Hematology 2 Complete Notes

SUMMARY – PRELIMS SECONDARY HEMOSTASIS
ACCORDING TO FUNCTION:
MEGAKARYOPOIESIS Substrate CF I (Fibrinogen)
1) Megakaryoblast
2) Promegakaryocyte Cofactors CF III, V & VIII (Labile factors) & HMWK
3) Megakaryocyte
Serine proteases (CF II, VII, IX, X, XI, XII)
4) Metamegakaryocyte Enzymes
Transaminase – CF XIII - ONLY
PLATELETS
ACCORDING TO PHYSICAL PROPERTIES:
Platelet Structures:
1. Fibrinogen
1) Peripheral Zone
 Factors I, V, VIII, XIII
 Substructures:
 Factor VIII complex:
a. Glycocalyx (Antigenic structure)
a. Factor VIII:C
b. Platelet membrane
b. Factor VIII:vWF
c. Open Canalicular System (OCS)
c. Factor VIIIR:Ag (Related Antigen)
d. Submembrane region
d. Factor VIIIR:RCo (Related Ristocetion)
2) Sol-gel Zone
2. Prothrombin (Vitamin K Dependent Group)
a. Microtubules
b. Microfilaments  Factors II, VII, IX, X
3) Organelle Zone 3. Contact
a. Mitochondria  Factors XI, XII, PK, HMWK
b. Dense Tubular System (DTS)
c. Granules PATHWAYS
Extrinsic pathway Factor III and VII
PRIMARY HEMOSTASIS Intrinsic pathway Factor VIII, IX, XI, XII, HMWK and PK
Parts of platelet plug formation Common pathway Factor I, II, V, X
o Primary hemostasis
o Secondary hemostasis Thrombin
o Fibrinolytic system 1. Procoagulant
2. Coagulation inhibitor
Primary hemostasis Plug formation Reversible, 3. Tissue repair
unstable
__________________________________________________
Secondary hemostasis Clot formation Irreversible,
stable
Fibrinolysis Removal of clot FIBRINOLYSIS
1) Plasminogen
2) Plasmin
Steps in Platelet Plug Formation (Primary Hemostasis)
3) Plasminogen activators
1. Platelet adhesion
a) tPA
2. Platelet shape change
b) Single Chain Urokinase (ScuPa)
3. Platelet aggregation
c) Double Chain Urokinase (TcuPa)
4. Platelet release reaction
d) Contact phase/Intrinsic activators
5. Platelet plug stabilization
e) Therapeutic activators
4) Plasmin inhibitors
Vascular response
a) Alpha-2-antiplasmin
 Extra Vascular Component
b) Alpha-2-macroglobulin
 Vascular
c) Alpha-1-antitrypsin
 Arteries and Veins 3 Major Layer: (Blood Vessel Layer)
d) Antithrombin III
1) Tunica Intima
e) C1 activator
2) Tunica Media
5) Fibrin and fibrinogen
3) Tunica Adventitia
Inhibitors of Coagulation
Factors/Substances Contributing to Thromboresistance 1. Protein C and S
a. Heparan sulfate 2. Antithrombin III
b. Thrombodulin 3. Heparin
c. CD 39 4. Alpha-2-macroglobulin
5. EPI (Extrinsic pathway inhibitor)
d. Nitric oxide
6. C1 inhibitor
e. Prostacyclin 7. Alpha-1-antitrypsin
f. 13-HODE (13-Hydroxyoctadecadienoic acid)
g. t-PA (Tissue Plasminogen Activator)
HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

PRELIMS 2. Promegakaryocyte
PLATELETS  Mistaken for osteoclast because they have 2 nucleus
 Cytoplasmic fragments interconnected with fibrin network
 Produced through megakaryopoiesis  20-80um in diameter
 Nuclear lobulation begins
HEMATOPOIESIS  The cytoplasm has visible bluish stained granules
 Production/synthesis of blood cells  NC ratio: 1:1 (equal space)
 Pluripotential or totipotential or multipotential o Has 2 nucleus
hematopoietic stem cell  Size increase
 Pluripotential hematopoietic stem cell (PHSC):  Tags/protrusions are present
 Lymphoid lineage: lymphocytes  Last stage to contain protrusions
 Myeloid lineage: RBC, WBC, Platelet formation  Distinguishing feature:
 Growth factors needed o Demarcating Membrane System (DMS)
 Individual network of platelets
MEGAKARYOPOIESIS
 Without DMS there’s no platelet production
 Maturation series of a hematological cell that is
commited for platelet product 3. Megakaryocyte (Owl’s eyes appearance)
 Maturing cells undergo endomitosis  Mistaken for Reed-Sternberg Cell
o Endomitosis: as cell mature, cytoplasm NOT o Non-Hodgkin lymphoma
divide, ONLY nucleus divide  80-100um in diameter
 From small to big (size)  NC ratio: 1:12
 CSF Meg  CFU Meg o 2 or more nuclei
 Growth factors: o (more than 2-3 nucleus: IMMATURE)
o Erythropoietin: Red cells  May or may not produce platelet
o GM-CSF: Neutrophils o Will produce platelet if it contains 4 or more
o CSF Meg nuclei
o Thrombopoietin: Most important growth factor for  Granules
platelet production o Has reddish-blue stained granules
o Cytokines: IL-3 o Equal distribution of granules
 Absence of protrusion/tags
Factors as the platelet mature
 Maturation or production of platelets 4. Metamegakaryocyte
 Production of megakarypoiesis  Last stage
o # of nucleus: increases  80-100um in diameter
o Granularity of cell: absent to present  Always produce platelets
o NC ratio: decreases  NC ratio: 1:12
o Cytoplasmic protrusion/tags: present to absent o 4 or more nuclei
o Size: increases  Granules
o With aggregated or clumped granules in
MEGAKARYOPOIESIS cytoplasm
 5-7 days or 1 week  Fragment aka platelets will be shed off and release
 Megakaryoblast, Promegakaryocyte, Megakaryocyte, from metamegakaryocyte
and Metamegakaryocyte o Platelets are coming out
o Sharing out/releasing of platelets
1. Megakaryoblast  Largest cell found in bone marrow
 Mistaken for osteoblast  Must not be present in peripheral blood or circulation
 15-20um in diameter
Megakaryocyte Metamegakaryocyte
 Earliest/1st recognizable stage under light microscope
Same size (80-100um)
 NC ratio: 4:1
 Immature  Mature
o High NC ratio
 2-3 nucleus  > 4 nucleus
o (1) Single nucleus (No endomitosis) Both contains granules
 Distinguishing feature  Granules: reddish  Granules: Scattered,
o ✔ DMS blue, equal aggregated,
o 0.2um vacuoles under electron microscope distribution clumped,
 Tags/protrusions are present NOTE:
Light Microscope Electron Microscope  For every 1000 bone marrow cells present, there are
 No granules  Granules/vacuoles 1 metamegakaryocyte present
 DMS not clear present  For every 1-4 metamegakaryocyte present,
1000-4000 platelets in a day

PLATELETS
 70% in circulation and 30% in spleen 3. Organelle Zone
o 70% in circulation will act normal even with  Metabolic regions of platelets
splenectomy a) Mitochondria
 2-4um diameter  Energy of platelets; provides ATP
o Inactivated (discoid)  10-60
o Activated form can assume many shape
 Volume: 7 femtoliter (fL) b) Dense Tubular System (DTS)
o It will be counted in automation with 2-20fL  Where Calcium is stored internally
 Anucleated cell o Promotes clotting
o Without Golgi bodies and rough endoplasmic  Where Prostaglandin (PGI) are synthesized
reticulum but with mitochondria and granules o Prostaglandin help platelets to go back
 Under Wright’s stain, round or oval granular purple to their original shape which is discoid
color under microscope
 Platelet circulate inactive in the body c) Granules
 Production: 5-7 days  Most essential component of platelets
 Life span: 7-10 days  Either Alpha, Dense, Lysosome and
Glycogen
 SI: 150-450 x 109/L (150,000-450,000 um of blood)
Alpha Dense Lysosome Glycogen

Platelet Structures:
 Beta  ADP  Neutral  Glycogen
1. Peripheral Zone thromboglobulin  ATP protease storage
 Surrounding of a structure (outside layer)  Platelet Factor 4  Ca  Acid
 Transmitter region of cell  PDGF  Serotonin hydrolase
 Stimulus or receptor site  Thrombospondin  Catecholamine  Bacteriocidial
 Substructures: pyrophosphate enzyme
a) Glycocalyx (Antigenic structure)
 Amorphous coat that surround platelet
 Contain immunologic activity
4 α-granules present only in
 Glycoprotein for ABO and HLA 2 most Alpha
platelets, unique
b) Platelet membrane important
granules ADP: allows platelet to
 Lipid bilayers Dense
aggregate
 Interaction of different plasma coagulation
proteins
 Responsible for formation of clot
Alpha granules
c) Open Canalicular System (OCS) 4 unique Needed for the repair
 Canal or passage of different component granules PDGF in damage vessel
which facilitates interaction intracellulary and among
BTG (vascular
extracellulary platelets
endothelium)
not present
d) Submembrane region in other PF4
 Another zone cells/tissues Important in clotting
Thrombospondin
 Facilitates collection of plasma procoagulation
 Ca2+
2. Sol-gel Zone Overall Function of the Platelets

 Cytoskeletal structure of platelets 1. Maintain vascular integrity
 Gives the framework and shape of platelets  Intact
a) Microtubules  Not be brittle
 It will maintain the discoid shape of platelets  Flexible
 By nurturing or supplying endothelial cells with
b) Microfilaments PDGF which is important in connective tissue
 Will facilitate changing the shape of platelets formation
o To release the granules and 2. Formation of platelet plug
components 3. Stabilize plug by activating the fibrin formation or clot
 Thrombostenin: contractile protein of platelet formation
that will help the microtubule and microfilament
to perform their functions
o aka Actin-myosin or acto-myosin

PRIMARY HEMOSTASIS  Extra Vascular Component
 Check and balance mechanism in the blood  Tissues: present outside the vessel, surrounds the
 Clot should be lysed by plasmin vessel wall
 Series of complex processes by which the body  Plays a part in hemostasis by providing back pressure
spontaneously stops bleeding and maintaining blood on the injured blood vessel through swelling and the
vessel damage trapping of the escaped blood.
 Important to have an intact tissue, because in cases of
Vascular response injury tissues that surrounds the vessel will help out to
Primary hemostasis
Blood vessel Platelet Response trap the escaped blood.
damage Secondary hemostasis Clotting system  Trap the blood or control the escaped of blood through
Tertiary hemostasis Fibrinolytic system process called SWELLING
 Young individuals have more intact vessel and more
Basic Sequence of Events in Primary and Secondary intact tissue.
Hemostasis after Vessel injury  In adults vessels are fragile; tissues are used that will
Events Comments take longer to heal the damage they have.
 Excessive bleeding (HYPOCOAGULABLE)
Controlled by vessel smooth  Uncontrolled thrombosis (HYPERCOAGULABLE)
Vasoconstriction muscle, enhanced by chemicals
secreted by platelets
 Vascular
Adhesion to exposed subendothelial  Deals with vessels; vessels that initiates the process of
Platelet adhesion hemostasis
connective tissue
 Vessels should be intact, integrity, flexible and elastic
Interaction and adhesion of platelets
so that the blood can easily flow
Platelet aggregation to one another to form initial plug at
 Vessels gave the ability to constrict and to dilate
injury site
o Constrict  Damaged vessel
Coagulation factors interact on  Low blood pressure
Fibrin – Platelet plug platelet surface to produce fibrin;
formation fibrin-platelet plug then forms at site o Dilate  High blood pressure
of vessel injury
Fibrin clot must be stabilized by  Arteries and Veins 3 Major Layer: (Blood Vessel Layer)
Fibrin stabilization 1. Tunica Intima
coagulation factor XIII
 Innermost layer
 Where endothelial cells and subendothelial cells
Parts of platelet plug formation
are formed
o Primary hemostasis
 Separates formed elements such as platelets from
o Secondary hemostasis
adhering on subendothelium
o Fibrinolytic system
 Separates or give the barrier from platelets to the
Components subendothelium containing collagen
o Extravascular: the tissues surrounding the blood  Endothelium cells where found
o Vascular: the blood vessels through w/c blood flows  Endothelial cells is important for the
o Intravascular: the platelets and plasma proteins that procoagulant and anticoagulant activities of
circulate within the blood vessels vessels.
 After injected glutathione next is injected with
Factors included in Primary hemostasis Vitamin C which promotes the formation of
 Blood vessel collagen, boost immune system and it makes
 Von Willebrand factor your skin looks younger because of collagen.
 Fibrinogen  Because of tunica intima, collagen is hidden in
 Calcium platelets, once collagen is exposed, it’s the time
 Platelet that platelets start to adhere to damage blood
vessel wall and attachment of platelet to blood
Vascular response vessel will start clot formation.
 Vasoconstriction  If injury or damage, the tendency that this layers
 Initiate contact activation for the platelets will be exposed, if this layer is exposed the
 Releases tissue thromboplastin collagen is also exposed.
 Exposure of collagen: intrinsic pathway of hemostasis  As platelets circulates on blood vessel and sees
 Thromboplastin: activate extrinsic factor of hemostasis collagen outside the layers, it triggers the platelet
to adhere on the site that leads to stimulate the
formation of clot.

