SAMPLEX – MIDTERMS [Lesson 1-7]

1. Clinical description of families with hemophilia was first d. Chromatin

published by year?
a. 1802 10. Glycocalyx is primarily composed of glycoproteins
b. 1905 including all of the following factors except?
c. 1803 a. Factor V
d. 1913 b. Factor VIII
c. Factor I
2. Gave the description of the two male siblings who died d. Factor III
because of excessive bleeding after circumcision.
a. Moises Maimonides 11. All of the following are true regarding prostacyclin
b. Schonlein except?
c. Paul Morawitz a. Stimulates vasoconstriction
d. Lee & White b. Inhibits platelet activation
c. Anticoagulant
3. Process of platelet release into the bone marrow sinus d. Blood vessel product
a. Endomitosis
b. Megakaryopoiesis 12. All of the following are true regarding endothelial cells?
c. Mitosis a. Plays a role in coagulation and inflammation
d. Platelet Shedding b. Contains connective tissues such as collagen
and elastin.
4. Platelet factor that accelerates prothrombin conversion c. Associated with proteoglycan heparin sulfate
to thrombin? d. AOTA
a. PF 1
b. PF 2 13. All of the following are regulator proteins except
c. PF 3 a. Anti-thrombin III
d. PF 4 b. A-2 antiplamin
c. A-2 macroglobulin
5. The site for platelet cyclooxygenase and of prostaglandin d. TPA
synthesis can be found in?
a. Membranous system 14. Which of the following statement is incorrect?
b. Sol gel zone a. Endothelium procoagulant property
c. Peripheral zone involves secretion of nitric oxide
d. Organelle zone b. Damage endothelium exposes tissue factor on
cell membrane
6. All of the following are alpha granules except? c. vWF is secreted by endothelium to
a. Fibrinogen subendothelium
b. Serotonin d. Intact endothelium maintains thrombomodulin
c. Factor V that is associated with protein C activation
d. vWF
15. All of the following conditions can be associated with
7. All of the following are true regarding megakaryopoiesis hypocoagulation except?
except? a. Hemophilia
a. The first stage can be seen under light b. Hemorrhage
microscope c. Malignancies
b. Takes place in the bone marrow d. vWD
c. Needed growth factors for differentiation and
maturation 16. Condition of uncontrolled thrombosis due to uncontrolled
d. NOTA formation of thrombi in the vascular system occluding
vessels and depriving organs of blood.
8. All of the following are true regarding platelet except? a. Bleeding
a. Anucleated b. Hypocoagulation
b. MPV 80-100 FL c. a and b
c. Very granular d. Neither of the following
d. Lavender and granular under Wright-stained
wedge preparation 17. The platelet rolling and clinging to nonplatelet surface
is?
9. The best point of difference to distinguish MK I to MKIII? a. Reversible
a. Granules b. Irreversible
b. Mitosis c. Either of the following
c. DMS d. Neither of the following

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28. In direct method of platelet counting, platelets are

18. Platelet secretion is important because? counted in a hemocytometer as in 5 squares of the
a. It sustains further coagulation central square and four corner large squares.
b. It activates Intrinsic pathway a. The statement is correct
c. It activates fibrinolysis b. The statement is wrong
d. Neither of the following is correct c. Either of the following is correct
d. Neither of the following is correct
19. All of the following sustains vasoconstriction except?
a. Epinephrine 29. In platelet adhesiveness test the adhesiveness may be
b. Serotonin measured in vitro by their ability to adhere on glass
c. a and b surfaces. One of the methods that can used in this test is
d. Neither of the following Salzman method.
a. First statement is correct, second statement is
20. Fibrinolysis occurs following the release of tissue? wrong.
a. t-PA b. First statement is wrong, second statement is
b. TAFI correct
c. PAI-1 c. Neither of the statement is wrong
d. PAI-2 d. Either of the statement is correct

21. Hemostasis is a complex process that? 30. The negative pressure method, wherein trauma is
a. Produces clot to stop the bleeding created by means of suction cups applied to the skin, is
b. Keeps the clot confined one of the methods that can be used under?
c. Dissolves the clot as the wound heals a. Capillary fragility test
d. All of the following b. Platelet Factor 3 availability Test
c. Platelet aggregation test
22. Which of the following is incorrectly match? d. Clot retraction test
a. Canalicular system – Pathway for granules
b. Sol-gel zone – Microtubles and microfilaments 31. In coagulation cascade enzyme precursors are called?
c. Active process – ADPase and nitric oxide a. Serine protease
d. Passive process – Tissue plasminogen b. Transglutaminase
activator c. Zymogen
d. Transaminase
23. Which of the following is incorrectly match?
a. Vasoconstriction – Vessel of smooth muscles 32. Principal site of coagulation factor synthesis?
b. Platelet adhesion – Exposed subendothelium a. Liver
connective tissue b. Kidney
c. Platelet aggregation – Platelet to platelet c. Spleen
d. Fibrin plug formation – Stabilization of d. Bone marrow
factor XIII
33. All of the following are other names of High molecular
24. Platelet stimulating agents for platelet aggregation weight kininogen except?
include/s? a. Fletcher factor
a. Collagen b. William factor
b. ADP c. Flaujeac factor
c. Epinephrine d. Fitzgerald factor
d. All of the following
34. Christmas factor is preferably called?
25. Test that reflects quality of platelets, number of a. Plasma thromboplastin component
fibrinogen, fibrinolytic activity and packed red blood b. Plasma thromboplastin antecedent
cells? c. Antihemophilic factor C
a. Clot retraction d. Platelet cofactor 2
b. Platelet Adhesion
c. a and b 35. Molecule that activates extrinsic pathway?
d. Neither of the following a. Tissue Thromboplastin
b. Factor IV
26. Methods of bleeding time include all of the following c. PK
except? d. Tissue thrombomodulin
a. Coply Lalitch Method
b. Adelson-Crosby method 36. All of the following are true regarding fibrinogen group
c. Duke’s method except?
d. Fonio’s method a. Composed of fibrinogen, labile factor.
antihemophilic factor, and stabilizing factor
27. Prolonged bleeding time may be seen in? b. Calcium dependent
a. Scurvy c. Vitamin K independent
b. Severe anemia d. Seen in serum
c. a and b
d. Either of the following 37. A medical technologist extracted blood in ICU around 5
in the morning using red top, and run the specimen

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around 6 am, what are the expected coagulation factor c. aPTT

to be consumed? d. Mixing study
a. Fibrinogen group
b. Prothrombin group except prothrombin 45. Mixing studies are used to follow up to abnormal PT or
c. Contact group APTT, the test is repeated on 1:1 mixture of patients’
d. a and b plasma & normal plasma. If patient has factor deficiency,
time will be corrected because normal plasma supplies
38. A specimen for coagulation collected in an extreme cold missing factor.
temperature are expected to? a. First statement is correct, second statement is
a. Activate labile factor and antihemophilic factor wrong
b. Activate proconvertin and plasma b. First statement is wrong, second statement is
thromboplastin antecedent correct
c. Activate proconvertin and plasma c. Either of the statement is wrong
thromboplastin component d. Neither of the statement is wrong
d. Consume fibrinogen group
46. After mixing study the patient’s specimen results are still
39. Specimen for coagulation test that is not process prolonged for all the substitute, Specific factor inhibitor is
immediately may lead to depletion of factors? considered, if Bethesda assay is used which of the
a. Factor VII and XI following might be detected?
b. Factor V and VIII a. Lupus anticoagulant titer
c. Factor I, V, VIII and XIII b. Factor VIII inhibitor titer
d. Factor II, VII, IX, X c. Factor V deficiency
d. Protein S deficiency
40. Coagulation laboratory tests are drawn on a 47-year-old
woman with the recent diagnosis of an autoimmune 47. Final stage in coagulation?
disease. The physician ordered a 1:1 mixing study after a. Fibrinolysis
the original results revealed a prolonged activated partial b. Secondary hemostasis
thromboplastin time (aPTT). Patient aPTT: 51 s c. D dimer formation
(reference range 38 - 42 s), Immediate 1:1 aPTT mixing d. Primary hemostasis
study: 50 s (after mixing study) Which of the following do
these laboratory results suggest? 48. Zymogen form of plasminogen?
a. Vitamin K deficiency a. Plasmin
b. Presence of inhibitor b. t-PA
c. Factor VII deficiency c. Fibrin
d. Factor VIII deficiency d. Neither of the following

41. A newly registered medical technologist performed 49. Endogenous source of plasminogen activator?
mixing study on a patient that is experiencing bleeding a. Streptokinase
for a week, Laboratory result shows: Patient aPTT: 55 s b. Tissue plasminogen activator
(reference range 38 - 42 s), PT: 12 s (reference range c. Transamidase
13-15 s), Substitution tests results shows: Patient’s d. Tissue plasminogen activator inhibitor
plasma + Adsorbed plasma: Corrected, Patient’s plasma
+ Fresh Serum: Corrected. Which of the following do 50. Exogenous source of plasminogen activator?
these laboratory results suggest? a. Streptokinase
a. Factor XII deficiency b. Tissue plasminogen activator
b. Factor XI deficiency c. Transamidase
c. Factor II deficiency d. Tissue plasminogen activator inhibitor
d. Factor VIII deficiency
51. Primary inhibitor of fibrinolytic system?
42. Prolonged aPTT and PT test may be due to deficiency in a. Protein C
coagulation factor? b. Protein S
a. Contact factor c. a2-antiplasmin
b. Fibrinogen d. a2-macroglobulin
c. Proconvertin
d. Plasma thromboplastic antecedent 52. All of the following are true regarding plasminogen
except?
43. A patient was admitted due to bleeding tendency, a. a glycoprotein
medical history shows recent cardiac bypass surgery, b. synthesized in the kidney
which test can be used to detect the presence of c. increase concentration associated in
heparin? inflammation
a. TT d. AOTA
b. Reptilase time
c. aPTT 53. Thrombin-Activatable Fibrinolysis Inhibitor is activated by
d. All of the following a serine protease; its activation helps in down regulating
fibrinolysis.
44. Patient undergoing anticoagulant therapy are best a. First statement is correct, second statement is
monitored using? wrong
a. INR b. First statement is wrong, second statement is
b. PT correct

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c. Either of the statement is wrong a. First statement is correct, second statement

d. Neither of the statement is wrong is wrong
b. First statement is wrong, second statement is
54. Which complex is not correctly matched? correct
a. Protein C: Protein S c. Either of the statement is wrong
b. VIII:vWF d. Neither of the statement is correct
c. Xa:Va
d. Neither of the following 63. Most common platelet aggregation agonists
a. Ristocetin, ADP, Collagen, Epinephrine
55. Plasminogen activator inhibitor is the major inhibitor of b. Ristocetin, ATP, Calcium, Epinephrine
exogenous t-PA and u-PA. Secreted constitutively by c. Ristocetin, ADP, Collagen, Thrombin
vascular endothelial cells d. NOTA
a. First statement is correct, second statement
is wrong 64. Storage pool disease characterized by large platelet and
b. First statement is wrong, second statement is absence of alpha granules
correct a. Gray platelet syndrome
c. Either of the statement is wrong b. Hermansky pudlack syndrome
d. Neither of the statement is wrong c. Wiskott-Aldrich syndrome
d. Chediak higashi syndrome
56. Plasmin also plays a role in complement system, it
cleaves C3 to form fragments C3a and C3b. 65. A patient with X-linked recessive disorder and shows
a. First statement is correct, second statement is triad of severe eczema, recurrent infections and
wrong bleeding. Are suggestion of
b. First statement is wrong, second statement is a. Gray platelet syndrome
correct b. Hermansky pudlack syndrome
c. Either of the statement is wrong c. Wiskott-Aldrich syndrome
d. Neither of the statement is wrong d. Chediak higashi syndrome

57. Plasminogen is normally found in the circulation; in right 66. All of the following laboratory test may help in
stimulus it is activated to a serine protease plasmin to differentiating Glanzmann thrombasthenia from Bernard
degrade clot which is the process of fibrinolysis Soulier Syndrome except;
a. First statement is correct, second statement is a. Peripheral blood smear
wrong b. Clot retraction
b. First statement is wrong, second statement is c. Bleeding time
correct d. Platelet aggregation
c. Either of the statement is wrong
d. Neither of the statement is wrong 67. Which of the following drug can induce qualitative
platelet disorder?
58. Thrombocytopenia may be associated with: a. Aspirin
a. Postsplenectomy b. Ibuprofen
b. Hypersplenism c. a and b
c. Increased proliferation of pluripotential stem d. Neither of the following
cells
d. Sudden blood loss 68. When performing platelet aggregation studies with the
most common agonists, which set of platelet aggregation
59. Normal platelet adhesion depends upon: results would most likely be associated with the disorder
a. Calcium associated in platelet membrane GPIb.
b. Glycoprotein Ib a. Normal platelet aggregation to collagen,
c. Glycoprotein IIb, IIIa complex ADP,and ristocetin
d. Fibrinogen b. Normal platelet aggregation to epinephrine and
ristocetin; abnormal aggregation to collagen
60. Fanconi anemia is a congenital hypoplasia considered to and ADP
have thrombocytopenia because of c. Normal platelet aggregation to collagen,
a. Pancytopenia ADP, and epinephrine; abnormal
b. Anemia aggregation to ristocetin
c. Mutation in bone marrow d. Normal platelet aggregation to
d. Giant platelets epinephrine,ristocetin, and collagen; abnormal
aggregation to ADP
61. Severe neonatal thrombocytopenia, inherited impaired
DNA repair disorder and elevated WBC count can be 69. Which set of platelet aggregation results using common
seen in? agonists would most likely be associated with the
a. Wiskott Aldrich syndrome disorder associated in platelet membrane GPIIb/IIIa?
b. May hegglin anomaly a. Normal platelet aggregation to collagen, ADP,
c. TAR syndrome and ristocetin
d. Bernard soulier syndrome b. Normal platelet aggregation to epinephrine and
ristocetin; abnormal aggregation to collagen
62. Amegakaryocytic thrombocytopenia is a congenital and ADP
disorder, caused by the mutation of c- myh9 gene

