Normal hemostasis
• Hemostasis: It is the process by which blood is
kept in a fluid state in the blood vessels and at
the same time prevent excessive loss in case of
injury to the blood vessels.
• Components of circulation which are
responsible for maintaining these balance are:
1. Vessel wall
2. Platelets
3. Coagulation factors
4. Anticlotting mechanism
Vessel wall
• Endothelial cells and of the vessel wall have
antiplatelet ,anticoagulant, fibrinolytic
properties as well as they are capable of
exerting procoagulant ( after injury or
activation) function.
platelet
• When blood vessels are injured , platelet
adhere to the endothelium and form platelet
plug and arrest bleeding.
• Platelet also participate in the coagulation
pathway. They help in conversion of
prothrombin to thrombin. It is also called
platelet factor 3.
Anticoagulants
• Body has natural anticoagulant to restrict the
coagulation to the local site of vascular injury
to prevent clotting of entire vascular tree.
• Clotting is controlled by natural anticoagulant
A. antithrombin ( antithrombun – III). B.
protein C and S C. plasminogen-plasmin
system
Coagulation system ( cascade)
• Coagulation system comprises of several
proteins , which are normally present in
inactive form. When there is injury to the
blood vessels ,the coagulation system
becomes activated and results in formation of
a fibrin clot.
Mechanism of blood coagulation
• 1. In response to injury to blood vessel a
complex of chemical reactions occurs in
the blood to form prothrombin activator.
• 2. the prothrombin activator catalize the
conversion of prothrombin into thrombin.
• 3. the thrombin act as an enzyme to
convert fibrinogen into fibrin which enmesh
the platelet ,blood cells and plasma to
form fibrin clot.
• There are two path ways for formation of
prothrombin activator
• 1. intrinsic pathway
• 2. extrinsic pathway
Intrinsic pathway
• Factor XII is activated to XIIa when it come in
contact with the sub endothelial element of
injured blood vessels.
• XIIa converts factor IX to IXa
• Factor IXa in presence of calcium, platelet, and
factor VIII converts factor X to Xa
• Xa in presence of factor V, platelet, and
calcium ion converts prothrombin to thrombin
• Thrombin than converts fibrinogen to fibrin
monomer
• The fibrin monomers form a cross linking
meshwork under the influence of XIII .
• In this meshwork blood cells get entangled to
form a clot.
eventual growth of fibrous tissue into blood
clot to close the vessel permanently.
Extrinsic pathway
• In Extrinsic pathway tissue factor ( cellular
lipoprotein ) released from damaged
endothelium activate VII to VIIa.
• VIIa activate factor X to Xa.
• From here it follow common pathway.
Coagulation Disorder
Definition: Bleeding due to defect in blood coagulation.
Classification:
1) Congenital coagulation disorder:
These disorders are almost invariably due to deficient
activity of a single coagulation factor which results from a
genetically determined abnormality in synthesis.
a) Haemophilia ( factor VIII def)
b) Von-Willibrand disease ( Von-Willibrand factor
deficiency)
c) Other coagulation factor deficiency
2) Acquired coagulation disorder:
Bleeding due to acquired defect in coagulation. e.g.
a) Vit K deficiency
b) Liver disease
c) Anti-coagulant drugs (heparin, warfarin)
d) Disseminated intravascular coagulation
e) Massive transfusion of stored blood
Investigation:
1) Bleeding time or BT: The time that elapse to cease bleeding is
called bleeding time.
Normal: 2-7 min
There are two methods
1. Duke’s method
2. Ivy’s method:
i. wrap the cuff of sphygmomanometer on the
arm
ii. Inflate the cuff to 40 mmHg , and maintain it
throughout the test
iii. Make a puncture with a lancet on the
frontal surface of fore arm
iv. Let the blood flow freely and start the stop
watch
v. Keep on touching the drop of blood with
blotting paper at ½ minute intervals and wipe
the blood . Keep on this process until the
bleeding stops and no blood spot on the paper.
vi. Stop the stop watch and note the time.
vii. This is bleeding time.
