What is the appropriate management for a patient with persistent bleeding, anemia, prolonged PT and aPTT, and decreased factor eight activity following a dental procedure?

Management of Persistent Post-Dental Extraction Bleeding with Prolonged aPTT and Reduced Factor VIII Activity

This patient most likely has mild von Willebrand disease (vWD) or mild hemophilia A, and should receive desmopressin (DDAVP) 0.3 mcg/kg IV as first-line therapy, with tranexamic acid 10-15 mg/kg IV followed by 1-5 mg/kg/h infusion for antifibrinolytic support. 1

Clinical Interpretation of Laboratory Findings

The laboratory pattern is diagnostic:

• Isolated prolonged aPTT (51 seconds) with normal PT (11.5 seconds) indicates a deficiency in the intrinsic coagulation pathway 2, 3
• Factor VIII activity of 64% (mildly reduced, normal range 50-150%) with normal Factor VII activity (90%) confirms the intrinsic pathway defect 2
• Normal platelet count (360,000) excludes primary platelet disorders 3
• Hemoglobin 9.2 g/dL represents significant blood loss requiring intervention 1

This constellation—prolonged aPTT, reduced Factor VIII, normal platelets, and mucosal bleeding after dental trauma—is pathognomonic for either mild von Willebrand disease (most common) or mild hemophilia A 4, 3.

Immediate Management Algorithm

Step 1: Local Hemostatic Measures

• Apply direct pressure with gauze soaked in tranexamic acid to the extraction site for 5-10 minutes 5, 6
• Pack the socket with absorbable hemostatic agents (Surgicel or gelatin sponge) and secure with sutures if possible 5
• These measures should be attempted first while preparing systemic therapy 4

Step 2: Systemic Hemostatic Therapy

Primary treatment: Desmopressin (DDAVP)

• Administer 0.3 mcg/kg IV in 50 mL normal saline over 30 minutes 4
• DDAVP releases endogenous von Willebrand factor and Factor VIII from endothelial stores, increasing levels 3-5 fold within 30-60 minutes 4
• This is effective for mild vWD (types 1 and some type 2 variants) and mild hemophilia A 4
• Expect Factor VIII levels to rise to >100% within 1 hour, providing adequate hemostasis 4

Adjunctive antifibrinolytic therapy:

• Tranexamic acid 10-15 mg/kg IV bolus, followed by continuous infusion of 1-5 mg/kg/h 1
• Antifibrinolytics are particularly effective for mucosal bleeding (oral, nasal, GI, GU) where fibrinolysis is prominent 1
• Continue infusion for 24-48 hours or until bleeding completely stops 1

Step 3: If DDAVP Fails or Is Contraindicated

Factor VIII concentrate replacement:

• Dose calculation: 25-40 IU/kg IV for mucosal bleeding 7
• Expected peak increase: 2 IU/dL per IU/kg administered 7
• For this patient (assuming 70 kg): 25 IU/kg × 70 kg = 1,750 IU will raise Factor VIII to approximately 50%, adequate for oral bleeding control 7
• Repeat dosing every 12-24 hours until bleeding resolves 7

DDAVP contraindications include:

• Age <2 years or >65 years with cardiovascular disease
• Coronary artery disease or history of thrombosis
• Type 2B or type 3 von Willebrand disease (can worsen thrombocytopenia)
• Hyponatremia or conditions predisposing to water retention 4

Blood Product Support

• Transfuse packed RBCs if hemoglobin drops below 7 g/dL or if patient is symptomatic (tachycardia, hypotension, chest pain) 1
• With current hemoglobin of 9.2 g/dL, transfusion is not immediately indicated unless bleeding continues 1
• Target hemoglobin ≥7 g/dL for most patients, ≥8 g/dL if coronary artery disease present 1

Critical Monitoring Parameters

• Recheck Factor VIII activity 1 hour after DDAVP to confirm adequate response (target >50% for mucosal bleeding) 7, 4
• Monitor hemoglobin every 4-6 hours until bleeding stops and levels stabilize 1
• Assess for continued bleeding by examining the extraction site every 2-4 hours 4
• Monitor for hyponatremia if using DDAVP (restrict free water intake to 1 L/24 hours) 4

Diagnostic Workup After Stabilization

Once bleeding is controlled, complete the diagnostic evaluation:

• von Willebrand factor antigen (vWF:Ag)
• von Willebrand factor activity (vWF:RCo or vWF:GPIbM)
• Repeat Factor VIII activity when not actively bleeding
• vWF multimer analysis if initial tests suggest type 2 vWD 4

Mixing study interpretation: The prolonged aPTT should fully correct with 1:1 mixing with normal plasma if this is a factor deficiency (vWD or hemophilia A), ruling out a factor inhibitor 2, 3. If the aPTT does not correct, consider acquired hemophilia A with Factor VIII inhibitor, requiring different management 2.

Common Pitfalls to Avoid

• Do not delay DDAVP while awaiting specialized testing—treat empirically based on clinical presentation and basic coagulation studies 4
• Do not use fresh frozen plasma (FFP) as first-line therapy—it contains insufficient Factor VIII and vWF concentrations to achieve hemostasis and risks volume overload 1
• Do not administer platelet transfusions—platelets are normal and transfusion will not help 3
• Do not use prothrombin complex concentrate (PCC)—it does not contain Factor VIII and is ineffective for this coagulopathy 1, 8
• Avoid NSAIDs and aspirin indefinitely until diagnosis is confirmed, as these impair platelet function and worsen bleeding risk 4

Disposition and Follow-Up

• Admit for observation if bleeding persists despite initial therapy or if hemoglobin continues to drop 4
• Consult hematology urgently for refractory bleeding or if Factor VIII inhibitor is suspected 4, 3
• Outpatient hematology referral within 1-2 weeks for definitive diagnosis and long-term management planning 4
• Provide emergency care card detailing diagnosis and treatment for future bleeding episodes 4