Hemostasis

DR. SEJIL T V
Learning objectives
Why does the blood not clot in the body?
Platelets: structure, functions, normal counts, variations in counts
Clotting factors
Clotting
◦ Intrinsic, extrinsic pathway, common pathway

Fibrinolytic system
Disorders of coagulation
◦ DIC, hemophilia, thrombocytopenia
Platelets
Structure
Small (2-4µm), non-nucleated, colorless,
granulated bodies
Normal blood count: 1.5-4 lakh/cu mm
Granules:
Alpha granules: PDGF, plasminogen,
fibronectin, factor 5, thrombospondin,
alpha-2 plasmin inhibitor, platelet factor 3,
Thromboxane A2
Dense granules: serotonin, ADP, Ca ions
Thrombopoiesis
◦ Occurs in the bone marrow
◦ Regulated by thrombopoietin,
megakaryocyte CSF
◦ Each megakaryocyte can form up to 4000
platelets

10 days
Destruction
◦ Life span of 8 to 12 days
◦ Destroyed in the spleen by the macrophage
system
Properties of Platelets
◦ Adhesiveness – thrombin, ADP, Thromboxane A2, Calcium
◦ Activation
◦ Aggregation – ADP, thromboxane A2

Functions
◦ Temporary hemostatic plug
◦ Stimulation of clotting
◦ Retraction of the clot
◦ Tissue repair - PDGF
◦ Phagocytosis
◦ Storage and transport: 5HT, heparin
Variations in Count
Normal blood count: 1.5-4 lakh/mm3

Thrombocytosis Thrombocytopenia
◦ Increase in platelet count ◦ Decrease in the platelet count
◦ Causes ◦ Causes
◦ Post splenectomy ◦ Idiopathic(immune)
◦ After surgery, trauma, hemorrhage thrombocytopenic purpura
◦ Bone marrow depression
◦ Dengue
◦ Allergic responses
◦ Symptoms
◦ Spontaneous bleeding
◦ Fatal bleeds in the brain and heart
Spontaneous cessation of bleeding
after trauma or injury to the blood
vessel
Hemostasis
Steps of coagulation
Trauma
Vasoconstriction
Temporary hemostatic plug formation
Permanent hemostatic plug formation
(coagulation)
◦ Intrinsic mechanism
◦ Extrinsic mechanism
◦ Final common pathway
Clot
Clot Retraction
Fibrinolysis
1. Vasoconstriction
◦ Narrowing of the injured vessel caused by the contraction
of the smooth muscle cells of the vessel wall
◦ Acts within seconds, but lasts only for a few minutes
◦ Causes
◦ Direct contraction caused by the trauma
◦ Mediators released by the platelets
◦ Serotonin
◦ Thromboxane A2
2. Formation of temporary hemostatic
plug
◦ Adhesion of platelets
◦ The platelets get stuck at the site of trauma
◦ Collagen, thrombin, ADP, thromboxane A2, Ca, von Willebrand factor
◦ Activation of platelets
◦ Degranulation of the platelets releasing ADP, serotonin, thromboxane A2,
histamine, platelet activating factor
◦ Aggregation of the platelets
◦ Platelets release cytokines which attracts more platelets
◦ ADP, thromboxane A2
Formation of definitive
hemostatic plug
Also called clotting
Soluble clotting factors present in the plasma
Conversion of these proteins into a jelly like mass at the site of trauma
Complex cascade of steps
Two pathways
◦ Intrinsic mechanism
◦ Extrinsic mechanism

Formation of a definitive clot

 Injury to vessel wall

Endothelium damaged and collagen exposed

Release of
thromboplastin
Release of 5HT and Adhesion of platelets to
thromboxane A2 damaged vessel wall
Intrinsic Extrinsic
Vasoconstriction Pathway Pathway
Activation of
platelets/degranulation
(ADP, TXA2)
Formation of prothrombin
activator
Aggregation/Adhesion of
Activation of common
platelets
pathway/
Formation of fibrin
Temporary hemostatic plug
Definitive hemostatic plug
Clotting
Non reversible process of converting a fluid blood into a
semisolid mass by the activation of clotting factors
Clotting factors
◦ Proteins synthesized in the liver and released into blood.
◦ Activated by trauma, help in the arrest of bleeding
◦ Total of 12 factors
 Clotting factors
Factor Name
I Fibrinogen
II Prothrombin
III Thromboplastin
IV Calcium
V Labile factor-proaccelerin
VII Proconvertin
VIII Anti-hemophilic factor
IX Christmas factor
X Stuart Prower factor
XI Plasma thromboplastin antecedent
XII Hageman’s factor
XIII Fibrin stabilizing factor
Others High molecular weight kininogen, kallikrein, platelet phospholipid
 Injury to vessel wall

