All coagulation disorders

1. APPROACH TO
COAGULATION DISORDERS
Dr.K.Pavithran, MD, DM
Assistant Professor,Dept of Hematology
Medical College Hospital
Trivandrum-695011, India

2. Clinical approach
1. Is the bleeding significant ?
2. Local Vs Systemic ?
3. Platelet Vs Coagulation disorder ?
4. Inherited Vs Acquired ?

3. 1. Demonstration of the defect
2. Identification of the defect(s)
3. Assessment of severity
4. Consequential studies eg. carrier detection
5. Monitoring of treatment
Laboratory Approach

4. 1. Platelet count & morphology
2. Bleeding Time
3. Clotting Time
4. Prothrombin Time
5. Activated Partial Thromboplastin Time
6. Thrombin Time
Screening Tests

5. Collection of blood sample
1. Minimum circulatory stasis
2. Clean venous puncture
3. Proper anticoagulant
4. Proportion of blood to anticoagulant
5. Separation of plasma and storage
6. Effect of stress, pregnancy, drugs
7. Effect of PCV on the proportion of plasma
to anticoagulant

6. • Coagulation factor deficiency/inhibitor
• Test plus control plasma - 1:1
• Repeat PT/APTT
• > 50% correction
– Yes - Factor deficiency
– No - inhibitor
Prolonged PT/APTT
timed incubation
abnormally increasing
specific inhibitor
no change
Lupus Anticoagulant

7. PT
TT
APTT
PT - 
APTT, TT, PLC - N
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I
* Factor VII deficiency
* Anticoagulant therapy

8. APTT - 
PT, TT, PLC - N
* Factor deficiency
* vWD
* Inhibitors
* Heparin therapy
PT
TT
APTT
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I

9. Mixing tests with APTT
APTT of test plasma +
Aged plasma Adsorbed plasma Diagnosis
No correction Corrected VIII
Corrected No correction IX
Corrected Corrected XI,XII

10. Prolonged APTT, BT
von Willebrand’s disease
Ristocetin Induced Platelet Agglutination
VIII:C
vWF:Ag
vWF multimeric analysis
Type 1 - Partial deficiency of vWF
2A - Absence of large and interm. multimers
2B - Absence of large multimers
2M- multimers normal, pl. function 
2N -  affinity for FVIII
3 - severe deficiency of vWF

11. PT
TT
APTT
PT, APTT - 
TT, PLC - N
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I
* Common Pathway Factor deficiency
* Vitamin K deficiency
* Oral anticoagulant therapy
* Liver disease

12. Mixing tests with PT
PT of test plasma +
Aged plasma adsorbed plasma Diagnosis
Corrected Not corrected X
Not corrected Corrected V
Not corrected Partial II

13. PT
TT
APTT
PT, APTT, TT - 
PLC - N
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I
* Hypo / dysfibrinogenemia
* Heparin
* Liver disease
* Systemic hyperfibrinolysis

14. PT
TT
* DIC
- FDP
- D-dimer
- Fibrin monomer
APTT
APTT, PT,TT all 
PLC - low
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I

15. PT
TT
APTT
PT, APTT- 
TT - N
PLC - 
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I
Massive transfusion
with stored blood

16. Thrombocytopenia
Pseudo vs True
Bone marrow biopsy to differentiate
 production
 destruction
PT
APTT
PT, APTT,TT-N
PLC - 
HMWK
XII
PK
XI
IX
VIII
VII
X
V
II
I TT

17. • Factor XIII deficiency
• Thrombasthenia
– congenital
– drug induced
• Disorders of vascular
hemostasis
• Factor XIII - clot
solubility
PT, APTT, TT, PLC - Normal
• Platelet function
– BT
– clot retraction
– 1 minute platelet count
– aggregation
• Tourniquet test

18. Asymptomatic Patient
Routine screening tests shows
prolonged APTT
– Inhibitor - lupus anticoagulant
– Factor XII deficiency
– Mild congenital factor deficiency

19. Antiphospholipid Antibody Syndrome
Criteria by Branch and Silver 1996
• Clinical
– Recurrent abortion
– Recurrent venous
thrombosis
– Recurrent arterial
thrombosis
– Persistent
thrombocytopenia
– Livedo reticularis
• Laboratory
– IgG/IgM anticardiolipin Ab
– Lupus anticoagulant
• Diagnosis
– 1 clinical + 1 lab criteria
– Lab result must be positive
on at least 2 occasions
more than 3 months apart

20. • Kaolin clotting time
• Dilute Russel’s viper venom time
• Platelet neutralization test
• Tissue thromboplastin inhibition test
Lupus Anticoagulant