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HEMOSTATIC PHYSIOLOGY

Mansyur Arif
Dept. of Clinical Pathology
Fac.of Medicine,Hasanuddin University,
Makassar

Feb 17, 2016

Regulation of hemostatic
mechanism involves complex
interaction between vessels walls,
blood cell elements and a variety
of plasma proteins.

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Blood clotting results from :


1. Interaction between endothelial cells and platelets
the primary hemostatic plug.
2. The coagulation phase thrombin is generated &
fibrin develops
3. Formation of peptide bonds stabilization of the
fibrin network.

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Fibrinolysis is the process of


enzymatic degradation of fibrin
clots whereby : coagulation activity
is limited to the area surrounding
vessels wall injury and patency of
vessels is maintained or restored

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Bilipid membrane
1. Glycoprotein Ib (GP Ib). MW of about
140 kD. It serves as the binding site
for vWf.
2. Glycoprotein IIb-IIIa (GP IIb-IIIa).
A prominent Ca-dependent membrane
protein complex that function as a
fibrinogen receptor.
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Platelet Physiology
When a blood vessels is injured:
Subendothelial tissue is exposed.
PLT adhere to subendothelial tissue.
Adherence mediated by vWf form a
bridge between subendothelial tissue
and GP Ib.
Thrombin stimulates membrane
phospholipids to release arachidonic
acid
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Platelet Physiology
AA is converted to cyclic endoperoxides

and TxA2.
Stimulate granules and dense bodies.
High concentration locally thrombin,
TxA2 and ADP will change GP IIb-IIIa
becomes receptor for fibrinogen to
forms a bond between adjacent PLT
creating a hemostatic plug.
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Phospholipid
Phospholipase
Arachidonic acid
Cyclo-oxygenase
(aspirin inhibits)
PGG2
Peroxidase
PGH2
Thromboxane synthetase

Prostacyclin synthetase

(platelets)

(endothelium)

TxA2

PGI2
H2O

TxB2

6-keto PGIa

Fig. 1. Arachidonic acid metabolism in platelets endothelium.


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Endothelium Contribution
Metabolize AA to Prostacyclin (PGI2).
PGI2 has major contribution as
antithrombotic in intact endothelium.
Low dose aspirin completely block TxA2
production.

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Coagulation phase :
1. Conversion of fibrinogen (soluble plasma
protein) into insoluble fibrin affected
by highly specific enzymatic action of
thrombin.
Thrombin must be generated from
zymogen, prothrombin, by a series of
reactions between serine proteases, co
factors & lipid moieties.
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2. Coagulation factors may be group as


follows : contact factors, thrombin sensitive factors, & vit K- dependent
factors.
Classically, the generation of thrombin
is described as occuring through the
extrinsic or intrinsic systems.
Table 1 summarizes the features of the
coagulation factors.
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Table 1. Plasma coagulation factors


Factor

Alternative name

Pathway

Half-life
(hours)

I
II
III
V
VII
VIII
IX
X
XI
XII
XIII
HMW kininogen
Prekallikrein

Fibrinogen
Prothrombin
Tissue factor
Proaccelerin
Proconvertin
Antihemophilic factor
Christmas factor
Stuart - Prower factor
Plasma thromboplastin antecedent
Hageman factor
Fibrin - stabilizing factor
Fitzgerald factor
Fletcher factor

C
C
I
C
E
I
I
I,E,C
I
I
I
I
I

90-120
48-120
Not available
12-24
2-6
10-12
18-30
24-60
45-80
40-70
72-200
150
48-52

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Coagulation systems :
1. The extrinsic systems : triggered by TF/
tissue factor (complete thromboplastin).
- TF + VIIa + Ca activates F X (F Xa)
- F Xa + V + Lipid (TF) extrinsic prothrombinase (converts prothrombin
thrombin). (Fig 1).

