1. RAFEAH RUSLI 03-200904-00277
RAFIDAH ABRAHAM 03-200904-00324
RANDY B. GUBUD 03-200904-00264
SANDRA LOUIS 03-200904-00274
SARTIKA AMRAN 03-200904-00180
VERA DIANE 03-200904-00244
Presenting…
PLATELET & COAGULATION
DISORDERS

2. Objective:
 Describe platelet
 List the types of platelet & coagulation
disorder
 Describe briefly about the disorders
 Laboratory diagnosis

3. Platelet
 Platelets are produced in blood cell formation (thrombopoiesis) in
bone marrow
 megakaryoblast > pro-megakaryocyte > immature megakaryocyte >
megakaryocyte > Platelet
 Platelets or thrombocytes are small
 irregularly shaped
 non-nucleated
 2–3 µm in diameter.
 lifespan of circulating platelets is 5 to 9 days.
 platelet production is regulated by thrombopoietin (hormone which
produced by the liver and kidneys)
 Old platelets are destroyed by phagocytosis in the spleen and by
Kupffer cells in the liver

4. Platelet formation:

5. Platelet cont…
 The platelet structure has 3 zones:
 Peripheral
 Structural
 Organelle
 Structural zone
 Consists of the cytoskeleton
 The cytoskeleton forms the support for the maintenance of the platelet’s discoid
shape
 Regulate contractile system that allows, upon activation, shape change,
pseudopod extension, internal contraction, and release of granular constituents.

6. Resting platelets
Activated platelets

7. Platelet

8. Platelet cont…
 Organelle zone
 consists of the granules and cellular components
 These organelles serve in the metabolic processes of the platelet and store
enzymes.
 dense granules contain non-metabolic adenosine triphosphate (ATP) and
adenosine diphosphate (ADP), serotonin, and calcium
 alpha granules contain adhesive proteins such as fibrinogen, fibronectin, von
Willebrand factor (VWF), thrombospondin, and vitronectin.
 alpha granules also contain growth-promoting substances such as platelet-
derived growth factor (PDGF), platelet factor 4, and transforming growth factor.
 Coagulation factors including factor V, high molecular weight kininogen, factor XI,
and plasminogen activator inhibitor-1 are also present in the alpha granule.

9. Platelet cont…
 Membrane / peripheral zone
 Consist of typical phospholipid bilayer membrane
 Embedded in this structure are different kind of glycoprotein.
Glcoprotein Function
GP IIb/IIIa Receptor for fibrinogen,
VWF, fibronectin, vitronectin
and Thrombospondin
For platelet aggregation
GP Ia/IIa Receptor for Collage
GP Ib/IX/V Receptor for insoluble VW
For platelet adhesion
GP VI Receptor for Collagen

10. General function of platelet
 The function of platelets is the maintenance of hemostasis.
 Platelets helps in blood clotting.
 Wound repair
 Platelets secrete platelet-derived growth factor (PDGF).
 Granule secretion.
 Adhesion and aggregation.
 Pro-coagulation.
 Cytokine signalling.
 Phagocytosis.
 Transport of enzyme and proteins critical to clotting.
 Formation of a platelet plug to slow blood loss.
 Contraction of a clot after it has formed, which then reduces the size of
the vessel break.

11.  platelet ultrastructure…..
Alpha granules Dense bodies
VwF ADP
Fibronectin ATP
Thrombospondin Serotin

12. Types of disorder:
 Divided into:
 Coagulation disorder
 Platelets disorder
 Coagulation disorder include:
 Henophilia
 Von Willebrand disease
 Platelet disorder include:
 Deficiency Of Vitamin K.
 Bernard - Soulier Syndrome.
 Thrombasthenia Of Glanzmann And Naegeli (Glanzmann Thrombasthenia)
 Gray Platelet Syndrome.
 Dense Granule Deficiency Syndrome.
 Thrombotic Thrombocytopenic Purpura (TTP).
 Idiopathic Thrombocytopenic Purpura (ITP).

13. Hemophilia
 Definition: disease associated with prolonged bleeding due to the
deficiency in clotting factor.
 Hemophilia is a X-linked disease
 Types of Hemophilia:
 Hemophilia A
 Factor 8 deficiency, x linked disease
 Hemophilia B
 Factor 9 deficiency, x-linked disease
 Hemophilia C
 Factor 11 deficiency, autosomal genetic disorder
 Symptoms of hemophilia:
 Bruising
 Bleeds easily
 Bleeding into a joint
 Bleeding into the muscles
 Bleeding from injury or bleeding in the brain
 Other sources of bleeding (eg. Stool & urine)

14. Von Willebrand disease
 The most common hereditary coagulation abnormality
 Can also be acquired as a result of other medical conditions
 Due to the deficiency of von Willebrand factor (vWF)
 Von Willebrand factor - mediates binding of glycoprotein Ib to
collagen
 This binding mediate activation of platelets and formation of
primary hemostasis
 Defect in this factor, resulting glycoprotein IB does not bind to
collagen.
 Thus unable to activate platelets, primary hemostasis does not occur

15. Lab findings: comparison between Hemophilia A, Hemophilia B
& von Willebrand disease
Condition PT APTT Bleeding time
Hemophilia A Normal Increased Normal
Hemophilia B Normal Increased normal
Von Willebrand disease Normal Increased increased
 Symptoms of von Willebrand disease:
 Abnormal menstrual bleeding
 Bleeding of the gums
 Bruising
 Nosebleeds
 Skin rash

