Case report: when routine gynecologic procedures unmask a systemic bleeding disorder: refractory uterine hemorrhage leading to the diagnosis of AL Amyloidosis

Abstract

Refractory peri-procedural bleeding may be the first manifestation of an occult systemic bleeding disorder. A 46-year-old woman with heavy menstrual bleeding developed severe uterine hemorrhage after endometrial sampling and intrauterine device removal, refractory to conservative treatment and requiring balloon tamponade and uterine artery embolization. Her history revealed spontaneous ecchymoses, hematemesis, and a previous nontraumatic subcapsular liver hematoma. Further evaluation showed nephrotic-range proteinuria, monoclonal IgG-lambda in serum and urine, an abnormal serum free light chain ratio, and gastrointestinal amyloid deposition. Bone marrow examination demonstrated 11% lambda-restricted clonal plasma cells, confirming AL amyloidosis. Factor X activity was mildly reduced to 63% (reference range: 70%-120%). This case highlights that near-normal routine coagulation studies do not exclude clinically significant bleeding risk. Careful bleeding history and recognition of systemic disorders are essential when peri-procedural hemorrhage is disproportionate to the intervention