Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

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Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : December | Volume : 5 | Issue : 8 | Page : 1589 - 1592

Adolescent Menorrhagia: Study of the Coagulation Profile in a Tertiary Centre in South India

Kishan Prasad H.L., Manjunatha H.K., Ramaswamy A.S., Prakash H. Muddegowda, Jyothi B Lingegowda, Suresha Hanagavadi, Kadam Sathyanarayana Rao

1. Corresponding Author. 2. M.D, Associate professor, Department of Pathology, PES College, Kuppam, Andhra Pradesh, India. 3. M.D, Associate professor, Department of Pathology, PES College, Kuppam, Andhra Pradesh, India. 4. M.D, Assistant professor, Department of Pathology, VMKV College. Salem. Tamil nadu. India. 5. M.D, Professor Department of Pathology, JJM Medical College, Davanagere, Karnataka, India. 6. M.D, Professor Department of Pathology, JJM Medical College, Davanagere, Karnataka, India. 7. M.D, Assistant professor, Department of Pathology, VMKV College. Salem. Tamil nadu. India.

Correspondence Address :
Kishan Prasad H.L., Asst professor,
Department of Pathology, K.S. Hegde Medical Academy of
Nitte University, Deralakatte, Mangalore, Karnataka, India.
Phone: 09480503190,
E-mail: dr_kishanpath@yahoo.com

Abstract

Background: Abnormal uterine bleeding accounts for approximately 50% of the visits of adolescent girls to gynaecologists. These complaints encompass disorders which range from minimal spotting to profuse bleeding. These affect the quality of life in a majority of women who are affected. The prevalence of menorrhagia in the adolescent population with bleeding disorders varies between 14 to 48%. The common conditions which are associated with adolescent menorrhagia include the von Willebrand disease (vWD), platelet functional disorders, and coagulation factor deficiencies. This prospective study was conducted to identify the frequency of the bleeding disorders in women who presented with menorrhagia from the Indian subcontinent.

Material and Methods: 688 adolescent girls were evaluated, amongst which 40 cases were included in our study. Each case was analyzed for the demographic profile, the duration of menorrhagia, the severity of the symptoms, the degree of anaemia, and laboratory investigations.

Results: Amongst the 40 cases, 14 (35%) cases were found to be suffering from haemostatic disorders. The haemostatic disorders were divided into platelet related abnormality i.e., primary (9 cases) and clotting factor abnormality i.e., secondary disorders (5 cases). The leading cause of menorrhagia was found to be vWD and quantitative platelet disorders. A majority of the girls had anaemia (97.5%). The commonest blood group which was found in the girls was O, followed by the A group, with all the cases of vWD having the O group.

Conclusion: Menorrhagia may be an important clinical manifestation in an inherited bleeding disorder and it has been suggested that these patients need to be investigated for these disorders, especially for vWD. Early diagnosis and treatment with individualization of each case is the keystone in the management of adolescent menorrhagia.

Keywords

Menorrhagia, vWD, Bleeding disorder, Adolescent

How to cite this article :

Kishan Prasad H.L., Manjunatha H.K., Ramaswamy A.S., Prakash H. Muddegowda, Jyothi B Lingegowda, Suresha Hanagavadi, et al.. ADOLESCENT MENORRHAGIA: STUDY OF THE COAGULATION PROFILE IN A TERTIARY CENTRE IN SOUTH INDIA. Journal of Clinical and Diagnostic Research [serial online] 2011 December [cited: 2019 Feb 18 ]; 5:1589-1592. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=December&volume=5&issue=8&page=1589-1592&id=1776

INTRODUCTION
Abnormal uterine bleeding accounts for approximately 50% of the visits of adolescent girls to gynaecologists. These complaints encompass disorders which range from minimal spotting to profuse bleeding. Adolescent menorrhagia is defined as excessive bleeding which occurs between menarche and 19 years of age. In 80% of the cases, puberty menorrhagia is caused by anovulatory cycles. There is an immaturity of the hypothalamus and an inadequate positive feedback results in sustained high levels of oestrogen. An organic disease or malignancy in particular, is very rare (1),(2),(3),(4),(5).

