Report of two cases of subconjunctival haemorrhage as first sign of postpregnancy acquired haemophilia a (AHA)

Purpose: To show that subconjunctival haemorrhage may be the first sign of post‐pregnancy acquired A haemophilia (AHA), a potentially fatal bleeding disorder. Methods: Case reports. Results: Two thirty‐year‐old caucasic women at first pregnancy presented slight pain without visual loss 2 weeks after uncomplicated spontaneous full‐term delivery. The only clinical findings were a subconjunctival bleeding for both and a small haematoma in the first case. The clinical history was negative for spontaneous bleeding also in infantile age and at previous surgery and no bleeding tendency was observed in the main relatives. The first patient was lost on follow‐up and admitted to urgent haemathologic evaluation due to large multiple cutaneous hematomas, a massive deep muscle haematoma, asthenia and dyspnea. In the second case quick routine coagulation labs were performed immediately after the subconjunctival bleeding. In both cases PTT ratio was increased. An extensive study of blood coagulation suggested the presence of a circulating inhibitor against factor VIII [1,2], confirming the diagnosis of AHA. First case was treated with a bypassing agent, however the eradication was obtained only with immunosuppressive therapy. Second case was initially placed in close follow‐up, since the post‐pregnancy form is often self‐limiting, however an immunosuppressive therapy was set after clinical progression due to the appearance of spontaneous hematoma. Conclusions: AHA is a relevant acquired bleeding disorder that can be fatal if not quickly recognized and treated even when the initial clinical signs are minor [3], how it can happen in post‐pregancy mainly in the first month [4]. Since it may present as spontaneous subconjunctival haemorrhage, routine hemathological and coagulation labs should be performed to exclude this serious condition or once identified, allow for proper clinical management.