HEMOSTATIC PHYSIOLOGY

Mansyur Arif
Dept. of Clinical Pathology
Fac.of Medicine,Hasanuddin University,
Makassar

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 Regulation of hemostatic
mechanism involves complex
interaction between vessels walls,
blood cell elements and a variety
of plasma proteins.

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Blood clotting results from :
1. Interaction between endothelial cells
and platelets  the primary hemostatic
plug.
2. The coagulation phase  thrombin is
generated & fibrin develops
3. Formation of peptide bonds 
stabilization of the fibrin network.

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 Fibrinolysis is the process of
enzymatic degradation of fibrin
clots whereby : coagulation activity
is limited to the area surrounding
vessels wall injury and patency of
vessels is maintained or restored

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 Bilipid membrane

1. Glycoprotein Ib (GP Ib). MW of about

140 kD. It serves as the binding site
for vWf.
2. Glycoprotein IIb-IIIa (GP IIb-IIIa).
A prominent Ca-dependent membrane
protein complex that function as a
fibrinogen receptor.

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 Platelet Physiology
When a blood vessels is injured:
• Subendothelial tissue is exposed.
• PLT adhere to subendothelial tissue.
• Adherence mediated by vWf form a
bridge between subendothelial tissue
and GP Ib.
• Thrombin stimulates membrane
phospholipids to release arachidonic acid

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 Platelet Physiology

• AA is converted to cyclic endoperoxides

and TxA2.
• Stimulate granules and dense bodies.
• High concentration locally thrombin,
TxA2 and ADP will change GP IIb-IIIa
becomes receptor for fibrinogen to
forms a bond between adjacent PLT
creating a hemostatic plug.

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 Phospholipid
Phospholipase
Arachidonic acid
Cyclo-oxygenase
(aspirin inhibits)
PGG2
Peroxidase
PGH2
Thromboxane synthetase Prostacyclin synthetase
(platelets) (endothelium)
TxA2 PGI2
H2O
TxB2 6-keto PGIa

Fig. 1. Arachidonic acid metabolism in platelets endothelium.

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 Endothelium Contribution

• Metabolize AA to Prostacyclin (PGI2).

• PGI2 has major contribution as
antithrombotic in intact endothelium.
• Low dose aspirin completely block TxA2
production.

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Coagulation phase :
1. Conversion of fibrinogen (soluble plasma
protein) into insoluble fibrin  affected
by highly specific enzymatic action of
thrombin.
Thrombin must be generated from
zymogen, prothrombin, by a series of
reactions between serine proteases, co
factors & lipid moieties.

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 2. Coagulation factors may be group as
follows : contact factors, thrombin -
sensitive factors, & vit K- dependent
factors.
Classically, the generation of thrombin
is described as occuring through the
“extrinsic” or “intrinsic” systems.

Table 1 summarizes the features of the

coagulation factors.

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Table 1. Plasma coagulation factors

Factor Alternative name Path- Half-life

way (hours)
I Fibrinogen C 90-120
II Prothrombin C 48-120
III Tissue factor I Not available
V Proaccelerin C 12-24
VII Proconvertin E 2-6
VIII Antihemophilic factor I 10-12
IX Christmas factor I 18-30
X Stuart - Prower factor I,E,C 24-60
XI Plasma thromboplastin antecedent I 45-80
XII Hageman factor I 40-70
XIII Fibrin - stabilizing factor I 72-200
HMW kininogen Fitzgerald factor I 150
Prekallikrein Fletcher factor I 48-52

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Coagulation systems :
1. The extrinsic systems : triggered by TF/
tissue factor (complete thromboplastin).
- TF + VIIa + Ca  activates F X (F Xa)
- F Xa + V + Lipid (TF)  extrinsic pro-
thrombinase (converts prothrombin
 thrombin). (Fig 1).