Heavy, irregular menstrual bleeding is a frequent complaint in adolescent girls. The prevalence of menorrhagia in adolescent populations with bleeding disorders varies between 14 to 48%. It is likely to be caused by mechanisms which are different from those which occur in women in the fourth or fifth decades of their life, where anatomic causes of bleeding are common. The common conditions which are associated with adolescent menorrhagia include the von Willebrand disease (vWD), platelet function disorders, and coagulation factor deficiencies. The other conditions that lead to increased blood loss in this age group include hypothyroidism, genital tuberculosis, and polycystic ovarian disease (1),(2),(3),(4),(5).

Coagulation disorders are prevalent in 1% of the general population and their incidence may be as high as 5% in the gynaecological population (4),(5),(6). Yet, gynaecologists under estimate the coagulation disorders in the aetiology of abnormal uterine bleeding (2),(4). A majority of the studies which have been conducted in the westhave reported vWD is the most common inherited bleeding disorder which leads to menorrhagia, whereas studies from south-east Asia have found platelet functional disorder as the leading cause (5),(6). Limited information exists on the inherited causes which underlie the women bleeders, especially in the Indian subcontinent. This research was conducted to study the frequency of bleeding disorders in women who presented with menorrhagia from the Indian subcontinent.

Material and Methods

This was a prospective study which evaluated 688 cases of adolescent girls with menorrhagia at a multidisciplinary tertiary care institute over a period of 2 yrs (Sept 2004 to Sept 2006). The data was collected from medical records in each of these cases.

Each case was evaluated for age of the patient, age at menarche, clinical features, family history, drug history, menstrual history, quantity of bleeding, and associated dysmenorrhoea or other symptoms. The laboratory investigations included the evaluation of haemoglobin, packed cell volume, blood grouping, platelet count, bleeding time (BT), clot retraction, clotting time (CT), peripheral smear, prothrombin time (PT), activated partial thromboplastin time (APTT) and inhibitor screening, correction studies and bone marrow examination.

The inclusion criteria included all the adolescent females who were referred to the Haematology Unit from the Gynaecology Department of a tertiary hospital in Davanagere, with the history ofheavy, irregular periods i.e. when the interval between the start of the successive cycle was > 21 days or the duration of the menstrual blood flow was >7 days.

Patients with gynaecological causes of menorrhagia, patients who were diagnosed with endocrine disorders and those who received treatment with anticoagulants, antifibrinolytics and non-steroidal anti-inflammatory drugs were excluded from the study.

Results

The present study was conducted over a period of two years. During this period, 40 patients with puberty menorrhagia were studied. All the 40 cases were evaluated for coagulation disorders. Amongst the 40 cases, 14 (35%) cases were found to be suffering from haemostatic disorders. The haemostatic disorders were divided into platelet related abnormality i.e., primary (9 cases) and clotting factor abnormality i.e., secondary disorders (5 cases). The various cases are as shown in (Table/Fig 1) and these cases formed the crux of the study.

Clinical Features
The age range of the patients was between 12 to 19 years, with a median age of 16 years. Bleeding immediately after menarche was a presenting feature in 5/40 (12.5%) cases. The remaining cases presented at variable periods after the attainment of menarche.

The assessment of blood loss during menstruation was done by checking the detailed history of pad/tampon changing. In 16/40 (40%) cases, heavy blood loss, amounting to approximately more than 100 ml/cycle was seen, whereas in the remaining 24/40 cases (60%), there was moderate loss of blood. In patients with haemostatic disorder, the amount of blood loss was severe in 7/14 (50%) cases. Dysmenorrhoea was an associated complaint in 16/40 (40%) cases. However, it was not a consistent symptom in patients with haemostatic disorders [3/14 (21%) cases].

It is found that 5/40 cases were associated with a positive family history and all of them were found to have haemostatic disorder. Other types of bleeding which were noted in our study included epistaxis, posttraumatic, gum bleeding and petechial bleeding.

Laboratory Investigations
A majority of the cases were anaemic (97.5%) and they were found to have Hb between 8.1–10 gm/dl (70%) cases. The average Hb level was 8.52gm/dl. The packed cell volume varied between 9-40%, the average value being 26.24%. The commonest blood group was O, followed by the A group.

