Introduction

„ Main categories
„ Approach to bleeding are
– Coagulation factor
disorders & vWDisease defeciency
– Quantitative and
Qualitative Plt
disorder
– Fibrinolytic
disorders
– Vascular

CLASSIFICATION Bleeding History

Acquired Low platelets
Liver, renal disease
Autoimmune,
Alloimmune,
Alloimmune, „ Crucial element
Drugs, Vit K deficiency
DIC, acquired, inhibitors.
Hypersplenism
„ Helps to define subsequent approach.
„ Following points worth considering.
Inherited Deficiency of Coag Hemophilia,
factors vWd
– Variation in response to haemorrhagic
Platelet disorders. Glanzmanns,
Glanzmanns, symptoms.
BS, etc
Fibrinolytic disorders. Alpha2-
Alpha2-antiplasmin Type of bleeding.
vascular HHT

CLINICAL MANIFESTATIONS TYPICALLY ASSOCIATED WITH

SPECIFIC HEMOSTATIC DISORDERS
Clinical manifestations
Mucocutaneous bleeding
Cephalhaematomas,
Cephalhaematomas,
haemarthrosis,
haemarthrosis, retroperitoneal
h’hages,
hages, intramuscular,
intracerebral bleeds
Injury related or mild
Bleeding from umbilical stump &
habitual abortions
Impaired wound healing
„ Assess extent of h’hage when subjected to
trauma, Sx,
Sx, childbirth, dental extractions
Hemostatic disorders
„ Objective data: Previous hospitalisations or
Low plts,
plts, plt dysfunction, vWD visit for bleeding symptoms, fe deficiency,
lab tests.
Severe haemophilia,
haemophilia, deficiency of
factors VII, X or XIII, severe vWD,
vWD, „ Medication h/o,
h/o, non prescription drugs.
afibrinogenemia.
afibrinogenemia.
„ Nutrition h/o
Mild deficiency of the above
„ F/h: h/o consanguinity, pedigree tree.
Afibrinogenemia,
Afibrinogenemia, factor XIII def
Factor XIII

Recurrent severe epistaxis HHT

1
Physical Exam

„ Examination of skin:

„ petechiae,
petechiae, eccymoses,
eccymoses, telengiectasis
„ Joint deformities.

HHT

Initial haemostatic tests Prothrombin time

„ PT, PTT, Platelet count, Fibrinogen, „ Sensitive to reductions

in I,II,VII,X & V
thrombin time.
„ Assessment of the
extrinsic system
„ Sensitivity depends on
the source of reagent-
reagent-
tissue factor.
„ Monitoring of oral
anticoagulant therapy.

2
Performing the PT PT in clinical states

„ At 37 ˚C PT prolonged in PT may be shortened

in
„ Plasma
1. Congenital & 1. Prethrombotic
„ Add thromboplastin states
acquired def of
„ Add Ca II,VII,V,X 2. High dose

„ Time the appearance of clot 2. On oral AC estrogen

3. Liver disease 3. Preop

4. Vit K def 4. Postpartum

PTT APTT reagent should

„ Sensitive to def of „ Detect mild def of intrinsic pathway
factors VIII, IX, XI, XII
& HMWK, factors.
Prekallekrein.
Prekallekrein. „ Detect Lupus AC
„ Assesses Intrinsic
Pathway „ Show a linear dose response curve for
„ Monitors IV heparin therapeutic levels of iv Heparin
„ Sensitivity depends on
the activator, source of
phospholipids

Performing APTT PTT in clinical states

At 37 ̊ C PTT prolonged in PTT shortened in

1. Congenital or 1. Pregnancy
Plasma acquired def of 2. In conditions
Add kaolin/elgaic
kaolin/elgaic acid intrinsic pathway causing activation
factors of factors.
Phospholipid source
2. Heparin
Calcium 3. Lupus AC
Time the appearance of clot 4. Severe dys or
afibrinogenemia

3
Thrombin Clotting Time TT in clinical states
„ Measures conversion of Shortened TT may be Prolonged TT may be
Fibrinogen to fibrin found in found in
„ Performed by adding
1. Dysfibrinogenemia 1. DIC
thrombin to plasma
„ Clotting time a function 2. Liver disease
of fibrinogen 3. Dysfibrinogenemia
concentration,
4. Heparin therapy
presence of
antithrombins