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 Prothrombin
TF
VIIa

(Ca 2+)
Xa
X
V
Lipid (TF)
(Ca 2+) Test : PT

(Quick)

Thrombin

Fig.1. Generation of thrombin via the extrinsic system. (TF = tissue fct ;
PT = prothrombin ; = prothrombin complex ; = F X activating
complex).
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2. The intrinsic system :
a. Contains all the elements necessary for
clotting.
b. Instead of tissue thromboplastin, the lipid
moiety in this system is PF3.
c. The contact fcts (F XII, XI, prekallikrein/PK,
High Molecular-Weight Kininogen/HMWK)
are activated by exposure to negatively
charged glass surfaces & other substances
(ellagic acid,uric acid crystals,skin,collagen
& antibody complexes)
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d. - F XIIa in the presence of PK and
HMWK activates F XI.
- F XIa activates IX, which in a complex
with VIII, lipid (PF3) and Calcium
activates F X.
- F Xa, V and lipid (PF3) comprise
“intrinsic prothrombinase”. (fig. 2).

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 Contact factors Prothrombin
PK
XII XIIa
HMWK

XI

XIa IXa
IX VIII
PF3
(Ca 2+)
Xa
X V
Lipid (PF3)
Test : aPTT
(Ca 2+)
Thrombin

Fig.2. Generation of thrombin via the intrinsic system. (PK = prekallikrein; HMWK/
high molecular weight kininogen ; PF3 = platelet factor 3 ; aPTT = activated
partial thrombplastin time ; = prothrombinase complex ; = F X activa-
ting complex.
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e. - Screening test : aPTT screens for all
the coagulation factors except F VII.
- intrinsic & extrinsic pathways
converge at the F X and V level.
- A coagulation factor deficiency (or
inhibitor) at this level results in
abnormal screening test for both
system.

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 Prothrombin
Intrinsic system Extrinsic system
IXa
VIII VIIIa
PF3

Xa Xa
V Va Va V
PF3 TF

Thrombin

Fig.3. Autocatalytic action of thrombin. (TF= tissue fct ; PF3 = platelet fct 3)
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 Prothrombin
Intrinsic system Extrinsic system

XIa TF
VIIa

IXa (Ca2+)
IX VIII
PF3
(Ca2+)

X Xa

Thrombin
Fig. 4. Linkage between extrinsic and intrinsic systems. Several interaction
occur at various levels of the two systems. Primary among these is the
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ability of TF and F VIIa and F IX.
• Protein C along with its cofactor, protein
S, degrades F VIIIa and Va.
• Plasmin is neutralized primarily by
2 - antiplasmin.

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 Plasminogen
Intrinsic system Extrinsic system

Contact
XII XIIa
HMWK
Exogenous

Prekallikrein Kallikrein TPA Urokinase

Streptokinase

Plasmin

Fig.7. The fibrinolytic system. Plasmin, the active fibrin(ogen)olytic enzyme,

is generated by activation of plasminogen as shown.
= plasminogen activator.
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INTRINSIC SYSTEM
HMWK
XII XII a
Kallikrein

XI XIa EXTRINSIC SYSTEM

VII
IX IXa + VIII TF
Ca 2+ Ca 2+ Ca 2+
PL

X Xa + V
Ca 2+
PL
Prothrombin Thrombin

Fibrinogen Fibrin

XIII XIIIa Stable fibrin clot

Ca 2+
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• Symptoms of mucosal bleeding, such as
epistaxis, gum bleeding, hematochezia,
melena, petechiae, or easy bruising 
signs of defective primary hemostasis
secondary to thrombocytopenia, pletelet
dysfuntion, or abnormalities of von
Willebrand factor (vWF)

• Hemarthroses, i.m hemorrhage, bleeding

into deeper structure  >> secondary
hemostasis disorder with a coag. factor
deficiency or dysfunction
 Laboratory test in the work up of
coagulation disorder
• The first lab test : CBC (+peripheral
slide), PT, aPTT, Thrombin Time (TT) .
• aPTT  activity of intrinsic factor
• PT  activity of extrinsic factor
• TT  common pathway
Bleeding time  <<, but evaluate
problems with primary hemostasis
CBC  first step in evaluation of bleeding patient
 thrombocytopenia, anemia, leukocytosis
or leukopenia implicate a hematologic
malignancy  cause of patient’s
coagulopathy or thrombocytopenia.
PB evaluation  platelet clumping and
WBC morphology
Coagulation Test
(PT, APTT, FIB, TT)
 TESTS OF COAGULATION SYSTEM