Bleeding time depend on number and function
of platelet
• Prolong bleeding time
1. thrombocytopenia
2. disorder of platelet function
[Link]-Willebrand disease
4. vascular abnormalities- Ehler – Danlos’s
syndrome
5. aspirin ingestion
[Link] deficiency of factor V or XI.
2) Taurniquet test (capillary resistant test of
Hess):
The taurniquet test is performed by placing a
sphigmomanometer cuff around the upper arm
& raising the pressure to 80 mm of Hg for 5-7
min. After that cuff is to be deflated & the
number of petechiae is counted in an area
within a 3 cm diameter 1cm below the cubital
fossae. Upto 20 is normal. More than 20 is
abnormal.
• This test measure the capillary resistance
(vascular fragility ) as well as platelet number
and platelet abnormality.
• Positive test due to
Thrombocytopenia
Platelet function defect
Decrease capillary resistance
3) Whole blood Clotting time or CT:
When blood obtained by venepuncture is put in
a test tube ,clotting mechanism are activated.
Whole blood clotting time is the time interval
between taking of blood & appearance of fibrin
thread.
Normal: 5-11 min
Cause – Prolongation occur in severe
coagulation factor defficiency. Haemophilia,
Christmas disease. Anticoagulant therapy.
• Keep three test tube in water bath to warm.
• Using disposable plastic syringe collect 5 ml of
venous blood. As blood enters the syringe start the
stop watch
• Pout 1 to 1.5 ml of blood in each test tube .
• initially tilt the test tubes after 4 minute and the
after every 30 second to see whether the blood
has clotted or not
• Take average of three reading.
• This is clotting time.
4) Prothrombin time ( PT):
Proextrinsic thrombin time measure the activity of clotting factor
of extrinsic and common pathway i.e factor I. II, V, VII, and X.
When thromboplastin and calcium is added to citrated
blood ,this
pathway is activated and fibrin clot is formed.
This test ( PT)measures the clotting time of plasma in the
presence of tissue factor ( thromboplastin ) after Ca ++ are added.
PT : 10 to 16 sec
Result: a) Abnormal/prolonged: If it is 2 sec more than control
(normal person) result.
b) The upper limit of the ratio of patient & control
clotting time is 1.2.
Prolong PT
Cause –
• administration of oral anticoagulant.
• Liver disease, obstructive jaundice
• Vit K deficiency
• DIC
5) Activated partial thromboplastin time (APTT):
This test determines the time which plasma (previously
incubated with kaolin or other surface active agents) takes
to clot in the presence of an optimum amount of platelet ,
phospholipid & Ca++.
APTT: 30 to 40 sec
Result: Abnormal result is indicated when the patient’s
clotting time is 10 or more sec longer than the control time.
• Platelet poor plasma is incubated with Kaolin
to activate contact phase reation.
Phospholipid is added to provide platelet
factor 3 activity and then the mixture clotted
by addition of calcium chloride . Time taken
for fibrin clot to appear is notted.
Cause of prolong APTT
• Deficiency of factors XII, XI, IX, VIII, X, V, II, I
• DIC
• Liver disease
• Massive blood transfusion
• Heparin administration
6) Thrombin clotting time:
Thrombin directly acts on fibrinogen and converts it to a
[Link] time plasma taken to form clot after addition of a
solution of thrombin to plasma is called thrombin time
Normal: 15 sec
Abnormal: >18 sec
Cause – heparin therapy, raised FDP, fibrinogen deficiency,
dysfibrinogenemia.
7) Clot solubility time
8) Measurement Fibrin degradation product (FDP)
9) Individual Factor assay :Firinogen assay, factor VIII assay,
factor XIII assay ect.
Coagulation time normal Bleeding time
abnormal - vascular defect, platelet number,
platelet defect.