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Prothrombin
TF
VIIa
Xa
V
Lipid (TF)
(Ca 2+)

(Ca 2+)
X

Test : PT
(Quick)

Thrombin
Fig.1. Generation of thrombin via the extrinsic system. (TF = tissue fct ;
PT = prothrombin ; = prothrombin complex ; = F X activating
Febcomplex).
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2. The intrinsic system :


a. Contains all the elements necessary for
clotting.
b. Instead of tissue thromboplastin, the lipid
moiety in this system is PF3.
c. The contact fcts (F XII, XI, prekallikrein/PK,
High Molecular-Weight Kininogen/HMWK) are
activated by exposure to negatively charged
glass surfaces & other substances
(ellagic
acid,uric acid crystals,skin,collagen
&
antibody complexes)
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d. - F XIIa in the presence of PK and


HMWK activates F XI.
- F XIa activates IX, which in a complex
with VIII, lipid (PF3) and Calcium
activates F X.
- F Xa, V and lipid (PF3) comprise
intrinsic prothrombinase. (fig. 2).

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Contact factors
XII

PK
HMWK

Prothrombin

XIIa
XI

IX

XIa

IXa
VIII
PF3

(Ca 2+)
X
Test : aPTT

Xa
V
Lipid (PF3)

(Ca 2+)

Thrombin
Fig.2.

Generation of thrombin via the intrinsic system. (PK = prekallikrein; HMWK/


high molecular weight kininogen ; PF3 = platelet factor 3 ; aPTT = activated
partial thrombplastin time ;
= prothrombinase complex ;
= F X activating
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2016complex.
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e. - Screening test : aPTT screens for all

the coagulation factors except F VII.


- intrinsic & extrinsic pathways
converge at
the F X and V level.
- A coagulation factor deficiency (or
inhibitor) at this level results in
abnormal screening test for both
system.

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Prothrombin
Intrinsic system

Extrinsic system

IXa
VIII
VIIIa
PF3

Xa
V

Xa

Va
PF3

Va

V
TF

Thrombin
Fig.3. Autocatalytic action of thrombin. (TF= tissue fct ; PF3 = platelet fct 3)
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Prothrombin
Intrinsic system
Extrinsic system
TF
VIIa

XIa
(Ca2+)
IX

IXa
VIII
PF3

(Ca2+)
X

Xa

Thrombin
Fig. 4. Linkage between extrinsic and intrinsic systems. Several interaction
occur at various levels of the two systems. Primary among these is the
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ability
of TF and F VIIa and F IX.

Protein C along with its cofactor, protein


S, degrades F VIIIa and Va.
Plasmin is neutralized primarily by
2 - antiplasmin.

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Plasminogen
Intrinsic system

Extrinsic system

Contact
XII

XIIa
HMWK
Exogenous

Prekallikrein

Kallikrein

TPA

Urokinase
Streptokinase

Plasmin
Fig.7.

The fibrinolytic system. Plasmin, the active fibrin(ogen)olytic enzyme,


is generated by activation of plasminogen as shown.
= plasminogen activator.

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INTRINSIC SYSTEM
HMWK
XII
XII a
Kallikrein
XI

XIa

EXTRINSIC SYSTEM
VII

IX

IXa + VIII
Ca 2+
PL

Ca 2+

TF
Ca 2+

Xa + V
Ca 2+
PL

Prothrombin

Thrombin
Fibrinogen

XIII
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XIIIa

Fibrin

Stable fibrin clot


Ca 2+

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Symptoms of mucosal bleeding, such as


epistaxis, gum bleeding, hematochezia,
melena, petechiae, or easy bruising
signs of defective primary hemostasis
secondary to thrombocytopenia, pletelet
dysfuntion, or abnormalities of von
Willebrand factor (vWF)
Hemarthroses, i.m hemorrhage, bleeding
into deeper structure >> secondary
hemostasis disorder with a coag. factor
deficiency or dysfunction

Laboratory test in the work up of


coagulation disorder
The first lab test : CBC (+peripheral
slide), PT, aPTT, Thrombin Time (TT) .
aPTT activity of intrinsic factor
PT activity of extrinsic factor
TT common pathway
Bleeding time <<, but evaluate
problems with primary hemostasis