2. Tunica Media B. Thrombodulin
 Middle layer  Counteract thrombin by absorbing thrombin
 Small amount of collagen is present  2 functions:
 Smooth muscle and connective tissue are found o Absorbs thrombin
o Smooth muscle o Activates a Vitamin K dependent CHON called
 Allows the vessel to dilate/constrict Protein C
 Without smooth muscle, vessels can  Protein C and S once presents, it inactivates
never be able to dilate or constrict. clotting factor V and VIII
 Contains collagen fibers and fibrinoblast
C. CD 39
3. Tunica Adventitia  Convert ADP to AMP
 Outermost layer  ADP aggregates the platelets, allow the platelet to
 Can find more or abundant collagen form a clot; can be present in other parts/tissues in the
 Connective tissue and collagen are present blood, binds them together
 Makes your blood vessels intact, flexible and  AMP – platelets will not aggregate
elastic
D. Nitric oxide
 Endothelial cells  Prevent platelet aggregation, stimulation and activation
Tunica Intima  Source of vWF
E. Prostacyclin
 Extract prostacyclin (prevents clot)
 Prostaglandin I2 (PGI2)
 most special
Tunica media  Derived from phospholipid layer of endothelial cells
component of
 Endothelial cell contains phospholipid on its layer or its
Collagen blood vessels
membrane
Tunica adventitia  makes blood
 Phospholipid releases out arachidonic acid which will
vessels healthy
undergo a pathway called cyclooxygenase
 Vasodilator
 Healthy blood vessels: healthy hemostatic mechanism
 Prevents platelet aggregation
 Vitamin C: important in collagen formation
(strengthens collagen)
 Scurvy: Vitamin C deficiency Arachidonic acid
 Too much collagen leads to keloids  CYCLOOXYGENASE PATHWAY –
 common with chronic glutathione user Cyclooxygenase ENDOPEROXIDE – will be acted
 upon an enzyme called
Types of Collagen Endoperoxide PROSTACYCLIN SYNTHASE –
 Collagen I and III  seen in Tunica media  PROSTACYLIN (from arachidonic
Prostacyclin synthase acid derived from the phospholipid of
 Collagen IV and V  seen in endothelial cells
 endothelial cell)
Prostacyclin
Characteristics of Blood Vessel
 Smooth: blood flow
 Contains ADP: platelet aggregation
 Release of ADPase: destroy ADP F. 13-HODE (13-Hydroxyoctadecadienoic acid)
 Nonthrombogenic: must not attract formation of clot  Prevents platelet adhesion
 Derived from linoleic acid of blood vessels
Factors/Substances Contributing to Thromboresistance  Prevention of platelet adhesion on the damage of
A. Heparan sulfate blood vessel wall
 Naturally occurring anticoagulant  Pushes away the platelets if the platelets attach even
 As associated with heparin as anticoagulant, heparin without injury
inhibits thrombin (prevent formation of clot by  Vessel without injury should never promote clotting
thrombin)
 Amplify the activity of Anti-thrombin III Linoleic acid
 Increase its activity 3000x 
 Anti-thrombin III (inhibits thrombin) Lipooxygenase
 If present it means more thrombin is inhibited 
 Thrombin is important for the conversion of fibrinogen Monohydroperoxide
to become fibrin (clot) 
 Fibrinogen  fibrin Peroxidase

13-HODE

G. t-PA (Tissue Plasminogen Activator) 1. Platelet Adhesion
 Activate plasminogen then converts to plasmin  Activated by exposure of collagen, fibronectin and
 Procoagulant properties basement membrane of blood vessel
 Promotes clotting  Platelet adheres to collagen with the help of
 Von Willebrand Factor Von Willebrand Factor (vWF) and glycoprotein Ia/Ib
 derived from endothelial cells  vWF – bridge or linked of glycoprotein Ia/Ib
 Platelet adhesion  gp Ia/Ib – has receptor sites on vessel
 Fibrinolytic-tPA: plasmin  dissolution of clot
 Urokinase: can also convert plasminogen to plasmin  Absence of glycoprotein is the inability of platelets to
adhere on the vessel with a condition which is called
Removal of Clot BERNARD SOLIER SYNDROME
 Plasminogen (inactive form)
 Plasmin (active form) 2. Platelet shape change
 From discoid to spherical with pseudopod formation
PLATELET RESPONSE  Calcium, actin and myosin/thrombostenin
 Part of the process of primary hemostasis
 Formation of platelet plug 3. Platelet aggregation
 Stimulators:
INTRAVASCULAR – made up of all things present in blood  ADP
 Thrombin
PLATELET AND CLOTTING FACTORS  Thromboxane A2 (TxA2)
 important in hemostasis  Stimulates platelet aggregation
 most important intravascular component  Vasoconstrictor
 Counterpart of prostacyclin
Reversible,  Mediator of platelet release reaction
Primary hemostasis Plug formation
unstable  Derived from phospholipids found in platelet
Secondary hemostasis Clot formation Irreversible, membrane
stable  As more platelets are activated there are more
Fibrinolysis Removal of clot phospholipid
 Enzyme: Thromboxane synthase
PRIMARY HEMOSTASIS  promotes aggregation
 Main objective: platelet plug formation
 Platelets and Blood Vessels: primarily involved in Arachidonic acid
primary hemostasis

Cyclooxygenase
 Blood vessels

 Formation of clot (vWF) Endoperoxide
 Prevent formation of clot (if there’s no injury) 
 Remove a clot Thromboxane synthase
 Constriction  Activation of platelets  Form a plug 
Thromboxane
 Vessels through exposure to collagen will activate the
intrinsic pathway of coagulation and extrinsic pathway
A. Initial aggregation
– activated when releases tissue thromboplastin
 Caused by the release of granules from the
adhering platelet
 Intrinsic and Extrinsic Pathway – once activated it
 Platelet to platelet interaction is made possible by
will lead to common pathway
the presence of membrane found in:
 Calcium
Steps in Platelet Plug Formation (Primary Hemostasis) Bridge; allows the platelet to
 Fibronectin
 Exposure of collagen, fibronectin and basement membrane aggregate together with ADP
 gp IIb/IIIa
of blood vessel
 ADP is responsible
1. Platelet adhesion
2. Platelet shape change
B. Secondary aggregation
3. Platelet aggregation
 Platelets form a link or bridge gp IIb/IIIa
4. Platelet release reaction
 As platelets aggregate, they release granules and
5. Platelet plug stabilization
ADP
 Allowing change shape of other platelets (ADP)

4. Platelet release reaction 5. Platelet plug stabilization
 Platelet Factor 3 (PF3)  Platelet Factor 3 (PF3) helps in the thrombin
 a lipoprotein (phospholipid) found in platelet formation through the activation of the clotting factors
granules and membrane in the extrinsic, intrinsic and common pathway.
 plays an important role in the activation of the  Participate in prothrombinase complex
coagulation mechanism  PF3 acts with certain plasma thromboplastin factors to
 will promote stabilization of plug convert prothrombin to thrombin (thrombin formation)
SUBSTANCES SECRETED BY PLATELETS AND THEIR ROLES

Role in Hemostasis Substance Source Functions
HMWK Alpha granules  Contact activation of intrinsic coagulation pathway
Fibrinogen Alpha granules  Converted to fibrin for clot formation
Promotes coagulation Factor V Alpha granules  Cofactor in fibrin clot formation
 Assists platelet adhesion to subendothelium to provide
Factor VIII: vWF Alpha granules
coagulation surface

ADP Dense granules  Promote platelet aggregation

Calcium Dense granules  Promote platelet aggregation
Promotes aggregation
PF4 Alpha granules  Promote platelet aggregation
Thrombospondin Alpha granules  Promote platelet aggregation

Serotonin Dense granules  Promotes vasoconstriction at site of injury

Promotes vasoconstriction Thromboxane A2 Membrane
 Promotes vasoconstriction at site of injury
precursors phospholipids

Platelet derived
Alpha granules  Promotes smooth muscle cell growth for vessel repair
growth factor
Promotes vascular repair
Beta
Alpha granules  Chemotactic for fibroblasts to help in vessel repair
thromboglobulin

Plasminogen Alpha granules  Precursor to plasmin which induces clot lysis

Alpha 2-
Alpha granules  Major inhibitor of plasmin: inhibits clot lysis
Other systems affected antiplasmin
C1 esterase
Alpha granules  Complement system inhibitor
inhibitor
Inhibitors of Platelet Activity

 Prostacyclin and Nitric oxide
 CD 39
 Aspirin and NSAIDS
 Prevent formation of TxA2 by inhibiting
cyclooxygenase

SECONDARY HEMOSTASIS b. Transaminase – act on the final product of system;
 Interaction of clotting factors in the body stabilize clot
 Goal: formation of irreversible clot (fibrin)  Clotting Factor XIII - ONLY
 Coagulate cascade: domino effect
 Involves pathway: ACCORDING TO PHYSICAL PROPERTIES:
 Extrinsic: upon release of thromboplastin 1. Fibrinogen
 Intrinsic: collagen  Factors I, V, VIII, XIII
 Common: both  Largest group because of Factor VIII
 Formation of prothrombinase complex  Consumed during clotting (therefore not in serum)
a. Prothrombin  thrombin   acute phase (pregnancy and inflammation)
b. Thrombin  fibrin  Factor VIII complex:
a) Factor VIII:C
Blood vessel  Coagulation (procoagulant portion)
 Low MW portion of CF VIII
Thromboplastin Exposure of collagen  Classic Hemophilia/Hemophilia A
 
Extrinsic Intrinsic b) Factor VIII:vWF
 Should be carried by vWF to be stable
Common pathway
 Platelet adhesion
 vWF: arise from endothelial cells or
Clotting Factors (Zymogens/ Enzyme precursors/ megakaryocyte
Inactivated Enzymatic Factors)
 Synthesized in the liver c) Factor VIIIR:Ag (Related Antigen)
o Except factor III and IV  Immunologic activity
 14 Clotting Factors
o CF I – XIII (there’s NO CF VI), PK, HMWK d) Factor VIIIR:RCo (Related Ristocetion)
 Circulates on its inactive form  Important in platelet aggregation
o Except factor III and IV  Demonstrates ristocetin cofactor activity
 CF III: tissue factor
 CF IV: calcium factor 2. Prothrombin (Vitamin K Dependent Group)
 Nomenclature:  Factors II, VII, IX, X
o Without “a”: inactivated form  Vitamin K gammacarboxylation of glutamic acid
o With “a”: activated form  Stable
 Classified into two: Function and Physical Properties  Inhibited by oral anticoagulant (warfarin)
 NOT consumed during clotting (except II)
ACCORDING TO FUNCTION:  Present in fresh and stored plasma and serum
1. Substrate – binds to active site producing  Help CF to interact with one another
 Clotting Factor I (Fibrinogen)
3. Contact
2. Cofactors  Factors XI, XII, PK, HMWK
 accelerates/enhances enzymatic reactions  Intrinsic coagulation pathway
 assist in activation of zymogens  Moderately stable
 Clotting Factor III (Tissue factor)  NOT consumed during coagulation
 Labile Factors:  It requires negatively charge particle/substrate or
o Clotting Factor V foreign substance
o Clotting Factor VIII o In vivo: collagen
 HMWK o In vitro: kaolin/glass tube
3. Enzymes PATHWAYS
a. Serine proteases (CF II, VII, IX, X, XI and XII) 1. Extrinsic pathway
 Activated enzymatic factors  Factor III and VII
 Cleaved peptide bonds
 Roman numeral followed by a suffix –a 2. Intrinsic pathway
Ex. IIa, VIIa, Xa, XIa  Factor VIII, IX, XI, XII
 No biologic activity  HMWK and PK
 ALL coagulation factors are serine proteases
upon activation EXCEPT factor XIII and 3. Common pathway
Fibrinogen  Factor I, II, V, X

