Professional Documents
Culture Documents
Coagulation
Disorders
Dr Nishant Verma
Hemostatic Mechanism
Platelet adhesion
Platelet aggregation
Clot formation
Clot stabilization
Limitation of clotting to the site of
injury by regulatory anticoagulants,
and
Re-establishment of vascular patency
through fibrinolysis and vascular
healing
von Willebrand‘s
Factor (vWF)
binds to
subendothelial
collagen.
GLANZMANN’s Thrombasthenia
Clotting Factors
I Fibrinogen
II Prothrombin
V Labile factor, proaccelerin
VII Stable factor or proconvertin
VIII Antihemophilic factor (AHF)
IX Christmas factor
X Stuart-Power factor
XI Plasma thromboplastin antecedent
XII Hageman factor
XIII Fibrin Stabilizing Factor
Waterfall cascade:
Ex
tr
in
si
Ti fac
c
s s to
pa
ue r
th
w
f a V II
ay
ct
or
,
Factor X Factor Xa
Fibrinogen Fibrin
HEMOPHILIA
Overview of fibrinolytic mechanism
von Willebrand Factor
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Congenital
• Acquired
– Von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
Classification of bleeding disorders
Clinical characteristic Primary Hemostatic Defect Coagulation Disorder
Site of bleeding Skin, mucous membrane Soft tissues, muscles, joints
Bleeding after minor cuts Yes No
Petechiae Yes No
Ecchymosis Small, superficial Larger, deeper
Hemarthrosis Rare Common
Bleeding after trauma/surgery Immediate Delayed
Example Platelet defect, vWD Hemophilia
Source: Nathan and Oski’s Hematology of Infancy and Childhood. 7 th Edition, Pg 1450
Clinical Approach to bleeding disorders
History
Physical Examination
Laboratory Evaluation
Clinical Approach to bleeding disorders
History
Nature of bleeding-
- Immediate vs delayed
- Superficial vs deep
- Surgical / dental history
Family H/O bleeding-
- Others involved ?
- Males only? (x-linked)
- Consecutive generations
Medication history-
-NSAID, Heparin (patients with central lines)
Others- Liver / renal disease
Clinical Approach to bleeding disorders
Physical Examination
Bruises-
- Number
- Location
- Site
Petechiae
Joint bleeding
Other Physical findings-
- Jaundice
- Skeletal deformity
- Hepatosplenomegaly
Clinical Approach to bleeding disorders
Screening Laboratory Evaluation
• Coagulation profile
– Prothrombin time (PT)
– Activated partial thromboplastin time (APTT)
– Bleeding time (BT)
BT / CT
• Bleeding time • Clotting time
– 3-9 min – 3-6 min
Coagulation profile
• Sample collection
– Citrated tube
– Gently mixed
– Immediate transport
Coagulation profile
• PT
– Method
– Normal – 10-11s
– INR = (Patient PT/Control PT)ISI
– Isolated PT
• APTT
– Method
– Normal – 26-35s
– Isolated APTT
– PT + APTT TT
• TT
Advanced tests
• Factor assays
• Liver disease
• Inhibitors of coagulation
• Miscellaneous
Vitamin K Dependent Proteins
Dietary
Vitamin K
Vitamin K
Reductase
Vitamin K deficiency
Drugs
Management
Vitamin K oral / sc / iv
Repeat PT after 6hr
Prevention
Prophylactic Vit K to at risk population
Coagulation Disorders: Inherited
Hemophilia A Incidence 1 in 5000 to 10,000
Hemophilia B
Factor XIII Deficiency
Prothrombin Deficiency
Factor V Deficiency
Factor VII Deficiency
Factor X Deficiency Rare
Factor XI Deficiency
Factor XII Deficiency
Prekillikrein Deficiency
High Molecular Weight Kininogen Deficiency
a2-antiplasmin Deficiency
Plasminogen Activator Inhibitor Deficiency
HEMOPHILIA
Hemophilia C XI Autosomal
recessive
Parahemophilia V Autosomal
recessive
28
Severity of Hemophilia is defined by measured
level of clotting factor activity
29
HEMOPHILIA
CLINICAL MANIFESTATIONS
• Following an
injury
/ surgery or
rarely
spontaneous.
31
CLINICAL MANIFESTATIONS
Musculoskeletal bleeding
– Deep bleeding into joints and muscles
site.
– Later knees and elbow become common
sites.