CBC first step in evaluation of bleeding patient


thrombocytopenia, anemia, leukocytosis
or leukopenia implicate a hematologic
malignancy cause of patients
coagulopathy or thrombocytopenia.
PB evaluation platelet clumping and
WBC morphology
Coagulation Test
(PT, APTT, FIB, TT)

TESTS OF COAGULATION SYSTEM


Screening Test
1. Partial thromboplastin time (PTT) and activated
partial thromboplastin time (aPTT)
2. Prothrombin time (PT)
3. Quantitative fibrinogen
4. Thrombin time (TT)
5. Screening test for factor XIII
6. CBC

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No

Test

Platelet
count

Condition

PT

APTT

TT

Long

Factor VII deficiency


Early oral anticoagulant

2.

Long

Factor VIII, IX, XI, XII deficiency


Prekallikrein, HMWK deficiency
Von Willebrands disease
Anticoagulant

3.

Long

Long

Vitamin K deficiency
Oral anticoagulant
Factor V,VII, X dan II deficiency

4.

Long

Long

Long

Heparin
Liver disease
Fibrinogen deficiency
Hyperfibrinolysis

5.

Low

Thrombocytopenia

6.

Long

Long

Low

Massive transfusion
Liver disease

7.

Long

Long

Long

Low

DIC
Acute liver disease

First-line tests used in investigating acute haemostatic failure

THANK YOU

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III. CONGENITAL HEMORRHAGIC DISORDER


A. Hemophilia A (factor VIII deficiency) and
Hemophilia B (factor IX deficiency)
1. Pathophysiology :
X chromosome, gene defect.
2. Clinical features :
mild, moderate and severe disease
3. Diagnosis :
a. screening tests
b. specific factor assay
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4. Therapy : to raise the deficient factor


a. Pharmacologic therapy :

1. Hemophilia A : Desmopressin (dDAVP)


2. Hemophilia B : no effective drugs
b. Replacement therapy :
1. Beware of adverse effects
2. The choice of blood product is critical
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c. Treatment options :
1. Fresh frozen plasma (FFP)
2. Cryoprecipitate
3. Factor concentrates
5. Complication : Arthropathy, Inhibitors,
Liver disease, HIV infection.
6. Interdisciplinary care hemophilia center
medical care, psychosocial care and
genetic counseling
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B. von Willebrands disease


1. Physiology of vWF :
- HMW glycoprotein, 250 kD
- In plasma and in platelets
- as a carrier protein for coag. F VIII
- important for primary hemostasis
- mediates adhesion of platelets to the s.endot
- vWF F VIII complex : F VIII : C, F VIII : Ag,
F VIII : Cag, F VIII : RCof.
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2. Clinical features : >> mucous membrane


bleeding, epistaxis, menorrhagia
3. Diagnosis :
- Combination of prolonged BT and a
decreased F VIII : C level classically
- Combination of abnormalities of the functional
measures of the vWF F VIII complex

variants of vWF (see table 2)


- Ristocetin aggregation
- Diff. of type F VIII multimer analysis :
type I, IIA, IIB, IIC, III.
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Table 2. Laboratory Findings in Hemophilia A


and Severe vWF Disease
Labotatory test
Bleeding time
VIII : C
VIII : Ag
VIII : RCof

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Finding
Hemophilia A
vWF disease
Normal
Prolonged
Decreased
Decreased
Normal
Decreased
Normal
Decreased

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4. Therapy
a. dDVAP
b. Cryoprecipitate
c. F VIII concentrates

C. Other inherited factor deficiencies


1. F XII, prekallikrein and HMWK
2. F I, II, V, VII, X, XI and XIII

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IV. ACQUIRED HEMORRHAGIC DISORDER