PLASMA COAGULATION FACTORS
Numeral Preferred Name Synonyms Active form/Function Genetic Disorder
Congenital afibrinogenemia
I Fibrinogen Fibrin clot
Familial renal amyloidosis
Prothrombin G20210A
II Prothrombin Prethrombin Serine protease
Thrombophilia
III Tissue Factor Tissue thromboplastin Cofactor
IV Calcium Serine protease
Labile factor Activated protein C
V Proaccelerin Cofactor
Accelerator globulin (aCg) resistance
Stable factor
Congenital factor VII
VII Proconvertin SPCA (Serum Prothrombin Serine protease
deficiency
Conversion Accelerator)
Antihemophilic globulin
VIII Antihemophilic Factor Antihemophilic factor A Cofactor Haemophilia A
Platelet Cofactor 1
Christmas factor
Plasma Thromboplastin
IX Antihemophilic factor B Serine protease Haemophilia B
Component
Platelet Cofactor 2
Stuart factor
Congenital Factor X
X Stuart-Prower Factor Prower factor Serine protease
deficiency
Autoprothrombin III
Plasma Thromboplastin Haemophilia C
XI Antihemophilic factor C Serine protease
Antecedent Rosenthal syndrome
Glass factor Hereditary angioedema
XII Hageman Factor Serine protease
Contact factor type III
Laki-Lorand factor
Fibrinase Congenital Factor XIIIa/b
XIII Fibrin-Stabilizing Factor Transglutaminase
Plasma transglutaase deficiency
Fibrinoligase
Prekalikrein (PK) Fletcher factor Serine protease Kininogen deficiency
Fritzgerald factor
High-Molecular-Weight Contact activation cofactor
Serine protease Kininogen deficiency
Kininogen (HMWK) Williams factor
Flaujeac factor
Purpose: Mixing studies Fresh plasma: All clotting factors

 Mixed with other blood component Aged plasma: All except CF V & VIII
 Specific CF is deficient in patient Adsorbed plasma: I, V, VIII, XI, XII, XIII
 APTT, PT, TT, Clotting time Absorbed plasma: V, VII, XI, XII, XIII
Physical Properties Fibrinogen Prothrombin Contact Fresh Serum: VII, IX, X, XI, XII
Consumed in coagulation Y N (except II) N Aged Serum: VII, IX, X, XI, XII
Present in serum N Y (except II) Y
Y
Present in stored plasma Y Y
(except V & VIII)
Absorbed by BaSO4 N Y N
Present in adsorbed plasma Y N Y
Vitamin K Dependent N Y N

COAGULATION CASCADE Fibrinogen
 Protein
EXTRINSIC  Large more
 Upon tissue damage, tissue thromboplastin react  Alpha, beta, gamma
 Thrombin will cleave alpha and beta
TT + Ca2+ Tissue thromboplastin will be joined by calcium  Alpha beta: fibrinopeptides A & B
 o Fibrin monomers
FVIII o Polymerize with each other
  Weak bond (H-bond)
VIIa + TF FVII will be activated and joined by tissue factor o Unstable
 o Should be stabilized
ETC Extrinsic tenase complex: every pathway should  FXIII: fibrin stabilizing factor
 end with tenase complex o XIII + thrombin + Ca2+  XIIIa
Activation of common pathway o XIIIa will stabilize fibrin
Blood vessel
INTRINSIC
 Collagen is negatively charged Thromboplastin Exposure of collagen
 
XII  XIIa XIIa + XIa + IXa
VIIa + TF
(Not all are converted, only partially) IXa + FVIII:C + Ca2+ + phospholipid
  
XIIa + HMWK + PK + Kalikrein Extrinsic Intrinsic
(HMWK serves as backup for XIIa to convert PK to K) Common pathway
 Xa + Va + Ca2+ + phospholipid
K + HMWK  XII  XIIa 
 Prothrombin
K + XIIa  Plasminogen  Plasmin 
(K + XIIa converts plasminogen to plasmin
II (Prothrombin)  IIa (thrombin)  I (fibrinogen)  Ia (fibrin)
Part of fibrinolytic system)
(IIa  XIIIa  Ia)
XII  XIIa  XI  XIa
 Thrombin
IX  IXa 1. Procoagulant
  Fibrinogen  fibrin
IXa + FVIII:C + Ca2+ + phospholipid  Low level = enhance factors V and VIII
(Intrinsic Tenase Complex) o Negative feedback mechanism
(Phospholipid from platelet) o  thrombin =  CF V and VIII
  Induces platelet activation and aggregation
Common Pathway  Stimulates ADP
 NOTE: ETC can also activate CF IX passing XII and XI
2. Coagulation inhibitor
 Binds with antithrombin III
COMMON PATHWAY  High levels = inhibits factors V and VIII
o  thrombin =  CF V and VIII
X  Xa
 Forms complex with thrombomodulin

o Absorbs thrombin
Xa + Va + Ca2+ + phospholipid
(Prothrombinase Complex)  Activate protein S and C
o Degrades and inhibits V and VIII

Prothrombinase
3. Tissue repair

 By stimulating platelet
F II: Prothrombin
 Release of PDGF (promotes connective tissue

formation)
Thrombin ← FIIa
 Chemotaxis and phagocytic cells

CFI  fibrin

FIBRINOLYSIS 5. Fibrin and fibrinogen
 Process of removal of fibrin or unwanted clot  Fibrin act as fibrinogen
 Bring back normal flow of blood  No will pursue
Process
1. Plasminogen  Plasminogen and tPA from endothelial cells in blood vessels
 Inactive plasma protein (normally present in the  tPA will be activated by thrombin
plasma)  tPA and plasminogen will be attracted to clot or fibrin
 MW: 90 Dalton  tPA and plasminogen will combine to clot or fibrin
 Should be active, in inactive form  Plasmin will be formed
 Plasmin will be cleaved into two forming fragment X which is
 Synthesized in the liver still clottable
 Stored and transported in eosinophils  Fragment X will be cleaved forming fragment D and
 Increased concentrations in inflammation fragment Y
 Fragment D is not clottable and fragment Y is clottable
2. Plasmin which will be cleaved into fragment D and E. These are
called dead end degradation products
 Active form
 Fibrinogen/fibrin degradation products or fibrinogen/fibrin
 Enzyme or protein for the removal of clot split products
 Serine protease  X and Y: early degradation products
 Digests/destroys fibrin, fibrinogen, Factor V & VIII  D and E: late or dead end degradation products
 Activates kinin and complement systems  Reticuloendothelial system (RES) will cleave D and E
 Fibrin DP: if 2 D fragments or D dimer is formed
 Fibrinogen DP: if 1 D fragment is formed
3. Plasminogen activators  DDAPP
a. tPA o 1-desamino-8-D-arginine vasopressin
 principal/main plasminogen activator o Release of tPA including endothelial cells
 from endothelium o Vasoactive drug
 Plasminogen (tPA, urokinase, CPA, streptokinase) 
b. Single Chain Urokinase (ScuPa) plasmin  clot  FDPs  RES
 from vascular endothelium
Plasmin
 in vivo fibrinolysis  Destroys VIII, IX, X, XI
 major activator of plasminogen in GUT  XII to XIIa  accelerated conversion
 XIIa and HMWK: kinin system
c. Double Chain Urokinase (TcuPa) o Promotes inflammatory process
 Activated by XIIa and plasmin o Vascular repair
o Clearing of damage or foreign particles
d. Contact phase/Intrinsic activators  PK to Kalikrein and complement system
o C3
 Activated by XIIa and kallikrein o Eliminate foreign substances
 Also HMWK, plasma proactivator o Involved in inflammatory process in body
 Plasminogen can be plasmin
Inhibitors of Coagulation
e. Therapeutic activators 1. Protein C and S
 Inhibitors of factor V and VIII
 Streptokinase/staphylokinase
2. Antithrombin III
4. Plasmin inhibitors  thrombin
a. Alpha-2-antiplasmin
 Major inhibitor of plasmin 3. Heparin
 Amplify activity of antithrombin III
b. Alpha-2-macroglobulin
4. Alpha-2-macroglobulin
 2nd to bind to plasmin
 Coagulation by forming complex with thrombin
 Not elicits action
c. Alpha-1-antitrypsin
 Last major naturally occurring defense against 5. EPI (Extrinsic pathway inhibitor)
plasmin  LACI or lipoprotein associated coagulation inhibitor
 Inhibits extrinsic tenase complex
d. Antithrombin III  VIIa and TF/III  XIIIa (ITC)
 Most potent inducer of tPA  Alpha-1-antitrypsin: Xa and XIa
 tPA: from endothelial cells 6. C1 inhibitor
 Prevent formation of fibrin and plasmin  Inactivate/inhibitors kalikrein (activated form of PK)
e. C1 activator 7. Alpha-1-antitrypsin
 Inhibits thrombin, Xa, XIa

SUMMARY – MIDTERMS 3. Clot retraction
a) Hirschboeck Method
SPECIMEN PROCESSING FOR HEMOSTASIS b) MacFarlane for Clot Retraction
 Glass 4. Contents (Internal & External)
 Hemolysis __________________________________________________
 Temperature
 Tourniquet application Instrumentation and Quality Control in Hemostasis
 Anticoagulant
 pH 3 WAYS OF DETECTING FIBRIN CLOT FORMATION
1) Visual Detection
Not Used for Anticoagulation 2) Electro mechanical Detection
 EDTA 3) Photo-optical Detection
__________________________________________________
 Heparin
 Oxalate
EVALUATION OF SECONDARY HEMOSTASIS
Two Types of Plasma
1. EXTRINSIC AND COMMON PATHWAY
 PPP or Platelet Poor Plasma
 Quick’s method
 PRP or Platelet Rich Plasma a. Prothrombin Time (PT) or One Stage PT
o ISI or International Sensitivity Index
Drugs Avoided in Hemostasis
o INR or International Normalized Ratio
 Aspirin b. Stypven TIme
 Heparin
 Warfarin/Coumadin 2. INTRINSIC AND COMMON PATHWAY
 Penicillin a. Clotting Time
 Sulfonamide o Lee and White
 Quinine b. Activated Clotting Time
 Procaine c. PRT (Plasma Recalcification Time)
________________________________________________ d. Activated Partial Thromboplsatin Time (APTT)
__________________________________________________
EVALUATION OF PRIMARY HEMOSTASIS
INDIRECT TEST FOR COAGULATION
FOR VASCULAR INTEGRITY 1. Two Stage PT
 Test 2. PT Consumption Test
 Bleeding Time 3. Thromboplastin Generation Time
 Capillary Fragility/Resistance Test 4. Thrombin Clotting Time
1. Tourniquet/ Rumpel-Leede/ Hess Test positive 5. Reptilase Test
pressure technique 6. 5M Urea Test
a) Quick’s Method __________________________________________________
b) Gothlin’s Method
2. Suction Cup/ Petechiometer Method/ Negative LABORATORY EVALUATION OF FIBRINOLYSIS
Pressure Technique
__________________________________________________ DETERMINATION OF LYSIS TIME
1. Whole Blood Clot Lysis Time
QUANTITATIVE EVALUATION OF PLATELET 2. Dilute Whole Blood Clot Lysis Time
1. Direct method (Reese and Ecker aka Toncantin’s) 3. Plasma Clot Lysis Time
2. Unopette system 4. Euglobulin Lysis Time
3. Indirect method aka Fonio’s __________________________________________________
4. Automated Counting Machine
__________________________________________________ FDPs
1. Protamine Sulfate Dilution Test
QUALITATIVE EVALUATION OF PLATELET 2. Ethanol Gelation Time
1. Platelet Adhesion 3. Latex FDP Assay
A. BLEEDING TIME 4. Latex D-Dimer Assay
a) Duke’s Method 5. Tanned Red Cell Hemagglutination Inhibition
b) Ivy’s Method 6. Staphylococcal Clumping Test
c) Modified Simplate or Modified Ivy’s __________________________________________________
d) Adelson – Crosby Method
e) Cody Lalitch SPECIAL COAGULATION TEST
f) MacFarlane for Bleeding time 1. Screening Test
g) Aspirin tolerance Test 2. Tissue Thromboplastin Inhibition Test
3. Platelet Neutralization Test
B. GLASSBEAD RETENTION TEST 4. Agarose Plasma Gel Technique
5. Bethesda Inhibition Assay
2. Platelet Aggregation 6. Ristocetin Cofactor VIII
o Turbidimetry 7. Factor VIII Assay
o Transmittance of Light __________________________________________________
 Bernard Soulier Syndrome
 Glanzmann thrombasthenia MIXING STUDIES