The haematological profiles of the cases are as shown in (Table/Fig 2) . The platelet count was done in all the cases and six cases were found to have thrombocytopaenia which ranged from 30,000 to 90,000 cells/cumm.

The BT values ranged from 2 to 20 minutes, with a mean of 7 min and 83 seconds. In haemostatic disorders, the values ranged from 3 min 30 seconds to 20 minutes, the mean being 13 min 15 seconds. In a majority of the haemostatic disorders, the BT was prolonged i.e., in 13/14 (92%) cases.

Clot retraction was noted and it was found to be within normal limits in 31/40 (77.5%) cases. The retraction was poor in 9 cases, which were subsequently diagnosed as quantitative or qualitative platelet disorders. The CT values ranged from 6 to 14 min 30 seconds, with an average of 8 min 85 seconds.

A detailed morphological study was done on Leishman stained peripheral smears, which showed dimorphic anaemia in 19/40 (47.5%) cases, followed by normocytic hypochromic anaemia in 9/40 (22.5%) cases. The peripheral smears showed thrombocytopaenia in 6/40 (15%) cases. The discrete distribution of platelets was noted among the three patients of Glanzmann thrombasthaenia.

The PT was found to be normal in all the cases, except in one case. The APTT was found to be abnormal in 5 (12.5%) patients. Later, they were diagnosed to have coagulation disorders. In haemostatic disorders, the average APTT was 36.2 seconds and the values in the clotting factor deficiency disorders had an average of 48.04 seconds. In all the cases of prolonged clotting tests, the inhibitor screening was done and none of the cases were found to be positive for the same.

The cases with the prolonged clotting tests were evaluated further by using correction studies. In one case, both the PT and the APTT were prolonged, and it was corrected by using normal control plasma and adsorbed plasma but not by aged plasma, which strongly suggested the deficiency of Factor V. In this case, the thrombin time was found to be within normal limits. The Factor V assay could not be done due to a lack of facilities for it.

In four cases where the APTT was prolonged and where the PT was normal, the correction studies with normal plasma and adsorbed plasma showed correction. No correction with aged plasma suggested a low level of Factor VIII activity. These caseshad a prolonged BT and they clinically presented with mucosal bleeding, thus strongly suggesting the diagnosis of vWD. A serum von Willebrand antigen assay was done, which showed low levels in all these cases. The various laboratory parameters in vWD are as shown in (Table/Fig 3). However, the further expensive investigations like ristocetin induced platelet aggregation (RIPA) could not be done in our study.

A bone marrow examination was done only in cases of thrombocytopaenia as a part of the evaluation. In all these cases, we found megaloblastic changes.

Discussion

Gynaecological problems of adolescents occupy a special place in the spectrum of gynaecological disorder of all age groups. This is because of the physical nature of the problems which are so unique, special and specific for the age group and also because of the associated psychological factors which are very important in the growth and psychological remodeling of someone who is in the transition between childhood and womanhood (1),(2),(3),(5),(6). Yet, adolescent gynaecology is a subspecialized area of gynaecology which has still not been explored optimally, especially in developing countries like India (3),(4),(7).

During the study period, 688 adolescents with menorrhagia were consulted in the Department of Gynaecology. After a thorough clinical evaluation, by applying our inclusion and exclusion criteria, we found 40 cases with possible haemostatic disorders, which accounted for 5.9% of the adolescents who were evaluated during the study period. Roy Chowdhury et al, found an incidence of 9.2%, which was almost comparable to our findings (5). Amongst these, 14 cases were classified under haemostatic disorders. The higher incidence of haemostatic disorders in our study in comparison with the above studies, may be explained, based on the selection criteria which we followed, which included only the adolescent age group and the small sample size. The distribution in various studies is as shown in (Table/Fig 4) (1),(8),(9),(10).

The commonest primary haemostatic disorder which was found in our study was menorrhagia due to quantitative platelet disorder, which was seen in 6/40 (15%) cases, followed by qualitative disorder, which was seen in 3/40 (7.5%) cases. In a study which was conducted by Bevan A et al, 9 / 71 (13%) girls had quantitative platelet disorder and 6/71 (9%) cases had qualitative platelet disorder, which correlated well with the findings of our study (1). A study by Roy Chowdhury et al, found thrombocytopaenia (9.2 %) as the leading haematological cause, which was similar to that which was seen in our study (5).