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c. Normal platelet aggregation to collagen, ADP, a. Escherichia coli 0157:H7

and epinephrine; abnormal aggregation to b. Leukopenia and thrombocytosis
ristocetin c. Fever, granulocytosis and thrombocytosis
d. Normal platelet aggregation to ristocetin d. NOTA
alone
79. Nomenclature for Factor VIII coagulant activity as
70. A 2-year-old child was admitted in the hospital due to measured in factor-specific clot-based assays.
abrupt thrombocytopenia, medical history shows recent a. VIIIa:IXa
viral infection, what is the possible diagnosis? b. VIII
a. Acute ITP c. VIII/vWF
b. Chronic ITP d. VIII:C
c. TTP
d. PTP 80. An individual with extremely hyperextensible joints and
hyperplastic skin that seems to be normal at first sight
71. Hereditary Hemorrhagic Telangiectasia: might actually experiencing a syndrome called?
a. Vascular malformations and skin lesions a. Marfan syndrome
b. Disorder of connective tissue b. Ehlers Danlos syndrome
c. Also known as Rendu-Osler-Weber Syndrome c. ROWS
d. All of the following d. HTS

72. Which of the following does not correctly describes the 81. vWD is the most prevalent congenital bleeding disorder,
disorder? the reason for the disorder maybe due to dozens of
a. Marfan syndrome – increase muscular fragility, possible germline mutation
unproportional extremities a. True
b. Pseudoxanthoma elasticum – calcification of b. False
small arteries leading to abnormality
c. Senile purpura – disorder of the elderly 82. Activation of intrinsic pathway happens when injured
d. Scurvy – vitamin D deficiency vessel exposed the collagen?
a. True
73. Patients with hemangioma-thrombocytopenia syndrome b. False
may show all of the following signs except;
a. Anemia 83. Thrombin converts fibrinogen to fibrin, activating factor
b. Thrombocytopenia XIII and activates Factors IV, VIII and Protein S.
c. Hypofibrinogenemia a. True
d. Polycythemia Vera b. False

74. Which of the following set of vWD is correctly paired? 84. The plasminogen within the clot is transformed into
a. vWD Type 1- qualitative disorder plasmin that has the capability to break fibrin clot into
b. vWDType 2- most severe fragments
c. vWD Type 3- most common a. True
d. Neither of the following b. False

75. A 7-year-old boy was admitted due to sudden 85. In secondary fibrinolysis, activation of plasminogen to
appearance of a purple reddish spot all over his body plasmin occurs even in the absence of coagulation
which of the following best describes the possible activation and clot formation.
disorder? a. True
a. An acute immunoglobulin A mediated b. False
disorder
b. Occurs after viral infection 86. Congenital hemangioma-thrombocytopenia syndrome is
c. due to absence of vitamin C due to excessive multiplication of endothelial cells.
d. most prevalent congenital bleeding disorder a. True
b. False
76. Vasculitis disorders includes all of the following except?
a. Anti-neutrophil cytoplasmic antibody
b. Cryoglobulinemia
c. HSP
d. Neither of the following

77. Which of the following is associated with post-transfusion

purpura (PTP)?
a. Nonimmune thrombocytopenia/alloantibodies
b. Immune-mediated
thrombocytopenia/alloantibodies
c. Immune-mediated
thrombocytopenia/autoantibodies
d. Nonimmune-mediated
thrombocytopenia/autoantibodies

78. Hemolytic uremic syndrome (HUS) is associated with:

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 LESSON 1. MEGAKARYOPOIESIS

OUTLINE - Growth factor: Interleukin-3 (IL3), Thrombopoietin (TPO),

I. Historical Review of Hemostasis Megakaryocyte Colony Stimulating Factor (Meg-CSF)
II. Megakaryopoiesis
a. Stages of Megakaryopoiesis
i. Megakaryoblast
ii. Promegakaryocyte
iii. Megakaryocytes
iv. Metamegakaryocyte
v. Platelet/Thrombocyte
b. Differences between MKI, MKII, and MKIII
III. Thrombopoietin
a. Hormones and Cytokines
IV. Cellular Ultrastructure of Platelets
a. Peripheral Zone
b. Sol-Gel Zone
c. Organelle Zone
d. Membranous System
V. Platelet Function
VI. Other important information
VII. Platelet Role in Hemostasis STAGES OF MEGAKARYOPOIESIS

HISTORICAL REVIEW OF HEMOSTASIS

2nd A.D hemophilia was first recognized.

century
x12th A.D. Moises Maimonides described 2 male siblings
century who died because of excessive bleeding after
circumcision.
1803 Clinical description of families with hemophilia was first
published. The disorder was given the name
HEMOPHILIA which means “love of hemorrhage” by
Schonlein.
1828 The disorder was first described in a thesis published Megakaryoblast • Earliest recognizable stage under
by Hoff. light microscope
1842 Platelets were described by Guilio Bizzozero as • 14-18 um in diameter
“petite plaques”. • N:C ratio is 3:1
1905 Theory on Blood Coagulation by Paul Morawitzwas • Granules are ABSENT
accepted. Promegakaryocyte • 15-40 um in diameter
1913 Lee & White: Whole Blood Clotting Time (WBCT) • Nuclear lobulation begins
was performed. – Lee & White method • The cytoplasm has visible bluish-
1930 Prothrombin time was introduced by Quick. stained granules
1940 Other tests for evaluating hemostatic mechanisms, • N:C ratio is 1:2
like plt. Count & BT were introduced Megakaryocytes • Largest cell in BM
WWII – field of medical technology was first introduced
• Do NOT undergo mitosis
in the Philippines
(endomitosis)
1964 “Cascade & Waterfall Theory” of coagulation was
• Ranging up to 160 μ in size.
introduced – describe the process of coagulation.
• Nucleoli are NO longer visible
• Occasionally pseudopod/ irregular
Hematopoiesis – collective term used to described the process
boarder
involved in the PRODUCTION OF BLOOD CELLS from human stem
• N/C ratio = 1:1-1:12
cells (HSCs)/pluripotential stem cells.
Metamegakaryocyte • Disintegrated cell surrounded by
platelet
MEGAKARYOPOIESIS
Megakaryopoiesis – takes place adjacent to the sinus endothelium.
Megakaryocytes – protrude through the vascular wall as small
cytoplasmic process to deliver platelets into the sinusoidal blood
- maturing cells undergo endomitosis

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Platelet/Thrombocyte • Anucleate CELLULAR ULTRASTRUCTURE OF PLATELETS

• Diameter: 2-4 µm ∙ MPV: 8-10 FL
• Shape: disk-shaped (inactivated) or 1. Peripheral Zone – composed of the membranes and is
circular to irregular (activated), responsible for platelet ADHESION (platelet to non-platelet) and
lavender and granular under Wright- AGGREGATION (platelet to platelet).
stained wedge preparation - originates from the plasma membrane of the
• NV: 150-450 x 109/L megakaryocytes
• Very granular a. Glycocalyx – primarily composed of glycoproteins
• Life span: 5-10 days including factors V, VIII and fibrinogen.
o composed of plasma proteins and carbohydrate
molecules that related to the coagulation,
Note!
complement, and fibrinolytic systems.
Megakaryocyte – largest cell in bone marrow
b. Plasma Membrane – composed of a bilayer of
Monocyte – largest cell in peripheral blood
asymmetrically distributed phospholipids embedded with
integral protein for surface receptors.
FEATURES OF TERMINAL MEGAKARYOCYTE Glycoprotein of Plasma membrane
DIFFERENTIATION i. Glycoprotein Ib (GP Ib) – serves as the binding site
for vWF, necessary for PLATELET ADHESION
Point of MKI MKII MKIII ii. Glycoprotein IIb-IIIa (GPIIb-IIIa; Integrin:αIIbβ3) –
Difference Megakaryo Promegakary Megakaryoc calcium-dependent membrane protein complex for
blast ocyte yte fibrinogen receptor necessary for PLATELET
% precursors 20 25 55 AGGREGATION
Diameter 14-18 um 15-40um 30-50 um
Nucleus Round Indented Multibilobed 2. Sol-Gel Zone – lies directly beneath the platelet membrane and is
Nucleoli 2-6 Variable Not visible composed of:
Chromatin Homogenou Condensed Deeply a. Microtubules – composed of protein tubulin which
s condensed maintains the platelet disc shape
N:C Ratio 3:1 1:2 1:4 b. Microfilaments – contain actin and myosin (contractile)
Mitosis Absent Absent Absent which upon stimulation of the platelet will interact to form
Cytoplasm Basophilic Basophilic and Eosinophilic actomyosin (thrombosthenin) for clot retraction
granular and granular
Alpha granules Present Present Present 3. Membranous System
Dense granules Present Present Present a. Dense Tubular System – derived from smooth
Demarcation Present Present Present endoplasmic reticulum and sequesters calcium for platelet
System (DMC) activation process
o also the site of platelet cyclooxygenase and of
THROMBOPOIETIN prostaglandin synthesis
Thrombopoietin – major hormone involve in PLATELET
PRODUCTION Note!
- a glycoprotein hormone produced mainly by the liver and Calcium – important for hemostasis as it is one of the coagulation
the kidney that regulates the production of platelets by the factors in secondary hemostasis; also known as Factor IV.
bone marrow. Platelet cyclooxygenase and of prostaglandin – released to stop
- stimulates the production and differentiation of clotting when it is enough
megakaryocytes.
b. Open Canalicular System – Surface connecting system
HORMONES AND CYTOKINES o an invagination of the plasma membrane
o acts as a canal for the release of the granule
Cytokine/Ho Differenti Differenti Late Thrombop constituents and cytoplasm to the exterior of the
rmone ation to ation to Matura oiesis platelet
Progenit Megakary tion
or ocyte 4. Organelle Zone – the part where the SECRETORY PRODUCTS
TPO + + + 0 of platelet come from.
IL-11 0 + + + - Mitochondria – for ATP synthesis used for platelet
IL-3 + + 0 - metabolism
IL-6 0 0 + + Granules
KL/SCF/MC + 0 0 0 a. α Granules – most abundant
GF • Platelet factor 4 – heparin neutralizing;
CSF-GEMM + 0 0 0 anticoagulant effect
TPO – Thrombopoietin; IL – Interleukin; KL – Kit Ligand; SCF – • β-thromboglobulin – affects megakaryocyte
Stem Cell Factor; MCGF – Mast Cell Growth Factor; CSF-GEMM maturation
– Colony Stimulating Factor-GEMM • Platelet-derived growth factor
• Fibrinogen – for coagulation (Factor I)
• Factor V – labile factor for coagulation
• vWF – for platelet adhesion
• Thrombospondin – binds in the active platelet with
anticoagulant effect

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• Fibronectin – attaches platelet to extracellular matrix b. Secondary – for blood coagulation forming fibrin clot that is
b. Lysosomal Granules – digestive granules more stable than platelet plug
• Acid phosphatase c. Fibrinolysis
• Hydrolytic enzymes
c. Dense Granules – “SCAAM” 2. Blood coagulation by releasing platelet Factor III that plays a
• Serotonin big role in forming fibrin clot.
• Calcium 3. Clot retraction by its actomysin
• ADP 4. Helps in localization of bacteria and other small objects and
• ATP producing aggregates too large to pass through capillaries.
• Magnesium
PLATELET ROLE IN HEMOSTASIS

Platelet factors Activity

PF1 Accelerates the conversion of PT
(inactivated or zymogen) to thrombin
PF2 Accelerates the clotting of purified fibrinogen
(Factor I) by thrombin
PF3 Phospholipid needed in the intrinsic
coagulation pathway under secondary
hemostasis
PF4 Antiheparin
PF5 Necessary for normal fibrin formation
PF6 Antifibrinolysis – prevent degradation of the
clot
PF7 Necessary in the formation of intrinsic
thromboplastin

OTHER IMPORTANT INFORMATION

PLATELET FUNCTION Endomitosis – multiple mitotic division WITHOUT cell division;
Platelet – participates in a sequence of events that lead to the generating giant-multinucleated polyploid cell
formation of a PLATELET PLUG and ultimately to the formation of a 1000-2000 platelets – ,umber of platelets produce by each
more stable FIBRIN CLOT at the site of vessel interruption. megakaryocytes
1. Primary hemostasis by adhesion, secretion and aggregation Platelet Shedding – release of platelets into the bone marrow sinus
with the end view of hemostatic plug or platelet plug formation. - process of platelet release
Demarcating Membrane System – network formed by invagination
Note! of the plasma membrane
Stages of Hemostasis: - function as future membrane system of platelet
a. Primary – for platelet plug formation

LESSON 2. BASIC PRINCIPLES OF HEMOSTASIS

OUTLINE INTRODUCTION
I. Introduction The maintenance of circulatory hemostasis is achieved through the
II. Brief History of Hemostasis process of balancing bleeding (hemorrhage) and clotting
III. Three Major Components of Hemostasis (thrombosis). Hemostasis, the arresting of bleeding, happens on
a. Extravascular component several components. The four components are the:
b. Vascular component
1. vascular system,
c. Intravascular component
2. platelets (thrombocytes),
IV. Properties of Endothelium
3. blood coagulation factors, and
a. Anticoagulant Properties of Intact Endothelium
b. Procoagulant Properties of Damaged 4. fibrinolysis in ultimate tissue repair.
Endothelium
c. Fibrinolysis BRIEF HISTORY OF HEMOSTASIS
V. Blood Vessels “heme” – blood
a. Important Blood Vessel Products “stasis” – stagnation or to halt
VI. Phases in Hemostasis Hemostasis – STAGNATION OF BLOOD; series of complex
a. Concept of Normal Coagulation processes by which the body spontaneously stops bleeding and
b. Concept of Hypocoagulation maintains blood on its fluid state within the blood vessel compartment.
c. Concept of Hypercoagulation - a continuous balance created between processes of:
VII. Overview of Primary Hemostasis o Coagulation/ thrombosis – clot formation
a. Adhesion o Bleeding/ haemorrhage
b. Aggregation involves the interaction of:
c. Secretion
Blood vessels – involved in primary hemostasis
Platelets – involved in primary hemostasis

