Bleeding Disorders

Normal Bleeding and Clotting

Blood carries vital nutrients within a liquid made up of plasma, red and white blood cells, and platelets. Plasma, a mixture of water, sugar, fat, and protein, also contains many chemicals that help form the clots necessary to stop bleeding. Red blood cells carry oxygen to all parts of the body. White blood cells fight infections and disease. When an injury occurs, platelets gather at the site of the injury and adhere to the edges of the wound, where they release chemicals that help start the process of clotting so that bleeding will stop.

To understand what is abnormal bleeding associated with bleeding disorders, we must first understand the normal process of how our bodies bleed and clot. Bleeding occurs in approximately four stages. (This process is the same for both external and internal bleeding.)

• Stage 1: The platelets in the blood activate and form a plug over the injured skin or vessel. This plug lasts for 12 to 24 hours.
• Stage 2: A substance called Von Willebrand factor reacts with the platelets to increase the “stickiness” of the platelets to each other and the surrounding collagen or tissue.
• Stage 3: Further platelet recruitment is involved via local hormone messengers such as fibrinogen and thromboxane.
• Stage 4: Activation of the clotting factors, produced by the liver, forms a series of reactions and stabilizes the bleed even further. These factors are XII, XI, IX, and VIII to VII and X, and V. Notably, a deficiency of Factor VIIIwhich is Hemophilia Ais the most common factor deficiency that causes a bleeding disorder.

Common Types of Bleeding Disorders

The three most common bleeding disorders in athletes are as follows:

• 1.
  Von Willebrand disease (VWD), an inherited disorder of platelet function (reflected by prolonged bleeding time) and a partial deficiency of functional Factor VIII, which occurs in about 1 in 100 people
• 2.
  Hemophilia, an inherited deficiency of Factor VIII or IX, which occurs in about 1 in 10,000 people
• 3.
  Immune thrombocytopenic purpura (ITP), which is an autoimmune or drug-induced disorder

Signs of a Bleeding Disorder

Athletes with bleeding disorders may show the following signs:

• Athletes with VWD usually have mucosal (nasal and gastrointestinal) bleeding. In women, it also includes heavy menstruation.
• Hemophilia in contact athletes is characterized by bleeding into a joint cavity (hemarthrosis), such as the knee, or into muscles. Prolonged bleeding times in the face of a skin injury can occur as well.
• Crops of little red blanched dots on the skin known as petechiae, along with purpura or bruising, may signal thrombocytopenia, low platelets, or ineffective platelet function.

Any bleeding disorder may be worsened by the use of aspirin or anti-inflammatory drugs, which can affect platelet function and therefore prolong bleeding. A physician along with a hematologist can diagnose a bleeding disorder. Routine tests such as cell blood count (CBC) will look for low platelets, anemia (low hemoglobin), prothrombin time (PT), and partial thromboplastin time (PTT). Prolonged PTT can be the initial clue in the diagnosis of hemophilia or VWD. Like hemophilia, VWD will have a prolonged bleeding time.

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