MIDTERMS
LABORATORY EVALUATION FOR HEMOSTASIS o Polycythemia vera

 Test for Primary hemostasis  Excess anticoagulant
 Handling and processing specimens for hemostasis  Less plasma
 Prolonged coagulation test PT, APTT, TT
SPECIMEN PROCESSING FOR HEMOSTASIS  Citrate is decreased
 Collected blood, evacuated system 100 – Hct x Volume of whole blood
 Prevents contamination and hemolysis 595 – Hct
 Glass
o Negatively charged
o Activates clotting factors
o Contact CF XII, XI, HMWK, PK  pH
o Contact glass o Most important factor in coagulation testing
o Citrate for coagulation (9:1) o Presence of absorbed labile clotting factor
o Contamination of tissue thromboplastin-like o CO2 escaped from tube which will increase pH
components o CF V and VIII will deteriorate in alkaline
o Blue top is affected if red first (with activator), so environment
blue top first o Tested within 2 hours
 Cellite o In the refrigeration, but not more than 4 hours
 Kaolin  Negative for platelet aggregation test
 Ellagic acid  Prematurely activates CF VII and XI
 -20 to -70C
 Hemolysis
o Do not accept hemolyzed sample
o RBC damaged will release ADP which is Not Used for Anticoagulation
responsible for platelet aggregation  EDTA
o Chelates calcium
 Temperature o All citrate will not preserve CF
o 37C o Thrombin and fibrinogen
o Coagulation test o Secondary hemostatis : end point is clot
o Labile clotting factors (CF VII and XI )
o If refrigerated  Heparin
 CF VII and XI prematurely activated o Inhibits thrombin
 Positive for platelet aggregation test o Primary antithrombin
o CF VII o No clot formed
 Extrinsic tenase complex (ETC)
 Prothrombin time ( PT )  Oxalate
o CF XI o Used in automation
 Intrinsic tenase complex ( ITC ) o Bind with calcium and forms crystal and
 Activated partial thromboplastin time precipitate
(APTT)
o Capped tube for coagulation
 For 6 hours, pH will change if capped Centrifugation
 Stable for 24 hours for PT Two Types of Plasma
 PPP or Platelet Poor Plasma
 Tourniquet application
o Heavy spin for 10-15 minutes
o Less than 1 minute
o Does not contain large platelet
o Prevents hemoconcentration
o 2000-2500 rpm
o Which leads to hemolysis
o RV : <10 x 109 /L
o ADP for platelet aggregation
o Test for clotting factors not with platelet
 Anticoagulant
o Black top ( 4:1 )
o Citrate ( 9:1 )  PRP or Platelet Rich Plasma
 Blue top o Test for platelets
 Buffered o Light spin for 10-15 minutes
 Preserve all CF o 60-150 rpm
 Maintains pH o RV: 250 x 109/L
 3.2% (0.109M) : preferred o Platelet aggregation test
 3.8% (0.129M) o RT or 37C

Drugs Avoided in Hemostasis o Tourniquet test (ex.for dengue)
 Aspirin  Inflate the bp cuff to half way between
o Prevents thromboxane A2 systolic and diastolic for 5 minutes
o Inhibits cyclooxygenase
o 7 days : for platelet aggregation test o Normal value: 0-10 petechiae
o 24 hours : Bleeding time o Normal: <10 petechiae
o Abnormal: >20 petechiae (possible vessel
 Heparin problems)
o Inhibits thrombin, therefore no fibrin o Equivocal: 10-20 petechiae
o Also assess number of platelets
 Warfarin/Coumadin
o Blood thinner 2. Suction Cup/ Petechiometer Method/ Negative
o Antagonist of Vitamin K Pressure Technique
o Vitamin K: responsible for the interaction of o Principle: employs the use of a modified da
prothrombin group ( CF II, VII, IX, X ) Silva Melle Instrument. The cup is applied to
o Prevents formation of clot the outer surface of the arm for a period of one
minute at 200 mmHg and the resistance of the
 Penicillin capillaries is expressed as the negative
 Sulfonamide pressure required to produce a macroscopic
 Quinine petechiae.
o Normal value: less than 4 petechiae
 Procaine
o Disrupts vessel wall
o Hemolysis will happen
QUANTITATIVE EVALUATION OF PLATELET
__________________________________________________  Absolute counting using hemocytometer
 Direct method
EVALUATION OF PRIMARY HEMOSTASIS
o Reese and Ecker aka Toncantin’s
 Deals with platelets
o Composition: citrate, formaldehyde, buffer,
 Major Important factor
brilliant cresyl blue
o Number of platelet
o Hemocytometer
 Quantitative evaluation of platelet
o RBC
 Qualitative evaluation of platelet  DF: 1:200
 10 or more squares
FOR VASCULAR INTEGRITY o WBC
 Primary hemostasis: intact or flexible  DF: 1:20
 4 squares
 Action of blood vessel
o Vasoconstriction  Unopette system
o Exposure to collagen which activates ITC o Contains ammonium oxalate
o Release tissue thromboplastin which activates o DF: 1:100
ETC o 25 RBC = 25/25
 Test o # of cells x 100 x 10 (depth factor) x 1 (25/25)
 Bleeding Time o # of cells x 1000 x 109/L
 Capillary Fragility/Resistance Test
 Test the stability of the small blood vessels to  Indirect method aka Fonio’s
retain the red cells in the lumen under the o Wright’s stain
conditions of stress and trauma o Indirect counting estimation
 10-40 RBC: 1 platelet
1. Tourniquet/ Rumpel-Leede/ Hess Test  100 RBC: 3-10 platelet
positive pressure technique  200 RBC: 5-20 platelet
o Principle: by partially obstructing the venous o Average number of cells x 20000
blood, the capillary pressure is increased. This
will give rise to intravasation of blood which  Automated Counting Machine
will be manifested in the form of small o Determined by size and volume
hemorrhages called petechiae. o Volume: 2-20 fL for platelet
o Electrical impedance
c) Quick’s Method
d) Gothlin’s Method

Smear: Platelet Estimates QUALITATIVE EVALUATION OF PLATELET
Platelet Estimate of Report Platelet Estimate as 1. Platelet Adhesion
0 – 49,000/uL Marked Decrease 2. Platelet Aggregation
3. Clot retraction
50,000 – 99,000/uL Moderate Decrease
4. Contents (Internal & External)
100,000 – 149,000/uL Slight Decrease
150,000 – 199,000/uL Low Normal __________________________________________________
200,000 – 400,000/uL Normal
401,000 – 599,000/uL Slight Increase 1. PLATELET ADHESION
600,000 – 800,000/uL Moderate Increase  Platelet adhesion test
Above 800,000/uL Marked Increase  Together with assessment of platelet number
 Ways/Methods:
Thrombocytopenia (abnormally low levels of thrombocytes)
A. Bleeding time
 Production defects, accelerated loss or destruction
 Duke’s Method
and splenic sequestration
 Ivy’s Method
 Primary thrombocytopenia
 Adelson-Crosby Method
o Idiopathic thrombocytopenic purpura (ITP)
 Cody Lalitch
o Post-transfusion,
 MacFarlane
o Heparin-induced
 Secondary thrombocytopenia
B. Platelet retention test
o Systemic lupus erythematosus (SLE)
o Viral Infection,
A. BLEEDING TIME
o Lymphoproliferative Disorders
 Standard skin wound, 2-3 mm
 In vivo platelet function and number
 Factors which affect bleeding time:
Leukemia 1. Elasticity of the cut tissue
Myelofibrosis 2. Ability of the blood vessels to constrict and
Marrow infiltrative process
Multiple myeloma retract.
Lymphoma 3. Mechanical and chemical action of platelets
in the formation of hemostatic plug.
Aplastic anemia
Fanconi’s anemia Evaluation of Platelet function and Number:
Aplasia
Chemotherapy a) Duke’s Method
Radiation  Subjective pressure
 More practical and convenient
Vitamin B12 Deficiency  Finger pricking and earlobes
Ineffective Blood Folic Acid Deficiency  Lancet, Cotton, Paper
production Alcohol Ingestion
MDS and PNH b) Ivy’s Method
 Better based on principle
Bernard-Solier  There’s a constant pressure applied
Congenital disorders TAR Syndrome  Important in determination
May-Hegglin of bleeding time
  pressure = longer
Abnormal platelet Hypersplenism
bleeding time
distribution Kassabach-Meritt
 Puncture forearm with blood pressure cuff
Primary Immune (40mmHg)
Increased platelet
Secondary Immune
destruction c) Modified Simplate or Modified Ivy’s
Microangiopathic
 Forearm, 5mm
Thrombocytosis Other ways:

 is an abnormal increase in the number of circulating d) Adelson – Crosby Method
platelets as a result of physiologic or pathologic  Almost the same with Duke’s but the
processes
difference is immersion of punctured finger
 Primary thrombocytosis:
in sterile physiologic saline solution (NSS)
 MDS (Myelodysplatic Syndromes):
o Polycythemia Vera (PV) warmed at 37℃ waterbath to check bleeding
o Essential thrombocythemia (ET)  Normal Values: >3minutes
 Secondary thrombocytosis (Reactive):
o After Hemorrhage e) Cody Lalitch
o IDA  Same as Adelson – Crosby Method
o Malignancy
o Epinephrine Administration

f) MacFarlane for Bleeding time Bernard/vWD Glanzmann
 Same principle with Adelson-Crosby method Ristocetin ✖ ✓
but it only uses ear lobe as the site of Arachidonic
puncture. Collagen ✓ ✖
Serotonin
g) Aspirin tolerance Test
 Assesses the effect of a standard dose of
Platelet aggregation
aspirin on the Duke’s Bleeding Time.
 Use PRP
 Light transmittance using aggregometer
ABNORMAL BLEEDING TIME:
 Anticoagulant: Citrate (Blue top)
 Thrombocytopenia  PPP: too low platelet, high transmittance
 Hypofibrinogenemia  PRP: too high platelet, low transmittance
 vWF Disorder  High platelet if aggregated will have high
 Connective Tissue Disorder transmittance
 Add aggregating agents if:
B. GLASSBEAD RETENTION TEST o Transmittance is high = good adhesion
 In vitro determination of platelet adhesiveness o Transmittance is low = abnormal adhesion
 Platelet retention percentage
 Using venipuncture Aggregating agents:
 EDTA as anticoagulant  Promote platelet aggregation
 Citrated blue top tube as anticoagulant choice
CTRL tube – Tube 3 x 100  Aggregate: Normal
CTRL tube
 Do not aggregate: Abnormal
 NV: 75-95%
 Aggregating agents:
ABNORMAL PLATELET RETENTION TEST  ADP
 Epinephrine: last to be added
Decreased Increased
 Thrombin
 Bernard Solier  Thrombotic
 Arachidonic acid
 Glanzmann Disorders
o ETA: biphasic
Thrombastenia  Hyperlipidemia
 Ristocetin
 vWD  Carcinoma
o Always add ristocetin first
 CHediak Higashi  Oral Contraceptives
o Broad
 Myeloproliferative  Pregnancy
 Collagen
Disorders
 Serotonin
 Uremia
o Weak aggregating agent
 Aspirin Administration
o 30% T
2. PLATELET AGGREGATION Three Types of Curves

 Low Curve
Platelet aggregation test
o U-shaped
 More important than adhesion o 30%T
 Same as platelet forming a plug o Serotonin
 Principle:
o Turbidimetry  Biphasic Curve
o 2 curves
o Transmittance of Light
o Optimum aggregating agent
 Purpose: to differentiate Bernard Soulier Syndrome o 1st curve: Primary hemostasis
from Glanzmann thrombasthenia o 2nd curve: caused by platelet
o Epinephrine, thrombin, ADP
 Bernard Soulier Syndrome
o Error in platelet adhesion  Broad Curve
o Gp Ia/IIb o High aggregating agent
o Ristocetin
o Upon adding ristocetin, fails to aggregate
o Add ECA (epinephrine, collagen, ADP) 
NORMAL SPECIAL CONSIDERATION:
 No hemolysis
 Glanzmann Thrombasthenia  Fasting is required
o Gp IIb/IIIa o For 8 hours
o Add ECA (epinephrine, collagen, ADP)  o Avoid lipemic sample
 pH: 6.5 to 8.5
ABNORMAL
 Temperature: 37C (Room temp only)
o Add ristocetin  NORMAL
 No NSAIDS for 7 days (1 week)
 Within 3 hours

3. CLOT RETRACTION INSTRUMENTATION AND QUALITY CONTROL
 Go back to its original form IN HEMOSTASIS
 Measures the entire platelet function
 Primary goal of secondary hemostasis: formation of
 Since you already form a clot, the plug has been first
clot, endpoint is clot, detection of clot
formed already
 Detects problems with coagulation
 Assess primary and secondary hemostasis
3 WAYS OF DETECTING FIBRIN CLOT FORMATION
Methods:
a) Hirschboeck Method
1) Visual Detection
 Using castor oil for constipation
 (+) Dimpling phenomenon for 15-45 minutes  Principle: Manual visualization of clot on the tilt tube
 Mickey mouse appearance process (like Lee and White)
b) MacFarlane for Clot Retraction  Disadvantages:

