These slides briefly tell about the bleeding disorders, their classification and diagnosis .

1. Presented by:
Rajat Hegde
BLEEDING DISORDERS:
CLASSIFICATION AND DIAGNOSIS

2. CONTENTS
 Introduction
 Hemostasis
 Coagulation cascade
 Classification
 Diagnosis
 Laboratory tests
 Conclusion
 References

3. INTRODUCTION
• Bleeding disorders are rare disorders affecting the way the body
controls bleeding.
• Excessive bleeding can result from:
1. Increased fragility of vessels
2. Platelet deficiency or dysfunction
3. Derangement of coagulation
• The normal hemostatic response involves the blood vessel wall, the
platelets and the clotting cascade.
• Various laboratory tests are used in evaluation of a bleeding
diathesis.

4. Blood vessel injury triggers the following sequence:
1. Vessel constriction.
2. Circulating platelets adhere to vessel.
3. A series of enzymatic reactions involving coagulation proteins,
produces fibrin to form a stable hemostatic plug.

5. HEMOSTASIS
Hemostasis is the mechanism that leads to cessation of bleeding from
a blood vessel.
Primary Hemostasis:
• Platelet plug formation at sites of injury.
Secondary Hemostasis:
• Plasma coagulation system reaction resulting in fibrin formation.

6. COAGULATION CASCADE

8. CLASSIFICATION
I) Coagulation Factor Deficiency:
Congenital:
• Hemophilia A and B
• von Willebrand Disease
• Other factor deficiencies
II) Fibrinolytic Defects:
• Streptokinase therapy
• DIC
Acquired
• Liver disease
• Vitamin K deficiency
• DIC

9. III) Vascular Disorders:
• Scurvy
• Purpura
• Hereditary hemorrhagic telangiectasia
• Cushing syndrome
• Ehlers Danlos syndrome

10. IV) Platelet Disorders:
1] Quantitative Disorders (Thrombocytopenia):
2] Qualitative Disorders:
Congenital:
• Glanzmann thrombasthenia
• von Willebrand disease
Acquired:
• Liver disease
• Drug-induced
• Alcoholism
Immune Mediated:
• Idiopathic
• Collagen vascular disease
• Sarcoidosis
Non-Immune Mediated:
• Microangiopathic hemolytic anemia
• Leukemia
• Myelofibrosis

11. DIAGNOSIS OF BLEEDING DISORDERS
Terminologies:
• Petechiae: small, pinpoint bleeding spot, measures 1-2 mm.
• Purpura: red, non-blanching maculo-paular lesions caused by
intradermal capillary bleeding. Measures ≥ 3mm.
• Ecchymosis: A discoloration of skin resulting from bleeding
underneath, typically caused by bruising. Measures ≥ 1cm.
• Hematoma: A pool of partially clotted blood in an organ, tissue or
body space, usually caused by a broken blood vessel.

12. • It’s important to have relevant clinical information before
interpreting results.
• From the history, it’s important to differentiate hereditary
disorders from acquired.
• Hereditary disorders generally start from an early age or
recurrent in nature and may have family history.
• Acquired disorders on the other hand occur at any age and have an
underlying predisposing cause.
• Depending on type of bleeding, it’s important to differentiate
between platelet and factor bleeds.

13. • History of medication should include replacement therapy, use of
anticoagulants like heparin besides intake of analgesics and
antibiotics etc.
• In general, symptoms of:
1. Platelet bleeds: petechial hemorrhage, mucosal bleed.
2. Coagulation factor disorders: deep abdominal bleeds, muscle
bleeds, hemostasis, ecchymotic patches.

14. LABORATORY TESTS
• Bleeding time
• Clotting time
• Platelet count
• Activated partial thromboplastin time (aPTT)
• Prothrombin time (PT)
• Thrombin time (TT)
• D-dimer
Bleeding Time:
• It’s the time from puncture of skin and stoppage of blood oozing out.
• Normal Range: 2 – 5 mins
• Prolonged in platelet disorders: thrombocytopenia, thrombocytopenic
purpura.

15. Clotting Time:
• It’s the time required for blood to form a clot.
• Normal Range: 4 - 10 mins
• Prolonged in: Hemophilias, vitamin K deficiency.
aPTT (Activated Partial Thromboplastin Time):
• It’s performed by adding a surface activator (like kaolin/ellagic
acid), phospholipid and calcium to patient’s plasma.
• Normal Range: 26 – 37 sec
• Prolonged aPTT: Hemophilia A and B, von Willebrand disease, DIC,
heparin therapy.

16. Prothrombin Time:
• It’s measured by adding tissue factor (thromboplastin) and calcium to
the patient’s plasma.
• Normal Range: 12 – 16 sec
• Prolonged in: liver diseases, DIC, vitamin K deficiency,
D-dimer:
• It’s a fibrin degradation product, a small protein fragment present in
the blood after a blood clot is degraded by fibrinolysis.
• It contains 2 cross-linked D fragments of the fibrinogen protein.
• D-dimer concentration helps to diagnose thrombosis.
• While negative result practically rules out thrombosis, positive result
can indicate thrombosis but does not rule out other potential causes.

17. CONCLUSION
• The medical and family history is very important in evaluating
patients with bleeding disorders.
• Dental extractions are very common major stresses of hemostatic
mechanism, and a prior history is very important.
• So, a thorough understanding and knowledge about bleeding
disorders is very much needed for dental professionals to minimise
the complications of many treatment procedures.

18. REFERENCES
 Robbins and Cottran Pathologic Basis of Disease.
 Davidson’s Essentials of Medicine.

19. THANK YOU