Hemostasis

Definition:
Body mechanism of intravascular
processes by which blood preservation
,smooth blood flow and prevention of
intravascular clot formation or bleeding.
ajor objectives
1- Blood preservation. ,
2-Smooth blood flow.
3- Prevention of intravascular clot formation
and internal or external bleeding.
Specific objectives
1-aintenance of smooth blood flow.
2-Prevention of bleeding.
3-Prevention of intravascular thrombosis.
4- Removal of formed fibrin clot by
fibrinolysis process.
5-Regulation of coagulation and fibrinolysis
process.
Hemostasis components
Normal blood vessels to constrict and reduce blood flow
at site of injury.
Normal platelets in number and function to aggregate.
Normal plasma coagulation factors level and function to
form normal blood coagulation at site of injury.
Functional fibrinolysis agents (plasminogen an plasmin).
Normal hemostasis regulatory agents to prevent
hemostasis imbalance (plasminogen activators and
inhibitors, protein C,S).
'ascular integrity
Normal vascular composed oI three layers:
1-Tunica adventitia: outer thicker layer make up oI
collagen and Iibroblast.
2-Tunica media:-elastic layer composed oI smooth
muscle and collagen. Thicker in arteries and arterioles
than in veinioles and capillaries.
3-Tunica intima: Inner layer consists oI
nonthrombogenic oI endothelial layer, basement
membrane contains collagen and internal elastic
membrane
Role of endothelium
The inner layer is formed by a single layer of
cells called the Endothelium. t is these cells that
secrete the various substances responsible for
relaxing or contracting the arteries including
Nitric Oxide.
These substances then percolate into middle
layer and signal the muscle present to either
relax or contract. A normally functioning
Endothelium is very significant to the health of
the arteries and the individual in turn.
Healthy individuals produce sufficient Nitric
Oxide in the blood vessels keeping them supple
and flexible.
High blood pressure, elevated cholesterol levels,
diabetes, smoking, lack of exercise and stress
all reduce the production of Nitric Oxide causing
endothelial dysfunction.
This endothelial dysfunction occurs in the entire
arterial system and begins years before the build
up of calcium and plaque in the coronary
arteries (coronary artery disease) actually
manifests.
Detection of these early vascular changes
under repeatable, sensitive tool to study the
endothelial function which quantifies large and
small artery relaxation.
Role of platelet in vascular integrity
1- Normal blood vessels with adequate number of
functional platelets prevent leakage of blood into
the tissue under normal shear forces, hence no
evident of bruising , purpura, petechia or
ecchymosis.
2- 'ascular integrity maintain by functional
platelets to prevent leakage of red blood cells
into the tissue
'ital functions of vessel walls
1-providea surface resistant to thrombus
formation.
2-Provide initial stimuli for thrombus formation
when disrupted. ( release of PAF, F111 and
exposed collagen )
3-Provide platelet activity inhibitors (P1
2
) and ( t-
PA ).
( feature of Hypercagulopathy or
hypocoagulopathy may occur in abnormal
condition )
Platelet production and function
egakaryocytic series
1-phsc.
2-egakayoblast
3-Promegakaryocyte
4-ature egakayocyte
Stimulating factors for
Thrombopoiesis
.
eg CSF,L3, L6. stimulate Phsc
TPO generated predominantly the kidney
stimulates megakaryocytic progenitor cells
to mature and release platelets in response
to a demand.
30% 0f the platelets are sequestered in the
spleen, splenic pool rapidly empty in sudden
depletion of platelets.
egkaryocte under go endomitosis or
creates multi-lobed nucleus with diploid lobe of
the nucleus(2N) 8N,16N, 16N and 32n pairs of
chromosome in a full complement. To produce
1500 2000 platelets in a steady state
Thrombopoiesis
Definition : process by which thrombocyte
formed in the bone.
akaryocytic series:- define as serial maturation
of megakaryobast for production of platelets in
the bone marrow.
1-MegakaryobIast:
Size-15-50
Shape-round with or without slight indentation.
Nucleus: round or oval and contains several
nucleus.
Cytoplasm: defuse blue.
Shape: irregular.
Nucleus: contains 2-4 nuceoli.
Cytoplasm: dark blue without granules
3-Promegakaryocyte: ( Granular egak.)
Size:25-100.
Shape: irregular.
Nucleus: 8 nucleus.
Cytoplasm: reddish-blue contains small
fine granules.
Occasionally travel to extra-marrow sites.
Occasionally encountered in normal PBP
Budding micromegakaryocytes seen in
PBF of patients with myeloproliferative
disaeses
3-ature egakaryocytic:
Size:30-120.
Nucleus:(16-32).
Cytoplasm:
Reddish contains aggregates granules and
platelet adhere to the membrane (budding
platelets)
Platelet shedding occurs by cytoplasm
fragmentation to release platelets in to blood
stream
Platelet
polymorphic cytoplasm particles. Contains
fine small granules.
Size: 2-4.
'olume 5-8fl.
Platelet structure
embrane:
1-Spongy bilayer membrane consist of several
glycoprotein's.Gp1a.1b,11b,111a.
2- Cytoplasmic contractile microtubules.
3- Cytoplasmic micro fibrils provide pseudopodia.
4- Platelet granules:
Dense granules.
Alpha granules.
Lysosome granules.
Glycogen granules.
Platelet Dense granules
Contains the following agents:-
ADP.
ATP.
serotonin.
Calcium. (1v)
Phosphate.
Alpha Granules
Platelet factor 4. ( heparin neutralizing factor)
Betathromboglobulin.
Thrombospondin.
Platelet derived growth factor. (PDGF)
Fibrinogen .(adsorbed)
Factor '.
vWF.
Fibronactin.
Plasminogen activator inhibitor 1.
Epinephrine receptor:- Platelet activation
Thrombospondin receptor:- Platelet
aggregation.
Thromboxane A2 and Prostacyclin l2
receptor:- calcium release from dense
tubular system and subsequent release of
dense, alpha and lysosomal granules
Specific platelet glycoprotein
receptors
Gly la,lla:- platelet adherence to collagen
Gly lb-lx :- adherence collagen or bound to v W
F
Thromin recptor
Gly lla- llla:- aggregation in presence of fibrinogen,
fibrin,fibronectin and v WF.
Gly v:- platelet activation.
PAF receptor:- activation, shape change and secretion
Factor v receptor:- Fv attachment to platelet
phospholipid.
ADP receptor:- nhibitor of adenylate cyclase
echanism of platelet specific
receptors
GPlb: is platelet specific receptor for 'WF, both
platelet and vWF are negatively charged by
sialic acid hence repel each other normally to
prevent platelet aggregation.
Gplb receptor stimulate by exposured collagen
and enhance platelet aggregation either with or
without libration of PAF from disrupted
endothelial cells in vessel walls.
GPlb receptor has been named the Bernard-
Soulier protein because it is missing in Bernard-
Soulier syndrme (BSS)
GP1b-1X and GP'
Platelet Gplb-1X receptor attach to vWF and
enhance platelets adhere to fibrinogen,
deposited fibrin and external formed clot, GP'
similar to GPlb in structutre both are missing in
BSS.
Both also act as receptors for vWF and thrombin
GPllb-llla Complex
The receptor for fibrinogen becomes
activated after stimulation by initial
activation, adherence and aggregation
The complex also couples fibronectin,
with vWF help in platelet adhere and later
cross linking together to stabilize plug.
Factor ' receptor
Adsorbed factor ' secreted from platelet
and complex with Fv receptor, generated
thrombin modifies Fv to F'm
Factor ' receptors hold 'm on platelet
surface ( PF3 ) in conjunction with plasma
factor Xa as cofactor for conversion of
prothrombin to thrombin.
Role of Epinephrine
Catecholamine is released during trauma
and activation of platelet occurs initiates
production of thromboxane A2 synthesis
and released of ADP from platelet dense
granules attaches to platelet external ADP
receptor allow further aggregation,
aggregated platelets joined to each other
by Gllb-lla with fibrinogen.
Thromboxane A
2
& Prostaglandin l
2
pathway
1-Endothelium and platelet release membrane
platelet phospholipids as initial substrate.
2-Enzyme phospholipids.
3- Archidonic acid (product) and substrate
4- Enzyme cycloxygenase
5-Prosogolandin intermediates
(PGG
2
&PGH
2
) as products and substrate.
6-Enzyme prostacycIin synthetase.
7- Prostacyclin(PGl
2
) enhance platelet inhibition
and vasodilatation then degraded into inactive
Keto-PGF1d
- Or Enzyme thromboxane synthetase
-Thromboxane A2 (TxA2) enhance platelet
aggregation and vasoconstriction and
degraded into inactive TxB2
10-Aspirin and similar analgesic inhibit
cycloxygenase activity that prevent
metabolism of arachidonic acid.