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Coagulation mechanism – involved in secondary

hemostasis where there is a series of plasma proteins Regulator Proteins
(coagulation factors) that activated one another to form a. Protein S and C, thrombomodulin – regulation of
a more stable fibrin clot. secondary hemostasis
Fibrinolysis – degredation of clot b. Anti-thrombin III – regulates thrombin, and can inhibit
Tissue repair. coagulation factors (Factor IX and X)
A complex process that c. a-2 antiplasmin – primary inhibitor of plasmin
Produces a clot to stop the bleeding d. a-1 antitrypsin – same as a-2 antiplasmin
Keeps the clot confined e. a-2 macroglobulin – same as a-2 antiplasmin
Dissolves the clot as the wound heals (fibrinolysis) f. Prostacyclin – vasodilator

Note! Other Proteins that Constitutes to Hemostasis

Primary hemostasis – the end product is platelet plug formation that a. Kinin System – coagulation proteins like prekallikrein for
is not as stable activation of bradykinin responsible for vasodilation
Secondary hemostasis – the end product is a more stable fibrin clot b. Complement system – cascade like coagulation factors,
but the end product is lysis
THREE MAJOR COMPONENTS OF HEMOSTASIS c. Other serine protease inhibitors – involved in secondary
hemostasis; activated form of coagulation factors
1. Extravascular component – tissue surrounding the blood vessel
bulk or amount of surrounding tissue PROPERTIES OF ENDOTHELIUM
type of tissue surrounding the injured vessel 1. As anticoagulant
tone of surrounding tissue 2. As Procoagulant
Example: 3. Fibrinolysis
Elastic tissue of aorta have more abundant elastic fibers that
is beneficial in the force that need the heart to pump blood. Anticoagulant Properties of Intact Endothelium
Ex. Skeletal tissue, Adipose tissue, Loose connective tissue composed of rhomboid cells presenting a smooth, contiguous
surface
2. Vascular component – vessels through which the blood flows secretes the eicosanoid platelet inhibitor – prostacyclin, a
Arteries and veins vasodilator
Small vessels – capillaries, arterioles and venules secretes vascular “relaxing” factor – nitric oxide
secretes the anticoagulant glycosaminoglycan heparan
Blood vessels – innermost lining of blood vessels is a monolayer of sulphate that coats the surface of endothelium
metabolically active endothelial cells (monolayer squamous epithelial secretes coagulation extrinsic pathway regulator – tissue factor
cells) pathway inhibitor
Endothelial cells – contains connective tissues such as Note!
collagen and elastin. Tissue factor (Factor III) – involved in coagulation cascade
Function: in secondary hemostasis
▪ Coagulation – because endothelial cells is maintains cell membrane thrombomodulin, a protein C
composed of collagen and other molecules coagulation control system activator – attaches itself in
involved in coagulation like vWF (glue platelets to thrombin that is a part of coagulation cascade
collagen)
▪ Inflammation Procoagulant Properties of Damaged Vessels
▪ Immune response – clot formation blocks the smooth muscle cells in arterioles and arteries – can induce
entry of antigen or pathogens that can further vasoconstriction
cause infection exposed subendothelial collagen binds vWF and platelets
Remember! damaged or activated endothelial cells nitric secrete VWF which
Collagen is important to hemostasis for it serve as magnet, that once attaches to collagen starting the coagulation
exposed by damaged endothelial cells activating coagulation by secrete adhesion molecules:
attracting vWF that will lead to platelet adhesion P-selectin – for leukocytes and platelets
ICAMs – intracellular adhesion molecule
3. Intravascular component – plasma proteins and platelets PECAMs – platelet endothelial cell adhesion molecule
exposed smooth muscle cells and fibroblasts – contains
Needed for Blood Coagulation collagen
a. Platelets – both primary and secondary hemostasis tissue factor exposed on cell membranes
b. Clotting factor – have cascade to form fibrin clots tissue factor is induced by inflammation
c. Cations (ex. Calcium)
Fibrinolysis
secretion of Tissue Plasminogen Activator (TPA) and
Note!
Plasminogen Activator Inhibitor (PAI-1)
Calcium (Factor IV) – one of the coagulation factor that is not a
protein
Note!
Plasminogen – inactivated form (zymogen) of plasmin that eats clot
Needed for Blood Clot Dissolution
for degradation
a. Plasmin – can degrade clots
Remember!
b. Tissue plasminogen activators – plasminogen can
Vasodilation – anticoagulant
transform into plasmi
Vasoconstriction – procoagulant

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 Hematology II | MIDTERMS

BLOOD VESSELS Concept of Normal Coagulation

IMPORTANT BLOOD
VESSELS FUNCTION
PRODUCTS
stimulates vasodilation
1. Prostacyclin inhibits platelet activation
anticoagulant
receptor for thrombin
2. Thrombomodulin bind with thrombin therefore inactivating
thrombin and enhancing the activity
of Antithrombin III.
coats the endothelial cell surface and
3. Heparan Sulfate weakly enhances activity of
antithrombin-III
anticoagulant
4. Tissue converts plasminogen to which Concept of Hypocoagulation
Plasminogen degrades the clot(fibrinolysis) Hypocoagulation – EXCESSIVE BLEEDING due to poor clot
Activator release only in appropriate to avoid formation or excessive fibrinolysis
excessive clot formation Ex. Hemophilia – rare disorder in which your blood doesn't clot
secreted by endothelium to sub- normally because it lacks sufficient blood-clotting proteins
5. von Willebrand
endothelium (clotting actor).
Factor
required for platelet adhesion
coagulation

PHASES IN HEMOSTASIS

Basic Sequence of Events Hemostasis after Vessel Injury

EVENT DESCRIPTION
Controlled by vessels of smooth
muscle
Enhanced by chemicals secreted
1 Vasoconstriction by platelets
Ex. Serotonin – induces
vasoconstriction to sustain
coagulation
PRIMARY

Adhesion to exposed sub-

Concept of Hyperoagulation
endothelial connective tissue
Hypercoagulation – UNCONTROLLED THROMBOSIS due to
2 Platelet adhesion (platelet to non-platelet)
uncontrolled formation of thrombi in the vascular system occluding
Ex. Collagen – vWF serves as
vessels and depriving organs of blood.
glue
Ex. Malignancies, Disseminated Intravascular Coagulation (DIC)
Interaction and adhesion of
– secondary disease causing excessive clot formation
Platelet platelets to one another to form
3
aggregation initial plug at injury site
Fibrinogen – serves as glue
Coagulation factors interact of
SECONDARY

platelet surface to produce fibrin;

Fibrin-Platelet
4 fibrin-platelet plug then forms at
plug
the site of vessel injury (stable
clot)
Fibrin clot must be stabilized by
5 Formation
Coagulation Factor XIII

1. Rapid vasoconstriction reduces blood flow and promotes contact

activation of platelets and coagulation factors.
2. Platelets adhere immediately to the exposed sub-endothelial
connective tissue, particularly collage. Then, aggregate platelets
enhance sustain vasoconstriction by releasing thromboxane A1 and
To ensure that the body has the balance between coagulation and
vasoactive amines, including serotonin and epinephrine.
bleeding certain steps must occur.
3. Coagulation is initiated through the intrinsic system or the
extrinsic system.
SUMMARY
4. Fibrinolysis occurs following the release of tissue through
1. Primary Hemostasis
plasminogen activators (t-Pas) from vascular. Fibrinolytic removal of
Vasoconstriction
excess hemostatic materials is necessary to re-establish vascular Platelet adhesion
integrity.

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 Hematology II | MIDTERMS

Platelet aggregation some secretion of growth factors in arterioles

2. Secondary Hemostasis requires von Willebrand factor
Interactive of coagulation factors to produce fibrin (secondary
plug) 2. Aggregation – platelets adhere to each other
Fibrin stabilization by Factor XIII
irreversible
3. Fibrinolysis
platelet plugs form, platelet contents are secreted
Release of tissue plasminogen activator
Conversion of plasminogen to plasmin requires fibrinogen
Conversion of fibrinogen to fibrinogen degradation product
3. Secretion – platelets discharge the contents of their granules
irreversible
OVERVIEW OF PRIMARY HEMOSTASIS occurs during aggregation
platelet contents are secreted
1. Adhesion – platelets roll and cling to nonplatelet surfaces essential to coagulation
reversible
seals endothelial gaps

LESSON 3. MECHANISM AND LABORATORY EVALUATION OF PRIMARY HEMOSTASIS

OUTLINE
I. Hemostasis
Concept of Normal Coagulation
II. Elements of Hemostasis
a. Extravascular Tissue Factor
b. Vascular Intima
c. Intravascular Component
III. Three Major Components of Hemostasis
a. Histology of Platelets
IV. Two Parts of Hemostatic Mechanism
a. Primary Hemostasis
b. Secondary Hemostasis
V. Primary Hemostasis
a. Platelet Adhesion
b. Platelet Secretion/Release Mechanism
c. Platelet Aggregation
VI. Laboratory Assessments
a. Tests for Vascular and Platelet Phases
i. Bleeding time
ii. Platelet count Concept of Hypocoagulation
iii. Electronic Method
b. Laboratory Evaluation of Vascular and Platelet
Phases Test for Specific Platelet Function
i. Test for Adhesion of Platelets or
Platelet Adhesiveness Test
ii. Platelet Aggregation Test
iii. Platelet Factor 3 Availability Test
c. Laboratory Evaluation of Vascular and Platelet
Phases Test for Determination of Clot
Retraction
d. Laboratory Evaluation of Vascular and Platelet
Phases Test for Capillary Fragility/Resistance
Test

HEMOSTASIS
Hemostasis – stoppage of blood flow
- involves the interaction of blood vessels, platelets, the Concept of Hypercoagulation
coagulation mechanism, fibrinolysis and tissue repair.
- a complex process that:
o produces a clot to stop the bleeding
o keeps the clot confined
o dissolves the clot as the wound heals

ELEMENTS OF HEMOSTASIS
1. Extravascular Tissue Factor/TF
- tissue surrounding the vessel.
2. Vascular Intima
- blood vessel through which the blood flows.
3. Intravascular Component
- plasma proteins and platelets.
o e.g. coagulation factors, inhibitors of coagulation,
inhibitors of Fibrinolysis, factors of fibrinolysis, Ca++ ,
vWF, platelets

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 Hematology II | Lesson 4. Mechanism and Laboratory Evaluation of Secondary Hemostasis

PLATELETS 5. Formation Fibrin clot must be stabilized by

Platelets – made in the bone BM: multinucleated (undergo coagulation factor XIII
endomitosis) megakaryocytes
- stimulated by THROMBOPOIETIN (TPO) PRIMARY HEMOSTASIS
- are not cells: fragments of megakaryocyte cytoplasm Primary hemostasis – refers to the role of blood vessels and
- 150-450 109/L is normal platelets in the primary formation of platelet plug in response to
- circulates in the blood for 5-10 days.
- spleen stores 1/3 body platelet mass (reservoir for trauma) vascular injury
- activated by desquamation and small injuries to blood
vessels
Note!
- involves vascular intima and platelets
In cases of splenectomy, there will be false thrombocytosis - rapid, short-lived response
(increased platelet count) - procoagulant substances exposed or released by damaged
HISTOLOGY OF PLATELTS or activated endothelial cells
1. Canalicular system – under membrane system zone
- let molecules in and out of the cell. 1. Vasoconstriction Controlled by vessel smooth muscle;
2. Dense granules – under organelle zone (“SCAAM”) enhanced by chemicals secreted by
3. Alpha Granules – under organelle zone platelets
4. Microtubules – cytoskeleton that maintains the shape 2. Platelet adhesion Adhesion to exposed subendothelial
- contributes to its discoid shape. connective tissue
5. Microfilament – involves actin and myosin 3. Platelet aggregation Interaction and adhesion of platelets
- contractile system of platelet to one another to form initial plug at
injury site
What keeps platelets from adhering to endothelium/sub-endothelium
normally?
1. Passive factor – NEGATIVE CHARGE on endothelial cell VASOCONSTRICTION → PLATELET ADHESSION → PLATELET
surface AGGREGATION = PLATELET PLUG FORMATION (product of
2. Active processes primary hemostasis)
a. Prostacyclin (PG12) – vasodilator, inhibits platelet
activation by raising cyclic AMP levels
b. ADPase – destroys ADP, decrease platelet activation.
c. Nitric Oxide (Endothelial-Derived Releasing Factor,
EDRF) – inhibits platelet function.
d. Tissue Plasminogen Activator – promotes clot lysis.
e. Thrombomodulin – inhibits thrombin, inactivates clotting
cascade; inhibits platelets found endothelial surface
o member of coagulation cascade in secondary
hemostasis