 More toxic/too much work  Lacks accuracy
 Blood is transferred in the clean test tube  Temperature maintained at 37C
 Incubated water bath for 24 hours  Less precise and less reproducible (tube 1)
Volume of serum x 100  Time consuming
Volume of whole blood  Pipetor
 Timing: most important and critical factor, time
 50% is normal
interval in seconds
 Subjectivity, lacks precision
4. CONTENTS (INTERNAL & EXTERNAL)
 Platelet adhesion test
2) Electro mechanical Detection
 Principle: Fibrin is detected by two wire loops as
PLATELET FACTOR ASSAY electrode which is incorporated to an electrode
 PF3 availability mechanical instrument
 PF3: Platelet phospholipid for tenase complex
 Instrument: Fibrometer
 Uses PPP, PRP and activators
 Measures clotting time then compare the result,  Advantage: Sensitive to low fibrinogen level:
promotes clotting <50 mg/dL fibrinogen
 0.0025M CaCI2 + plasma + activators = clot
 If PRP is near control, it is normal  Disadvantages:
 If PPP is near control, it is abnormal  Interval 0.5 seconds
 Specimen carry over excessive anticoagulants
 PF4 and BTG  Diluted with 2% acetic acid
 Alpha granules synthesized in platelet
 Platelet are activated, change shape, release granules
 Presence means on going platelet activation 3) Photo-optical Detection
 Temperature: cold temperature  Most common way/most accurate/precise
 Method is radioimmunoassay of RIA
 Instrument: Ortho Koagulab
 Principle: depends on the increased light scattering

 Once the light passes, the transmittance will increase
 Sources of errors:
 Transmittance is affected by
 Icteric sample
 Lipemia
 Hemolysis
 Low Fibrinogen
 Rich heparin
 Protein precipitate
 Interval time: 0.1 second
 Guard time interval
 Delay in measurement clotting time
 Always longer to the clotting time of patient
 Of less than 0.1 second, problem with machine
and reagent

Variables Affecting Coagulation Testing & Quality Control Proficiency Testing
 Instrument  External quality control program
o Provide enough temperature  Interlaboratory comparison of the test result obtained
o Light source to assess laboratory performance
 Unknown specimen by different laboratory to reference
o Detector
laboratory
o Timer  Quality assurance among different laboratory
o Reagent delivery __________________________________________________
 Specimen EVALUATION OF SECONDARY HEMOSTASIS

o Collection  Error in both extrinsic and intrinsic the problem lies in
o Anticoagulant common pathway
o Delays  Error in extrinsic, problem in intrinsic
o Storage  Error in intrinsic, problem in extrinsic
1. EXTRINSIC AND COMMON PATHWAY

 Reagent and Control
 Tissue thromboplastin, CF VIII
o Shipping
 Quick’s method, discovered by Adam Quick
o Storage o Test of choice under oral anticoagulant
o Record therapy such as Warfarin or Coumadin
o Deterioration
o Lot changes (bar code number) a. Prothrombin Time (PT) or One Stage PT
 Allow and inform the machine to read and o Reagent
recognize new lot number first  Simplastin
 Composed of 0.025M CaCI2 and
thromboplastin
Reagent and Control
 PT reagent o ISI or International Sensitivity Index
o Sources: Rabbit brain or rabbit blood  Simplastin (How sensitive your reagent)
 APTT uses insoluble activators  Because of different sources, different
 Reagent compatibility sensitivity
o Close system: fixed, same brand of reagent  ISI = 1 set by WHO (1:1)
and machine  If lower than 1, more sensitive
o Open system: different brand of reagent and  If more than 1, less sensitive
machine  If contains thromboplastin, activates
CF VII
System Advantage Disadvantage  Formation of clot
Closed system More accurate and precise More expensive  Normal value: 11-14 seconds
Open system Less accurate and precise Less expensive o INR or International Normalized Ratio
 International reference thromboplastin
 Cost reagent used in standardizing the PT
o Does not mean cheap is not accurate time ratio
o Should not compromise the result  Oral anticoagulant status/capacity of
patient
 Reproducibility  PT ratio: under oral anticoagulant
 Sensitivity  Normal: I
 Cost  Under warfarin INR is increased or >1 or
o Ability of test to detect small amount of 2 – 2.5
concentration of analyte  If more than 1 bleeding tendencies may
occur even if under warfarin
 Purposes
( Patient’s PT )
(Mean of normal)
Considerations of Control Materials Used
o Intrinsic problem: CF VIII
 To monitor precision
o Control materials use only precision in
laboratory but not reference range b. Stypven TIme
o Used to differentiate CF VII or X deficiencies
 To determine SD
o Russell’s viper (Snake’s venom)
 Not measures reference value/range/normal value
 Thromboplastin like substance
 Run
 Assume function of CF VII
o Once or every after shift
 Activates factor X
o After 20 test, run control again
o CF X:  PT,  ST
o CF VII:  PT, ⓃST

2. INTRINSIC AND COMMON PATHWAY INDIRECT TEST FOR COAGULATION
 Triggered by exposure to collagen 1. Two Stage PT
 Collagen is negatively charged  Amount of fibrinogen need to add to form a clot
 As well as glass surface
 1st stage: Plasma + Thrombin
a. Clotting Time o Blood with clot ( I, V, VIII, XIII)
o Lee and White o Remove clot
 Visual detection by tilting pf tube o Leftover plasma
o Normal Value: 10-15 minutes  Used for 2nd stage
o Under heparin: 180 seconds
 2nd stage:
o Mircomethod: Slide + Capillary tube (Blue) o X, V, Ca+2, thromboplastin
+ (mix)
o Remaining plasma
b. Activated Clotting Time o Thrombin formed is then measured by adding
o Activator: Diatomite (12 mg diatomite or aliquots of the activation mixture to standard
diatomaceous earth) fibrinogen solutions and recording the clotting
 Enhance activation of CF time.
o Normal Value: 75-120 seconds
o Under heparin: 145-180 seconds
2. PT Consumption Test
 aka Serum PT
c. PRT (Plasma Recalcification Time)  Sample: Serum
o Gives back calcium to form a clot  Clot first of blood
o Removes red cell  Thrombogenesis
o Citrate as anticoagulant o Number of platelet
 Missing fibrinogen group: CF I, V, VIII, XIII
o PRP + 0.025M CaCI2  CF II: somehow consumed, <20% left
 Normal value: <50 seconds  Uses Simplastin A
 Faster to form a clot o Composed of thromboplastin, calcium,
fibrinogen and CF X
o PPP + 0.025M CaCI2  Normal result: longer, >20 seconds
 Normal value: 130-240 seconds
o Normal value: 100-150 seconds 3. Thromboplastin Generation Time

 aka Mixing Studies
 Fresh, stored, serum, adsorbed
d. Activated Partial Thromboplsatin Time (APTT) o Fresh plasma: No CF
o Test of choice for heparin therapy patients o Stored Plasma: CF V & CF VIII (Labile
o Affected by circulating anticoagulant factors)
o Serum: CF I, V, VIII, XIII (Fibrinogen group)
o Reagent o Adsrobed plasma: CF II, VII, IX, X (PT or
 Made up of: Contact group)
 Platelet substitute  Determination of specific CF missing
 Activators
 Ellagic acid
 Kaolin 4. Thrombin Clotting Time
 Silica  Affected by fibrinogen
 Cellite  By pass formation of clot except conversion of fibrin
 0.025M CaCI2 to fibrinogen
 Add thrombin and if there is a problem, it will take
o PT: start time upon addition of simplastin
time
(CaCI2 + TT)
 Problems such as Afibrinogenemia,
Dysfibrinogenemia
o APTT: Start timing upon addition of CaCI2
 Affected by heparin
 Affected by circulating anticoagulant
o Normal value: 20-45 seconds
o Cause lupus anticoagulant

5. Reptilase Test LABORATORY EVALUATION OF FIBRINOLYSIS
 Detects fibrinogen  Fibrinolysis; lysis of fibrin clot
 Not affected by heparin  Plasminogen and plasminogen activators activates
 Derived from snake venom: Bothrops atrox plasmin
o Assumes function of thrombin  Plasmin degrades clot
 Not affected by circulating anticoagulant  Fibrinolytic system
 Problem in CF I  Presence of FDPs or fibrin or fibrinogen degradation
o  TCT,  RT products
 Problems in other CF or circulating anticoagulant
o  TCT, ⓃST
 Normal value: 18-20 seconds DETERMINATION OF LYSIS TIME
1. Whole Blood Clot Lysis Time
 Allow to clot in a test tube @ 37C
6. 5M Urea Test
 Place in water bath to 48 hours
 aka Duckert’s test
 Form a clot
 CF XIII
 Normal: clot is intact in 48 hours
o Fibrin stabilizing factor, stabilizes fibrin
 Abnormal: clot is lysed before 48 hours
 After 24 hours:
 Clot is lysed before 48 hours, meaning there is
Normal: If there’s a clot, sufficient amount of CF XIII
excessive fibrinolysis or fibrinolytic system
Abnormal: If there’s no clot, less amount of CF XIII
 Excessive fibrinolysis or fibrinolytic system meaning
thrombosis or bleeding
__________________________________________________
2. Dilute Whole Blood Clot Lysis Time

 Blood is diluted by adding inhibitors
 More sensitive
3. Plasma Clot Lysis Time

 Citrated plasma + Calcium chloride  forms a clot
 Recalcified plasma (PRT)
4. Euglobulin Lysis Time

 Test that measures overall fibrinolysis
 Citrated platelet poor plasma with acid in a test tube
 Plasma is diluted with water then acidified (weak HCI)
which leads to the formation of protein precipitate
 Protein precipitate:
o Plasmin
o Plasminogen
o Plasminogen activators
o Fibrinogen
 Clotted by adding thrombin
 Component: fibrinogen, plasmin, plasminogen
activators and plasminogen
 Normal value: more than 2 hours
 More fibrinogen, more time to lyse
 Less than 2 hours, excessive fibrinogen activities
 Euglobulin: insoluble in water but soluble in saline
solutions

FDPs 6. Staphylococcal Clumping Test
 Activities of the fibrinolytic system  Uses diluted coagulase negative staphylococcus
aureus in a microplate
1. Protamine Sulfate Dilution Test  S.aureus strain: Newman D2C
 Detection of early and late degradation products  It acts against X and Y fragments
 Protamine will react to FDP causing coagulation which  Normal value: 0-8 ug fibrinogen equivalent/mL of
is called paracoagulation serum
 Test to distinguish primary and secondary fibrinolysis __________________________________________________
 FDP is cleared by phagocytic system, macrophage
and RES SPECIAL COAGULATION TEST
 FDP must be cleared otherwise will react to protamine  Determination of circulating anticoagulant aka
 Primary fibrinolysis: (Degradation fibrinogen, (–) rxn) inhibitors
 no available or present fibrin but with fibrinolytic  All CF are present in fresh normal plasma
system
 Secondary hemostasis: (Degrad’n of fibrin, (+) rxn) 1. Screening Test
 there will be fibrinolytic system only if fibrin is  APTT is used
present  If prolonged, there is deficiency in CF
 Protamine is under secondary hemostasis  Then add fresh plasma to normalize
 Normal value: no coagulation or agglutination  If inhibitors are present, there will be abnormal result
o There will be prolongation
 Prolongation is caused by inhibitors not CF
2. Ethanol Gelation Time
 Inhibitors: most common is lupus anticoagulant
 Primary and secondary hemostasis
 Inhibitors are direct against phospholipid
 Forms clot if FDP are present
 Phospholipid is an important component in tenase
 50% ethanol + FDP  clot
complex
 Less sensitive but more specific
 Normal value: no agglutination
2. Tissue Thromboplastin Inhibition Test
 Aka Modified Clotting Time
3. Latex FDP Assay
 Patient clotting time: Normal control
 Mixed with antibody to D and E fragments (late
 Add thrombin and calcium chloride
degradation products)
 Usually 1:1
 Anti-D and Anti-E
 <1:1 Normal
 Antibody to FDPs will react
 >1:1 Abnormal
 Rapid and sensitive
 Sensitivity: 2 ug of FDPs/mL
 Inhibitor: soybean trypsin 3. Platelet Neutralization Test
 APTT is increased
 Use of freeze thawed platelet
4. Latex D-Dimer Assay  Shortening of APTT means presence of circulating
 Specialized fragment from fibrinogen degradation inhibitors, most common is lupus anticoagulant
products from fibrinolysis  To confirm if it is lupus anticoagulant:
 Latex: Mouse anti-human D-dimer o ELISA & Anticardiolipin assay
 Plasma is used
 Any anticoagulant can be used
 This test is after or for FDPs 4. Agarose Plasma Gel Technique
 Normal value: 200 ng/mL  Fresh plasma + calcium chloride
 Cloudy or opaque gel means there is clot
 If gel is not cloudy, there is presence of inhibitors
5. Tanned Red Cell Hemagglutination Inhibition
 Rabbit derived antihuman fibrinogen  human group 5. Bethesda Inhibition Assay
O  Factor VIII inhibitor: intrinsic
 Normal value: <12 ug fibrinogen like antigen/mL  APTT (plasma)
 Reagent + plasma  human plasma  1 Bethesda unit: 50% FVIII inhibited
 No agglutination: If there is fibrinogen after addition of  100 mg FVIII, measure FVIII = no inhibited against
human group O FVIII
 (+) Agglutination: If there is no FDP  Lower than 50%, there are inhibitors