Screening Test
1. Partial thromboplastin time (PTT) and
activated partial thromboplastin time (aPTT)
2. Prothrombin time (PT)
3. Quantitative fibrinogen
4. Thrombin time (TT)
5. Screening test for factor XIII
6. CBC
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No Test Platelet Condition
PT APTT TT count
1 Long N N N Factor VII deficiency
Early oral anticoagulant

2. N Long N N Factor VIII, IX, XI, XII deficiency

Prekallikrein, HMWK deficiency
Von Willebrand’s disease
Anticoagulant

3. Long Long N N Vitamin K deficiency

Oral anticoagulant
Factor V,VII, X dan II deficiency

4. Long Long Long N Heparin

Liver disease
Fibrinogen deficiency
Hyperfibrinolysis

5. N N N Low Thrombocytopenia

6. Long Long N Low Massive transfusion

Liver disease

7. Long Long Long Low DIC

Acute liver disease

First-line tests used in investigating acute haemostatic failure

 THANK YOU

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25-Sep-18 30
III. CONGENITAL HEMORRHAGIC DISORDER
A. Hemophilia A (factor VIII deficiency) and
Hemophilia B (factor IX deficiency)
1. Pathophysiology :
X chromosome, gene defect.
2. Clinical features :
mild, moderate and severe disease
3. Diagnosis :
a. screening tests
b. specific factor assay
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4. Therapy : to raise the deficient factor

a. Pharmacologic therapy :

1. Hemophilia A : Desmopressin (dDAVP)

2. Hemophilia B : no effective drugs

b. Replacement therapy :

1. Beware of adverse effects

2. The choice of blood product is critical

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 c. Treatment options :
1. Fresh frozen plasma (FFP)
2. Cryoprecipitate
3. Factor concentrates
5. Complication : Arthropathy, Inhibitors,
Liver disease, HIV infection.
6. Interdisciplinary care  hemophilia center
medical care, psychosocial care and
genetic counseling
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 B. von Willebrand’s disease

1. Physiology of vWF :
- HMW glycoprotein, 250 kD
- In plasma and in platelets
- as a carrier protein for coag. F VIII
- important for primary hemostasis
- mediates adhesion of platelets to the s.endot
- vWF – F VIII complex : F VIII : C, F VIII : Ag,
F VIII : Cag, F VIII : RCof.
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2. Clinical features : >> mucous membrane
bleeding, epistaxis, menorrhagia
3. Diagnosis :
- Combination of prolonged BT and a
decreased F VIII : C level  classically
- Combination of abnormalities of the functional
measures of the vWF – F VIII complex 
variants of vWF (see table 2)
- Ristocetin aggregation
- Diff. of type  F VIII multimer analysis :
type I, IIA, IIB, IIC, III.
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Table 2. Laboratory Findings in Hemophilia A
and Severe vWF Disease

Labotatory test Finding

Hemophilia A vWF disease
Bleeding time Normal Prolonged
VIII : C Decreased Decreased
VIII : Ag Normal Decreased
VIII : RCof Normal Decreased

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 4. Therapy
a. dDVAP
b. Cryoprecipitate
c. F VIII concentrates

C. Other inherited factor deficiencies

1. F XII, prekallikrein and HMWK
2. F I, II, V, VII, X, XI and XIII

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IV. ACQUIRED HEMORRHAGIC DISORDER
A. Vitamin K deficiency
1. Etiology
a. dietary deficiency
b. malabsorption
c. antibiotic therapy
d. hemorrhagic disease of the new born
2. Clinical features : severe bruising or
excessive bleeding or asymptomatic