TWO BASIC PARTS OF HEMOSTATIC MECHANISM

1. Primary Hemostasis – desquamation and small injuries vessels

- involves vascular intima and platelets
- factors: platelet and blood vessels A. Platelet Adhesion
- rapid, short-lived response - contact of PLATELETS WITH THE SUB-ENDOTHELIUM
- damaged or activated endothelial cells. (collagen fibers, fibronectin – less efficient than collagen))
and their adhesion to it.
o occurs because vWF (in the plasma that binds platelets
2. Secondary Hemostasis – large injuries to blood vessels and to exposed endothelium with the help of a receptor
surrounding tissues GpIb) is deposited in the injured tissue
- involves platelet and coagulation - In vivo: collagen
- factors: coagulation factors - In vitro: glass
- release of tissue factor as it is exposed on cell - REVERSIBLE, less stable
B. Platelet Secretion/ Release Mechanism
BASIC SEQUENCE OF EVENTS IN PRIMARY IN PRIMARY AND - platelets undergo shape changes with the intrusion of
SECONDARY HEMOSTASIS AFTER VESSEL INJURY numerous pseudopods due to the contraction of
microtubules.
1. Vasoconstriction Controlled by vessel smooth muscle; - platelet granules move to the center of the platelet and fuse
enhanced by chemicals secreted by to the open canalicular system connected to the outer portion
platelets of the platelets.
2. Platelet adhesion Adhesion to exposed subendothelial - the contents of the granules (ADP, serotonin, β-
thromboglobulin, PF4, vWF, PDGF, etc.) are released
connective tissue (vWF) outside.
3. Platelet aggregation Interaction and adhesion of platelets - IRREVERSIBLE, more stable
to one another to form initial plug at
injury site (fibrinogen) Alpha granules
4. Fibrin-platelet plug Coagulation factors interact on 1. Platelet derived growth factor (PDGF)
platelet surface to produce fibrin; 2. Platelet Factor
fibrin-platelet plug then forms at site 3. Beta thromboglobulin
4. Factor V
of vessel injury 5. Fibrinogen
6. vWF

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 Hematology II | Lesson 4. Mechanism and Laboratory Evaluation of Secondary Hemostasis

Dense granules o Epinephrine

1. Calcium, o Snake venom
2. ADP– activates neighboring platelets o Thrombin arachidonic acid
3. ATP o Ristocetin
4. Serotonin – vasoconstriction
R.A.C.E – most common
C. Platelet Aggregation
- platelet stimulating agents (collagen, ADP, epinephrine, ANTIPLATELETS ANTIBODY ASSAY
thrombin) binds to platelets, causing them to adhere to one - Complement fixation
another – agonists - Platelet bound immunoglobulins – uses competitive
- requires fibrinogen and Ca2+ inhibition assay, would compete with some antiplatelet
- platelet plug forms antibodies
- change in GP IIb/IIIa receptor allows the attachment of
fibrinogen
- irreversible, not as stable TESTS OF THE VASCULAR AND PLATELET PHASES
- for rapid response, short-lived
- the GOLD STANDARD TEST TO DETERMINE PLATELET A. Bleeding time – principally a measure of platelet plug formation;
FUNCTION. test for primary hemostasis
Factors which affect bleeding time
Antiplatelet Agent a. Elasticity of the cut tissue
1. Aspirin b. Ability of the blood vessels to constrict and retract.
2. Clopidogrel c. Mechanical and chemical action of platelets in the formation of
3. Prasugrel
hemostatic plug
4. Dipyramidole
5. GP IIb/IIIa antagonist
Methods of Bleeding time determination
Aspirin 1. Duke’s Method – MOST CONVENIENT METHOD
1. Drug induced dysfunction - puncture site: ear lobe
2. Inhibition in COX-1 (catalyzes production of TX2 – released 2. Modified Ivy’s Method
by the platelet that is reused for vasoconstriction and - BEST METHOD TO ASSESS PLATELETS, standardized
activation of platelet aggregation) - considered to be the best screening test available for
Note! platelet’s role in hemostasis.
Aspirin – do not take within 3 days prior to blood donation - Uses blood pressure cuff (40 mmHg), inure forearm using
standardized lancet
Clopidogrel 3. Coply Lalitch Method
1. ADP receptor antagonist – inhibits ADP (activates 4. Adeison-Crosby Method – puncture site: finger
neighboring platelets) from binding to platelet, inhibiting 5. Macfariane’s Method
further platelet plug formation - same principle with Adelson Crosby method but it only uses
ear lobe as the site of puncture
LABORATORY ASSESSMENTS 6. Aspirin tolerance Test
Platelet count – a fundamental component in evaluation of a - assesses the effect of a standard dose of aspirin on the
patient. Duke’s Bleeding Time
PBS – platelet count and morphology is critical for evaluation. - administer standard dose of aspirin before testing

Laboratory Assessment of Platelet Function Bleeding time is prolonged in the following conditions
1. When the blood platelets are greatly reduced.
Peripheral blood smear Platelet lumiaggregation a. Thrombocytopenic purpura – decreased in platelets
Platelet count (release) b. Acute Leukemia
Petechiometer Platelet antibodies (IgM and c. Aplastic anemia
Platelet ggregation IgG) 2. Injury of capillary wall
Adenosine diphosphate (ADP) Platelet membrane a. Scurvy – vitamin C deficiency (Vit. C tightens the
endothelium), bleeding of the gums
Epinephrine glycoproteins (flow cytometry)
b. Toxins (infection, chemical, snake venom)
Collagen Platelet factor IV 3. Platelet deficiency
Ristocetin Beta-throboglobulin a. Destructive disease of the liver
Arachidonate Thromboxanes b. HDN
Thrombin 4. Slightly prolonged severe anemia

CLOT RETRACTION Note!

- ability of platelet to contract the formed clot However, bleeding time test is not that accurate since there are a lot
- reflects quality of platelets, number of fibrinogen, fibrinolytic of factors that may affect results such as medical technology factor
activity and packed RBC (PRBC) (force of puncture is not standardized) and patient factor (callus may
- mirrors the quality and viability of platelets
affect bleeding)
- directly proportional to number of platelets and inversely
proportional to hematocrit.
B. Platelet count
PLATELET ADHESION
- In-vitro – uses glass bead Indirect Method – platelets are counted in their relationship red
- amount of adhesion reflects the ability of platelets to cells on a fixed-stained smear.
adhere
- NOT RELIABLE because the results depend upon the
PLATELET AGGREGATION distribution of platelets and the red cell count.
- Uses agonists (stimulate function) such as: o Quality of smear is a factor
o ADP
o Collagen

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 Hematology II | Lesson 4. Mechanism and Laboratory Evaluation of Secondary Hemostasis

1. Fonio’s Method – 14% MgSO4 + 1gtt of blood + Wright Stain. 3. Test for adhesion of platelets to collagen fibers – platelet
2. Dameshek Method – Brilliant Cresyl Blue, Sodium sucrose rich plasma containing EDTA is assessed for adhesion collagen
and formalin; counter stain with Wright’s Stain. in the absence of aggregation.
o based on enumeration of free and adherent platelets.
Calculation:
Platelets/uL= platelets x RBC count
100 Computation:
Platelet retention (%) = 1 PC (initial) – Final PC X100
1 platelet count (initial)
Direct Method – platelets are counted in HEMOCYTOMETER as in
erythrocytes and leukocytes; MORE RELIABLE
B. Platelet Aggregation Test
1. Guy and Leake – diluent is made of sodium oxalate,
- the MOST COMMONLY USED QUANTITATIVE METHOD
40% formalin and crystal violet.
that uses various aggregometers (agonists)
Calculation: C. Platelet Factor 3 Availability Test
Platelets/uL= platelet counted x 5 x 10 (depth) x 100 (dilution) - activation of intrinsic pathway coagulation
- platelets are incubated with kaolin and epinephrine, and are
2. Rees and Ecker – diluent is made up of sodium oxalate, stimulated to provide PF3 activity.
brilliant cresyl blue, formalin and distilled water.
D. Determination of Clot Retraction
Calculation:
Platelets/uL = platelets counted x 10 x 200 1. Qualitative Test – observation
4 a. Hirshcoeck or Castor Oil Method
b. Single Tube Method
3. Brecher-Cronkite – diluent is 1% ammonium oxalate. 2. Quantitative Test – measurement
o method uses phase contrast microscope a. Stefanini Method – similar with single tube method.
o MOST ACCURATE METHOD because there is no o measure the platelet left in the plasma after removing
difficulty in distinguishing platelets from debris. the packed RBC to measure the quantity of clot
retraction
b. Macfarlane Method
Calculation:
Platelet/uL= platelets x 5 x 10 x 100
E. Capillary Fragility/Resistance test
- tests the stability of the small blood vessels (capillary)
Note! retain the red cell in their lumen under conditions stress and
Cases of estimation is acceptable, if it’s too high or low (flooding) trauma.
through smear when viewed under microscope. - Platelets and Vitamin C are important in the maintenance of
normal capillary integrity or resistance.
Normal: 6-8 platelets/1000 magnification (OIO)
Get the average of 10 fields and multiplied to 20,000 1. Tourniquet or Rumpel-Leede or Hess Test positive pressure
technique.
C. Electronic Method – red cells must first be removed from whole - Principle: by partially obstructing the venous blood, the
blood, either by sedimentation or by controlled centrifugation capillary pressure is increased. This will give rise to
- Platelet rich plasma is needed, thus light centrifugation is intravasation of blood which will be manifested in the form of
used small hemorrhage called PETECHIAE. (positive pressure)
1. Voltage-pulse counting a. Quick’s Method
2. Electro-optical counting b. Gothlin’s Method

LABORATORY EVALUATION OF VASCULAR AND PLATELET 2. Suction Cup/ Petechiometer Method/ Negative Pressure
PHASES TEST FOR SPECIFIC PLATELET FUNCTION Technique
- in the negative pressure method, trauma is created by means
A. Test for Adhesion of Platelets or Platelet Adhesiveness Test of suction cups applied to the skin. (negative pressure)
- Principle: employs the use of Modified da Silva Melle
Principle: The adhesiveness of platelets may be measured in vitro Instrument
o The cup is applied to the outer surface of the arm for a
by their ability to adhere glass surface
period of one minute at 200 mmHg and the resistance
1. In vivo method of Borchgrevink – measures adhesion of of the capillaries is expressed as the negative pressure
platelets to the wound surface. required to produce macroscopic petechiae
2. Salzman Method – test of the retention of platelets within glass
bead column

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 Hematology II | Lesson 4. Mechanism and Laboratory Evaluation of Secondary Hemostasis

LESSON 4. MECHANISM AND LABORATORY EVALUATION OF SECONDARY HEMOSTASIS

• completely consumed during

OUTLINE coagulation
I. Secondary Hemostasis • Seen in plasma
II. Coagulation Factors
• Absent in serum
a. Classification of Coagulation Factors by
• II, VII, IX, X
Hemostatic Function
b. Classification of Coagulation Factors by • Calcium and Vit. K
Physical Properties dependent
III. Pathway of Coagulation • First: VII à IX à X à II: Last
a. Extrinsic Pathway • inhibited by warfarin
PROTHROMBIN GROUP
b. Intrinsic Pathway • Adsorbable factors: removed
c. Common Pathway by adsorbing agents [BaSO4,
IV. Fibrin Formation Al(OH)3]
V. Thrombin • Seen in plasma
a. Thrombin-mediated Reactions in Hemostasis
• Present in serum
VI. Inhibitors of Coagulation
VII. Laboratory Evaluation • XII, XI, PK, HMWK
a. Coagulation Tests • Ca2+ independent
CONTACT GROUP
i. Prothrombin Time • Vit. K independent
ii. Activated Partial Thromboplastin • involved in the contact phase
Time (APTT)
b. Specialized Coagulation Tests Warfarin – MOST COMMONLY USED ANTICOAGULANT during
i. Activated Clotting Time therapy for those with high risk thrombosis.
ii. Ecarin Clotting Time - Can greatly affect prothrombin group
iii. Clot Waveform Analysis
iv. Stypven Time
Factors Preferred Name Other Names
c. Assays for Fibrin Formation
Fibrinogen
i. Fibrinogen Levels
I A substrate, activated by enzyme and most
ii. Thrombin Time
iii. Reptilase Time abundant, increased during inflammation
iv. D-dimer Testing II Prothrombin Prethrombin
III Tissue Factor o Tissue Thromboplastin
SECONDARY HEMOSTASIS Calcium/Ionizedo
IV
Blood coagulation basic concept: Calcium
- Sequential process of chemical reaction involving plasma o Labile factor
proteins, phospholipid and calcium ion. V Proaccelerin
o Accelerator globulin (aCg)
Goal: to FORM FIBRIN MESH WORK (secondary hemostatic plug) o Stable factor
- a mechanism consisting of a series of cascading reactions
VII Proconvertin o Serum prothrombin conversion
involving development of enzymes from their precursors
accelerator(SPCA)
(ZYMOGEN) which will further be converted to an activated
o Antihemophilic factor globulin
state (SERINE PROTEASE)
Antihemophilic (AHG)
VIII:C
COAGULATION FACTORS factor o Antihemophilic factor A
Hepatic cells – PRINCIPAL SITE of the synthesis of coagulation o Platelet cofactor 1
actors. Plasma o Christmas factor
- most of the circulating factors are designated by Roman IX thromboplastin Antihemophilic factor B
numerals. component Platelet cofactor 2
Stuart factor
Common Characteristics of Coagulation Factors Stuart-prower
X o Prower factor
1. A deficiency to the factor generally produces a bleeding factor
o Autoprothrombin III
tendency disorder with exception with factor XII.
Plasma Antihemophilic factor C
2. The physical and chemical characteristic of factors are known.
XI thromboplastin
3. The synthesis of the factor is independent of other proteins
antecedent
4. The factors can be assayed in the laboratory.
o Glass factor (in vitro)
XII Hageman factor
o Contact factor (in vivo)
Classification of Coagulation Factors by Hemostatic Function
Substrate – Fibrinogen (Factor 1) Laki-Lorand factor
Fibrin
Cofactors – Factor V (labile factor), Factor VIII:C, serve as helper o Fibrinase
XIII stabilizing
Enzymes – Serine Proteases, Ia, IIa, VIIa IXa, Xa, XIa, XIIa, o Plasma transglutaminase
factor
Transaminase Factor XIIIa, Prekallekrein o Fibrinoligase
Prekallikrein Fletcher factor
Classification of Coagulation Factors by Physical Properties -
(PK)
• I, V, VIII, XIII Fitzgerald factor
FIBRINOGEN GROUP • Calcium dependent -
High-molecular
Contact activation cofactor
• Vit. K independent weight
Williams factor