Endothelium damaged and collagen exposed Injury to tissues

Release of
thromboplastin

Intrinsic Extrinsic
Pathway Pathway

Formation of prothrombin
activator

Activation of common
pathway/
Formation of fibrin

Definitive hemostatic plug

 Activated by:
Intrinsic Mechanism
Trauma to the blood
Contact with collagen
Exposure to water wettable
surface XII XIIa
This step also requires HMWK,
Kallikrein
XI XIa
Cascade of steps
Requires XII, XI, IX, X, VIII, V factors IX IXa
Requires Ca at every step
Takes about 3-6 minutes This step requires
X Xa
activated Factor
Prothrombin activator VIII
◦ Activated factor X, V, Ca,
Phospholipids
Prothrombin
activator
(Xa, PL, Ca, Va)
Extrinsic mechanism
Activated by:
Entry of tissue thromboplastin
from the damaged tissues
outside the vessel

VII VIIa

Requires VII and X factors only

X Xa
Calcium required at every stage
Rapid – 10-30 seconds
Prothrombin
Formation of Prothrombin activator activator
◦ Activated fact X, V, Ca, Phospholipids (Xa, PL, Ca, Va)
 Final common pathway
Formation of the fibrin clot from Prothrombin
the prothrombin activator activator
(Xa, PL, Ca, Va)
Prothrombin activator
◦ Activated fact X, V, Ca,
Phospholipids Prothrombin Thrombin

Platelets get trapped in the fibrin

strands – Clot retraction Fibrinogen Fibrin

XIII

Cross linked
Fibrinolytic System
Fibrin

Clot
Fibrin Clot Retraction (Cross linked fibrin
Degradation by platelets strands, platelets, RBCs,
Products (FDP) WBCs trapped in it)
Fibrinolytic system
Removal of formed clots by dissolution
Plasmin (fibrinolysin)
◦ Precursor plasminogen – secreted by the liver, platelets, endothelial
cells
◦ Activated to plasmin by
◦ Extrinsic mechanism – entry of tissue plasminogen activator (TPA, urokinase) from
the vascular endothelium
◦ Intrinsic mechanism – activation of factor XII leads activates plasminogen

Conversion of fibrin to fibrin degradation products

Role of fibrinolytic system
❑House-keeping: removal of spontaneous microclots
❑Liquefaction of menstrual blood
❑Healing process – lysis of clots at the site of trauma and activation of
fibroblasts
❑Liquefaction of sperms
Bleeding time:
◦ Time required for the spontaneous cessation of bleeding from the time of
the trauma
◦ Usually 2-5 minutes
◦ From trauma – to the formation of temporary hemostatic plug
◦ Exclusively a function of platelets

Clotting time
◦ Time required for the formation of fibrin strands from the time of trauma
◦ Usually 5-8 minutes
◦ From trauma to the formation of definitive hemostatic plug
◦ Exclusively a function of the clotting factors
Role of Calcium
◦ Required for platelet function
◦ Required at multiple steps of the intrinsic and extrinsic pathways
◦ Required for the formation of the prothrombin activator
◦ Required for clot retraction

EDTA, oxalates, citrates – bind with calcium and prevents coagulation

Role of Vit K
Vit K required for the post translation modification of the factor II, VII,
IX, X
Both intrinsic and extrinsic pathways affected in Vit K deficiency
Vit K antagonist – warfarin, dicoumarol block the action of Vit K
Can be used in vivo
Reduced activity of the above factors – inhibition of coagulation
Anticoagulants
In vivo anticoagulants
◦ Heparin - prevents conversion of prothrombin, inhibits the action of
thrombin
◦ Antithrombin III – inactivates thrombin
◦ Protein C/S – activated by thrombin, inactivates clotting factors,
prothrombin activator, activates fibrinolytic system

In vitro anticoagulants
◦ Oxalates
◦ Citrates All of them act by removing
◦ EDTA active calcium from blood
◦ Fluoride
Why blood does not clot in the
vessels?
◦ Flow of blood
◦ Endothelium
◦ Smooth surface lined by glycocalyx
◦ Presence of thrombomodulin which inactivates clotting factors
◦ Anti platelet aggregation – prostacyclin(PGI2)
◦ Effect of aspirin
◦ In vivo anticoagulants
◦ Heparin - prevents conversion of prothrombin, inhibits the action of thrombin
◦ Antithrombin III – inactivates thrombin
◦ Protein C/S – activated by thrombin, inactivates clotting factors, prothrombin
activator, activates fibrinolytic system
◦ Liver – removes the activated clotting factors
◦ Fibrinolytic system
◦ Plasmin
Disorders of
hemostasis
Disorders of platelets
◦ Decrease in number
◦ Abnormal functionality

Disorders of clotting factors

◦ Vit K deficiency
◦ Hemophilia

Disorders of vessel wall integrity

◦ Vit C deficiency

Disseminated intravascular coagulation

Hemophilia
Classical hemophilia – deficiency of Factor VIII
Sex linked recessive disease
Males are affected
Females are carriers
Bleeding on minor trauma into joints, soft tissues
Arthrosis/ankyloses – fibrosis of joints
Tests – CT, BT, Assays
Treatment
◦ Factor VIII concentrates
◦ Prevention of trauma
◦ Monitoring of factor VIII levels before any procedure

Hemophilia B – deficiency of factor IX

Hemophilia C – deficiency of factor XI
Tests of coagulation
Platelet count
Bleeding time – 1-6 min
Clotting time - 2-8min
Prothrombin time: 11-15s (Extrinsic Pathway)