HEMOSTASIS

soalan
Edited :Dairion Gatot, Heny Syahrini

Divisi Hematology -Onkology Medic

Internal Departement of Medical Faculty of North Sumatera
University /Haji Adam Malik Hospital,
Medan 2015

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 Seorang laki-laki datang untuk memeriksakan giginya,
dan oleh dokter dianjurkan pencabutan gigi, pada
pemeriksaaan fisik tanda tanda perdarahan tidak ada
seperti petechie, purpura tidak dijumpai. Pada
pemeriksaan laboratorium Hb 12 gr/dl, WBC 10.000/mm3,
Platelet 90.000/ml3. Pemeriksaan koagulasi normal.
Apakah ada pemeriksaan tambahan yang diperlukan ? :

 A. Faktor Coagulasi
 B. Masa Trombosit
 C. Masa perdarahan
 D. Masa pembekuan
 C. Tidak memerlukan pemeriksaan lain.
 Seorang penderita penyakit jantung koroner yang
menggunakan aspirin 100mg setiap harinya selama 3 tahun,
ternyata setelah menjalani tindakan pencabutan gigi
mengalami perdarahan. Gangguan perdarahan manakah
yang terjadi pada penderita tersebut ?

 A. Gangguan vaskular
 B. Gangguan fungsi trombosit.
 C. Trombositopenia
 D. Gangguan koagulasi
 E. Gangguan hemostasis
Patient 1
 Female 53 years
 History :
 bleeding problem from any cut
 Severe post appendectomy bleeding in the
age of 30 years which stopped after fresh
blood transfusion
 She is much trouble by bleeding from the
gums and menorrhagia
 She fell two days ago on her forehead
 Sign :
 large local hematoma  circumorbital
hematoma
 Physical examination:
 no signs other than those mention above

LAB:
Plat count: 300x109/l
Plat morfo: normal
BT : >30 min
PT : normal
APTT : normal
Thrombin time: normal

Diagnosa:
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Patient 1
 Female 53 years
 History :
 bleeding problem from any cut
 Severe post appendectomy bleeding in the
age of 30 years which stopped after fresh
blood transfusion
 She is much trouble by bleeding from the
gums and menorrhagia
 She fell two days ago on her forehead
 Sign :
 large local hematoma  circumorbital
hematoma
 Physical examination:
 no signs other than those mention above

LAB:
Prolonged BT with a normal platelet number indicates a thrombocytopathy
Plat count: 300x109/l
Plat morfo: normal Futhe study of platelet function is required:
BT : >30 min Platelet retension: prolonged
PT : normal Platelet agregation ADP, adrenalin, and cllagen: only shape change
APTT : normal Clot Retraction: decreased
Thrombin time: normal

Diagnosa: Glanzmann’s disease (thrombasthenia)

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 Patient 2
History
Young man 29 years old suffering since infancy from spontaneous deep
painful hematomas and from bleeding in to joints particularly the knees
and shoulders.
He was admitted many times to hospital because of these complain.
He was not trouble by bleeding from cuts.
In recent years his complaints have been alleviated by adequate therapy

Physical examination
Atrophia of upper leg with prominent joints, rethrograde displacement of
the femur on the right joint, limitation in extension and flexion on both side.
Some limitation of flexion was present in the rightbelbow

Lab data
screening:
Platelet number : 150 X
10 /l
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Plat morfo: normal

BT : normal
PT : normal
APTT : strongly prolonged
Thrombin time: normal
Diagnosis: ?
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 Patient 2
History
Young man 29 years old suffering since infancy from spontaneous deep
painful hematomas and from bleeding in to joints particularly the knees
and shoulders.
He was admitted many times to hospital because of these complain.
He was not trouble by bleeding from cuts.
In recent years his complaints have been alleviated by adequate therapy

Physical examination
Atrophia of upper leg with prominent joints, rethrograde displacement of
the femur on the right joint, limitation in extension and flexion on both side.
Some limitation of flexion was present in the rightbelbow