Activation and adhesion
nitiaI adherence of pIateIets to sub
endotheIiaI tissues:
1-nitial nteraction between GP1b and 'WF.
2-Secondary adherence to fibrinogen through
GP11ba GP111ba and fibrinogen interaction.
3- additional blood 'WF allow adherence of
tissues bound platelets to activated platelets
near the wound to build solid platelet plug over
the dammage area.
Aggregation phase 1 reaction
1-Activated and adhered pIateIet reIease dense
granuIes ADP, ATP, serotonin, caIcium.
2-ADP binding to its receptor enhance cellular
cytoplasm calcium accumulation and enhances
platelet aggregating.
3-serotonin is powerful vasoconstrictor released
from dense granules causes of smooth muscle
contraction in the tunica media.
4-resultant vessel contraction with slow blood flow
(stasis) at the site of vessel injury.
5-Stasis makes platelets and factors more
available and decreased inhibitor proteins in the
area.
Aggregation phase 2 reaction
continued aggregated of pIateIets requires aIpha
granuIes reIease fibrinogen, fibrnoectin and v WF
react with pIateIet surface receptors (GPIIb-IIIa and
GPIb-1X ). To form stabiIize and cohesive pIateIet
pIug.
Continued aggregation also requires realse of additional
calcium raising effects of PAF and ADP
Release of arachidonic acid which is converted to
thromboxane A
2
or prostacycline 1
2
to balance platelet
aggregation, vasoconstriction and inhibition ,
vasodilatation.
Clot retraction
Platelet plug constricted by the action of
ATP-stimulated calcium accumulation ,
which expelled trapped fluid and reduces
the plug.
Retraction requires fibrinogen receptors
interaction ( fibrinogen, firinoectin and
fibrin)
Thrombasthenia referred to lack of clot
retraction due to miss of mention receptors
Platelet inhibition
The reverse activation of platelet occur generally by
increasing the level of cAP which favor calcium
sequestration.
The mechanism of PG12 play major role when reacts
with its receptor on platelets the signal phosphrylate
receptors proteins in dense tubular these phosphorylated
receptors attract cellular calcium and reduced ca++
levels (Platelet inhibition )
PG12 also act as a powerful vasodilator cause platelets
relaxation and smooth muscle downstream enhance
blood flow to provide additional platelets and clotting
factors ate site of injury
Aspirin and similar drugs can be
irreversibly inhibit cylooxygenase in
platelets and prevent their activity.
Aspirin also effects endothelial PG12
production.
Congenital deficiency of enzymes in the
Thromboxane/prostacyclin pathway which
mimic the aspirin effect.
Platelet effectiveness
The reference rang for platelet count are 150 to
400x10/L S units.
Hemostasis maintain by platelet function rather than
platelet number.
Bleeding tendency with dysfunctional thrombocytosis
were encountered, on the other hand thrombocytopenia
with functional platelet do not bleed.
Thrombocytopenia of counts between 10 -50x10/L often
don't cause bleeding.
Spontaneous bleeding may occur with platelet counts
below 10x10/L.
Plasma coagulation factors
General features:
1-Proteins and glycoprotein in nature and
expressed as inactive pro-proteins.
2-Produced by the liver in exception the
tissue factor F1'.
3-Refers by Roman numerals and preferred
names.
Factors characteristics - 1
Factor numeral Preferred Name Activity feature Vitamin K required
1 ibrinogen Substrate No
11 Prothrombin Thrombin substrate Yes
111 Tissue Iactor CoIactor Ior V11 No
1V Calcium Mineral coIator No
V Labile Iactor(proaccerlrin) CoIactor No
V11 Proconvertin(stable Iactor) Serine protease Yes
V111 Antihemophilic Iactor A CoIactor No
1X Chrismas Iactor (AHB) Serine protease Yes
X Stuart Iactor Serine protease Yes
X1 AHC Serine protease No
X11 Contact Iactor (Hageman) Serine protease No
X111 ibrin stabilizing Iactor Transglutaminase No
- Prekallikerin( eltcher) Serine protease No
- HMWK (William) Contact and substrate No
Factors characteristics - 2
Factor M.W. X 10
3
/
Dalton Concentration Half-life /Hours
1 340 200-400mg/dl 90
11 69 10mg/dl 60
111 45 0 -
Calcium 40 8-10mg/dl -
V 268 5-10g/ml 12-36
V11 53 10-20g/ml 5-8
V111-c 260 1-2mg/dl 8-12
V111/vW 1000-2000 7mg/dl 10
1X 57 3-4g/ml 48-72
X 59 6-8g/ml 48-52
X1 160 2-7g/ml 48-84
X11 84 30-40g/ml 48-52
X111 300 2.5mg/dl 72-120
letcher 100 35-50g/ml 35
itzgerald 120 70-90g/ml 156
plasmonogen 90 15-21mg/dl 24-26
Protein C 62 4-6g/ml 7-9
Protein S 69 20-25g/ml -
Factors characteristics - 2
Factor M.W. X 10
3
/
Dalton Concentration Half-life /Hours
1 340 200-400mg/dl 90
11 69 10mg/dl 60
111 45 0 -
Calcium 40 8-10mg/dl -
V 268 5-10g/ml 12-36
V11 53 10-20g/ml 5-8
V111-c 260 1-2mg/dl 8-12
V111/vW 1000-2000 7mg/dl 10
1X 57 3-4g/ml 48-72
X 59 6-8g/ml 48-52
X1 160 2-7g/ml 48-84
X11 84 30-40g/ml 48-52
X111 300 2.5mg/dl 72-120
letcher 100 35-50g/ml 35
itzgerald 120 70-90g/ml 156
plasmonogen 90 15-21mg/dl 24-26
Protein C 62 4-6g/ml 7-9
Protein S 69 20-25g/ml -
Factor 1
Fibrinogen is betaglobulin produced by the liver serves
as substrate for thrombin.
The molecule consists of three poly peptide chains
alpha, beta and gamma to form three domains D,E D
held by disulfide bonds.
Thrombin cleavage beta and alpha fibrin peptides to
form unstable fibrin monomer D-E-D in 5-mol urea.
Crosslink platelets through 11b and 111b receptors.
Platelet adsorb fibrinogen into their alpha granules.
Control gene on chromosome 4, plasma reference range
200-400mg/dl
Spontaneous condensation of monomers to
form fibrin polymers.
Factor x111a catalyzes formation of covalent
bonds between adjacent D domain to stabilize
fibrin polymer in 5-mol urea.
Act as acute phase protein increased in many
disease states, pregnancy smoking
Elevation is associated with myocardial
infarction and stroke.
Low level hypofirinogenemia or dysfunction is
associated with bleeding.
Factor 11
prothrombin is alpha globulin produced in the liver by
gene on chromosome11.
Single chain glycoprotein of 6000D.
Post synthesis maturation required 'K to make
functional prothrombin.('K-dependet factor)
Release into the blood as zymogen precursor active
form consist of F1F2+Pre2
Cleavage by xa,v,ppl,ca++ from N-terminal to F1.2 and
prethrombin2 molecules.
Further cleaved to an active serine protease thrombin
have serine active center capable to hydrolyze arginyl or
lysyl bonds of their substrate.
Thrombin substrate is fibrinogen and can
activates factors v, v111, x1 , x111 and
protein C.
Factor 111
Assigned to tissue thromboplastine and referred as
tissue factor released from traumatized tissue.
Transmembrane lipoprotein found in all tissue
particularly in the brain, liver, lung and placenta.
Ca++ clings to negative charged phospholipids surface
of tissue factor.
'K dependent factors bind to the ca++ attached to tissue
factor.
Serves as a cofactor for activation of v11 in extrinsic
pathway ( tissue factor pathway)
On the other hand platelet phospholipd surfacessimilar
to tissue factor in attraction of ca++ for intrinsic pathway.
Factor 1'
ts referred to ionized calcium mediator of platelet
activation and binds 'K dependent factors or itrinsic
factors to phospholipids surfaces ( F111 and PF3).
Without ca++ 'K dependent factors will not anchor to
thrombogenic phospholipids and prevent clotting.
Chelating agents remove ca++ from the blood and
prevent clotting hence used as anticoagulants.
40% of blood calcium in ionized state, also intracellular
calcium mobilization from platelet dense granules
enhance platelet aggregation and ensure sufficient
calcium availability.
Factor '
Called proaccelerin or labile factor single chain
glycoprotein produced by the liver, its activity diminishes
quickly at room temperature citrate plasma should be
tested within 30 minutes to avoid deterioration of factor
'.
Act as cofactor and accelerating conversion of
prothrombin to thrombin.