A. Vitamin K deficiency
1. Etiology
a. dietary deficiency
b. malabsorption
c. antibiotic therapy
d. hemorrhagic disease of the new born
2. Clinical features : severe bruising or
excessive bleeding or asymptomatic
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3. Diagnosis
- severe : prolonged PT and PTT
- early or milder def. : prolonged PT
4. Therapy
- Parenteral vit. K
- FFP
B. Liver disease
1. Etiology
a. decreased synthesis of coag. factors
b. Vit. K def
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c. Functionally abnormal fibrinogens


d. Disseminated Intravasc. Coagulation
(DIC) and consumption of coag. factors
2. Clinical features
- vary with the course of the patients liver
disease
- >> GIT bleeding
3. Diagnosis
- Lab. findings varies widely
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4. Therapy
- trial of parenteral vit K therapy
- Replacement therapy FFP
C. Clotting factor inhibitors autoantibodies
1. Inhibitors in hemophilia
2. Inhibitors in patients without preexisting
bleeding disorders
a. Etiology : drugs, autoimmune or
lymphoproliferative disorders,
spontaneous a.coagulants
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b. Diagnosis : mixing study, factor assays


c. Therapy : supportive
3. Lupus anticoagulant cardiolipin
a. Prolonged PTT, false + serologic test
b. associated with recurrent spont.abortions.

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COAGULATION REGULATION
AND
HYPERCOAGULABLE STATES

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I. CONTROL MECHANISMS IN COAGULATION


A. Naturally occuring a.coagulants
1. Antithrombin III (AT III) acts as a serine
protease inhibitor
2. Protein C, Protein S Vit K dependent
3. Other plasma protease inhibitor : heparin
cofactor II, 2- macroglobulin.

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B. Fibrinolitic system
1. Activation :
a. Intrinsic activation : a poorly understood
mechanism of activation
b. Extrinsic Activation : Tissue plasminogen
activator (t-PA), urokinase
c. Exogeneous (therapeutic) activation :
streptokinase, urokinase and t-PA
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2. Sites of action
a. Fibrinogen
b. Fibrin
II. THROMBOTIC DISORDER
A. Congenital thrombotic disorder
1. AT III deficiency
2. Protein C deficiency
3. Protein S deficiency

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B. AQUIRED THROMBOTIC DISORDER


THROMBOEMBOLIC DISEASE
1. Risk factors :
a. abnormalities of blood flow
b. abnormalities of the vasculature
c. abnormalities of the coagulation system
2. Clinical manifestations :
a. Venous thrombosis
- superficial thrombosis
- deep vein thrombosis
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b. Pulmonary embolism
c. Arterial thrombosis
d. Other
4. Therapy
a. Agents treatment and prevention
1. Anticoagulants :
- Heparin
- Warfarin
2. Thrombolytic agents :
- Streptokinase
- Urokinase
- t-PA
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b. Treatment approaches
1. Deep vein thrombosis : >> heparin,
thrombolytic agent
2. Pulmonary embolus : heparin, thrombolytic
agent
3. Myocardial infarction : thrombolytic agent
4. Peripheral artery and catheter thrombosis :
thrombolytic agent.
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III. THROMBOHEMORRHAGIC DISORDER


A. Disseminated intravascular coagulation(DIC)
1. Pathophysiology (see table 3)
a. Initiation : pathologic activation of
the coag. cascade
b. Thrombosis
c. Consumption
d. Fibrinolysis
e. Hemolysis
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Table 3. Conditions that commonly precipitate DIC


Infectious condition
Gram negative septicemia
Other endotoxin-related condition
Obstetric conditions
Abruptio placentae
Amniotic fluid embolism
Retained dead fetus
Vascular conditions
Aneurysm
Giant cavernous hemangioma
Hematologic conditions
Massive hemolysis
Promyelocytic leukemia
Snake venom
Trauma
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2. Clinical features varies widely


a. diffuse bleeding from multiple sites
b. thrombotic lessions
3. Diagnosis lab. findings vary with time &
circumstances
Severe DIC :
a. Thrombocytopenia
b. Prolonged PT, PTT, TT
c. Decreased fibrinogen
d. FSPs
e. Microangiopathic hemolytic anemia
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4. Therapy :
a. Low grade DIC treatment may not
be necessary
b. Clinically significant bleeding
replacement of depleted coagulation
factors and cells
c. Thrombosis : heparin
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B. Thrombotic thrombocytopenic purpura


(TTP) and hemolytic-uremic syndrome
(HUS)
C. Heparin thrombocytopenia

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THANK YOU

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