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 Hematology II | Lesson 5. Mechanism of Fibrinolysis

kininogen Flaujeac factor

(HMWK)

Note!
Fibrinogen and prothrombin – true coagulation factor proteins
Factor VI – activated form of Factor V, not used
Labile factor – easily affected in in-vitro situation
Factors VII, XI – activated in cold temperature
Serum prothrombin conversion accelerator (SPCA) – accelerates
conversion of prothrombin
Factor VIII, IX, XI – deficiency involves hemophilia,
Factor VIII deficiency – most common, classic hemophilia
Factor IIa – thrombin Note!
Upon activation of Factor XII to XIIa, it activates PK to form kallikrein
Remember! with the help of HMWK
Plasma – fibrinogen is present, with anticoagulant, no clot formation
Serum – consumed fibrinogen, tubes without anticoagulant (ex. Red COMMON PATHWAY
top), with clot formation Common Pathway – starts with the activation of Factor X to Factor
Xa by either intrinsic or extrinsic pathway.
PATHWAY OF COAGULATION
1. Intrinsic Pathway
2. Extrinsic Pathway
3. Common Pathway

PATHWAY SUMMARY ILLUSTRATION

EXTRINSIC PATHWAY
FIBRIN FORMATION
Extrinsic Pathway – activated by the release of Factor III
Clotting – the visible result of fibrinogen conversion to fibrin
(TF/Tissue Thromboplastin) into the circulation from injured tissue.
stabilize clot
- With the help of calcium, activates factor XII, and factor X.
Fibrin formation – occurs in three phases:
a. Proteolysis – conversion of fibrinogen to fibrin
b. Polymerization – accumulation of monomers of fibrin
to form polymers of fibrin
c. Stabilization – through factor XIII
Fibrin – insoluble gel
- reinforces platelet plug

4. Fibrin-platelet plug Coagulation factors interact on

formation platelet surface to produce fibrin;
fibrin-platelet plug then forms at
INTRINSIC PATHWAY site of vessel injury
Intrinsic Pathway – activation occurs when a vessel is injured, 5. Fibrin stabilization Fibrin clot must be stabilized by
exposing the subendothelial basement membrane and collagen. coagulation factor XIII
- will lead to the activation of the “Contact Factor”, Factor XII
together with Factor XI, HMWK and prekallikrein.
THROMBIN
Thrombin – converts fibrinogen to fibrin
- Plays a critical role in secondary hemostasis
- Activation of factor XIII (fibrin stabilizing factor)
- Activation of platelet aggregation/ factor V and Factor VIII:C/
Protein C (inhibitor of coagulation)
- Weak activation of factor VII

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 Hematology II | Lesson 5. Mechanism of Fibrinolysis

- Thrombin formation marks a critical event in the hemostatic - Two commonly used coagulation test:
process. a. Prothrombin Time (PT)
b. Activated Partial ThromboplastinTime (APTT)
THROMBIN-MEDIATED REACTIONS IN HEMOSTASIS
a. Prothrombin time
PROCOAGULANT COAGULATION INHIBITOR - basis for International Normalized Ratio
• Induces platelet activation • Binds antithrombin-III to - evaluates the generation of thrombin and the formation fibrin
and aggregation inhibit serine proteases via Extrinsic Pathway and Common Pathway
• Activates cofactor VIII to • Binds to thrombomodulin to - uses thromboplastin (Factor III) reagent
VIIIa activate Protein C (inhibits - reference range :10-13 seconds
• Converts Factor XIII to XIIIa Va & VIIIa) - PROLONGED, if there is EXTRINSIC PATHWAY
• Va autocatalysis converts • Inhibits thrombin DEFICIENCY/FACTOR VII DEFICIENCY
Prothrombin to Thrombin o oral anticoagulant (coumarin, coumarin-containing
products)
INHIBITORS OF COAGULATION (ANTICOAGULANTS) INR – used to standardized the result of PT
- recommended for monitoring anticoagulant therapy-
1. Protein C – major inhibitor mathematical calculation
- GP that is produced by the liver and is a major inhibitor of
blood coagulation.
- inactivates Factors VIII:C and Va in the presence of cofactor
Protein S b. Activated Partial Thromboplastin Time (APTT)
- most commonly used screening test to investigate bleeding
2. Protein S – major inhibitor patients, monitoring anticoagulant therapy of preoperative
- vitamin-K dependent protein and also produced by the liver screening.
- enhance binding of Protein C to phospholipid surfaces and - measures the integrity of Intrinsic Pathway and Common
increase the rate of Factors Va and VIIIa inactivation by Pathway
Protein C - reference range: < 35 seconds
- PROLONGED, if there is INTRINSIC PATHWAY
3. Thrombomodulin DEFICIENCY
- inhibits thrombin and inactivates the clotting cascade o Presence of inhibitor
- If prolonged, proceed to mixing studies
4. Antithrombin III
- major inhibitor of thrombin and Factor Xa Mixing Studies – can be adopted if primary tests like PT or APTT
are abnormally prolonged and the indicate a FACTOR
5. Heparin Cofactor – minor inhibitor DEFICIENCY.
- inhibits thrombin; activity is enhanced by heparin - a common coagulation test used to distinguish between a
coagulation factor deficiency, such as factor VIII, and a factor
6. Alpha 2-macroglobulin – minor inhibitor inhibitor, such as a specific factor VIII inhibitor or lupus
- forms complex with thrombin, kallikrein, thus inhibiting their anticoagulant.
activities - The patient’s deficient plasma is diluted 1:1 with a plasma or
serum substitute and the APTT or PT is repeated...
7. Extrinsic Pathway Inhibitor – minor inhibitor - A correction if the original prolonged APTT or PT indicates
- lipoprotein associated inhibitor (LACI) that inhibits VIIa which that the deficient factor has been added to the patient’s
is a tissue complex factor plasma by substitution solutions as follow:

8. C1 Inhibitor – minor inhibitor Types of Inhibitors

- inactivates Factor XIIa and plasma kallikrein, Factor XIa and
1. Specific Factor Inhibitors
plasmin.
- mixing studies will NOT be corrected or shortened
- part of complement pathway because of the linked
- to distinguish APTT results can be analyzed in conjunction
coagulation, complement, and kinin system
with PT results.
- presence of factor inhibitor can be confirmed by a Bethesda
9. Alpha 1-antitrypsin – minor inhibitor
assay for that factor.
- slow reacting thrombin inhibitor which inhibits Factor XIa and
2. Nonspecific Inhibitors
Xa.
- presence of lupus anticoagulant (antibodies against protein-
phospholipid complexes)
Activated Protein C Inhibitor – procoagulant
o Common to patients of Systemic Lupus
- inhibits Protein C Erythematosus (SLE)
- more active when heparin is present. - Lupus Anticoagulant (LA) increases risk of
Thromboembolism
LABORATORY EVALUATION - further test: phospholipid based screening tests and
phospholipid dependent assays.
I. COAGULATION TEST 3. Anticoagulant
Coagulation test – tests the composite action of all plasma factors - presence of heparin:
acting simultaneously. o Fondaparinux
- Clot based often used for suspected bleeding and o Dabigatran
anticoagulant monitoring o Direct thrombin inhibitors.
- medication should be viewed.

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 Hematology II | Lesson 5. Mechanism of Fibrinolysis

- Thrombin Time with heparin assay. III. ASSAYS FOR FIBRIN FORMATION

II. SPECIALIZED COAGULATION TEST a. Fibrinogen Levels

- useful in detecting deficiency of fibrinogen and alteration in
a. Activated Clotting Time the conversion of fibrinogen to fibrin.
- modified classic Lee-White whole blood clotting time - normal value is 200-400 mg/dL
- ACT is a point-of-care, bedside
- used to monitor high dosed of heparin therapy or bivalirudin b. Thrombin time
- ACT does not correlate well with other coagulation tests - should be measured in specimen with prolonged APTT
- PROLONGED:
b. Ecarin Clotting Time o Presence of heparin
- uses venom from Echis caritanus snake o Fibrinogen deficiency
- used for Hirudin therapy o Fibrin Degradation Product (FDP) / Fibrin Split Product
o Streptokinase
c. Clot Waveform Analysis
c. Reptilase Time
- based on the traditional APTT assay.
- similar to TT
- uses computerized graph
- uses snake venom (thrombin like in nature)
- possible applications:
- not inhibited by heparin
o Monitoring course of DIC
o Sensitive to mild factor deficiencies
o Potentially predicting the severity and prognosis of d. D-dimer Testing
sepsis - similar to TT
- uses snake venom (thrombin like in nature)
d. Stypven Time (Rusell’s Viper Venom Time) - not inhibited by heparin
- used to distinguish deficiencies of Factor X and those of
Factor VII. I Example for mixing studies :
- used to detect deficiencies in prothrombin, fibrinogen and 1. PT and APTT are prolonged, but are corrected after the addition
factors V and X. of adsorbed plasma, but not aged serum or plasma.
- differs from prothrombin time in that deficiencies in factor VII 2. PT is normal and APTT is prolonged. APTT is corrected after
are not detected the addition of aged serum but not with adsorbed plasma or
- like prothrombin time, but less sensitive to Factor VII aged plasma.

LESSON 5. MECHANISM OF FIBRINOLYSIS

OUTLINE
I. Introduction
II. Fibrinolysis
a. Primary and Secondary Fibrinolysis
III. Fibrinolysis Molecular Components
IV. Fibrinolysis Inhibitors
V. Test of Fibrin Degradation Products
VI. Other Functions of Plasmin

INTRODUCTION PRIMARY AND SECONDARY FIBRINOLYSIS

Fibrinolysis – a complex process that CONTROLS BOTH Primary and secondary fibrinolysis – recognize as extreme
HEMOSTASIS AND THROMBOSIS. complications of variety of intravascular and extravascular disorders
- mediated through a wide array of cofactors and inhibitors and may have life threatening consequences.
that maintain the hemostatic balance in a delicate equilibrium.
- physiologic process includes gradual or progressive
a. Primary Fibrinolysis – a rare pathological condition in which a
removal of fibrin cleaving it into soluble fragments which is
then removed by the phagocytic cells of the RES. SPONTANEOUS SYSTEMIC FIBRINOLYSIS occurs.
- associated with conditions which gross activation of the
MAIN OBJECTIVE: To REMOVE THE UNWANTED CLOT to fibrinolytic mechanism with subsequent fibrinogen and
restore the normal flow of blood on the area to facilitate the repair of coagulation factor consumption occur.
the damaged blood vessel. - plasmin is formed in the absence of coagulation activation
and clot formation.
FIBRINOLYSIS - associated with increased production of plasminogen and
plasmin, decreased plasmin removal from the
Fibrinolysis – last stage of coagulation
circulation, and spontaneous bleeding.
- polymer and releasing fibrin degradation products (FDP)
- digestion of fibrin clot
b. Secondary fibrinolysis – the breakdown of blood clots due to a
- keeps the vascular system free of deposited fibrin/fibrin clot
medical disorder, medicine, or other cause. This may cause severe
- begins with activation of plasminogen to plasmin
bleeding.
- normal fibrinolysis refers to the enzymatic pathway of clot
- spontaneous activation of both coagulation and fibrinolysis
dissolution in which:
- ex: Disseminated Intravascular Coagulation (DIC)
o Plasmin – the KEY ENZYME responsible for breaking
FIBRINOLYSIS MOLECULAR COMPONENTS
down bonds in the fibrin
Plasminogen o circulating INACTIVE protein with a MW of
90,000 D

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 Hematology II | Lesson 6. Hemostatic Disorders (Qualitative and Quantitative Platelet Disorders)

o a glycoprotein
o synthesized in the liver
o stored and transported in eosinophil’s
o increased concentration associated with
inflammation.
Plasmin o ACTIVE form of fibrinogen
o an enzyme responsible for clot digestion
o a serine protease that can destroy
fibrinogen, fibrin and factors V and VIII
o promotes coagulation and activated the
kinin and complement system
Tissue o source: vascular endothelium
Plasminogen o endogenous
Activator (t-PA) o primary plasminogen activator
o released from the endothelial cells by the Coagulation Complexed with Protein S and
action of protein C Fibrinolytic inhibits factor Va and VIIIa
o converts plasminogen to plasmin Protein C
(enhanced) Inactivated inhibitors of
Single-chain o source: kidney plasminogen activators
Urokinase o primary activator within genitourinary tract Same with Same with Protein C
o U-PA is an activator of PLG to plasmin Protein S
Protein C
o primarily involved in extra-vascular Protein C and cofactor Protein S are Vit. K dependent
remodeling and repair after tissue injury glycoproteins.
Contact Phase o Factors XIIa and its fragments, kallikrein , - enhances fibrinolysis by inactivating inhibitors of plasminogen
Activator and Factor XIa participates in the activators.
plasminogen activation
Streptokinase o Product of B-hemolytic streptococci 1. Plasminogen and t-PA – adsorbed within the formed clot.
- molecules are readily adsorbed in the clot due to their high
FIBRINOLYSIS INHIBITORS attraction or affinity with fibrin
A2-antitrypsin o MAIN INHIBITOR OF PLASMIN 2. Plasminogen within the clot – transformed into plasmin that has
o cross-linked into the fibrin clot by F the capability to break fibrin clot into fragments.
XIIIa and so renders the clot - Conversion of plasminogen to plasmin is also initiated by
resistant to fibrinolysis several components such as urokinase, activated Protein C,
Antithrombin (formerly o inhibits plasmin and kallikrein contact activators
Antithrombin III) o synthesized in the liver 3. Plasmin degrades fibrin in the clot and also fibrinogen in the
o enhanced by heparin plasma forming fibrin or fibrinogen split/degradation products
C’1-inactivator o inhibits plasmin (FDP’s)
Plasminogen Activator o major inhibitor of t-PA and u-PA. 4. Fibrin becomes Fragment X , Y, and D, E
Inhibitor secreted constitutively by vascular
endothelial cells TESTS FOR FIBRIN DEGRADATION PRODUCT
o also stored in the platelet 1. Fibrin Degradation Product (FDP) – test detects the LATE
Thrombin-Activatable o activated by thrombin to TAFIa DEGRADATION PRODUCTS (fragments D and E) and not the early
Fibrinolysis Inhibitor o it down regulates fibrinolysis. ones(fragments X and Y).
(TAFI) 2. D-dimer assay – EVALUATES FIBRIN DEGRADATION.
- a nonspecific screening test that is increased in many
conditions in which fibrinolysis is increased, such as DIC and
fibrinolytic therapy.