Lab data Prolongation of APTT with normal PT and Thrombin Time indicates
screening: A disturbance of the intrinsic pathway of coagulation
Platelet number : 150 X Spesific clotting factor assays of the intrinsic syetem were therefore
10 /l
9 Carried out.
Plat morfo: normal F VIII – 1%, FIX – normal, F XI – normal, F XII – normal
BT : normal Pletcher factor(prekalikrein) and Fitzgerel (HMWK) are very rare
PT : normal And do not cause a hemorrhagic disorder
APTT : strongly prolonged
Thrombin time: normal
Diagnosis: Hemophilia A
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Patient 3
 Woman of 45 years of age who had no symtoms of
bleeding disorder until 7 months ago. Previously she
underwent tonsillectomy, an operation for vaginal
prolapse and various tooth extractions without bleeding
 In the last 7 months she was troubled by easy bruising
(hematomas after slight trauma), she had prolonged
bleeding from cuts.these complaints have gradually
become more severe but now less pronounced than
two week ago.
 The patient visited her GP because of feeling of
weakness and fatigue.

Phisical examination :
showed pallor With several hematomas
and purpura on the legs and palateand
at points of presure of her clothes

Lab data screening:

Platelet number : 8 X 109/l
BT : >30 min
PT : normal
APTT : normal
Thrombin time: slightly prolonged

Diagnosa: ?
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Patient 3
 Woman of 45 years of age who had no symtoms of
bleeding disorder until 7 months ago. Previously she
underwent tonsillectomy, an operation for vaginal
prolapse and various tooth extractions without bleeding
 In the last 7 months she was troubled by easy bruising
(hematomas after slight trauma), she had prolonged
bleeding from cuts.these complaints have gradually
become more severe but now less pronounced than
two week ago.
 The patient visited her GP because of feeling of
weakness and fatigue.

Phisical examination :
showed pallor With several hematomas
and purpura on the legs and palateand The bleeding disorder was apparently caused
at points of presure of her clothes
by an acquired thrombocytopenia. The
Lab data screening: pallor of the patient was due to coexistent
Platelet number : 8 X 109/l anemia. A leukocytopenia was also present.
BT : >30 min
PT : normal A bone marrow smear showed the presence
APTT : normal of 80% myeloblast with Auer rods.
Thrombin time: slightly prolonged

Diagnosa: thrombocytopenia due to myelobalstic leukemia

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Patient 4
History:
Young female, 26 years, has a bleeding tendency, bleeding
after tooth extraction. Menorrhagia which has caused
repeatedly an iron deficiency anemia. Bleeding from cuts is
very prolonged and large hematomas may appear on bruising
Her brother and his son are affected by a similar bleeding
tendency.

Phisical examination:
No abnormality

Lab:
Plat count: 176x109/l, Plat morfo: normal, BT: >30 min, PT: normal,
APTT: prolonged, Thrombin time: normal

Diagnosis: ?
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Patient 4
History:
Young female, 26 years, has a bleeding tendency, bleeding after tooth extraction.
Menorrhagia which has caused repeatedly an iron deficiency anemia. Bleeding from
cuts is very prolonged and large hematomas may appear on bruising Her brother
and his son are affected by a similar bleeding tendency.

Phisical examination:
No abnormality

Lab:
Plat count: 176x109/l, Plat morfo: normal, BT: >30 min, PT: normal,
APTT: prolonged, Thrombin time: normal

The combination prolonged BT and partial thromboplastin time is allready very

suggestive
Analysis of prolonged BT: Plat retention-decreased. Plat aggregation-normal
Analysis of prolonged APTT: F VIII-10%, F IX- normal, F XI- normal, F XII- normal

Diagnosis: Von Willebrand’s disease (VWD)

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 Patient 5

History:
27 years old pregnant woman without a history of bleeding symptoms. She is in her
38th week of pregnancy, with her 4th child, 4 hours before admittance she
suddenly had severe pain in the abdomen followed by start of birth pains that were
almost continuous. Half an hour after admittance she lost some blood from vagina
that did not clot.

Physical examination:
patient is a healthy young pregnant woman who was in apparently in great pain.
Blood pressure normal The uterus was tender and completely contracted

Lab:
Plat count: 100x109/l, Plat morfo: normal, BT: normal, Prothrombin T: prolonged,
Partial thromboplastin time: unclottable, Thrombin time: unclottable

Diagnosis: ?
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Patient 5
Diagnosis:

Diffuse Intravascular Coagulation (DIC)

The history is characteristic of diffuse intra vascular coagulation.

A specific investigation was carried out:
Fibrinogen: 20%. Factor V: 15%, Ethanol gelation: neg, FDP: 60%

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