6. Ristocetin Cofactor VIII Examples:
 vWF + Ristocetin   PT, APTT is normal
 vWF agglutinates platelets (normal) o You have an idea that the problem is in
 Ristocetin + platelet  no agglutination instrinsic pathway
o PT: CF VII is involved
 Normal value: 50-150% activities
o Upon addition of:
 vWF: for adhesion
 Fresh plasma: Ⓝ
 Stored plasma: Ⓝ (V, VIII)
 Serum: Ⓝ (I, V, VIII, XIII)
7. Factor VIII Assay
 Adsorbed plasma:  (II, VII, IX, X)
 Laurel-Rocket Immunoelectrophoresis
o CF missing is CF VII
 Fletcher Factor (PK): APTT is corrected by Kaolin and  Since CF VII is involved in extrinsic
celite pathway and it is missing in
adsorbed plasma
__________________________________________________
  PT,  APTT
MIXING STUDIES o You have an idea that the problem is in
 Specific missing CF determination common pathway
o CF X, V, II, I
o Upon addition of:
 PT
 Fresh plasma: Ⓝ
o If increased, problem in extrinsic pathway
 Stored plasma:  (V, VIII)
o CF VII
 Serum:  (I, V, VIII, XIII)
 Adsorbed plasma: Ⓝ (II, VII, IX, X)
 APTT
o CF missing is CF V
o If increased, problem in intrinsic pathway
 Since CF X, V, II, I are involved in
o CF XII, XI, IX, VIII common pathway and it is missing in
both serum and stored plasma
 PT and APTT
o If increased, problem in common pathway
o CF X, V, II, I   PT,  APTT
o You have an idea that the problem is in
 Fresh plasma common pathway
o All are CF present, none are absent o CF X, V, II, I
o Upon addition of:
 Stored plasma  Fresh plasma: 
o CF V and VIII are absent  Stored plasma:  (V, VIII)
 Serum:  (I, V, VIII, XIII)
 Serum  Adsorbed plasma:  (II, VII, IX, X)
o CF I, V, VIII, XIII are absent o The possible explanation is that the person
has circulating anticoagulant specifically
lupus anticoagulant
 Adsrobed plasma
o CF II, VII, IX, X are absent
Pathway Extrinsic Intrinsic Common

CF involved VII XII, XI, IX, VIII X, V, II, I
Test involved PT APTT PT and APTT
Missing Clotting Factors

Fresh Plasma Stored Plasma Serum Ads. Plasma
None V, VIII I, V, VIII, XIII II, VII, IX, X

SUMMARY – FINALS THROMBOCYTOSIS
A. PRIMARY THROMBOCYTOSIS
PRIMARY PURPURA o Myeloproliferative disorders
1. Simple Purpura  Polycythemia Vera
2. Mechanical Purpura 1. Polycythemia Vera
3. Psychogenic Purpura o Relative Polycythemia Vera
4. Senile Purpura o Secondary Polycythemia Vera
5. Schamberg’s Purpura 2. Secondary Polycythemia Vera
6. Factitious Purpura  Essential thrombocythemia
B. SECONDARY THROMBOCYTOSIS (Reactive)
SECONDARY PURPURA ________________________________________________________
1. Infectious Purpura
o Waterhouse-Friedrichsen Syndrome BLEEDING DISORDERS
2. Allergic Purpura  Afibrinogenemia
o Henoch-Schonlein Purpura CF I Deficiency  Hypoibrinogenemia
3. Metabolic Type Purpura  Dysfibrinogenemia
o Scurvy: Vitamin C Deficiency
 Prothrombin deficiency
o Diabetes Mellitus CF II Deficiency
Hypoprothrombinemia
o Cushing syndrome: Hypercorticolism
o Protein C deficiency  Owren’s Disease
CF V Deficiency
4. Connective Tissue Disorder  Parahemophilia
o Ehler’s Danlos Syndrome CF VII Deficiency  Hemophilia
o Pseudoxanthoma Elasticum  Hemophilia A
o Marfan Syndrome CF VIII Deficiency  Classic Hemophilia
o Ostegenesis Imperfecta
 Royal’s disease
o Hereditary Hemorrhagic Telangiectasia
o Congenital Hemangiomata  Christmas factor disease
CF IX Deficiency
 Kasabach–Merritt syndrome  Hemophilia B
5. Amyloidosis CF X Deficiency  Stuart-Prower disease
6. Autoimmune Vascular Purpura  Hemophilia C
__________________________________________________ CF XI Deficiency
 Rosenthal Disease
QUALITATIVE PLATELETS DISORDERS  Associated with poor wound
CF XIII Deficiency
healing
 Bernard–Soulier Syndrome
 Glanzmann’s Thrombocytopenia
OTHER BLEEDING PROBLEMS
 Von Willebrand Disease 1. Liver problem
2. Vitamin K Deficiency
STORAGE POOL DEFECT 3. Circulating anticoagulant
1. Gray Platelet Syndrome 4. Presence of FDPs
2. Wiskott-Aldrich Syndrome 5. Massive transfusion
3. Metabolic Type Purpura 6. DIC
4. Chediak-Higashi Anomaly __________________________________________________
5. Prostaglandin Enzyme Deficiency
__________________________________________________ THROMBOTIC DISORDERS
 Hypercoagulable state
QUANTITATIVE PLATELET DISORDERS  Thrombophilia
 Thrombosis
THROMBOCYTOPENIA
CAUSES OF THROMBOSIS ANTICOAGULANT
A. DECREASED PRODUCTION
A. Anti-Thrombin Iii Deficiency THERAPY
 Aplastic Anemia
 Acquired: A. Heparin therapy
 Suppression of Megakaryocyte o Liver Disease B. Oral
 TAR Syndrome o Nephrotic Syndrome Anticoagulants
 Myelophthisic process o Oral Contraceptives C. Antiplatelet
 Ineffective thrombopoiesis  Congenital: Function Therapy
o Type I At Deficiency
B. PLATELET DESTRUCTION o Type II At Deficiency
1. IMMUNE PLATELET DESTRUCTION B. Protein S Deficiency
 Alloantibodies  Type I Protein S Deficiency
o Post transfusion purpura  Type II Protein S Deficiency
o Neonatal Isoimmune thrombocytopenia  Type III Protein S Deficiency
C. Protein C Deficiency
 Autoantibodies  Type I Protein C Deficiency
o Platelet Refractoriness
 Type II Protein C Deficiency
o Immune thrombocytopenic purpura (ITP)
 Warfarin Induced Skin Necrosis
o Secondary Immunte Thrombocytopenia
D. Homocystinuria
E. Prothrombin 20210 Mutation
2. NON-IMMUNE PLATELET DESTRUCTION
F. Factor V Leiden
 DIC (Disseminated Intravascular Coagulation)
G. Lupus Anticoagulant
 MAHA (Microangiopathic Hemolytic Anemia) H. Heparin Co-Factor Ii Deficiency
o HUS (Hemolytic-uremic syndrome)
 Type I Quantitative
o TTP (Thrombotic thrombocytopenic purpura)
 Type II Qualitative
I. Thrombomodulin Deficiency
C. ABNORMAL PLATELET DISTRIBUTION
J. Plasminogen Deficiency
 Splenomegaly
 Type I Plasminogen Deficiency
 Type II Plasminogen Deficiency

FINALS SECONDARY PURPURA
 Association to a specific condition/underlying disease
HEMOSTATIC DISORDER
 Vascular and qualitative platelet disorder 1. Infectious Purpura
 Primary, Secondary, Fibrinolytic system
o Caused by bacterial, fungal, viral and parasitic
 Thrombosis: excessive blood clotting
microorganisms: releases toxins which damages
 Bleeding: excessive fibrinolytic system
blood vessels (induced inflammatory response 
VASCULAR DISORDER allowing blood vessels to be permeable)
o Platelets have alpha granules: BTG or PDGF
 Vessels: Primary hemostasis
o Purpura fulminans – unique disorder affecting
o Hemostatic: problems of the blood vessel
the vessel
o Release tissue thromboplastin: extrinsic problem
o Septic emboli
o Then expose collagen: intrinsic problem
o Waterhouse-Friedrichsen Syndrome: DIC
 If you have a problem, it’s most likely in the genes
 Classified into two:  Caused by Neisseria meningitis
 Manifested by purpuric lesions  Excessive lysis and formation
 Poor vessel integrity  Kinin system: activated by prekallikrein (PK)
 Most important component for vascular integrity,  Inflammatory process begins
collagen with vitamin C  DIC: cause of death is usually toxic shock
o Vitamin C for reabsorption of collagen and overload
o Excessive collagen: keloid
o Hydroxylation of amino acids: lysine and proline 2. Allergic Purpura
o Formation of connective tissue in the blood vessel o Henoch-Schonlein Purpura
 Allergic vasculitis (IgA) involves the skin
PRIMARY PURPURA affecting GIT, kidneys heart, joint problems
 Loss of integrity of blood vessels, not attributed to the and CNS (Autoimmune process)
diseases of organ disease  Common in children, Might exist as single
disease or may coexist
1. Simple Purpura
o “Devil’s pinches” o Henoch Purpura
o Skin fragility  Abdominal pain, secondary to GIT bleeding
o Every time you bump on the chair  vessels
injured o Schonlein Purpura
 Secondary to joint pain, rheumatoid arthritis,
2. Mechanical Purpura
loss of cartilage in joints
o Sudden increase on body’s pressure 
extravasation of RBC’s 3. Metabolic Type Purpura
o Sneezing and Coughing o Scurvy (Vitamin C Deficiency)
 causes gum bleeding or gingivitis
3. Psychogenic Purpura
o Emotional trauma (accident, loss, injury)
o Diabetes Mellitus
o Hormonal changes in the body; creating
 Lack of insulin/ inhibitors of insulin
permeability to blood vessels
 Increase concentration of sugar in blood,
makes blood viscous and thick
4. Senile Purpura
 Glucose in blood passes in the blood vessel
o Brown spots (Old people);
which slows down blood flow and destroy
o As we grow old, formation of collagen slows
blood vessels
down (Collagen degeneration)
o Normal process in the body
o Cushing syndrome:
5. Schamberg’s Purpura  Hypercorticolism, increased
o Progressive pigmented purpura glucocorticoids, especially cortisol which is
o Petechiae: Cayenne pepper purpura appearance a steroid hormone, which causes abnormal
(orange color) enlargement of muscle/vessel, increased
o Various skin problems leads to purpura testosterone.
o E.g.: Buni, An-an (damages tissues, damages  Signs: face (moon face), shoulders
blood vessels) (buffalo hump) and pink or purple stretch
o Red cells can easily escaped out marks (striae)
6. Factitious Purpura
o Self-induced trauma

o Protein C deficiency: proteins are large and big 6. Autoimmune Vascular Purpura
substances and destroy blood vessels, o Excessive destruction of own cells by your own
secondary to dysproteinemia antibody
 Waldenstrom: o Can be caused by either allergic reaction or drug-
  amount of proteins induced endothelial damage
o Drug induced purpura:
CHON  Cryoglobulinemia  Quinine, Procaine, Penicillin, Aspirin,
(leads to  blood contains large amounts of Sulfonamides, Coumadin, Sedative
kidney cryoglobulins – proteins __________________________________________________
problems)
 Hyperviscocity
 plasma is too viscous, too much
amount of proteins
 Result from
hypergammaglobulinemia
4. Connective Tissue Disorder

o Ehler’s Danlos Syndrome
 Manifested and characterized by
hyperextensible joints and hyperelastic skin
 Inability to convert procollagen to collagen
o Pseudoxanthoma Elasticum
 Elastic fibers and blood vessels are not
elastic enough
 Elastic fiber calcification, prone to fragility
o Marfan Syndrome
 Elongated extremities and fingers, not
proportional to patient bodies
 Mutations in the FBN1 gene that codes
fibrillin (essential for the formation of
elastic fibers found in connective tissue &
blood vessels)
o Ostegenesis Imperfecta
 Soft and fragile, incomplete formation of
bone
 Mutation in type I collagen genes
o Hereditary Hemorrhagic Telangiectasia

 “Osler–Weber–Rendu syndrome”
 Most common blood vessel disorder
 Lesions on skin, lip and tongue
 Thin dilated vessels
 Caused by Iron Deficiency Anemia
 Common vascular disorder, bleeding
usually occurs on GIT
o Congenital Hemangiomata
 “Kasabach–Merritt syndrome”
 Tumor forming which blocks functions of
blood vessel and destroy them
5. Amyloidosis
o Deposited of vital organs
o Heavy metal poisoning

