indicators of treatment effectiveness:
  
  
  
  • No fresh bleeding/reduction in sanitary pad requirement and weight
  
  
  • Stabilization of haemoglobin/haematocrit level
  
  
  • No further requirement for transfusion
  
  
  
  


• The following may be indicators of worsening condition:
  
  
  
  • Increased fresh bleeding/increase in sanitary pad requirement and weight
  
  
  • Deterioration of haemoglobin/haematocrit level
  
  
  • Requirement for transfusion
  
  
  
  


• The optimal interval for assessing whether haemostasis has been achieved is every 6 h.


• A complete response to haemostatic treatment will be defined as cessation of bleeding from the site, with no evidence of recurrent bleeding from that site for 2 d after the withdrawal of the haemostatic treatment.


• If initial treatment for bleeding has not been effective, a different/more intensive treatment should be considered every 6 h.

"These consensus statements reflect the clinical opinion of specialists from around the world in the monitoring of bleeds and evaluating the efficacy of bleeding treatment, across specific anatomical locations in patients with AH. These findings could be applied in practice and validated by individual population surveys. In the future, we hope to again harness expert consensus in development of guidance in AH management," concluded the authors.

More Information: Clinical evaluation of bleeds and response to haemostatic treatment in patients with acquired haemophilia: A global expert consensus statement published in Haemophilia journal.

DOI: https://doi.org/10.1111/hae.13844

Journal Information: Haemophilia