04-11-2011, 10:36 PM
A 28-year-old female develops severe uterine bleeding with coagulation profile abnormalities eight hours after a successful delivery. She does not have any prior medical history, and the pregnancy was uncomplicated. She does not take any medications at home, except for multivitamins. The family history is unremarkable for any bleeding disorders. She has had tooth extractions in the past with no increase in bleeding.
On physical examination the patient presents as an anxious, nervous female, that looks her stated age. Her temperature is 97.8 F, blood pressure is 110/50 mm Hg, heart rate is 90/min, and the respiratory rate is 16/min. Her skin is pale. The uterus is enlarged, soft, and mildly painful on palpation. There are no external tears on vaginal exam. The amount of bleeding increases during palpation of the uterus.
Laboratory studies show the following results:
WBC 5,800/mm3; hemoglobin 9.8 g/dL; hematocrit 32.1 %, platelets 188,000/mm3; PT 12.4 seconds, INR 0.9, PTT 56 seconds. Bleeding time is normal. Fibrinogen 330 mg/mL; factor VIII: C level 22%.
The bleeding started three hours ago. During this time, the patient has received two units of packed red blood cells and six units of fresh frozen plasma (FFP), but the PTT remains elevated, and the bleeding still continues. Which test would be most useful in this situation?
(A) Von Willebrand's factor level
(B) Antiphospholipid antibody
© Russell viper venom (RVV) time
(D) PTT 1:1 mixing test
(E) Fibrin degradation products