C. VON WILLEBRAND DISEASE
PLATELETS DISORDERS
o Associated with either quantitative deficiency or
 Aka Thrombocytopenia qualitative abnormalities of vWF
 Primary: platelets o Uncommon type 3 variant is the most severe form
 Secondary: clotting factors o In 1926, Eric von Willebrand described a bleeding
disorder in 24-66 members of a family from the
QUALITATIVE PLATELET DISORDERS Aland Islands
o Endothelial cells
 Within function, inherited o Can be acquired
o Poor platelet adhesion
A. BERNARD–SOULIER SYNDROME o Hemophilia A (absence of factor VIII)
o Inherited disorder of the platelet gp Ib/IX/V complex o vWF: carries factor VIII to be stable in plasma
o Characterized by:
 Thrombocytopenia
 Giant platelets Laboratory Tests Hemophilia A vWF
 Failure of the platelets to bind gp Ib ligands Bleeding time (platelet adhesion) N A/N
o Platelet adhesion problem Clot retractable time N N
o In 1948, Bernard and Soulier described two children
Glassbead retention adhesion (in vitro) N A
from a consanguineous family who had a severe
Platelet count N N
bleeding disorder characterized by mucocutaneous
Ristocetin aggregation N A
hemorrhage.
Prothrombin time N N
APTT (extrinsic) A A/N
o Features of Bernard Soulier Syndrome:
Factor VIII:C activity N A
1. Thrombocytopenia
2. Von willebrand’s factor vWF R:Co N A
3. Abnormal platelet interactions with thrombin vWF R:Ag N A
4. Abnormal platelet coagulant activity
5. Abnormal platelet interactions with P-selectin
6. Abnormal platelet interactions with Variants of vWF Disease
leukocyte integrin αMβ2 Type 1 Reduced level of vWF
Lack of intermediate and high MW
Type 2a
B. GLANZMANN’S THROMBASTHENIA multimers
o Absence or deficiency of the membrane gbIIb/IIIa Type 2b Lack of high MW multimers
o In 1918, Edward Glanzmann a swiss pediatrician, Type 2c Lack of high MW multimers
described a group of patients with hemorrhagic Complete
Type 3
symptoms and a defect on platelet function. 2b/3a: platelet aggregation
o Features of Glanzmann’s thrombasthenia: Pseudo-vWD
Platelet type vWF
 Bleeding is most common from mucosa surfaces Detect in gp 1b
 Facial petechiae and subconjugal hemorrhages seen
in infants associated with crying  If fail to aggregate no plug and release of internal
components of platelet, without internal components
especially phospholipid, there is no clot.
Bernard Soulier Glanzmann’s  Phospholipid is important in tenase complex
Laboratory Test
Syndrome Thrombocytopenia
Platelet count Decreased Normal
Platelet Treatment: (vWD)
Giant platelet Normal
morphology  DDAVP (1-desamino-8-D-arginine vasopressin or
Bleeding time Prolonged Prolonged desmopressin)
Platelet Aggregation  Humate P
ADP Normal Abnormal  Cryoprecipitate
Thrombin Abnormal Abnormal  In type 3 vWF disease: factor VIII products or
Collagen Normal Abnormal cryoprecipitate
Epinephrine Normal Abnormal _________________________________________________
Ristocetin Abnormal Normal
Clot retraction Normal Abnormal
Clotting time Prolonged Prolonged

STORAGE POOL DEFECT QUANTITATIVE PLATELET DISORDERS
1. Gray Platelet Syndrome  Concerns with platelet count
o Autosomal dominant  30% sequestered in spleen, 70% in circulation
o Lacks alpha granules  Two types:
o Healing and formation of connective tissue in blood o Thrombocytopenia
vessel o Thrombocytosis
2. Wiskott-Aldrich Syndrome THROMBOCYTOPENIA

o Lacks dense granules
o ADP (dense granules) – primary aggregating agent  Decreased number of platelets
o Triad of recurrent infections, thrombocytopenia,  <50 x 109/L
eczema  Manifested by bleeding problem
o Sex-linked immunodeficiency  Cause: Problem in bone marrow
o Myeloid lineage
3. Hermansky-Pudlak Syndrome o Hypoproliferative precursor cells to decreased
o Autosomal recessive condition (rare) megakaryocyte results to decreased platelets
o Albinism
o Triad of tyrosinase (+) occulocutaneous albinism
A. DECREASED PRODUCTION
4. Chediak-Higashi Anomaly
1. APLASTIC ANEMIA
o Albinism, recurrent infections, giant lysosomes
o General suppression of bone marrow
o Cells containing granules fuse platelet
o Not only platelet will be decreased but all of the
o Staphylococcus aureus
formed elements – Leading to decrease in all
cell types (pancytopenia)
5. Prostaglandin Enzyme Deficiency
o Shut down of bone marrow
o Cyclooxygenase
o Fanconi syndrome: congenital form of aplastic
o Function: inhibits thromboxane A2 (TxA2)
anemia
o Aspirin
o <WBC: immunocompromised or
__________________________________________________
prone to infection
o <RBC: Hypoxia; anemia or decreased oxygen
o  Platelet: susceptible to bleeding
o Causes:
 Toxic substances: Benzene
 Viral infection implicated by BM hypoplasia:
 eg. Parvovirus B19, HIV, HBV,
EBV, CMV
 Drugs: Chloramphenicol (destroys BM)
Carbamazepine
 Ionizing radiation and Chemotherapy
 Cancer patients: radiation, dangers
bone marrow, cause anemia
o 50% of population will die in 6 months

o Treatment: bone marrow transplant, same with
leukemia
2. SUPPRESSION OF MEGAKARYOCYTE
o #1 target: Megakaryocyte (largest cell in BM)
o Associated w/ Cholorthiazide administration
o Chlorothiazide (diuretic) is for problems in
kidneys to allow diuresis
o Decreases thrombopoietin
o Renal failure causes bleeding
o NOT immunologic but related to drug toxicity

3. TAR SYNDROME
o Observed in children  Platelet Refractoriness
o Thrombocytopenia with absent radius o Platelet count not  because Own
o Inherited disorder of megakaryocyte production antibodies will be destroyed by own
o  number of platelets platelet
 Immune thrombocytopenic purpura (ITP)

4. MYELOPHTHISIC PROCESS o Associated with viral infections
o Space-occupying lesion in the bone marrow:  e.g. Dengue: platelet destruction
 Metastatic tumor because of activation of immune
 Fibrosis system
 Leukemia o Immune system has been stimulated
o Block the production and synthesis of precursor to produce antibody that can destroy
cells an organism that affects platelets
o Lesions formed because of tumors
 Secondary Immunte Thrombocytopenia
o aka Leukemia: WBC problem, bone
5. INEFFECTIVE THROMBOPOIESIS marrow decreases number of
o Associated with ethanol abuse with or without megakaryocyte
malnutrition o Drug: QPPSACS lower platelet control
o BM can undergo megakaryopoiesis but
produces abnormal cells (immature cells)
 Megakaryoblast 2. NON-IMMUNE PLATELET DESTRUCTION
 Promegakaryocyte  No immune complexes involved
o Megaloblastic states  Not related to antigen and antibody
 Megaloblastic Anemia  External factors that destroys plateletes
 Impaired DNA synthesis caused by:
 Folate deficiency  DIC (Disseminated Intravascular Coagulation)
 Vitamin B12 deficiency o Excessive coagulation and lysis
o Severe IDA  iron (protein synthesis) o Coagulation: consumes all platelets
o Paroxysmal Nocturnal Hemoglobinuria o Lysis: platelets will be destroyed by FDPs
 Membrane defect, abnormal sensitivity to o Cause of death is usually toxic shock and
complement and various antibodies. overload
o Problem: form clot to fast  lysed clot to
fast = activating coagulation and fibrinolytic
B. PLATELET DESTRUCTION mechanism also activates kinin system thus
1. IMMUNE PLATELET DESTRUCTION activating inflammatory response w/o no
 Involves the antigen and antibody apparent cause
o If there’s inflammation = BV becomes
 Alloantibodies (Isoimmune) permeable
 Antibody against the antigens of another o DIC is always a secondary disease,
member (other person) of the same complication of a primary disease
species.
MAHA (Microangiopathic Hemolytic Anemia)
 Post Transfusion Purpura  HUS (Hemolytic-uremic syndrome)
o Rare complication, sudden, profound o Lysis  bleeding
and self-limiting thrombocytopenia o In the urinary tract only
o Immmunized by alloantibody
 TTP (Thrombotic thrombocytopenic purpura)
 Neonatal Isoimmune Thrombocytopenia o Excessive clot, consume platelet causing
o caused by platelet destruction by thrombocytopenia
maternally derived antibody o All over the body
o IgG crosses placenta
o IgG can be anti-platelets
o Platelet antibodies from mother that
C. ABNORMAL PLATELET DISTRIBUTION
destroys babies platelets
 Splenomegaly – increased sequestration of spleen
 Autoantibodies
 Ownself destroys own antigen/cells

THROMBOCYTOSIS  Treatment of Megaloblastic anemia
 Recovery from postoperative thrombocytopenia
 Hyperproliferative
 Cancer
 Increased megakaryocyte, increased platelet
 Inflammation or infection
production
 Surgery, especially splenectomy (removal of
 Myeloproliferative diseases
the spleen)
 Eg: Essential thrombocythemia, Thrombocytosis and
Polycythemia Vera Treatment
 Platelet transfusion
 PLATELET COUNT
 <50 x 109/L needs transfusion
Absolute Relative
 50 x 109/L no need for transfusion unless you are
 excessive production of  temporary bleeding
cells in the bone marrow __________________________________________________
Leukemia Injury, trauma (accident,
 uncontrolled and loss, surgery)
unregulated production
of red cells
 Elevated platelet ct:
 Polycythemia Vera
 Essential
thrombocythemia
A. PRIMARY THROMBOCYTOSIS
o Uncontrolled proliferation of platelets
o Problem in bone marrow hyperproliferation
o Cause serious bleeding or clotting complications
o Myeloproliferative disorders
 Polycythemia Vera
 Essential thrombocythemia
1. Polycythemia Vera
o Relative Polycythemia Vera:
 dehydration and stress
o Secondary Polycythemia Vera
 due to Congestive heart failure (CHF)
o Vera: means true
o Increased hyperproliferation of precursor
cells
2. Secondary Polycythemia Vera

o Increased platelet count because of
secondary infection
o E.g.: Dengue: increased platelet for short
period then decreased platelet due to
compensating mechanism
B. SECONDARY THROMBOCYTOSIS (Reactive)

o Transient or temporary
o Benign form of thrombocytosis
o Not typically lead to abnormal blood clotting
o Caused by another condition the patient may be
suffering from, such as:
 Anemia due to iron deficiency
 Hemolytic Anemia
 Acute blood loss
 After cessation of cytotoxic drugs
 Withdrawal of drugs

BLEEDING DISORDERS  CF II Deficiency
 Clotting factors promotes formation of clot  Prothrombin deficiency or hypoprothrombinemia
 Has relationship with the lab test o Mild form of bleeding
 Episodes: Epistaxis, GI bleeding, Gum bleeding  Thrombin can also be found in vascular
 Mostly inherited endothelium
 CF synthesized in the liver except CF III and IV
 Laboratory Test
o PT and APTT: prolonged
 Afibrinogenemia
o Since CF II is involved in common pathway
CF I Deficiency  Hypoibrinogenemia
 Dysfibrinogenemia
------------------------------------------------------------------------------------
 Prothrombin deficiency
CF II Deficiency  CF V Deficiency
Hypoprothrombinemia
 Deficiency in labile factors or proaccelerin
 Owren’s Disease
CF V Deficiency  Aka Owren’s Disease or Parahemophilia
 Parahemophilia
 Associated with antibody causing destruction of
CF VII Deficiency  Hemophilia CF V
 Hemophilia A  Laboratory Test