Attaches to its receptors on activated platelet and tissue
factor.
ntrinsically large amounts of Factor ' attaches to PF3.
Small modified factor 'm in extrinsic pathway holds xa
and prothrombin on th ppl to activate proth.to throm.
Factor '11
Single chain glycoprotein ' k dependent factor named
procnovertin common name is stable factor because
stable for several hours (4-5hous) in plasma and serum
or blood up to 2weeks at refrigerator temperature.
Fv11 activated to '11a by contact with ca++ anchored to
tissue factor,'11a/ca++/111 complex activate factor x to
xa. The complex affected by tissue factor pathway
inhibitor. ncreased levels associated with myocardial
infarction and stroke.
Fv11a also can activate factor 1x from intrinsic pathway.
Has a lower concentration and shorten half life5-8 hours
of the 'K dependent factors first factor affected by
administered of 'K antagonist such as warfarin.
Factor '111:C (the coagulation
portion) antihemphilic factor
Produced mainly by the liver, synthesis
controlled by gene on x chromosome and found
as '111-C or '111:vWF complex the later of the
complex is produced by megakaryocytic and
endothelial cells.
After modification by xa or thrombin v111a
becomes cofactor to 1xa in coagulation scheme
to x to xa in intrinsic pathway.
s heat labile quickly diminished in plasma at
room temperature.
s unstable in circulation when found as
unbound to vWF.
Factor 1X
Plasma thromboplastin component commonly
named Christmas factor for the first family found
this deficiency. Synthesis controlled by gene on
X chromosome.
Produced in the liver as single chain
glycoprotein and serves as 'K dependent
Bound Ca++ on ppl surface, it activated by X1a
or '11a and 1Xa serine protease activates X to
Xa in common pathway.
Factor 1X deficiency described as hemophilia B
or Christmas disease.
Factor X
'K dependent glycoprotein produced by
the liver under controlled of gene on
chromosome 13.
Called the Stuart power factor, and can be
activated into serine protease by both
'11a and 1Xa. ts activation requires
calcium and v111 as cofactor.
Factor Xa/ca++/ppl / 'm complex known
as prothrobinase complex
Factor X1
Contact factor clings to negatively charged
surfaces such as glass, sub endothelial tissue
and activated platelets.
Found in complex with HWK another contact
factor.
X1 activated by X11a and becomes important
serine protease in the intrinsic pathway.
Only 15-25% of normal factor X1 activity
required to maintain normal hemostasis.
FX1 deficiency called hemophilia C
Factor X11
Called the Hageman factor was named for first person
known to be deficient in this factor. Single chain
glycoprotein produced by the liver controlled by gene on
chromosome 5.
Auto activate to serine proteases upon binding with
negatively charged surfaces such as glass, celite, kaolin
dextran sulphate, endotoxin and suendothelial tissue.
X11a is initial agent in contact factor system to activate
X1 to X1a in presence of HWK as cofactor.
X11a activates HWK bound prekallikerin to Kallikerin
X11a and Kallkerin activate additional X11a
X11a, PK and HWK deficiency do not bleed
uncontrollably.
Factor X111
Alpha2 globulin produced in the liver
activated by thrombin and called fibrin
stabilizing factor.
X111a forms covalent bonds between
adjacent D domains in polymerized
insoluble fibrin.
Also crosslink's alpha2 antiplasmin to fibrin
mesh to prevent premature breakdown of
formed clot.
Fletcher factor
Also known as PK is the a fast gamma
globulin with serine protease activity when
activated by X11a attached to a cofactor
HWK then PK converted to active
enzyme Kallikerin.
Kallikerin Activates plasminogen to
plasmin and hydrolyzes LW bradykinis
produced kinins serves as vasodilator
reverse vasoconstriction of thrmboxane A2
Fitzgerald factor
Also known as HWK, single chain
glycoprotein produced by the liver member
of the contact group
Acts as a cofactor to accelerate the
activation of X1 by X11a.
Acts as substrate for Kallikrein in the
production of Kinins.
Platelet factor 3
imic tissue factor is PPL surface
supports coagulation attracts ca++ to
provide binding sites for functional 'K
dependent factors.
Role of 'K
'K plays a major role in carboxylation of
prothrombin group factors by facilitating
additional of second carboxyl group on
gamma carbon of glutamic acid residues
to factors 11,'11, 1X,X and proteins C
and S.
'k antagonist prevent the post synthesis
additional.
The contact group
X11
X1
X1
PK
HWK.
Found in fresh normal plasma and serum.
Prothrombin group
11
'11
1X.
X
Proteins C ND S.
All are precipitated and removed from plasma adsorbed
with barium sulfate or aluminum hydroxide.
Adsorbed plasma contains the fibrinogen group and the
contact group factors
Aged serum contains the prothrombin group in exception
of factor 11.
All are produced in the liver and potent serine protease
inexcept protein S and C.
Fibrinogen group
1,' '111 and X111
Present in normal and adsorbed plasma.
issing from serum.
Hemostasis processes
nclude following processes:
1-primary process involves:-
Primary vascular constriction to reduce blood at site of injury.
Primary platelet adhesion at site of injury.
Primary platelet aggregation at site of injury.
Primary process evaluation tests include (Bleeding time, capillary
resistant test and platelet count and platelet function test).
2-Secondary hemostasis process involves:
Coagulation cascade which defined as serial activation of plasma
clotting factors to convert final substrate fibrinogen to fibrin at sit of
injury in the following three pathways.
1-ntrinsic pathway.
2-Extrinsic pathway.
3-Common pathway.
'essel Damage
'essel damage initiates the following
hemostasis mechanisms:-
'asoconstriction is nervous and vessel
muscular response.
Platelet and coagulation factors activation
with platelet fibrin clot formation.
Firinolysis tissue response to release TPA
To convert plasminogen to plasmin for
formed clot dissolution and vessel heals.
Extrinsic Coagulation Pathway
Tissue factor and ionized calcium required
for initial activation of this pathway and
particularly activation of factor '11 to
'11a to form extrinsic complex (
TF+'11a+ca++) for activation of X to Xa
and 1X to 1Xa.
The pathway evaluates by performance of
prothrombin time (PT).
ntrinsic pathway
nvolves activation of the contact factors
presence in blood circulation included contact
activation of factors ( PK,HWK , X11,X1).
Activation initiated by their contact to the blood
vessels wall exposure collagen at site of injury to
form intrinsic complex ( 1Xa+PL+'111a+ca++)
to activate factor X.
Contact factors are presence in fresh normal
plasma and serum
This pathway evaluated by activated partial
thromboplastin time (APTT).
Common Coagulation pathway
nitial activation of factor X to Xa by both
intrinsic and extrinsic pathways and
involves Factors( X,'m,11,1,X111,ca++)
to form common complex (
Xa+PL+'m+ca++) for conversion of
fibrinogen to fibrin.
The pathway evaluated by thrombin time
and fibrinogen level (TT&FL), and fibrin
hemolysis test.
Fibrinolysis system
The aim is to gradually dissolved of fibrin
clot as vessel heals in order to restore
normal blood flow.
Plasminogen activated to plasmin and
capable for degradation of fibrin to D-D
dimer and E fragments
As well as factors degradation of 1,' and
'111.
Regulation of homeostasis by
protein C and S
Excess thrombin binds quickly to
thrombomodulin on healthy endothelial cells
adjacent to the thrombus site.
The complex activates plasma protein C in along
with its cofactor protein S which inactivates
cofactors 'm and '111m by degradation to stop
localized clotting event and signals for beginning
of fibrin removal.
60% of Protein S bound to C4, remaining 40% is
free active used to stop clotting.
nhibitors of Coagulation
1-Activated protein C is the major inhibitor, the
complex of protein C with cofactor free protein S
degraded 'a and '111a. Found that 40% free S
in plasma and 60% of protein S bound to C.
2- Antithrombin 111 is the major thrombin inhibitor,
alone acts very slow, vessel wall heparin sulfate
binds Anti-111 and enhance the rate of activity,
the complex also inhibits 1Xa, Xa, X1a, X11a,
kallikerin and plasmin.
3- Heparin Cofactor 11:-
Greatly enhances by heparin to inhibits thrombin.
4- alpha
2
macroglobulin form complex with
thrombin, kallikerin, plasmin to inhibit their
activity.
5-Extrinsic pathway inhibitor (EP):- also refers as
lipoprotein associated coagulation inhibitor
( LAC) inhibits '11a-tissue factor complex.
6- C1-inhibitor:- inactivate factors X11a, Kallikerin
and plasmin.
7- alpha 1-Antitrypsin:- acts as a weak thrombin
inhibitor and also inhibits factors Xa and X11a.