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 3. Diagnosis
- severe : prolonged PT and PTT
- early or milder def. : prolonged PT
4. Therapy
- Parenteral vit. K
- FFP
B. Liver disease
1. Etiology
a. decreased synthesis of coag. factors
b. Vit. K def
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 c. Functionally abnormal fibrinogens
d. Disseminated Intravasc. Coagulation
(DIC) and consumption of coag. factors
2. Clinical features
- vary with the course of the patient’s liver
disease
- >> GIT bleeding
3. Diagnosis
- Lab. findings  varies widely
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 4. Therapy
- trial of parenteral vit K therapy
- Replacement therapy  FFP
C. Clotting factor inhibitors  autoantibodies
1. Inhibitors in hemophilia
2. Inhibitors in patients without preexisting
bleeding disorders
a. Etiology : drugs, autoimmune or
lymphoproliferative disorders,
spontaneous a.coagulants
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 b. Diagnosis : mixing study, factor assays
c. Therapy : supportive
3. Lupus anticoagulant  cardiolipin
a. Prolonged PTT, false + serologic test
b. associated with recurrent spont.abortions.

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COAGULATION REGULATION AND
HYPERCOAGULABLE STATES

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I. CONTROL MECHANISMS IN COAGULATION

A. Naturally occuring a.coagulants

1. Antithrombin III (AT III)  acts as a serine
protease inhibitor
2. Protein C, Protein S  Vit K – dependent
3. Other plasma protease inhibitor : heparin
cofactor II, 2- macroglobulin.

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B. Fibrinolitic system

1. Activation :
a. Intrinsic activation : a poorly understood
mechanism of activation
b. Extrinsic Activation : Tissue plasminogen
activator (t-PA), urokinase
c. Exogeneous (therapeutic) activation :
streptokinase, urokinase and t-PA
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2. Sites of action
a. Fibrinogen
b. Fibrin

II. THROMBOTIC DISORDER

A. Congenital thrombotic disorder
1. AT III deficiency
2. Protein C deficiency
3. Protein S deficiency

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B. AQUIRED THROMBOTIC DISORDER
 THROMBOEMBOLIC DISEASE
1. Risk factors :
a. abnormalities of blood flow
b. abnormalities of the vasculature
c. abnormalities of the coagulation system
2. Clinical manifestations :
a. Venous thrombosis
- superficial thrombosis
- deep vein thrombosis
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 b. Pulmonary embolism
c. Arterial thrombosis
d. Other
4. Therapy
a. Agents  treatment and prevention
1. Anticoagulants :
- Heparin
- Warfarin
2. Thrombolytic agents :
- Streptokinase
- Urokinase
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- t-PA 48
b. Treatment approaches
1. Deep vein thrombosis : >> heparin,
thrombolytic agent
2. Pulmonary embolus : heparin, thrombolytic
agent
3. Myocardial infarction : thrombolytic agent
4. Peripheral artery and catheter thrombosis :
thrombolytic agent.

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III. THROMBOHEMORRHAGIC DISORDER

A. Disseminated intravascular coagulation(DIC)

1. Pathophysiology (see table 3)
a. Initiation : pathologic activation of
the coag. cascade
b. Thrombosis
c. Consumption
d. Fibrinolysis
e. Hemolysis
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Table 3. Conditions that commonly precipitate DIC
Infectious condition
Gram negative septicemia
Other endotoxin-related condition
Obstetric conditions
Abruptio placentae
Amniotic fluid embolism
Retained dead fetus
Vascular conditions
Aneurysm
Giant cavernous hemangioma
Hematologic conditions
Massive hemolysis
Promyelocytic leukemia
Snake venom
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2. Clinical features  varies widely
a. diffuse bleeding from multiple sites
b. thrombotic lessions
3. Diagnosis  lab. findings vary with time &
circumstances
Severe DIC :
a. Thrombocytopenia
b. Prolonged PT, PTT, TT
c. Decreased fibrinogen
d. FSPs
e. Microangiopathic hemolytic anemia
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4. Therapy :
a. Low grade DIC  treatment may not
be necessary
b. Clinically significant bleeding 
replacement of depleted coagulation
factors and cells
c. Thrombosis : heparin
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B. Thrombotic thrombocytopenic purpura
(TTP) and hemolytic-uremic syndrome
(HUS)
C. Heparin thrombocytopenia

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 THANK YOU

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