Further investigation if „ Example of an inhibitor

Pts PTT 67
Prolonged PT/PTT
„
„ 50:50mix(pts plasma +normal plasma). run PTT on this
sample
„ If normal-
normal-38,then it is a factor deficiency, but say 60,then its
„ A Mixing study an inhibitor, ask for inhibitor screen, which is again a 50:50
mix but this time do a PTT after mixing and than incubate the
„ If corrects with normal plasma-
plasma-factor mix for 2hrs then do a PTT.
If PTT prolonged before( 65) & also post incubation(65),
def
„
immediate acting inhibitor-
inhibitor-mot likely LUPUS, ask for DRVVT.
If PTT corrects or somewhat corrects before incubation(49)
If does not correct then it is either an
„
„ and is prolonged after incubation (65)-
(65)-delayed inhibitor-
inhibitor-Most
likely factor inhibitor , ask for Factor levels; VIII & IX.
inhibitor to a factor or a lupus type
inhibitor.
„ Following this ask for inhibitor screen
and DRVVT.

Investigations of patients with

normal screening tests

„ Peripheral blood film

„ Bleeding Time
„ Platelet Function assay
„ Von willebrands work up
„ Platelet Aggregation Test
„ Platelet Gp Analysis
„ Clot Solubility Assay-
Assay-FXIII

4
 BLOOD FILM Normal Platelets

„ Abnormalities in Platelet size

• Macrothrombocytopenia

• Granule defeciency-
defeciency-Gray plt syndrome
• Storage pool disease

Bleeding time

„ Done with a template.

„ 2 horizontal cuts are made parallel to the ante-
ante- Bleeding & PT,PTT,Plt Normal
cubital fossa(1mmx6mm)
Bleeding Time
„ Time taken for the blood to stop
„ Normal range 2- 2-10mts
„ Prolonged in plt disorders, low plts,
plts, severe
anaemia,
anaemia, Vwd,
Vwd, collagen vascular disease NORMAL

„ Great variability in results, unreliable, invasive, • Factor XIII Def Increased

insensitive •
•
Α-2Antiplasmin def
Dysfibrinogenemia •RCF-abn-vWD
•RCF-n-platelet disorders
• HHT

5
 Platelet Function Analyser

„ Uses whole blood flow through a capillary to

mimic high shear stress conditions that
occur in vivo.
„ Gives a single end point reading (when
blood flow through the capillary ceases) as
a result of plt adhesion & subsequent
aggregation when exposed to plt agonist
coated onto the cartridges, this is closure
time
„ Normal between1-
between1-3minutes

Advantages and Limitations

„ Advantage „ Limitations
„ More sensitive than „ Plt count<80 &
BT Hct<30
Hct<30 results in
„ Easy to perform increased CT
„ Non invasive „ Low sensitivity to
„ High sensitivity to SPD,PSD
vwd „ If clinical suspician
„ Can be used as a high, n PFA,then
point of care test other tests still reqd
Schematic diagram of the test cartridge used in a rapid platelet function analyzer, the PFA-100.

Tests for vWD & FXIII

Platelet Aggregation
assay
„ VWF:Ag „ Blood is centrifuged to obtain PRP
„ Placed in a cuvette at 37
37 ˚C b/w light source and
„ FVIII level photocell
„ VWFRiCoF „ Addition of agonists results in plt aggregation-
aggregation-
absorption decreases and transmission increasesas
„ Clot solubility assay, does not give a plts clump
level, but if abnormal suggests „ The addition of different agonists at a range of
concentration allows detection of certain defects
level<5%. „ Different agonists are ADP,Collagen,Epi,Arachidonic
acid & Ristocetin

6
 Platelet Glycoprotein analysis

„ Done by flow cytometry with CD41, 42 & 61

„ Bernard Soulier-
Soulier-gp Ib-
Ib-IX defect –detected
by CD42 negativity
„ Glanzmann’
Glanzmann’s thromboasthenia,gp-
thromboasthenia,gp-
IIb/IIIadefect-
IIb/IIIadefect-CD41/61 negativity

Platelet aggregation patterns in platelet disorders

Summary

„ If patient comes with a h/o bleeding

problems with normal initial screening tests,
do
„ Bleeding time & or PFA, vWDisease work
up, FXIII assay and if needed plt
aggregation tests.
„ If all this is normal and there is strong
bleeding history work up for alpha-
alpha-
antiplasmin2 defeciency etc should be done.