8- Activated protein C inhibitor:- inhibits activity of
protein C and enhance in presence of heparin.
-alpha 2 antiplasmin acts as principle inhibitor of
fibrinolysis by binding any free plasma plasmin
forming irreversible complex for neutralizing
plasmin
Plasminogen Activators
ntrinsic activators:-
-X11a
-Kallikerin
-HWK.
Extrinsic activators:-
-t-PA. release from endothelial cells.
-U-KA release from the kidney.
Therapeutic activators:-
-Streptokinase.
-Urokinase.
nhibitors of fibrinolysis
1- alpha 2 antiplasmin found in plasma and
platelets.
2-alpha 2 macroglobulin
3-Thrombospondin.
4- PA-1 and PA-2 natural plasminogen
activator inhibitors provided by platelet and
epithelial cells.
Coagulation and complement
system
The complement system primarily important in the
mediation of immune and allergic reactions.
Plasmin in the presence of AgAb complexes to which C
has bound can directly activate the first complement
cascade
C1(ciq,c1r,c1s) cleaves C3 to C3a and C3b.
C3b is anaphlatoxin, increase vascular permeability,
hypotension and shock are common findings in diffuse
intravascular coagulation (DC), also enhancing
phagocytosis.
Plasmin can directly activate C3 in the absence of Ab
alternate complement pathway
C1 inhibitor binds Cr1 and C1s prevent activation of C3
Also c1 inhibitor inhibits complement
activation by inhibiting factors X11a,
plasmin and kallikrein. (inhibits plasmin
and plasminogen activators)
"uantitative disorders of platelet
1-Thrombocytopenia.
Three categories:-
1- diopathic thrombocytopenia
2- Hypoplastic thrombocytopenia.
3- Acquired thrombocytopenia.
diopathic thrombocytopenic
purpura (TP)
Refers to acute, chronic or recurrent form of
thrombocytopenia result of non etiological
causes but considered to be due to
immunological process of platelet destruction in
RES.
Characteristic features:
-Polymorphic platelets.
-count of less than 20000/mm
3
_
bone marrow of single nuclei megakaryocytic
hyperplasia.
-Prolonged BT and platelet retraction deficient.
Symptoms of TP
Are variable according to the severity of
disorder and include:
- Petechial hemorrhagic.
- Purpura.
- Bleeding from gum, GT and UT.
- Bruising tendency.
- Recurrent epistaxis.
Treatment of TP
- Consists of:
- Steroids.
- Splenectomy
- Occasional immunosuppressive agents
- Platelet transfusion in frequent..
Congenital hypolplastic
thrombocytopenia
Due to bone marrow megakaryocytic
hypoplasia seen in various of clinical
situations including the following:-
1-Fanconi syndrome.
2-ay Hegglin anomaly autosomal
dominant disorder with feature of Dohle
bodies in neutrophil and thrombocytopenia
of giant platelets.
Acquired thrombocytopenia
Result from suppresser of megakaryocytic maturation by
large number of agents:-
onizing irradiation.
Alkalizing agents.
Severe Alcoholic.
Certain antibiotic.
Anticonvulsants.
Aplastic anemia and megaloplastic anemia
Splenomegaly.
'iral infection. H'.
Bacterial toxins thrombocytopenia
Bone marrow infiltration.
Drugs induced thrombocytopenia
ngestion of certain drug such as quinine
enhance formation of antibodies reacts with
platelets in the presence of drug and cause
thrombocytopenia. Drug antibody immune
complex adsorbed or binds to platelet by Fab
regions.
Severe thrombocytopenia of less than
10000/mm
3
occurs.
Severe and rapid of bleeding onset.
Bone marrow megakarycytes normal or
elevated.
Treatment is discontinuing of the drug.
nfectious nduced
Thrombocytopenia at Birth
Thrombocytopenia at birth of lower than
70000/mm
3
of platelets counts with marked lack
of bone megakaryocyte result from severe
rubella infection
Neonatal mmune-antibodies
Related Thrombocytopenia
The mechanism mimic fetal erythroblatosis of Rh
system immunization.
aternal negative to Pl
A1
immunized by fetal
positive P1
A1
red cell during pregnancy, results
in the development maternal anti-platelet
antibodies against fetal platelet.
Can cross the placenta and caused clinically
significant thrombocytopenia with scattered
petechial and purpuric hemorrhages seen
mainly in firstborn. ( 1 in 5000 newborns of
incidence).
Treatment
administered of steroids to the mother.
Exchange blood transfusion in severe
cases.
compatible mother's Platelet transfusion.
ortality rate of 14% is reported, many
infants recover over a 1-2 week period is
estimated.
Post-Transfusion soimmune
nduced Thrombocytopenia
Rapid onset thrombocytopenia and
moderate to severe develops
approximately 1 week after transfusion of
platelet- containg blood products causing
thrombocytopenia of counts less than
10000/mm
3
.
Usually results from anti-Pl
A1
in each
reported case.
Secondary Autoimmune nduced
Thrombocytopenia
Found in;-
5-10% of patient's with CLL, in a small
percentage with other lymophoproliferative
disorders.
14-15% of patient's with SLE.
Results from self immune antibodies
against individual own platelets.
Pregnancy nduced
Thrombocytopenia
Occurs in about 5% of women during or
after delivery with platelet counts of
21000/mm
3
to 135000/mm
3
resolves within
1week of delivery.
Related to physiological lower level of
platelet accompanies pregnancy or with
hemolsysis elevated liver enzymes and
lower platelet count (HELLP) of severe
preeclampsia.
Thrombotic Thrombocytopenic
purpura (TTP)
A syndrome characterized by the
presence of capillary or artery thrombi,
hemolytic anemia and thrombocytopenia.
High incidence in women at age of 30-40
years.
Syndrome symptoms
Severe anemia and thrombocytopenia at
presentation.
Renal dysfunction.
Headache, confusion and coma.
Death occurs within few days to weeks in
the majority of untreated patients.
Sever intravascular hemolysis of TTP can
occasionally triggered DC.
echanism and general features
Primary endothelial cell damage with
subsequent platelets and fibrin thrombus
formation account for all clinical features of the
syndrome.
The thrombotic lesions results in
microingiopathic red cells and platelets
destruction.
As consequence microspherocytes schistocytes
and platelet fragments may result.
Evidence of intravascular hemolysis
hemolobinurea hemosiderinuria, retiulocytosis
polychromasia, nRBCs and low haptoglobin.
Diagnosis
Thrombocytopenia of less than
20000./mm
3
Reticulocytosis with red cell fragments.
arked elevated of red cell enzymes.
arked elevated of unconjugated bilirubin.
ild renal impairment.
Pathogenesis
The exact pathogenesis remain uncertain
however 4 causes have been suggested:
1-Platelet -aggregation inhibitor factor deficiency.
2-Large vWF multimers promote platelet
aggregation.
3-Endothelial cell damage result from plasma
factor induces platelet adhesion.
4-Defect in PG12 leading to poor maitntence of
blood vessel lining.
Hemolytic uremic syndrome
(HUS)
Resembles TTP except predominately occurs n
children follows an acute viral infection.
Adult form HUS closely resembles TTP
differentiated from TTP by lack of neurological
symtps and prevalence of renal disease often
occurs in women in association with oral
contraceptive, preeclampsia -eclampsia or other
obstetric complications.
Clinical signs
Hemolytic anemia reticulocytosis and
schistocytes.
Thrombocytopenia.
Glomerulus's defect and common
Hypertension.
ore common renal failure.
proteinuria, proteinuria and casts
Pathogenesis
Hyperactivation of coagulation cascade by
variety of agents, resulting in consumptive
coagulpathy with entraps of platelet in
intravascular fibrin mesh causing acute or
chronic DC.
With in vivo thrombin generation leading to
decreased levels of factor v, v111, and
fibrinogen in addition to thrombocytopenia
The prognosis relatively good.
anagement
Renal dialysis.
Antihypersetive.
Transfusion.
Heparin induced thrombocytopenia
Represented as important causes of hospital
acquired morbidity of two separated
syndromes:-
1- ost common benign and mild
thrombocytopenia related to property of heparin
induced platelet aggregation.
2- Less common and severe thrmbocytopenia
appears as drug related immune
thrombocytopenia associated with serious
thrombotic complications.
Sequestration and Dilutional
Related Thrombocytopenia
Normally spleen sequesters one third of the total
platelet.
ild thrombocytopenia associated with enlarged
spleen syndrome such as splenomegaly of
portal hypertension.
Hypothermia for cardiovascular surgery result in
transient thrombocytopenia of platelet
sequestration in the spleen and liver.
Thrombocytopenia results from massive
transfusion of stored blood contains impaired
platelet viability.
Thrmbocytosis
Defined as abnormal high platelet count above
400000/mm
3
in whole blood.