32
Hemophilic arthropathy
• Target joint
– Repeated bleeds
33
Other manifestations
• Intracranial haemorrhage
• Hematuria
• Traumatic bleeding
• Venipuncture
34
Hemophilia : Diagnosis
• Screening tests
– Normal PT , Raised APTT.
• Mixing studies
Three approaches:
1. Patient and family history
Prenatal diagnosis
36
Case
6yr boy is brought to the OPD with
complaints of recurrent painful swelling
of the Lt Knee joint since 2yr of age. He
also has a history of prolonged bleeding
from cut sites.
O/E, Lt Knee joint swollen, tender
Investigations ???
• Lifestyle modifications
• Available therapeutic options
• Inhibitors complicating Hemophilia
• Prophylactic factor therapy
• Transfusion transmitted infections
Hemophilia: Management
Lifestyle modifications: Goal - Prevention of bleeding.
• Factor concentrates
• Cryoprecipitate
•Dose of factor VIII= desired % rise x • Dose of factor IX= desired % rise x
body wt (kg) x 0.5 body wt (kg) x 1.4
Type of Hemorrhage Desired factor level Duration (days)
(longer if indicated)
Hemophilia A Hemophilia B
CNS/head
•initial 50%–80% 50%–80% 1-3
•maintenance 30%–50% 30%–50% 4-7
WHF 20%–40% 20%–40% 8-14
Recommendations Throat and neck
for target factor • initial 30%–50% 30%–50% 1-3
levels •maintenance 10%–20% 10%–20% 4-7
Gastrointestinal
• initial 30%–50% 30%–50% 1–3
• maintenance 10%–20% 10%–20% 4–7
Cryoprecipitate
- Prepared by slow thawing of FFP at 4°C for 10–24 hours.
- Contains – FVIII, vWF, fibrinogen, & FXIII (not FIX or XI).
- supernatant - cryo-poor plasma and contains other coagulation
factors VII, IX, X, and XI.
- FVIII /bag of cryoppt is 60-100 units (avg-80 units) in a 30-40 ml
vol.
-does not contain factor IX, so no use in Haemophilia B
Concerns :
- factor content of individual packs variable.
- not subjected to viral inactivation procedures
Hemophilia: Management
Fresh Frozen Plasma
• FFP can be used to treat both hemophilia A &B
• 1 U FFP contains about 160-250ml plasma with activity of ~80%.
• Rate and total dose limited by the risk of acute or chronic circulatory
overload.
• How to use
– Thaw.
– Transfuse over how many minutes.
– Reusing after thawing
• Disadvantages:
– No viral inactivation
– F level >20-25% difficult to achieve
Hemophilia: Management
Desmopressin
• Physiotherapy
47
Hemophilia: Management
Inhibitors:
• Suspected - when no / inadequate response to factor
replacement.
• Detected by:
– Measuring factor levels after factor replacement
– Mixing studies
• Treatment:
– low-responders - specific factor at a much higher dose
– High responders - alternative agents like bypassing agents : as
recombinant factor VIIa and prothrombin complex
concentrates.
Hemophilia: Management
Prophylactic Therapy
• Administration of clotting factors at regular intervals to prevent
bleeding
- Patients with clotting factor level > 1% seldom have
spontaneous bleeding
50
Case
6yr boy is brought to the OPD with
complaints of recurrent painful swelling
of the Lt Knee joint since 2yr of age. He
also has a history of prolonged bleeding
from cut sites.
O/E, Lt Knee joint swollen, tender
Investigations ???
Diagnosis
•BT
•Platelet counts
•Failure to agglutinate by Ristocetin
•PFA
•Flowcytometry
•Genetic testing
GLANZMANN’s Thrombasthenia
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative (Thrombocytopenia)
SPURIOUS THROMBOCYTOPENIA
Case
2 yr girl is brought to the ER with complaints of red
colored spots over entire body for last 3 days.
H/O, URI 2wk back.
O/E, Afebrile. No Pallor
Spleen : just palpable
DDx ?
Investigations ?
Source: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia
Investigations
• Peripheral smear
Observation only
RBC
Y YAnti D
IVIG Anti D
1 line Medical Therapies in ITP
st
Corticosteroids
2 line Treatment options
nd
• Rituximab
• Other immunosuppressants
• Splenectomy
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative
– von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
von Willebrand Disease
• Pathophysiology
• Types
• Manifestations
• Treatment
DIC
Activation of
coagulation
cascade
• Causes
• Manifestations
• Diagnosis
• Treatment
Thank You