OTHER FUNCTION OF PLASMIN

a. Destroys clotting factor V, VIII, IX, XI
b. Indirectly enhances or amplifies conversion of factor XII to factor
XIIa
c. Enhances or amplifies conversion of PK to kallikrein liberating the
kinins from kininogen
d. Promotes coagulation and activates the kinin and complement
system.
e. Cleaves C3 protein of the complement system into fragments to
C3a (helps in anaphylatoxin) and C3b (helps in kinin system)

LESSON 6. HEMOSTATIC DISORDERS (QUALITATIVE AND QUANTITATIVE PLATELET DISORDERS)

OUTLINE
DEFINITION OF TERMS
VIII. Definition of Terms
IX. Quantitative Platelet Disorder 1. Hemorrhage – severe form of bleeding that requires intervention
a. Disorder of Production a. Localized – SINGLE location, commonly indicates injury,
b. Disorder of Destruction infection, tumor or isolated blood vessels defect
c. Disorder of Platelet Distribution and Dilution b. Generalized – bleeding from MULTIPLE sites, spontaneous
X. Qualitative Platelet Disorder and recurring bleeds, or a hemorrhage that requires physical
a. Acquired intervention and transfusion
b. Hereditary c. Acquired – when a patient bleeding began after infancy, are
associated with some disease or physical trauma and are
NOT DUPLICATED IN RELATIVES

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 Hematology II | MIDTERMS

d. Congenital – occurring during 1 per 100 people, are - 1/3 to 1/2 of patients are affected with thrombocytopenia
unusually diagnosed in infants or young children who often - mutation in MYH9 gene
have RELATIVES WITH SIMILAR SYMPTOMS
b. Congenital Amegakarocytic Thrombocytopenia – autosomal
2. Petechiae – purplish red pinpoint hemorrhagic spots in the skin.
recessive disorder reflecting bone marrow failure spontaneous
3. Purpura – hemorrhage of blood into small areas of skin, mucous activation of both coagulation and fibrinolysis
membranes and other tissues. - half of infants with this condition develop aplastic anemia
4. Hemarthrosis – leakage of blood into joint cavities. - caused by mutation in the c-mlp gene
5. Hematemesis – vomiting of blood. - complete loss of TPO receptor function
6. Hematoma – swelling or tumor in the tissues or a body cavity that
contains clotted blood. c. Neonatal Hypoplasia – infection due to TORCH (TOxoplasma,
7. Hematuria – RBC in urine. Rubella, Cytomegalovirus, HIV) and in utero exposure to some
8. Hemoglobinuria – Hb in urine. certain drug.
9. Hemoptysis – expectoration of blood secondary to hemorrhage
in the larynx, trachea, bronchi or lungs. d. Acquired Hypoplasia – chemotherapeutic agents used for
10. Hematochezia – stool containing bright red blood. treatment of hematologic malignancies suppress BM megakaryocyte
11. Ecchymosis – form of purpura in which blood escapes into production of other hematopoietic cells.
large areas of skin and mucous membranes but not into deep - Ex. Methotrexate, busulfan, cytosine arabinoside,
tissues. cyclophosphamide and cisplatin.
12. Epistaxis – nosebleed. - Other drugs specifically affect megakaryopoiesis without
13. Melena – stool containing dark red or black blood. significantly affecting other marrow elements.
14. Menorrhagia – excessive menstrual bleeding.
e. Ineffective Thrombopoiesis – usual feature of megaloblastic
Platelet Disorder anemia (pernicious anemia, folic acid deficiency, vitamin b12 def.)
a. Quantitative – Normal: 150-450 x 109/L - megakaryocyte production is enough but the platelet released
b. Qualitative – involved the membrane or the granules of the into the circulation is decreased.
platelets
2. DISORDER OF DESTRUCTION
QUANTITATIVE PLATELET DISORDER a. Post-transfusion Purpura – a rare form of alloimmune
Thrombocytopenia – platelet count below 100 x 109/L can be thrombocytopenia
classified based into major categories. - characterized by severe thrombocytopenia following
transfusion of blood or blood products
1. Artifactual o platelet clumping – caused by clot - caused by antibody-related platelet destruction in previously
formation immunized patients.
o giant platelets – abnormal size of platelet
o platelet satellitism – neutrophils are b. Drugs – or foreign substance can produce platelet destruction
surrounded by platelets - Immunologic Drug induced Thrombocytopenia – many drugs
2. Disorder of o maybe caused by hypoproliferation of the can induce antibodies that interacts with platelets, platelet
megakaryocytic cell line or ineffective falls rapidly
Production
thrombopoiesis - Ex. Quinidine, sulfonamide derivatives, heroin, morphine and
o acquired or hereditary snake venom
3. Disorder of Immunologic
c. Bacterial Sepsis – causes increased destruction of platelets
Destruction or • idiopathic
- thrombocytopenia may occur 1-3 weeks following infection
Utilization • secondary to drugs, infection and other
causes
d. Immune Thrombocytopenia – antibodies produce causes
• neonatal thrombocytopenia destruction
• post-tranfusion purpura - Immune (Idiopathic) Thrombocytopenia Purpura (ITP)
Non-Immunologic o Acute ITP – disorder of children(2-9 y/o), abrupt onset,
• Thrombotic microangiopathies, in previously healthy child, usually occur after a viral
• Thrombotic Thrombocytopenic infection
Purpura, Hemolytic Uremic Syndrome o Chronic ITP – found in patient of any age(20-50),
• damage to platelets by abnormal female outnumbered men, platelet destruction is a
vascular result of immunologic process
• surfaces
• miscellaneous e. Isoimmune Neonatal Thrombocytopenia – result from
4. Disorder of o Splenic disorder immunization of a pregnant female by a fetal platelet antigen
Platelet o Dilution of platelet due to transfusion
Distribution f. Heparin Induced Thrombocytemia – common side effect of
heparin therapy
and Dilution
- most common drug induced thrombocytopenia
- ”White clot syndrome”
1. DISORDER OF PRODUCTION - Type I (Non-immune mediated) – mild
- Type II (Immune mediated) – patients with HIT have
a. Congenital Hypoplasia – lack of adequate BM megakaryocyte immunoglobulins that causes platelet aggregation
- Ex. Fanconi Anemia, Thrombocytopenia with Absent Radius
(TAR) Syndrome, Wiskott-Aldrich Syndrome (WAS) (ql), May *NIHIT – benign disorder, direct interaction between platelets and
hegglin anomaly, Bernard soulier syndrome (ql) heparin.
TAR syndrome – rare autosomal recessive disorder *IHIT – caused by antibody that recognizes heparin bound to PF4 on
- severe neonatal thrombocytopenia and congenital absence the platelets surface
or extreme hypoplasia of the radial bones of the forearms.
- inherited impaired DNA repair disorder Increased Utilization
- elevated WBC count 1. Disseminated Intravascular Coagulation – rapid consumption
May hegglin Anomaly – rare autosomal disorder of platelets spontaneous coagulation in the system
- PBS – Dohle bodies (neutrophils, occasionally in monocyte) 2. Thrombic Thrombocytopennic Purpura – formation of
microthrombi in the microvasculature

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 Hematology II | MIDTERMS

- severe thrombocytopenia, MAHA, neurologic symptoms and biosynthesis, and phosphoesterase

renal disease activity
a. Idiopathic TTP – has been linked to an enzyme ADAMTS-13 HEREDITARY
which is responsible for the breakdown of vWF multimers Platelet Membrane Defects
o an autoimmune disease associated with - Glanzmann’s Thrombasthenia (aggregation)
autoantibodies produced against vWF cleaving - Bernard-Soulier Syndrome (adhesion)
enzyme (ADAMTS-13) Platelet Release (Secretion Defects)
b. Secondary TTP – diagnosed with patients with history of - Primary Secretion Defect (enzymatic pathway defects)
MEDICATIONS - Storage Pool Deficiency (granule defect)
c. Upshaw-Schulman Syndrome – associated with Platelet Coagulant Defects
CONGENITAL BLEEDING DISORDER Von Willebrand’s Disease (Adhesion)

3. DISORDER OF PLATELET DISTRIBUTION AND DILUTION 1. Glanzmann’s Thrombasthenia (aggregation defect) – rare
Post-transfusion Thrombocytopenia – massive blood transfusion primary aggregation disorder
is complete replacement of patients’ blood volume within 24 hours. - abnormality of the surface membrane GP complex IIb/IIIa
- dilutional thrombocytopenia significant decrease 50-100 - platelet dysfunction, easy continuous bruising, subcutaneous
x109/L hematoma, and petechiae
LAB FINDINGS:
Thrombocytosis o platelet aggregation test, normal aggregation with
a. Primary Thrombocytosis – BM itself is involved Ristocetin only
b. Secondary Thrombocytosis (external cause) – due to o BT prolonged
secondary infection o CR decreased
- 1918, Eduard Glanzmann, a Swiss pediatrician, described a
1. Polycythemia vera o pancytosis group of patients with hemorrhagic symptoms and a defect
o thrombosis is related to height of on platelet function (weak platelet or thrombasthenia)
the red cell volume with increase - In the mid-1970, Nurden & Caen, Phillips & colleagues
blood viscosity discovered that thrombasthenic platelets are deficient in both
o primary polycythemia vera – due IIb and IIIa
to BM
o secondary polycythemia vera – 2. Bernard Soulier Syndrome (adhesion defect) – autosomal
unrelated diseases like recessive hereditary bleeding disorder
dehydration - disorder in platelet membrane GPIb.GPV and GPIX are
2. Primary myelofibrosis o dysmegakaryocytopoiesis missing
leading to overproduction of - bruising, epistaxis, hyper menorrhagia, and petechiae
defective platelets - In 1948, Bernard and Soulier described two children from a
3. Essential o significant increase of circulating consanguineous family who had a severe bleeding disorder
thrombocythemia platelets (1,000 x 109/L) characterized by mucocutaneous haemorrhage
o morphology appears normal - In 1975, Nurden & Caen identified an abnormality in platelet
*The three are related to the mutation in JAKII v617f gene GPIb as the cause of the disease

QUALITATIVE PLATELET DISORDERS Defects that can lead to giant platelets

1. May hegglin Anomaly
ACQUIRED 2. Thrombic Thrombocytopennic Purpura
1. Hemolytic Uremic o progressive renal failure 3. Bernard and Soulier Syndrome – largest
Syndrome o peak incidence 6 months to 4 y/o
o caused by E. coli 0157:H7 Glanzmann’s Bernard-Soulier
o associated with ingestion of E. coli Thrombasthenia Sydrome
contaminated foods Platelet count Normal Decreased
o commonly seen in children. Platelet morphology Normal Giant platelets
2. HELLP Syndrome o Hemolysis, Elevated Liver enzyme, Bleeding time Prolonged Prolonged
Low Platelet count. Platelet aggregation
o life threatening potential complication • ADP Abnormal Normal
of late pregnancy and delivery • Thrombin Abnormal Abnormal
3. Paraproteinemia o increased in gammaglobulins
• Epinephrine Abnormal Normal
o multiple myeloma, waldenstroms
• Ristocetin Normal Abnormal
macroglobulinemia (IgG), or
monoclonal gammopathies (IgM, Clot retraction Abnormal Normal
IgA) Platelet GP defect GP IIb/IIIa GP Ib/IX/V
o dysfunction is due to paraprotein
coating the platelet membrane. 3. Storage Pool Diseases
4. Cardiopulmonary o major importance in surgical bleeding a. Hermansky-Pudlak Syndrome – an autosomal recessive
bypass after bypass disorder characterized by a severe DEFICIENCY OF DENSE
o heparin is the most used GRANULES.
anticoagulant o patients show albinism (oculocutaneous) and may
5. Drug-induced o aspirin and other NSAID, COX-2 have hemorrhagic events
inhibitors and antibiotics. b. Chediak-Higashi Syndrome – an autosomal recessive
- cyclooxygenase enzyme – help disorder, in which patients show albinism and GIANT
in the production of LYSOSOMAL GRANULES IN NEUTROPHILS
prostaglandins for o storage pool DEFECT ON DENSE GRANULES
inflammation, fever, and pain o patients show frequent infections because of impaired
and can inactivate platelet phagocytic ability and death usually occurs in
leading to bleeding childhood
- aspirin – irreversibly o patients manifest thrombocytopenia and enlarged liver
inactivating cyclooxygenase-1 and spleen
o most common interference is on the c. Gray Platelet Syndrome – characterized by large platelets
receptor site, prostaglandin o ABSENCE OF ALPHA GRANULES

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 Hematology II | MIDTERMS

▪ Abundant granules that can give pigment to the - death from infection, hemorrhage or malignancy is common
platelet before adulthood
o patients are prone to mild long deficiency - a defect in the surface glycoprotein sialophorin (CD43,
Wiskott-Aldrich Syndrome – an X-linked recessive disorder in gp115, leukosialin) has also been described in WAS
which patients shows triad of severe eczema, recurrent infections,
immune defects, thrombocytopenia and small platelets.