1-Reactive thrombocytosis often secondary to
inflammation or trauma rarely exceeds
8000000/mm
3
.
2-arked persist thrombocytosis of
myloproliferative disorders of count exceed
1000000/mm
3
3-Essential Thrombocythemia in which counts
are between 1000000/mm
3
and 2000000/mm
3
Secondary Reactive
thrombocytosis
Of platelet counts between 440000 and 800000
with normal platelet function. And not associated
with thrombosis or bleeding, disappears with
management of underlying disorder.
Causes:
nflammation
Trauma.
Acute blood loss.
DA.
Heavy exercise.
Post- splenectomy.
Post- splenectomy Thrombocytosis
Counts reaches 1000000/mm
3
regardless of the
clinical reason for spleen removal, there is no
sequestration of platelet occurs.
DA reIated thrmbocytosis:
Result from mild DA with chronic blood loss,
iron deficiency inhibit thrombopoietin production.
Counts may be as high as 2000000/mm
3
, while
thrombocytopenia is more common in severe
DA.
nflammatory thrmbocytosis
Thrombocytosis is indicator for
inflammation results from infectious,
systemic or collagenic disease and usually
correlated with the activation of
inflammatory process
Exercise thrmbocytosis
Results from hemoconcentraion due to
transfer of plasma water to extarvascular
compartment causing reversible
thrombocytosis.
Essential Thrombocythemia
Essential or primary thrombocythemia results
from proliferation of bone marrow
megakaryocytes with platelet counts between
1000000/mm
3
and 2000000/mm
3
, and
occasional hemorrhage and occasional
thrombosis.
Prevalent in middle aged and older both males
and females affected equally
Lab findings
Bleeding time normal.
No clotting disorder.
Thrombocytosis.
Occasional qualitative abnormality with defected
platelet aggregation may be found.
Occasional a granular or hypogranular platelet
may be present.
Size heterogeneous may be observed.
Platelet clumped on blood smears is seen.
Bone marrow megakaryocyic hyperplasia.
Diagnosis
There is no specific clinical sign or
laboratory test establishes the diagnosis.
Other diseases cause reactive
thrombocytosis should be well considered
in diagnosis of ET
Clinical features
Bleeding fro mucus membrane of the
nose, mouth and ecchomoses aggravaed
by aspirin use.
"ualitative disorders
GeneraI feature:
State of prolonged bleeding time in a
patient's with normal platelet count
indicates an acquired or a congenital
platelet dysfunction result of four phases
platelet abnormalities involves adhesion,
aggregation, secretion and elaboration of
procoagulant activity.
Bernard- Soulier syndrome
Definition:-
Platelet quantitative disorder associated
with defective platelet adhesion and
aggregation result from inability to interact
with vWF at site of injury.
Causes:
-Decreased platelet membrane GP 1b, 1X
receptors.
Genetics
The disorder inherited as an autosomal
recessive trait , heterozygous individual is
usually asymptomatic.
General features
Platelet don't bind factor 1X and 'WF in normal
manner.
Failure of platelet to adequately bind vWF result
in inresponse to Ristocetin -induce platelet
aggregation.
the defect not corrected by addition of plasma
or cryoprecipitate such in von Willebrand's
disease.
Aggregation is normal with platelet agonists
such as ADP, collagen, thrombin and archidonic
acid.
von Willebrand's disease
Definition:
Heterogeneous familial bleeding syndrome
that result from a quantitative or qualitative
abnormality of vWF( with distinct minor
variants).
vWF is glycoprotein , synthesized by
endothelial cells and megakaryocytes.
Genetics
vWF gene is located on the short arm of
chromosome 12 and spanning 175 Kilo bases of
genomic DNA, codes for a polypeptide
containing signal peptide of 22aa, followed by a
171aa peptide identical antigen for vWF that
followed in turn by mature subunit of 2050aa of
sequence has been determined.
vWF structure
Pro-v W F monomers.
v W F dimers through interchain
disulphide bonds.
v w F dimer transfer to the Golgi
apparatus to for series of vWF multimers
of W in range of 800.000 to 12 million D.
'WF large multimer or small polymer
complex with '111:C and circulated in
plasma.
Nomenclature of vWF
'111:C/ ' W F complex found in plasma.
vWF:Ag antigenic determinant located on
the vWF used to measure plasma vWF by
immunoassay.
vWR:CO ristocetin cofactor activity of vWF
based on detection of plasma 'WF by
restiocetin induced platelet aggregation.
Clinical features
Spherical circulated platelet rather than
discoid shape found with count in range of
50.000 to 80.000/mm
3
and bleeding time
of 20 minutes.
There is no specific treatment but steroid
and platelet transfusion appeared to be
effective in a few cases.
Path physiology
mpaired binding of vWF to specific receptor on
the platelet membrane and endothelial surface
result from 'WF deficient or aberrant in patients
with this disorder.
'111 deficient due quantitative reduction or
aberration of its specific carrier protein.
Deficient of ristocetin induced platelet
aggregation.
Clinical symptoms
Overall mild hemorrhage diathesis.
ucocutaneous bleeding is the most common.
Chronic gastrointestinal bleeding is prominent in
10% may be associated with hereditary
telangiectasia.
post traumatic bleeding is common.
ild bleeding post dental extraction or
tonsillectomy or after major trauma.
Abnormal menstrual bleeding is very common.
Hematoma, posttraumatic and post operative
hemorrhage are characteristic
Classification of von Willebrand's
disease
Type1 autosomal dominant, vwF decreases and
plasma multimeric structure are normal.
Type 11A autosomal dominant with vWF decreased or
normal and large and intermediate forms of multimeric
absent.
Type 11B autosomal dominant with decreased or
normal vWF and large multimer absent.
Type 11C autosomal recessive with normal vWF large
multimer absent or doublet.
Type 111 autosomal recessive, homozygous or
double heterozygous resemble hemophilia A with vwf
marked decreased abnormal or absent large multimer.
Laboratory Diagnosis
BT prolonged.
A pTT and PT variable.
TT normal.
Platelet count normal.
'111 assay.
vWF assay.
vWF antigen assay.
Resticotein cofactor assay to measure ability of
vWF to agglutinate platelet in presence of Rio.
Treatment
Human single donor cryoprecipitate is
principle treatment .
Fresh frozen plasma.
'111/ v WF concentrates commercially
provided.
vWF multimers.
Anti-von Willebrand's Factor
antibodies
Polyclonal gG inhibitors produced in
about 10% of patient's with severe type
111 after transfusion of vWF-containing
plasma products in familial tendency of
patients.
Glanzmann's Thrombasthenia
Definition:
Bleeding disorder associated with abnormal
clot retraction.
Causes:
-Platelet membrane complex receptor
11b/111a deficiency or abnormality.
- receptor for fibrinogen,vWF and
fibrinectin.
Genetics and classification
Glanzmann's thrmbasthenia inherited as
autosomal recessive disorder with high
incidence in gypsies of France.
Classification:
-Type 1 have no clot retraction and alpha
granule fibrinogen.
-Type 11 have decreased clot retraction and
detectable alpha granule fibrinogen.
General features
Platelet adhesion normal but failure to form
hemostaic plugs.
Lack of clot retraction is characteristic finding
associated with prolonged bleeding.
Not response to ADP, collagen, thrombin and
epinephrine to form macroscopic platelet
aggregation.
prevent Ricto induced platelet and ' W F
interaction.
Clinical important
Occurs neonatal and infancy hood with
epistaxis and bleeding after circumcision.
Hemorrhagic manifestation include,
purura, menorrhagia, GT bleeding and
hematuria.
arked prolonged bleeding time.
Platelet count and morphology are normal.
Treatment
Transfusion of HLA compatible normal
platelets to correct bleeding time.
Acquired disorders in diabetes,
cholestrolemia and multiple my Loma
should be consider.
Auto antibodies to 11b/111a complex in
few patients frequently found.
Storage pool diseases
1-Dense granuIes deficiencies:
-decrease storage intracellular granules include ADP, ATP,
Ca, P and serotonin. With marked BT prolonged. And
inrespose to collagen secondary to ADP absent.
-decreased number of dense bodies.
-greater decrease ADP with increased ATP:ADP ratio
higher than in normal platelets is diagnostic.
-acquired forms found in leukemia, SLE and acute alcoholic
toxicity.
Acquired form result from autoantibodies.
Genetics
Autosomal dominant inherited forms are most common.
Hermansky-pudlak syndrome is autosomal recessive
result in pigmented macrophages of minor bleeding.
Wisskott -Aldrich syndrome is a sex linked trait with
features of sever eczema and T&B dysfunction.