CF VIII Deficiency  Classic Hemophilia o PT and APTT: prolonged
 Royal’s disease o Since CF V is involved in common pathway
 Christmas factor disease
CF IX Deficiency  Mixing studies
 Hemophilia B
o Corrected by adsorbed plasma and fresh
CF X Deficiency  Stuart-Prower disease plasma
 Hemophilia C
CF XI Deficiency ------------------------------------------------------------------------------------
 Rosenthal Disease
CF XIII Deficiency
 Associated with poor wound  CF VII Deficiency
healing
 Hemophilia
 Low levels are mostly found in connection with
------------------------------------------------------------------------------------
liver damage
 Mucus membrane and soft tissue hemorrhage
 CF I DEFICIENCY may occur in children
 Due to increased consumption/degradation in
serious DIC or due to decreased synthesis in  Laboratory Test
evident damage to the liver. o PT is prolonged and APTT is normal
o Since CF VII is involved in extrinsic
 Fibrinogen deficiencies pathway
o Afibrinogenemia
 Absence of fibrinogen ------------------------------------------------------------------------------------
 Most deadly  CF VIII Deficiency
 Hemophilia A; Sex linked or X-linked disorder
o Hypoibrinogenemia
 Aka Classic Hemophilia or Royal’s disease
 Low amount of fibrinogen
 Most severe form of hemophilia
o Dysfibrinogenemia  Consumption dependent deficiency is often found
 Abnormal structure of fibrinogen in DIC with bleeding
 Excessive bleeding causes death
 Treatment
o Blood transfusion  Mistaken for Von Willebrand Disease (vWD)
o FFP  process  cryoprecipitate (CF I o vWF problem  CF VIII problem
and VIII) o CF VIII problem  no vWF problem
 Laboratory Test  Laboratory Test

o PT and APTT: prolonged o Glassbead retention and APTT
o Since CF I is involved in common pathway  Test to differentiate vWD and
Hemophilia A
------------------------------------------------------------------------------------

 Treatment  CF XII Deficiency
o Cryoprecipitate
o DDAVP or 1-desamino-8-D-arginine-  Partial or total deficiency of one of this factor does
vasopressin NOT lead to an increased in bleeding risk
 CF VIII will be released in the
endothelium ------------------------------------------------------------------------------------
o Prothrombin complex concentrate
 CF II, VII, IX, X (Vit. K dependent CF)  CF XIII Deficiency
 By passes action CF VIII which helps
 Stabilizing clot factor/ Fibrin stabilizing factor
in the formation of clot
 Associated with poor wound healing
o Blood transfusion
 Occassionally found in patients with hereditary
------------------------------------------------------------------------------------ bleeding disorder
 CF IX Deficiency  Severe form often shows symptoms in the
neonatal period
 Christmas factor
 Christmas factor disease  Laboratory Test
 Aka Hemophilia B o APTT and PT are normal
o Milder form of hemophilia
o Sex linked: Males are affected  Test for CF XIII: Duckert’s test or 5M Urea Test
 Laboratory tests ------------------------------------------------------------------------------------

o PT is normal, APTT is prolonged
 Mixing studies OTHER BLEEDING PROBLEMS

o Corrected by adding all types of plasma 1. Liver problem
except adsorbed plasma o Proteins are synthesized in the liver
o Problems in synthetic ability
------------------------------------------------------------------------------------
 CF X Deficiency 2. Vitamin K Deficiency
 Stuart-Prower factor o Inadequate dietary source of Vitamin K
 Stuart-Prower disease o CF II, VII, IX, X (Vitamin K dependent CF)
 Bleeding episodes includes easy bruising, soft
tissue bleeding and post traumatic and
post-operative bleeding 3. Circulating anticoagulant
o Related to either antibody to CF to antibody of any
 Treatment: Blood transfusion substance with hemopoiesis
o Most common circulating anticoagulant
 Lupus anticoagulant
 Laboratory Test
 Against platelet phospholipid
o Prolonged BT and CT
 3 forms: IgG, IgA, IgM
------------------------------------------------------------------------------------
 CF XI Deficiency 4. Presence of FDPs
 Plasma thromboplastin antecedent or o FDPs destroys platelets
Hageman factor o FDP’s also acts as anticoagulant
 Aka Hemophilia C or Rosenthal Disease  By inhibiting polymerization of fibrin
 Mildest form of hemophilia
 Usually due to decreased synthesis
 Common in Jews of east European origin 5. Massive transfusion
o Citrate in vivo
 CF XII, HMWK and PK Deficiency do not manifest
o Citrate can be carried into the system
bleeding
o Excessive citrate means dilutional loss of citrate
 To differentiate CF XI and XII deficiencies:
o CF XI causes bleeding
6. DIC
o CF XII do not cause bleeding
o Consumption of clotting factors and platelets
------------------------------------------------------------------------------------

THROMBOTIC DISORDERS CAUSES OF THROMBOSIS
 ANTI-THROMBIN III DEFICIENCY
 No problem with clot, problem with CF  Inhibits thrombin
 Problem with regulatory factors: no damage or injury   Thrombin: important in clot and fibrinolytic system
inhibiting factor necessary for clotting
 Causes thrombosis or recurrent venous
 Elements for clot: Clotting factors and Platelet thromboembolism
 Activities clot system result to thrombotic episodes
 Problems in blood transport oxygen and nutrients  Acquired:
because the persons have deep-vein thrombosis o Liver disease
 Refers to an increased tendency to develop thrombi or o Nephrotic syndrome
emboli. o Oral contraceptives
 Hypercoagulable state – unwanted/unnecessary clot
 Congenital:
o Type I AT deficiency: genetic alteration usually
THROMBOPHILIA leads to drastic decrease levels in AT.
 Abnormality of blood coagulation that increases the risk
of thrombosis o Type II AT deficiency: genetic alteration leads
 it may be due to physical, biologic or chemical events to abnormal function of the plasma protein
 Treatment:
THROMBOSIS o Heparin: amplifies action of antithrombin
VEIN ARTERIAL  PROTEIN S DEFICIENCY

 Increased tendency for venous thrombotic disorders
Deep vein thrombosis:
“Atherosclerotic plaque”
formation of blood clot in  Type I Protein S Deficiency: there is a proportional
Causes infection to different
deep vein
organs in the body decrease in the level and activity of Protein S
Portal vein thrombosis: Common to 5% of patient
affecting the hepatic portal not receiving anticoagulant  Type II Protein S Deficiency: levels of the free and
vein therapy. bound forms are normal, but there is an abnormal
e.g. MI, Stroke function due to genetic alteration in the gene sequence
Renal vein thrombosis:
Obstruction of the renal vein  Type III Protein S Deficiency: there is a normal level
by a thrombus to total Protein S but with clinically significant decrease
Jugular vein thrombosis: in free protein S levels.
May occur during infection,
malignancy or infusion of  PROTEIN C DEFICIENCY
intravenous drug  Leads to recurrent superficial or deep vein thrombosis
and frequent pulmonary emboli
Budd chiari syndrome:
blockage of the inferior vena  Type I Protein C Deficiency: low protein C levels and
cava by a thrombus activity.
Paget–Schroetter disease:
Usually occurs after exercise  Type II Protein C Deficiency: low protein C activity
due to genetic alteration of protein C sequence
Cerebral venous sinus resulting to abnormal functioning.
thrombosis: rare form of
thrombosis  Warfarin Induced Skin Necrosis: caused by rapid
drop in Protein C and Factor VII resulting to temporary
clotting state in the extremities.
PROTEIN C AND S DEFICIENCY

 Inhibits Va and VIIIa
 Involved in tenase complex in intrinsic and common
pathway
 Excessive formation of clot
 Treatment: Warfarin and Coumadin: so clotting will
no elicit

 HOMOCYSTINURIA  PLASMINOGEN DEFICIENCY
 Increased incidence of arterial and venous  Deficiency primarily involve the veins and
thrombosis due to endothelial cell injury thrombophlebitis and stroke
 a disorder of methionine metabolism, excessive
amount of amino acids (Aminociduria)  leading  Type I Plasminogen Deficiency: proportional
to an abnormal accumulation of homocysteine decrease on the level of plasminogen and its
 Accumulation of homocysteine which damages activity.
endothelial cells or vascular endothelium
 Forms a clot  Type II Plasminogen Deficiency: also called
 Deficiency in 3 enyzmes: dysplaminogenemia, there is a decrease in the
o Methionine synthase functional activity of the protein.
o Cystathionine-β-synthase __________________________________________________
o 5,10-Methylenetetrahydrofolate reductase
ANTICOAGULANT THERAPY
 PROTHROMBIN 20210 MUTATION
A. Heparin therapy
 Involves the alteration of guanine to adenine at
o Used to prevent the formation of thrombi in veins
the base of the 20210 of the 3’ untranslated
o Activates CF II, IX, X, XI, XII
region of prothrombin gene.
o Half-life: 1-2 hours
 Associated with higher levels/increased o Injected every 4-6 hours
production of prothrombin, averaging to 130% o For the next 21 days: thrombocytopenia occurs;
monitor platelet count every 2 days
 FACTOR V LEIDEN o Anticoagulant activity
 Resistance with protein C o Types: LMW and HMW
 The mutation happens in Factor V protein, which is o Administration:
known as the “Leiden protein”  Continuous IV infusion
 Subcutaneous injection
 Factor V Leiden homozygotes: possess only the o Protamine Sulfate/Histamine: to prevent excessive
Leiden protein and an 80-fold increased risk of bleeding due to heparin
clotting disorder compared to the general
unaffected population.
B. Oral Anticoagulants
 Factor V Leiden heterozygotes: are believed to o Dicumarol and warfarin
produce about 50% of Leiden protein and have o Anticoagulant activity
5-7 fold increased risk of clotting disorder o Administration: Heparin-oral anticoagulants
compared to the general population.
 LUPUS ANTICOAGULANT C. Antiplatelet Function Therapy

 Inhibition of the action of prostacyclin o Used in preventing arterial thrombosis
 Prostacyclin: inhibits platelet aggregation o Aspirin
 Excessive platelet aggregation results to clot o Others:
 NSAIDs: Phenylbutazone and Indomethacin
 HEPARIN CO-FACTOR II DEFICIENCY  Antibiotics: Penicillin and Cephalosporin
 Deficiency leads to increased thrombi formation  Antidepressants: Chlorpromazine
due to low/deficient activity to inhibit thrombin.  Propranolol and Beta-Blockers, Diuretics,
Sulfinpyrazone, Dextran and Alcohol
 Types of Heparin Co-Factor II Deficiency:
 Type I quantitative: decreased in both levels and
functional capacity.
 Type II qualitative: decreased in functional

capacity but with normal levels of heparin
cofactor II.
 THROMBOMODULIN DEFICIENCY
 Increased level are seen in patient with venous and
arterial clotting conditions and DIC.
“Be strong and courageous. Do not be afraid; do not be discouraged, for the
Lord your God will be with you wherever you go.” (Joshua 1:9)

DISORDERS BT CT PT APTT STYPVEN TT DUCKERT’S
1. Disorder of 1 hemostasis  N N N N N N
2. Fibrinogen deficiency N      N
3. Prothrombin deficiency N     N N
4. Parahemophilia N     N N
5. Factor VII deficiency N   N N N N
6. Hemophilia A (Classic) N  N  N N N
7. von Willebrand Disease   N  N N N
8. Hemophilia B N  N  N N N
9. Factor X deficiency N     N N
10. Hemophilia C N  N  N N N
11. Factor XII deficiency N  N  N N N
12. Factor XIII deficiency N N N N N N ABN
13. DIC       N

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Hematology 2 Complete Notes

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SUMMARY – PRELIMS SECONDARY HEMOSTASIS

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

Alpha Dense Lysosome Glycogen

2. Sol-gel Zone Overall Function of the Platelets

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

SUBSTANCES SECRETED BY PLATELETS AND THEIR ROLES

ADP Dense granules  Promote platelet aggregation

Serotonin Dense granules  Promotes vasoconstriction at site of injury

Plasminogen Alpha granules  Precursor to plasmin which induces clot lysis

Inhibitors of Platelet Activity

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

Purpose: Mixing studies Fresh plasma: All clotting factors

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

LABORATORY EVALUATION FOR HEMOSTASIS o Polycythemia vera

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

Thrombocytosis Other ways:

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

2. PLATELET AGGREGATION Three Types of Curves

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

b) MacFarlane for Clot Retraction  Disadvantages:

 Principle: depends on the increased light scattering

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

 Specimen EVALUATION OF SECONDARY HEMOSTASIS

1. EXTRINSIC AND COMMON PATHWAY

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

o Normal value: 100-150 seconds 3. Thromboplastin Generation Time

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

2. Dilute Whole Blood Clot Lysis Time

3. Plasma Clot Lysis Time

4. Euglobulin Lysis Time

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

Pathway Extrinsic Intrinsic Common

Missing Clotting Factors

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

4. Connective Tissue Disorder

o Hereditary Hemorrhagic Telangiectasia

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

2. Wiskott-Aldrich Syndrome THROMBOCYTOPENIA

o 50% of population will die in 6 months

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

 Immune thrombocytopenic purpura (ITP)

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

2. Secondary Polycythemia Vera

B. SECONDARY THROMBOCYTOSIS (Reactive)

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

 Hemophilia A  Laboratory Test

 Laboratory Test  Laboratory Test

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017

 Laboratory tests ------------------------------------------------------------------------------------

 Mixing studies OTHER BLEEDING PROBLEMS

HEMATOLOGY 2 Discussed by: Anton Pascua Revamped by: | 2017