All the patients with quantitative platelet disorder were evaluated further and they were found to have megaloblastic anaemia. Our findings were unlike those of other studies, in which most of the thrombocytopaenias were caused due to idiopathic thrombocytopaenic purpura (1),(2). In teenagers where there is an increased nutritional demand and compounded with a decreased intake ofVitamin B (12) and folate, it is not unusual for them to have megaloblastic anaemia. It is well known that megaloblastic haematopoesis can cause dyshaematopoesis, which causes thrombocytopaenia. The literature states that patients with megaloblastic anaemia may present with bleeding manifestations (11).

We found that 3 / 40 cases had functional platelet disorder, which accounted for 7.5% cases. These three patients with bleeding manifestations were diagnosed as Glanzmann thrombasthaenia, based on the marked prolongation of BT, normal CT, poor clot retraction with a normal platelet count and the discrete arrangement of platelets in the peripheral blood smear. Saxena R et al study showed inherited platelet dysfunction as the predominant cause in 83.9% of the cases, of which Glanzmann thrombasthaenia accounted for 10.6% cases, which correlated well with the findings of our study (8).Hossain et al reported three cases of puberty menorrhagia due to platelet function disorders like Glanzmann thrombasthaenia and the Bernard Soulier syndrome (6).

The diagnosis of vWD was made in four cases and one case had factor V deficiency. vWD accounted for 10% of the cases and factor V constituted for 2.5% cases. The prevalence as compared with other studies is shown in (Table/Fig 5) (9),(10). All four cases of vWD were of the O blood group. Our study correlated well with findings which were elicited by Dilley et al and Shankar M et al (10),(12). The common association of blood group O with vWD is well documented (10),(12),(13),(14),(15),(16),(17),(18),. The O blood group tends to have low levels of the von Willebrand antigen as compared to other blood groups (Table/Fig 6) .

The rare coagulation factor deficiency which we found in our study was factor V, which accounted for 2.5% of the cases. This case of factor V deficiency presented with menorrhagia and abdominal pain and after evaluation, was found to have acute appendicitis. The patient developed life threatening post-operative bleeding and on further evaluation, was found to have factor V deficiency. This observation reiterates the importance of pre-operative PT and APTT. On review of literature, the rare coagulation factor deficiencies which were seen were found to be factor XIII, factor X, factor VII, factor XII and combined deficiencies, whereas, none of the studies showed the factor V deficiency which was seen in our study (12),(13),(14),(15),(16),(17),(18).

Menorrhagia, at all stages of life, severely affects the quality of life. The common treatment modalities which are available for this age group include anti-fibrinolytic agents, desmopressin, replacement therapy with factor VIII concentrates (in diagnosed cases of vWD), hormonal therapy, blood and blood products and the use of rFVIIa to control acute episodes of blood loss (5),(6),(12),(13),(14),(15),(16),(17),(18). The use of progestins to control acute episodes of bleeding, followed by maintenance with combined oral contraceptive pills in a cyclical manner, have been found to be effective.

Conclusion

In the present study, an effort was made to evaluate the causes of menorrhagia among adolescent girls who consulted the tertiary center in Davangere. Menorrhagia may be an important clinical manifestation in a bleeding disorder and it has been suggested that these patients need to be investigated for these disorders, especially for vWD. For the evaluation of puberty menorrhagia, more emphasis should be given to rule out primary haemostatic disorders i.e., quantitative as well as qualitative. The lack of awareness of this common inherited bleeding disorder and a paucity of good diagnostic facilities add to the problem.

Future suggestions • The haematology laboratory facilities should be improved by adding the coagulation profile including RIPA and the vWF Ag assay to the investigations. • A general public awareness regarding the proper evaluation of menorrhagia should be created for those who are affected to get appropriate treatment. • The pre-operative evaluation of haemostatic disorders by a battery of screening tests like PT and APTT should be made mandatory.

• More and more studies need to be undertaken, as there is inadequate data in the literature on this topic from the Indian subcontinent.

References

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