LESSON 7. HEMOSTATIC DISORDERS (DISORDERS OF PRIMARY HEMOSTASIS)

OUTLINE o Lesions may develop on the tongue, lips, palate, face,

I. Definition of Terms hands, nasal mucosa, and throughout the
II. Quantitative Platelet Disorder gastrointestinal tract
a. Disorder of Production c. Ehlers-Danlos Syndrome
b. Disorder of Destruction o Autosomal dominant
c. Disorder of Platelet Distribution and Dilution o The affected individual has hyperextensible joints and
III. Qualitative Platelet Disorder hyperplastic skin, which can be stretched much more
a. Acquired than normal skin, but which returns to normal on
release.
b. Hereditary
d. Marfan Syndrome
o Inherited disorder that affects connective tissue
o Increase vascular fragility
INTRODUCTION
o Most commonly affects the heart, eyes, blood vessels
A defect in any aspect of primary hemostasis can manifest as and skeleton.
hemorrhage, typically from mucosal surfaces (the sites where the e. Pseudoxanthoma elasticum/Gröenblad - Strandberg
primary platelet plug is important due to rapid fibrinolysis). Syndrome, Grönblad -Strandberg Syndrome
o Autosomal recessive
Hyperactivity in primary hemostatic components – a cause of o The connective tissue elastic fibers in small arteries
hypercoagulability and a risk factor for thrombosis are calcified and structurally abnormal
Defective primary hemostasis – platelet plug formation is 3. Acquired
inadequate with a defect in any primary hemostasis event, including a. Senile purpura/Solar purpura
thrombocytopenia o Acquired and chronic disorder of the elderly causing
- usually manifests as hemorrhage from small blood vessels abnormalities in connective tissues.
subjected to daily minor trauma, i.e. those supplying o Due to lost cutaneous fats and amount/quality of the
mucuosa (e.g epistaxis, hematuria). collagen.
- Hemorrhage can be spontaneous with severe defects or o Cases are thrombosis instead of bleeding
induced by trauma or surgery with milder defects. Since b. Scurvy - Vitamin C deficiency
platelets plug small holes in vessels, thrombocytopenia or o In absence of vitamin C collagen is weakened
abnormal platelet function (thrombopathia) can result in o Abnormal collagen results in defective perivascular
pinpoint mucosal or cutaneous hemorrhages (petechiae). supportive tissues, capillary fragility, delayed wound
Petechiae are not typical in vWD. healing, petechiae and purpura
- Bruises (ecchymoses) can also occur. c. Henoch-Schonlein purpura/ Purpura rheumatica
Hyperactive primary hemostasis – platelet hyper-reactivity and o Occurs primarily in children
increased vWf concentrations contribute to hypercoagulability, i.e. o Most distinct and universal sign: Reddish-purple spots
are risk factors for thrombosis, but are unlikely to induce thrombosis o Is an acute immunoglobulin A mediated disorder
alone. (Cornell University CVM, 2013) characterized by a generalized vasculitis involving the
small vessels of the skin, GI tract, kidney, joints and
DISORDERS OF PRIMARY HEMOSTASIS rarely lungs.
Involve in primary hemostasis:
1. Platelets B. VON WILLEBRAND FACTOR DISEASE
2. Blood vessels
3. vWF 1. Acquired
- Symptoms similar to those with congenital vWD
- Pathogenesis varies and may involve production of
A. VASCULAR DISORDERS antibodies or absorption of vWF to abnormal cell surface
1. Mechanical Force – most frequent cause of purpura - Manifests with moderate to severe mucocutaneous bleeding
- due to external pressure due to trauma
2. Congenital
2. Hereditary - Most prevalent of the congenital bleeding disorder
a. Congenital Hemangiomata/Congenital Hemangioma- - vWD is caused by any one of dozens germline mutation
Thrombocytopenia Syndrome/Kasabach-Merritt - Abnormal platelet function as a result of decrease vWF
o Excessive multiplication of endothelial cells - Abnormality in primary hemostasis or combined with mild to
o Congenital hemangiomas are equally common in boys moderate deficiency of factor VIII(vWF is the carrier of factor
and girls VIII)
o Two rare vascular tumors: Kaposiform - Qualitative or quantitative vWF abnormalities the
o Hemangioendothelioma (KHE) and Tufted Angioma reduced platelet adhesion
(TA) Type 1 vWD – quantitative vWD
b. Hereditary Hemorrhagic Telangiectasia/Osler-Weber- o Approximately 75% of patients with VWD
Rendu Disease/Rendu-Osler-Weber Syndrome o Mild to moderate bleeding
o Characterized by vascular malformations and skin Type 2 vWD – qualitative vWD
lesions o Levels maybe normal to moderate
o A connective tissue disorder associated with o Subtypes: 2A, 2B, 2M, 2N
telangiectases (skinlesions) (dilated capillaries) of the Type 3 vWD – produces severe mucocutaneous and anatomic
mucous membranes and skin. hemorrhage
o vWF is nearly absent or absent from plasma

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 LESSON 8. Hemostatic Disorders (Disorders of Secondary Hemostasis)

OUTLINE 3. Renal disease

I. Introduction o Chronic renal failure can lead to platelet
II. Disorders of Coagulation Causing Clotting Factor dysfunction
Deficiencies ▪ can lead to increase accumulation of
a. Defective Production toxin which can affect the platelet
i. Vitamin K Deficiency adhesion and aggregation
o Nephrotic syndrome- Excretion of coagulation
ii. Severe Liver Disease
factors in the urine (II,VII,IX,X,XII)
iii. Renal Disease
▪ ESRD final stage
iv. X-linked related ▪ increased glomerular permeability
b. Excessive Destruction or Increase Consumption allowing important proteins to be
c. Underlying Pathologic Disorder excreted
4. X-linked related
INTRODUCTION
o Factor deficiency - involved are factor VIII and
The Disorders of coagulation factors can be categorized
factor IX (8 and 9)
accordingly to defective production, excessive destruction or
o Factor 1 – autosomal dominant
involvement in pathologic disorders. Which we will be discussing
o Associated in mutation
for this lesson.
▪ Mostly affected is male because if they
• Autosomal Recessive Deficiencies other than coagulation have inherited the mutated X it will
factors are relatively RARE. manifest due to the one copy of X
o Examples of rare defects include factor ▪ Female are mostly carriers because
deficiencies, including factors I, II, V, VII, X, XI, they have two copies of X which can
XII, and XIII (1,2,5,8,10,11,12,13) as well as High compensate in case the other is in
Molecular Weight Kininogen (HMWK) mutated form
(Fitzgeral factor) and Prekallikrein (Fletcher
• It takes two abnormal X
Factor). Laboratory Screening Tests
chromosome for the disease
differentiates these factors.
to manifest which is very rare
Recall!
Coagulation Proteins – mainly involved in secondary hemostasis B. EXCESSIVE DESTRUCTION OR INCREASE
Fibrinogen (I, V, VIII, XIII) – all consumed during process of coagulation CONSUMPTION
Prothrombin (II, VII, IX, X) – vitamin K and calcium-dependent 1. Fibrinolytic system-protection to excessive fibrin deposit
Contact factors: XI, XII, prekallikrein (Fletcher Factor) and HMWK o Hyperactivity can lead to increase destruction of
(Fitzgerald Factor); these are involved in intrinsic coagulation pathway clot and coagulation factors involved
FACTOR XII DEFICIENCY- no apparent bleeding tendencies, look for 2. Excessive usage of coagulation factors
bleeding tendency o Increase consumption by obstetrical
Coagulopathy- imbalance on hemostasis that can lead to bleeding or complication, trauma, burn, shock or advance
clotting malignancies, septicemia (systemic bacterial
infection virulence factor released; leads to
Disorders of Coagulation Causing Clotting Factor Deficiencies
hypercoagulation) and intravascular hemolysis
A. DEFECTIVE PRODUCTION
(can prematurely activates coagulation; when
1. Vitamin K deficiency
specimen in blue top - centrifuged-plasma part-
o Disease related
pink or red- reject – hemolysed)
▪ malabsorption
▪ Biliary Obstruction - ADEK (fat-soluble
C. UNDERLYING PATHOLOGIC DISORDER
vitamin;bile acids to absorb)
1. Related pathologic diseases
▪ Neonates - Vitamin K is not synthesized
2. SLE (systemic lupus erythematosus), autoimmune disease,
by the body, they are acquired through
Malignant disorders (Myeloproliferative disease- blood
diet; Pregnant woman should intake
cancer)
double portions of Vitamin K
3. DIC (Disseminated Intravascular Coagulation) -increase
o Drug therapy
coagulation and fibrinolytic activity
▪ WARFARIN - can inhibit the synthesis
of Vitamin K, directly through inhibiting
Sex Linked Deficiencies
the enzyme that is involved in
1. FACTOR VIII/AHF
catalyzing the biological activity of
inactivated Vitamin K to become • Hemophilia A / Classic Haemophilia / Vwd (carrier
activated Vitamin K molecule of F8 in the plasma)
Remember: The vitamin K dependent factors Prothrombin group: *FACTOR 9 (Hemo. B), FACTOR 11 (Hemo. C) - group of hemophilia;
Factors: II, VII, IX, X (2, 7, 9, and 10) acts individually
- Common inherited coagulation factor deficiency - Hemo A- 85%
2. Severe Liver disease * VIII: vWF ratio
o Liver is the primary site for coagulation factors • Responsible gene: Chromosome X
synthesis, • Male is genetically afflicted; Female-carrier (if one is mutated
o Impacts primarily in coagulation and fibrinolysis , had spare to compensate the abnormal one)
▪ Key enzyme: PLASMIN, the activated • Gene deletion and point mutation.
form of plasminogen that is synthesized
• Signs and Symptoms (severe)
in the liver o hemathrosis (bleeding of joints) and cerebral
o Liver disease predominantly alters the production bleeding
of the Vitamin K-dependent
• TX (treatment)
▪ Adipose tissue as storage of Vitamin K

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 Hematology II | LESSON 8. Hemostatic Disorders (Disorders of Secondary Hemostasis

o recombinant factor VIII concentrate

Acquired (underlying reason) coagulopathy; because of: Differential Diagnosis of Abnormal Coagulation Screening Tests
✓ DIC - increased clot formation (1,2 5, 8, 13); 1. Abnormal Partial Thromboplastin Time (PTT) Alone
✓ Fibrinolysis - increased destruction; increased degradation • Associated with bleeding: VIII, IX, XI defects
of clot; (I,II) o 30+ seconds prolonged
• Not associated with bleeding: XII, PK, HMWK
LAB TEST:
• aPTT (prolonged) (intrinsic, 12,11,8,9) 2. Abnormal Prothrombin Time (PT) Alone
• History • Factor VII defects
• Mixing Study
o corrected by fresh plasma 3. Combined Abnormal PTT and PT
• Medical conditions: anticoagulants, DIC (common pathway
2. FACTOR IX / PTC (plasma thromboplastin component) def.), liver disease, Vitamin K deficiency, massive
• Autosomal recessive transfusion
• Hemophilia B/ Christmas disease (Stephen Christmas) • Rarely dysfibrinogenemia, Factor X, V and II defects
• Can be partial or complete deficiency
• Signs and Symptoms SUBSTITUTION TEST
o indistinguishable from factor VIII deficiency Fresh Aged Adsorbed Fresh Aged
• TX: Plasma Plasma Plasma Serum Serum
o column-purified plasma derived factor IX I + + + - -
concentrate II + + - + (<20%) -
Acquired (underlying reason) coagulopathy; because of: V + - + - -
✓ Liver disease VII + + - + +
✓ Vit. K deficiency VIII + - + - -
✓ Anticoagulant therapy - *warfarin
IX + + - + +
X + + - + +
LAB TEST:
XI + + + + +
• aPTT (prolonged)
XII + + + + +
• History
XIII + + + - -
• Mixing Study
o corrected by fresh plasma and serum but not • Fresh Plasma: all factors are present (except III and IV)
absorbed plasma • Aged Plasma: no factor V and VIII
• Adsorbed Plasma: no Prothrombin Group (II, VII, IX,X)
Acquired Coagulopathy • Fresh Serum: no Fibrinogen group (I,V,VIII,XIII) + few
FIBRINOGEN GROUP Thrombin
Factors: I, V, VIII, XIII (1, 5, 8, 13) - hyper clotting; destruction of clot • Aged Serum: no Fibrinogen group (I,V,VIII,XIII) + Thrombin
✓ Liver disease – primary site of fibrinolysis
✓ DIC Deficient
PT PTT TCT Reflex Test
✓ Fibrinolysis Factor
✓ Factors I, V, VIII and XIII, thrombin cleaves all four I Prolonged Prolonged Prolonged Fibrinogen Assay
coagulation factors in this group. They are consumed during Prothrombin V, VII, and X
II Prolonged Prolonged Normal
clotting and as a result, they do not exist in serum. assays
Prothrombin V, VII, and X
PROTHROMBIN GROUP V Prolonged Prolonged Normal
assays
Factors: II, VII, IX, X (2, 7, 9, 10) - vit K dependent grp VII Prolonged Normal Normal VII assay
✓ Liver disease VIII Normal Prolonged Normal VIII, IX, and XI assay
✓ Vitamin K deficiency IX Normal Prolonged Normal VIII, IX, and XI assay
✓ Anticoagulant therapy Prothrombin V, VII, and X
✓ The factors in the prothrombin group are vitamin K X Prolonged Prolonged Normal
assays
dependent in order to be functional. (Factors II, VII,IX and XI Normal Prolonged Normal VIII, IX, and XI assays
X) XIII Normal Normal Normal XIII quantitative assay
CONTACT GROUP
Factors: XI, XII, PK, HMWK Reading Assignment:
✓ Unclear 1. What is the gene responsible for Fibrinogen mutation?
TYPES OF COAGULOPATHY • FGA, FGB, or FGG
• TYPE I 2. What is the enzyme responsible for catalyzing vitamin K active form
o QUANTITATIVE / DECREASE COUNT (HYPO) / that can be inhibited by anticoagulant like warfarin?
ABSENCE (A) • vitamin K epoxide reductase (VKOR), y-glutamyl
o Hypo– : decrease count carboxylase (GGCX),
o A– : absence 3. Read in advance Hemostatic Disorders (Disorders of Fibrinolysis)
• TYPE II
o MOLECULAR ABNORMALITY / DYSFUNCTION
(DYS)
o Dys– : trouble on its function