TAR syndrome is autosomal recessive trait with
congenital with bones abnormality, cardiac disease and
thrombocytopenia.
Chediack-Higashi syndrome rare auosomal recessive
trait with large lysosomal leukocytes ad megk granules
thrombocytopenia and albinism featured.
Symptoms
Lifelong bleeding tendency
Prolonged bleeding time.
oderate thrombocytopenia.
dense bodies absent.
-AIpha granuIe deficiency ( gray pIateIet
syndrome):-nability to release PF4, '111
receptor, beta-thromboglobulin , acid hydrolases
and thrmbospondin.
-Rare disorder with feature of large gray platelets
appear on a Wright's stained blood film.
-Genetics:
-Probably Autosomal dominant inheritance of a
marked alpha granules deficiency , occurs in the
most of the younger patients.
Symptoms
Lifelong bleeding tendency
Prolonged bleeding time.
oderate thrombocytopenia.
Platelet gray appearances.
Normal dense bodies.
Platelet's enzymes disorders
1-Throxane pathway disorders.
-phosphlipases.
-cyclooxygenase
-thrmboxane synthase
-acquired suppression of platelet enzymes.
2- prostaglandin pathway inhibition.
The most common drugs are aspirin and its derivatives.
3-platelet phosphodiestraese inhibition.
Such as caffeine
4- hereditary aspirin-like defects with aberrant ADP
release.
Hereditary vascular disorders
1-Hereditary hemorrhagic telangectasia.
- is autosomal dominant characterized by
structural vascular defective.
- Fragile or dilated blood vessel.
- -Telngiectasias or red to purple lesion -3
diameter most frequently seen on the lips,
tongue, conjunctiva, nasal mucus face and
hands.
Nosebleeds major problem in early
childhood.
Bleeding tendency
Normal bleeding time
Tourniquet test normal or variable.
DA is common.
nfrequent platelet dysfunction, '111&vWF
deficiency.
Diagnosis
Based on characteristic skin or mucous
membrane lesions
Family history
Capillary resistance test.
Others acquired vascular disorder
Allergic pupura primary disease of children.
Amyloidosis and paraproteinemia vascular
disorder.
Drug-induced vascular purpuras.
'itamin C deficiency (scurvy)
Psychogenic purpura with nausea, bruising,
vomiting and fever in women with emotional
problems.
Purpuras of unknown origin.
Hemophilia A
The most common hereditary coagulation disorder
occurs in ethnic groups with equal frequencies.
ncidence 1male:10000
Genetics: Deficiency or aberration of the low molecular-
weight subunit of '111:C.
History:-"ueen 'ictoria of Great British, a carrier of the
hemophilia gene, she passed the hemophilia gene to two
of her five daughters, who transmitted it to the royalty
of Spain, Germany and Russia.
Genetics
Hemophilia A is inherited as X-linked recessive trait,
males are affected and females are obligatory carriers.
Homozygous inherited female is affected.
Sex- linked inheritance pattern of hemophilia A show that
all daughters of an affected male are obligatory carriers.
Sons of carriers have a 50% chance of being affected
with hemophilia A
Familial form patterns of inheritance and sporadic form
pattern result from spontaneous mutation.
New cases without family history either due to a higher
mutation rate or several generations of silent carriers
appear.
General features
'111 mean level of carrier females= 50U/dl
mean of normal 100U/dL ( NR 50-200Udl)
0% patients have '111:C and '111:CAg both
deficiency.
10% lack '111:C activity but have normal
'111:Ag.
The absence of '111:Ag in most severely
hemophilic patients allowed use of ' 111:Ag
immunoassay for prenatal detection of
hemophilia A.
Severity and clinical symptoms
1- severe hemophiIia A V111:C activity <1% (0-&dL
pIasma IeveI)
-spontaneous bleeding or life-threatening bleeds from
minor trauma.
-hemarthrosis ( bleeding into the joints).
-Permanent joint damage with disability for movement.
-synovial inflammation and thickening.
-delayed post surgical bleeding.
-Subcutaneous and intramuscular hematomas.
-Hematuria, bone lesions and soft tissue hematomas
- Moderate hemophiIia A:
-'111:C activity 1-5% ( 3-6UdL in plasma).
-serious post- traumatic bleeding.
-Hemarthrosis is less severe.
- MiId hemophiIia A:
- '111:C >5% of activity ( 7-30 U/ d L in
plasma).
- uncommon bleeding manifestations.
- nconspicuous Hemorrhage after post
minor injuries.
Lab. Findings
Bleeding time variable.
Clotting time variable
PT usually normal .
APTT usually prolonged.
Prolonged APTT corrected with normal plasma
and not corrected with '111 deficient plasma.
'111 assay is mandatory.
Platelet count normal or high.
Treatment
Cryoprecipitate contains 50-120 U of '111 in 10-40 m L
purified '111 up to 400 times higher than in plasma
level.
'111:C levels of 10-20% required for homeostasis after
minor trauma.
'111:C levels of 50-100% for hemostasis after major
injury.
The half-life of transfused '111:C is 8-12 hours hence 2-
3 times a day or in home therapy program adopted to
maintain adequate level.
Fibrinolysis inhibitor to protect labile plug degradation.
Complication
Dental care and serious tooth decay.
chronic liver dysfunction.
Transmission of hepatitis H'
'111 inhibitor developed in 10-15% of
patients as chronic complication.
Christmas disease( hemophilia B;
Factor1X deficiency
The rare hereditary coagulation disorder occurs
in equal frequencies in some ethnic group and
results from 1X deficiency .
ncidence 1:100000
Genetics: sex linked recessive trait and
expressed in mild , moderate or severe of
inheritance with less spontaneous mutation of
occurrence. And generally considered to be
milder than hemophilia A in features of bleeding
tendency.
Dysfunctional 'ariants of
Hemophilia B
There is three variants on basis of the antigenic reactivity
of 1X:C procagulant with specific antibody as following:
1- Cross - reactive material positive ( CR+) if antigen
reactive with specific antibody (10)%
2- (CR ) if the antigen undetectable with true deficiency
of factor 1X. (70-80)% of Hemophilia B
3- (CR
R
) if antigen reactivity reduced but detectable.
There no correlation exists between antigen presence and
clotting activity (1X:C)
CR+ dysfunctional variants sub-
class basis on PT
Hemophilia B
m
with prolonged PT of Ox
brain thromboplastin, constitute 15% of
hemophilia B.
Hemophilia B
Chapel Hill
and B
Alabama .
Hemophilia B
Lay den
in which factor 1X
tendency to increase with age.
Severity
Severe affected patients have factor 1X
activity levels <1%.
oderately affected patients possess 1%
to 5%.
ild affected patients are manifested as
6% to 4%.
Clinical Symptoms
Less sever of bleeding than in factor '111
deficiency.
'arying degree of severity.
'arying degree of complications.
Laboratory Findings
oderate to severe:-
-APTT, prolonged corrected by aged serum and
not by adsorbed plasma.
-PT and TT prolonged.
-ild Cases of normal APTT.
- Rabbit or lung thromboplastin PT normal.
- Ox thromboplastin PT prolonged used for
subgroup.
- 1X assay for diagnosis and during therapy
Therapy
Single donor plasma unit infusion of
concentrated products.
Commercial concentrates is effective but with
same risk discussed of factor '111.
Normal plasma exchange.
Recombinant products eliminates the infection
risk.
20-30% raise of factor 1X:C prevents minor
bleeding.
50% raise activity prevents CNS and GT
bleeding.
Complications
Serious thromboembolic complications in
patients with liver disease and in
premature infants.
Hepatitis and H'.
Anti-factor 1X antibodies develop in 5-7%
of patients with hemophilia B.
Hereditary Fibrinogen Disorders
Three types:-
1-Afbrinogenemia.
2-Hypofirinogenemia fibrinogen < 100mg/dl.
3-Dysfibrinognemia of abnormal functional
protein.
(Normal hemostatic level for fibrinogen is
about 100mg/dl and normal range 200-
400mg/dl)
Hereditary Afibrinogenemia
Rare autosomal recessive trait in which
plasma fibrinogen is totally absent. PT,
APTT, TT , and clotting time are
abnormal.
Bleeding time high in 50% of cases.
Hereditary Dysfibrinogenemia
Function defect of fibrinogen, there are
more than 100 types of dysfibrinogemia
were encountered.
nherited as an autosomal dominant or
codominant trait.
Dysfibrinogen variants
1- Thrombin cleavage defective
dysfibrinogenemia.
2-polymerization defective dysfirinogenemia.
3-Crosslincking of fibrin polymers by X111a
deficiency.
Clinical Features:-
- Bleeding tendency.
- Defective wound healing.
- Thrombosis results of polymerization defective.
