Our 15 yr old had quite an unexpected severe bleed during her tonsillectomy.  She required tranexamic acid and blood product support intraoperatively.  Surgical haemostasis was eventually successful.  Surgeons inform us that they used the cold steel method (this meant nothing to me!!- but I believe it reduces bleeding rate).  The girl had a normal coagulation pre-op and there was nothing to suggests this would be a difficult procedure.

Her blood results post op:

Hb 11.3 g/dl

WCC 10.4 x 10 9/L

plt 74 x 10 9/l

PT 12 sec

APTT 36 sec

fibrinogen 3.6 g/l

Blood film has been reviewed with no obvious abnormalities.

Following recovery:

You manage to speak to patient and mother.

Mother reports menorrhagia and easy bruising but has never been reviewed regarding this

There are no other reports of a family history of bleeding.

The patient reports menorrhagia.  She started menstruating approximately 1yr ago.  She reports that she was heavily bleeding for up to 10days so she has recently started the COCP.  She denies easy bruising, has occasional noted some epistaxis and has had no previous surgery or dental extractions.  She is taking no other medication.

What would you do next?

investigations?

immediate short term management?

Does your differential still fit with this case?