UNCOMMON HEREDITARY CLOTTING DEFICIENCY

• Autosomal recessive deficiencies
• Factors I,II,V,VII,X,XI,XII,XIII (1, 2, 5, 7, 10, 11, 12, 13)
HMWK (needs two copies of abnormal/mutated gene to
disease to manifested) and PK
• Laboratory screening test differentiates these factors
o PT(extrinsic (Factor 7), aPTT (Intrinsic factors
8&9, 11 and 12(auto recessive), Thrombin time,
fibrinogen level

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Factor Inherited Coagulopathies Acquired Coagulopathy Laboratory Tests Other Information

Inheritance Pattern Coagulopathy

I -Autosomal recessive -Afibrinogenemia Liver disease • aPTT, PT (prolonged),TT ✓ Type 1: decrease level
-Autosomal dominant -Hypofibrogenemia DIC • FIBRINOGEN LEVEL ✓ Type 2: dysfunction of molecule
-Dysfibrinogenemia Fibrinolysis • Platelet aggregation test ✓ most abundant
• Mixing study coagulation factor
✓ still bleeding
II -Autosomal recessive -Prothrombin Liver disease • LAB TEST ✓ Type 1 and Type 2
deficiency Vit. K deficiency • aPTT and PT (prolonged) ✓ Hypoprothrombinemia and
Anticoagulant therapy • MIXING STUDY dysprothrombinemia
- Fresh plasma ✓ Prothrombin 202010a mutation(
- not corrected by VTE) increase plasma
absorb plasma prothrombin
V -Autosomal recessive -Owren’s disease Liver disease • Prolonged aPTT and PT ✓ Associated with alpha granules
-Labile factor DIC • Mixing Study def.
deficiency Fibrinolysis ✓ The great platelet syndrome*
-Parahemophilia
VII -Autosomal recessive -Factor VII deficiency Liver disease • aPTT and PT ✓ Type 1 and Type 2
-Alexander’s disease Vit. K deficiency • Mixing Study
Anticoagulant therapy

VIII -X-linked recessive -Hemophilia A DIC ✓ Common inherited coagulation

-Autosomal dominant -Classic hemophilia Fibrinolysis factor deficiency
-vWD ✓ Hemophilia A/Classic
hemophilia/Royal disease =
Queen Victoria’s son
✓ Male is genetically afflicted
✓ Female=carrier
✓ Gene deletion and point
mutation.
✓ S&S, hemathrosis and cerebral
bleeding
IX -Autosomal recessive -Hemophilia B Liver disease ✓ Can be partial or complete
-Christmas disease Vit. K deficiency deficiency
Anticoagulant therapy ✓ S&S,indistinguishable from
factor VIII deficiency
X -Autosomal recessive -Factor X deficiency Liver disease • aPTT,PT,RVVT ✓ World’s most rare factor
Vit. K deficiency • Mixing Study deficiencies
Anticoagulant therapy • *combined def/ multiple ✓ Type 1 and Type 2
factor def
XI -Autosomal recessive -Hemophilia C Unclear • -aPTT (prolonged), PT
-Rosenthal syndrome (normal), RVVT
(MIESCHER- • Mixing Study -corrected by
MELKERSSON RS) all
- Common in
Jewish descent/
Ashkenazi Jews
XII -Autosomal recessive Factor XII deficiency Unclear • -aPTT (pRolonged) ✓ Do not suffer from a bleeding
• Specific factor assay dx disorder-benign to
• Mixing STudy asymptomatic
• all corrected ✓ may be vulnerable to excessive
clotting/thrombosis
✓ COMMON IN ASIANS
✓ IF THERE IS OR NO
BLEEDING TENDENCIES

XIII -Autosomal recessive Factor XIII deficiency Liver disease • 5M UREA CLOT LYSIS ✓ Associated with spontaneous
DIC abortion and poor wound
Fibrinolysis healing
✓ Deficiency does not affect
APTT and PT, TT
✓ 5-M urea solution
PK -Autosomal recessive Fletcher trait Unclear • aPTT Possible prolonged ✓ Mutation of klkb1 gene
PKK deficiency or ✓ No history of abnormal bleeding
fletcher factor tendency
deficiency ✓ No history of abnormal bleeding
tendency
✓ Associated with an inhibitor to
clot that promotes activities of
glass like surface
✓ Prolonged APTT normal PT
HMWK -Autosomal recessive Fitzgerald trait - true Unclear ✓ Do not have hemorrhagic
high molecular tendencies
Williams trait/flaujeac ✓ Prolonged APTT
trait - both high
molecular kininogen
and low is deficient

*Factor VII and X – can be found in combined deficiency

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Hematology II | LESSON 8. Hemostatic Disorders (Disorders of Secondary Hemostasis

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 LESSON 9. HEMOSTATIC DISORDERS (DISORDERS OF FIBRINOLYSIS)

OUTLINE DISORDERS OF FIBRINOLYTIC SYSTEM

I. Introduction A. HEREDITARY
II. Disorders of Coagulation Causing Clotting Factor
1. Deficiency in Plasminogen
Deficiencies
a. Defective Production
TYPE I
i. Vitamin K Deficiency
- Quantitative
ii. Severe Liver Disease
- Also known as CONGENITAL PLASMINOGEN
iii. Renal Disease
DEFICIENCY
iv. X-linked related o Mainly affects the conjunctiva of the eye
b. Excessive Destruction or Increase - Autosomal recessive – it takes two mutated gene to manifest
Consumption the disease, thus rare
c. Underlying Pathologic Disorder - Due to PLG GENE MUTATION – responsible for instruction
in coding plasminogen
- More common
Recall!
Fibrinolysis – last stage of hemolysis Ligneous conjunctivitis – commonly associated with decrease level
- Key enzyme involved: plasmin of plasminogen
- Conjunctivitis – inflammation of conjunctiva
INTRODUCTION - Ligneous – came from the Latin word Lignum which means
“wood”
Primary and secondary fibrinolysis are recognized as extreme - Eyelids with thick, woody growths on the conjunctiva of the
complications of variety of intravascular and extravascular disorders eye
and may have life threatening consequences.
TYPE II
Primary fibrinolysis is associate with conditions in which gross - Qualitative
activation of the fibrinolytic mechanism with subsequent Fibrinogen - Usually asymptomatic, and does NOT lead to a specific
and coagulation factor consumption occurs. clinical manifestation
- important characteristic of primary fibrinolysis is that no - Sufficient for normal wound healing
evidence of fibrin deposition occurs.
- occurs when large amount of plasminogen activator enters 2. Deficiency in Plasminogen Activator Inhibitor (PAI-1
the circulatory system as a result of trauma, surgery and Deficiency)
malignancies. - Rare disorder
- Although the same clinical conditions may also induce - Autosomal recessive disorder
secondary fibrinolysis or DIC, the distinction between the two - Leading to bleeding tendencies
is essentially in the demonstration of fibrin formation. - Involved gene mutation: SERPINE-1 GENE
- Follow circadian rhythm for collection – peaks at morning
In secondary fibrinolysis, excessive clotting and fibrinolytic activity
occur. Recall!
- Increased amounts of fibrin split products (FSPs/FDPs) and PAI-1 – principal inhibitor/regulator of two endogenous plasminogen
fibrin monomers are detectable because of the action of activator: tissue plasminogen activator and urokinase plasminogen
thrombin activator)
- On fibrinogen molecule. This fibrinolytic process is only
caused by excessive clotting therefore, it is secondary
B. ACQUIRED
condition. (M. Turgeon, 2012)
Recognized as extreme complication of variety of intravascular and
extravascular disorder
Physiological fibrinolysis occurs in an orderly fashion, producing
measurable products that can be captured by laboratory assays.
1. Primary Fibrinolysis
- Specifically, the by-products of an orderly fibrinolytic system
- defects as in severe liver diseases and malignant tumors
are fibrin split/degradation (FSP/FDP) products composed of
- increase amount of plasminogen (PA) released from a
fibrin fragments labeled as X, Y, D, and E and the D-dimers,
damaged/malignant cells
D-D.
- converts plasminogen to plasmin in the ABSENCE OF
FIBRIN FORMATION
The accurate and precise measurement of these products is the
- ABSENCE of:
basis for therapeutic decisions once pathological clot forming and
o Fibrin polymer
lysing has been initiated. FSPs/FDPs are formed from plasmin action
o Fibrin monomer
on fibrin and fibrinogen. As plasmin degrades the fibrinogen molecule,
o D-dimer
different fragments are split leading to early and late degradation
products. Pathological levels of FDPs interfere with thrombin
2. Secondary Fibrinolysis
formation and platelet aggregation. Elevated levels may be seen in
- defects as in DIC
DIC, pulmonary embolism, obstetrical complications, and other
- excessive clotting and bleeding
conditions. Individuals with an intact and operational hemostatic
- mostly seen in Disseminated Intravascular Coagulation (DIC)
system have normal FDPs.
- Also seen in: Infections, Neoplasms, Snake bite and HTR
- PRESENCE of:
o Fibrin monomer
o Fibrin polymer
o D-dimer

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 Hematology II | Lesson 9. Hemostatic Disorders (Disorders of Fibrinolysis)

Conditions that may elevate fibrin degradation product TESTS OF FIBRINOLYSIS

o DIC
o Pulmonary embolism EUGLOBULIN CLOT LYSIS TIME
o Abruptio placentae Euglobulin is a portion of plasma which consist of plasminogen,
o Preeclampsia plasminogen activators and fibrinogen
o Eclampsia - Normal Result if there is no clot lysis even after two hours
o Fetal death in utero - Increased fibrinolysis if there is clot lysis in less than two
o Polycystic disease hours
o Postpartum hemorrhage
o Malignancies ETHANOL GELATION TEST
o Lupus nephritis - Determines fibrin monomers
o Thrombolytic therapy - Result: precipitation

DISSEMINATED INTRAVASCULAR COAGULATION LATEX AGGLUTINATION TEST FOR D-DIMER

Disseminated Intravascular Coagulation – also known as - Most specific for DIC
CONSUMPTIVE COAGULOPATHY (due to association to - Uses coat latex (Anti-D-dimer antibodies)
spontaneous coagulation where, coagulation factors are decreased) - Result: turbidity
- serve as a complication or an intermediary phase of many - **Most methods can detect at las low as 10ng/mL of D-dimer
diseases process involve coagulation factors, platelets,
vascular endothelial cells and fibrinolysis. PROTAMINE SULFATE
- associated with obstetrical complications, malignancy, - Detects fibrin monomers
massive trauma, bacterial sepsis, asplenia, or necrotic tissue. - Plasma with protamine sulfate
- increasing fibrin degradation product (D-D fragements) - Result: Positive if there is a gel-like clot
- FDP (X, Y, D, E and D-dimer)
- detected by D-DIMER POSITIVE TEST D-DIMER TEST
- mechanism varies, it can either between coagulation and
fibrinolysis.

Several Types of DIC

1. DIC: Clotting and lysis strongly activate
2. DIC: Clotting predominates with little or no lysis (poor prognosis)
3. Only lysis is activated but many coagulation factors are consumed

ACUTE DIC
- Rapid onset/sudden
- Severe and life threatening
- Both fibrinogen and platelet may be both depleted

CHRONIC DIC
- Mild manifestation
- May only be detected by laboratory data
- Hemorrhagic complication may be seen
- Activated thrombin activates the fibrinolytic system with the
production of plasmin at the site of the clot.
DIC causes
- Plasmin lyses the fibrin and produces FDP that contain the
o Sepsis portion called D-dimer.
o Blood transfusion reaction - Plasmin will also lyse fibrinogen, but will NOT produce the D-
o Cancer, especially acute promyelocytic leukemia dimer.
o Pregnancy complications (retained placenta) - The presence of D-dimer indicates that a STABLE FIBRIN
o Recent surgery or anesthesia CLOT HAS BEEN LYSED
o Severe liver disease - Which can be found in
o Severe tissue injury (as in burns and head injury) o Pulmonary embolism
o Deep vein thrombosis
LABORATORY DIAGNOSIS o DIC
o Presence of schistocytes, although not all types can manifest o Arterial thromboembolism
schistocytes o Sickle cell disease
▪ Part of RBC anomaly: Microangiopathic Hemolytic
Anemia (MAHA)
Remember!
o Thrombocytopenia – decreased platelet count Emboli vs Thrombi
o Prolonged clotting times (PT, APTT)
Emboli – movable clot; fragmented thrombus
o Presence/ prolonged of Fibrin degradation products and D-
Thrombi – fixed clot
dimer
o Low levels of coagulation inhibitors
o Low levels of coagulation factors FSP/FDP D-dimer
o Fibrinogen levels not useful diagnostically but low Other pathological
+ -
fibrinolysis
DIC + +

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