Hereditary Deficiency of
prothrombin
Autosomal recessive trait of inheritance for both
hyporothrobinemia or dysprothrminemia.
True hyprothrombinemia (CR variant) is the
most common type.
CR + variants is characterized by normal level
of prothrombin antigen in association with clear
deficiencies ( Prothrombin Cardeza , and
Houston)
Hemorrhagic episodes in most patients are
primarily post-traumatic in origin.
Lab diagnosis
Prolonged PT.
Prolonged APTT.
Factor 11 assay requested for definitive
diagnosis.
Blood clotting time variable.
Ruled out acquired deficiency of prothrombin
before diagnosis of 11 hereditary deficiency.
Personnel and family history.
Ruled out presence of circulating anti-11
antibodies
Hereditary Factor ' deficiency
'ery rare with hemorrhagic disorder called Para
hemophilia, Owner's disease or labile factor
deficiency.
nherited as autosomal recessive trait, the
homozygous is symptomatic with post-traumatic
bleeding severe cases of <1% functional factor
' for both CR- an CR+ are encountered.
Congenital deficiency differentiated from
combined deficiency of factors ' and '111.
Specific anti-factor ' antibodies reported in
some occasions.
Lab findings
PT prolonged.
APTT prolonged.
Both are corrected by addition of normal plasma
adsorbed with barium salts.
Clotting time variable.
Bleeding time variable.
Specific factor ' assay for functional activity to
confirm diagnosis
The normal hemostatic level of factor ' is 15-25
U/dL.
Hereditary Factor '11 deficiency
Rare congenital disorder inherited as an
autosomal recessive homozygous have bleeding
symptoms heterozygous are asymptomatic.
Childhood bleeding tendency.
ild with '11 level <10%.
Severe of factor '11 less than 1% or 2% such
as other hemophilia A or B.
'11 deficiency commonly associated with other
'K dependent factors.
Few cases associated with inferior vena cava
thrombosis.
Lab diagnosis
APTT is normal.
PT is prolonged.
Bleeding time is normal.
'11 level 0-20U/dl in homozygous and
50% in heterozygous.
Hereditary X deficiency
ild of factor X >10%.
Severe of factor X less than 1%.
-Lab findings:-
-PT prolonged.
-APTT prolonged.
-Stypven time test abnormal in which diluted
Russell's viper venom 1:2000 with tris-buffer
saline the reagent activates factor X without
need for factors '11,'111,1X or X1 or contact
factors, prolonged only factors 1,11, ' and X
deficiencies.
Hereditary deficiency of factor X1
Known as Rosenthal disease or hemophilia C
with features of quantitative or qualitative
(CR+) abnormality.
Occurs 1:100000 in population high incidence in
Jewish populations
Autosomal recessive trait both males and
females are equally affected. Homozygous
shows level of factor X1 of <1 -5% ,
heterozygous have normal factor X1 activity.
Lab findings
Homozygous patients have pattern of
Hemophilia A and B bleeding .
-APTT prolonged.
-PT normal.
-PTT corrected with addition of normal aged serum
or plasma adsorbed with barium salts.
-bleeding time normal.
-factor X1 assay for final diagnosis.
-acquired factor X1 antibodies have been reported.
nherited ultiple Coagulation
factor deficiencies
The most commonly reported is combined
factor ' and '111 deficiency appears to
be caused by deficiency of factor C
inhibitor ( protein C can inactivate factors
' and '111).
Other familial multiple factor deficiency
have been identified such as '11
deficiency and von Willebrand's syndrome.
Acquired Factor deficiencies
ild manifest as enhanced operative bleeding not
congenital onset.
anifest as acute generalized bleeding associated with
abnormalities of more than one screening test.
There are 4 categories:-
1-Destructive or consumption disorders such as DC.
2-production defects of synthesis such as liver disease,
renal disease and 'K deficiency.
3- circulating inhibitors.
4-assive transfusions.
Disseminated ntravascular
Coagulation
Syndrome characterized by uncontrolled formation and
deposition of fibrin thrombi and consumption of
coagulation factors and platelets.
DC contributions:
-bleeding.
-factors and platelet deficiency.
-vascular occlusion.
-Hypotension and shock.
Hence DC refereed as consumptional coagulopathy and
defibrination syndrome.
General features
DC is not a disease but it intermediately
mechanism of disease associated with
well defined clinical disorders.
DC usually begins with a bleeding
tendency, consumption and microthrobus
in later.
Early recognition of DC is laboratory
dependent on laboratory findings.
Etiology of DC
njury involving the blood vessels, platelets coagulation factors or
fibrinolysis agents.
ntravascular hemolysis,septicemia,and disseminated malignancy.
Leukemia (3) and burns.
Prosthetic devices such as intra-aortic ballon.
Amniotic embolism is common life threatening emergencies.
Placenta pathological abnormalities.
Severe precclampsia and ecclampsia.
Disseminated solid malignancies.
'enom from snake bites.
Bacterial endotoxcin initiate coagulation cascade
Pathophysiology
Summary:-
- Pathological activation of coagulation system:
-Fibrinogen formation.
-Factors and platelets consumption with
hemorrhagic disorders.
-Plasminogen activated to plasmin lead to factors
', '111, 1X and X1 degradation and
complement activation.
-activation of Kinin system initiated by the action of
x11a.
Clinical symptoms
Usually dominated by underlying disease.
The major clinical problem is hemorrhage
rather than microthrombosis, hypotension
and shock.
Bleeding from at least three unrelated
sites
Laboratory Diagnosis
-Lower fibrinogen level in most cases.
-Common thrombocytopenia.
-Abnormal platelet function test.
-Reduced activity of factors 11, ', '111 and X but
variable levels obtained in some occasions.
-Decreased plasminogen, protein C, and protein S.
-PT usually prolonged normal or shortened in some cases.
-APTT usually prolonged, normal or shortened.
-Thrombin time is prolonged.
-FDPs test is positive.
Peripheral Blood Findings
Schistocymes common in many patients with
DC.
Leukocytosis with left shift or leukopenia
secondary to sepsis DC.
Young bizarre platelets usually seen.
positive D- dimer and FDPs test.
Elevated platelet markers PF4 and beta-
thromboglobulin.
Decreases anti-thrombin 111.
Elevated fibrinopeptides alpha and beta.
Treatment
Stop of intravascular clotting process, by
administered of intravenous heparin, or
subcutaneous calcium heparin in
continued bleeding.
Whole blood or blood products.
Cryoprecipitate or platelet concentrates.
Liver Disease
Liver disease produce a variety of
haemostatic defects:-
1-Deficicncy of clotting factors and natural
inhibitors.
2-Abnoral production of clotting factors and
natural inhibitors produce low grade DC.
3-mpaired clearance of activated circulating
clotting factors produce low grade DC.
4-accumulation of plasminogen activators
Patophysilogy of Liver Disease
Liver normally synthesizes all coagulation
(1.11.', '11, 1X. X ) factors except factor '111
and 111.
'itamin K dependent factors ( 11, 1X, '11 and
X) are most affected.
Factor ' affected by severe liver disease.
Plasminogen, Anti- 111 are also more affected.
n obstructive jaundice only 'itamin K dependent
protein are affected because of malabsorption
results from reduce of absent of bile salt. n the
gastric lumens
'111:C and '111:C:Ag levels are increased in
liver increased in acute hepatocelluar liver
lower level of fibrinogen found in chronic liver
disease. n contrast high level found in liver
cirrhosis and in chronic hepatitis.
Factors structural and functional abnormality are
common feature of of liver disease .
Thrombocytopentia common cause of bleeding
in liver disease due to sequestration of platelet
in the spleen
Abnormal platelet function has been
described in liver disease.
Overt DC has been documented in
pregnant women with fatty liver.
Clinical symptoms
Pupura and ecchymosis
Recurrent mucosal bleeding.
Post-traumatic and post-surgical bleeding.
Bleeding follows biopsy procedures and
tooth extraction occasionally.
Gastrointestinal hemorrhage.
Laboratory Diagnosis
Lab tests are mportant for diagnosis and prognosis
PT is sensitive for liver function.
Carboxy-11 prothrombin serve as early marker for liver
disease.
Deficiency of fibrinogen indicates severe liver disease or
development of DC or fibrinolysis.
Thrombin clotting time sensitive for several abnormality
associated with liver disease.
Factor ' assay its independent of 'K hence reduced its
level reflect pure hepatocellular abnormality
Reduced levels of AT 111 is characteristic
of hepatocelular disease.
Test for fibrinolytic activity or Plasminogen
activator
Hemostasis of renal disease
Tendency for both thrmbosis and bleeding in acute and
chronic renal failure.
There is qualitative of platelet abnormality.
'111, fibrinogen and Plasminogen inhibitors are elevate.
