From the Guidelines
This patient should undergo a coagulation disorder workup due to her clinical presentation, which includes recurrent IUD expulsion, large clots, and laboratory findings such as an elevated platelet count of 502, indicating a potential hypercoagulable state or a bleeding disorder of unknown cause (BDUC) 1. The combination of these symptoms and lab results raises concern for a potential underlying coagulation disorder that may be contributing to her heavy menstrual bleeding and iron deficiency. Initial testing should include prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, D-dimer, and a complete thrombophilia panel (including Factor V Leiden, prothrombin gene mutation, protein C and S levels, antithrombin III, and antiphospholipid antibodies) to rule out any thrombophilic conditions. Her severe iron deficiency (iron saturation 5%, ferritin 4, iron 21) is likely secondary to heavy menstrual bleeding, which may be exacerbated by both the fibroid and a potential coagulation disorder. While addressing the iron deficiency with oral or IV iron supplementation is important, as suggested by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1, identifying any underlying coagulation disorder is crucial for proper management of her gynecological issues and prevention of future complications. The elevated platelet count (thrombocytosis) could be reactive to iron deficiency but might also indicate a myeloproliferative disorder, which can increase thrombotic risk, further supporting the need for a comprehensive hematologic evaluation. Given the recent study on the management of bleeding disorders of unknown cause 1, it is essential to consider the use of tranexamic acid (TXA) and desmopressin (DDAVP) in the management of heavy menstrual bleeding in women with BDUC, and to follow a standardized approach for the assessment of a bleeding phenotype, such as the ISTH BAT score. Overall, a thorough workup and management plan should prioritize the patient's morbidity, mortality, and quality of life outcomes.
From the Research
Patient Presentation
The patient is a 26-year-old female with a small uterine fibroid, a history of IUD expulsion twice, and passing large clots about the size of a quarter. Her laboratory results show normal hemoglobin (Hg) and hematocrit (Hct) levels, low mean corpuscular hemoglobin concentration (MCHC), very low iron saturation at 5%, low ferritin at 4, and low iron at 21. Additionally, her platelet count is elevated at 502.
Iron Deficiency Anemia
- Iron deficiency anemia is a common cause of anemia, and the patient's low iron saturation, ferritin, and iron levels are indicative of iron deficiency 2, 3.
- The patient's symptoms, such as passing large clots, may be related to her iron deficiency anemia, as iron plays a crucial role in coagulation 4.
- Iron replacement therapy may be necessary to address the patient's iron deficiency anemia, and oral or intravenous iron supplementation can be considered 2, 5.
Coagulation Disorder
- The patient's history of passing large clots and elevated platelet count may suggest a coagulation disorder, and further evaluation may be necessary to rule out any underlying conditions 4.
- Iron supplementation can affect coagulation, and the patient's iron deficiency anemia may be contributing to her coagulation issues 4.
- A thorough evaluation, including a complete blood cell count, iron panel, and other supplemental tests, may be necessary to investigate the cause of the patient's anemia and coagulation issues 6.
Laboratory Results
- The patient's laboratory results show low iron saturation, ferritin, and iron levels, which are consistent with iron deficiency anemia 2, 3.
- The patient's elevated platelet count may be related to her iron deficiency anemia or an underlying coagulation disorder 4.
- Further evaluation of the patient's laboratory results and medical history may be necessary to determine the underlying cause of her anemia and coagulation issues 6.