Elevated of X111 and fibrinolytic activity with presence of
FDPs.
DC, HUS, TTP result in firbrin deposition in the renal
microvascular and play a role in renal vascular and
glomerular disease.
Destruction of transplanted kidney within minutes to
hours associated with extensive deposition of fbirin in the
glomerular
Glomerulonephritis and of systemic lupus
erythromatosus with FDPS increased in blood
and urine up to 100 g / mL reflect disseminated
as well as localized consumption.
Deposition of interaglomerular fibrin correlated
with the degree of proteinuria.
Localized damage associated with presence of
FDPs in the urine and absent in the blood.
Nephritic Syndrome
There is loss of low- molecular weight proteins
including some clotting factors AT 111 and
protein C demonstrated in urine of nephritic
patients.
Plasma deficient in only '11, 1X, X111 and AT
111, however most studies show normal levels
of mention factors.
Significant factors deficiency and bleeding
tendencies are uncommon in NS.
Thrombotic complications occur in some 25% of
patients results of consumption decreased AT
111.
Renal Failure
Thrombocytopenia in 50% of patients.
arked thrombin time with slight PT and
APTT in 50% of patients
Platelet , fibrin monomer polymerization
associated with uremia syndrome.
'itamin K deficiency
Activity of vitamin K-dependent factors
decreased in following states:-
1- during neonatal period, oral
anticoagulants.
2-Severe liver failure.
3-mpaired vitamin K dietary intake or
malabsorption.
4-obstructve jaundice.
5-Prolonged antibiotic intake.
Diagnosis
Decreased activity of factors 11, '11, 1X
and X corrected by addition of normal
plasma.
'11 affected first because of shortest half-
life span.
Prolonged PT and normal APTT in early
stages.
Thrombin Time is normal.
Hemorrhagic disease of Newborn
Causes:-
1-Results from liver immaturity in some
occasions. ( defect of synthetic
mechanism)
2-Lower levels of 'K of mother milk. ( breast
milk)
3-Lack of newborn's gut bacteria.
Symptoms
Persistence severe bleeding appears after
on the second or third days after birth .
Bruising.
Bleeding after circumcisions.
GT bleeding.
Lab findings
Full term newborn usually have about
50% lower levels than in adult for factors
11, '11, 1X and X activity with slight PT
and APTT prolonged.
n HDN there is <25% decreased in 'K
dependent factors with quite prolongation
of PT and APTT.
Fibrinogen , thrombin time and platelet
count are normal.
Treatment
Fresh frozen plasma.
Administration of 'K at birth to all
newborns or at least premature and low-
birth infants or infants at high risk.
alabsorption states
Cause pure 'K deficiency occurs in
infants and in adults of poor diet intake.
Diarrhea or steatorrhea.
ucus membrane bleeding.
Lack of bile salts in obstructive jaundice
prevent absorption of fat soluble 'K.
Coagulation tests are mandatory.
'itamin K antagonist
The most popular ' K antagonist is warfarin.
Warfarin interferes with carboxylation 'K
dependent factors in liver.
Decrease in '11 level is noted first.
Followed by decrease 1X an X levels.
And finally decease in factor 11 level
Over dosage of oral anticoagulant results in
bleeding tendency.
Broad-spectrum antibiotics are capable of
intestinal tract sterilization can lead to 'K
deficiency.
Treatment
ntramuscular administered 'K corrected
PT within 24 hours.
ntravenous administration corrected PT
within few hours.
Life-threatening bleeding required FFP or
prothrombin - complex infusion
Acquired anticoagulants
Presence of excessive circulating
inhibitors or antibodies
Associated with certain disease entities,
ingestion of drugs or other clinical situation
Or inhibit of the hemostatic mechanism by
heparin or FDPs.
Types of inhibitors
rreversible inhibitor:- inactivate individual
coagulation factor, its time dependent.
Reversible inhibitor:- reversible or partial
reversible inhibitor with immediate action
often seen in patients with malignant
Third unique inhibitor have been described
with Down syndrome and CL.
Fourth heparin like substance release in
patient with multiple myeloma.
Common Factor inhibitors
Factor 1 inhibitor.
Factor 11 inhibitor.'
Factor ' inhibitor.
Factor '11 inhibitor.
Factor '111:C inhibitor.
'on Willebrand factor inhibitor.
Factor 1X inhibitotr.
Factor X inhibitor.
Factor X1 inhibitor
Factor X11 inhibitor
Factor X111 inhiitor.
Factor '111 inhibitors in
hemophilic patients
High responders show rise of antibodies
after infusion of trace amounts of '111.
Low responder show little or no rise in titer
after factor '111 infusions
Non specific nhibitors
Not specific for any single factor.
nteracted and binds phospholipids
surface
Not associated with bleeding.
Not-temperature dependent
nhibit APTT reactions PT in less.
Lupus nhibitors ( Lupus anti-
Coagulants)
ost common of acquired inhibitor encountered.
nterferes with phospholipids dependent tests.
direct against phospholipids that provide
reactive site for FX and T' interaction.
Not inhibit specific factor.
uch occur in patient with systemic lupus
erythromatasous.
Found in various malignant and autoimmune
disease or after viral infection
Lupus inhibitors are polycolonal gG or G in
nature
Clinical manifestation
Not associated with significant bleeding.
Associated with a tendency for thrombosis
recurrent abortions or intrauterine death.
Placental insufficiency resulting from
thrombosis and causes of abortions.
Thrombosis may involve arteries or veins
Lab diagnosis
Prolonged phospholipids dependent tests.
PT slightly prolonged.
APTT prolonged uncorrected by addition of normal
plasma.
TT normal or slightly prolonged.
Prolonged of PT using diluted thrmboplastin than
undiluted one. ( False positive)
Stypven time ( false positive)
Platelet neutralization test ( Highly specific)
Prolonged Kaolin clotting time and corrected by addition
of phospholipids but not by normal plasma ( specific and
sensitive)
Anti- cardiolipdin antibody test predictive
test for at risk of thrombotic tendency.
Treatment
Not required for great majority of patients.
Steroids and aspirin during pregnancy.
'111 for prolonged APTT.
Plasaphorsis.
Factor '111 Antibodies in non
hemophilic patients
F v111 antibodies may develop in the
postpartum patients.
Spontaneousious '111 inhibitors found
SLE, rheumatic arthritis and in
dermatologic disease or drug reactions
such as penicillin allergy .
Also with disorder such as multiple
myloma, Waldenstrom's macroglbuliemia.
Clinical manifestations
State of acquired hemophilia in non
hemophilic patients.
Sever bleeding in hemophilic patients and
less severe bleeding in nonhemophilic
patients.
'ariable clinical course extended to a fatal
hemorrhage occasionally.
Antibodies may disappear within months
or years after their appearance.
Lab diagnosis
Features of hemophilia A of lab findings.
Prolonged APTT
Normal PT
Time dependent APTT
'111 antibodies nature gG, monoclonal,
rarely g or gA
Treatment
Bovine '111
Spontaneous remission have been
reported most commonly in postpartum
women
Fibrinolysis
:
Fibrinolys
Terms refers to fibrinogenolysis or inappropriate
fibrinolysis results from excess amounts of
fibrinogen activators.
Types:
Primary fibrinolysis in absence of underlying
disease.
Secondary fibrinolysis followed fibrin deposition in
DC,with excess FDPs.
Rare cases of malignancies accompanied by
fibrinolysis without evidence of DC or results
from thrombotic therapy.
Causes of fibrinlysis activation
Occurs in patient with liver disease.
- Decreased alpha 2 anti-plasmin.
-decreased alpha 2 macroglobulin.
-Biodegradation of factors 1,11 and ' by plasmin.
-localized hyperfibrinolysis in which increased
fibrinolytic activity in organs the uterus and renal
plevis.
-increase level of Plasminogen activators such as
urokinase and streptokinase
Lab diagnosis
Short euglobulin lysis test.
Decreased plasma levels of plasminogen and
plasmin.
Decreased levels of factors ', '111 and X111
ncreased FDPs with severe platelet dysfunction.
Coagulation tests similar of DC with some
differences.
PT,APTT and TT are generally prolonged.
Platelet count usually normal.
Treatment: Basis on inhibition of plasiogen
activators
Hypercoagulability
State of hypercoagulability results from natural inhibitors
deficiency and fibrinlytic activity. The concepts of
hypercoaguability is vascular injury and impairment of
blood flow leading to thrombosis.
Causes
1- Primary disorders with quantitative and qualitative of
specific haemostatic agent such as AT-111, protein C
and S deficiencies uncommon.
2- Secondary disorders of unknown causes. s the most
common in which inhibition of blood flow, malignancy,
pregnancy and oral contraceptives