16. Bernard-Soulier syndrome
 Also known as hemorrhagiparous thrombocytic dystrophy
 It is due to deficiency of glycoprotein Ib (GPIb), the receptor for von
willebrand factor
 Lacks of GPIb cause vWF unable to bind to the glycoprotein
 finally lead to decrease in primary clot formation / primary
hemostasis
 Characterized by
 Characterized by abnormally large platelets / giant platelets
 Characterized by prolonged bleeding time, thrombocytopenia, increased
megakaryocytes, and decreased platelet survival
 Some of the symptoms:
 Purpura.
 Epistaxis.
 Menorrhagia.
 Gingival and gastrointestinal bleeding.

17. Deficiency of Vitamin K
 Role of Vitamin K in blood coagulation:
 Important in maturation of clotting factor.
 modification of certain proteins required for blood coagulation
 If the clotting factor does not mature, it is useless in the hemostasis
process.
 Factor which causes the deficiency of vitamin K
 Disturbed intestinal uptake.
 By therapeutic or accidental intake of vitamin k-antagonists or very rarely.
 By nutritional vitamin k deficiency
 Some of the possible symptoms of vitamin K deficiency:
 Risk of massive uncontrolled bleeding
 Hematomas

18. THROMBASTHENIA OF GLANZMANN
AND NAEGELI
 extremely rare coagulopathy
 can be inherited in an autosomal recessive manner or acquired as an
autoimmune disorder
 due to deficiency in glycoprotein IIb/IIIa (GpIIb/IIIa)
 glycoprotein IIb/IIIa (GpIIb/IIIa) is receptor for fibrinogen.
 When glycoprotein IIb/IIIa (GpIIb/IIIa) receptor is dysfunction,
fibrinogen cannot bind to the platelets.
 As a result, no fibrinogen bridging of platelets to other platelets
occur
 In other words, primary hemostasis inhibited and prevent platelets
aggregation
 Bleeding time is significantly prolonged

19. THROMBASTHENIA OF GLANZMANN
AND NAEGELI
 Symptoms includes:
 Increased mucosal bleeding.
 Epistaxis.
 Menorrhagia.
 Increased bleeding post-operatively.
 The bleeding tendency is variable but may be severe.
 Platelet numbers and morphology are normal.
 Platelet aggregation is normal with ristocetin, but impaired with other agonists
such as ADP, thrombin, collagen or epinephrine.

20. GRAY PLATELET SYNDROME
 Gray platelet syndrome (GPS) is a rare inherited bleeding disorder.
 The abnormal alpha-granules appear grey on blood films stained by
the May-Grünwald-Giesma stain - hence, the syndrome's name.
 It caused by the inability of platelets to store alpha-granule proteins.
 The platelets' haemostatic proteins are not released at the site of
vascular injury.
 Thus slows aggregation and vessel repair
 And contribute to the bleeding tendency.
 Symptoms may include:
 platelets that have a gray appearance
 severe thrombocytopenia
 myelofibrosis
 splenomegaly

21. DENSE GRANULE DEFICIENCY
SYNDROME
 it is a bleeding disorder caused by a deficiency in dense granules in
the platelets
 Dense granules release chemicals in the clotting process and help
platelets stick together to form clots.
 Lacks of dense granules in platelets means lacks of storage sites for
substances for clotting.
 Therefore no chemicals which facilitates in the clotting process will
be released.
 Finally leads to slow platelet activation, and prolonged bleding.

22. THROMBOTIC THROMBOCYTOPENIC
PURPURA (TTP)
 A blood disorder that causes blood clots to form in small blood
vessels around the body, and leads to a low platelet count.
 The two main types of TTP are inherited and acquired.
 In inherited TTP, the ADAMTS13 gene is faulty and doesn't
prompt the body to make a normal ADAMTS13 enzyme. As a
result, enzyme activity is lacking or changed.
 Acquired TTP is the more common type of the disorder. The
ADAMTS13 gene isn't faulty. Instead, the body makes antibodies
(proteins) that block the activity of the ADAMTS13 enzyme.
 A lack of activity in the ADAMTS13 enzyme causes TTP.
 The ADAMTS13 gene controls the enzyme, which is involved in
blood clotting.
 The enzyme breaks up a large protein called von Willebrand
factor that clumps together with platelets to form blood clots.

23. IDIOPATHIC THROMBOCYTOPENIC
PURPURA (ITP)
 Also known as immune thrombocytopenic purpura, is classified as an
autoimmune disease.
 The term “idiopathic” indicates that the disease is of an unknown
cause or origin: in other words, modern medicine has not yet figured
out what it is.
 And the word “purpura” comes from a description of the bruise-
colored skin of someone afflicted with the disease: the purple color
caused by blood that leaked under the skin.

24. IDIOPATHIC THROMBOCYTOPENIC
PURPURA (ITP)
 Idiopathic thrombocytopenic purpura is a bleeding disorder in which
the immune system destroys platelets
 Persons with the disease have too few platelets in the blood
 The two types of ITP are acute (temporary or short-term) and
chronic (long-lasting).
 Acute ITP generally lasts less than 6 months. It mainly occurs in children—both
boys and girls—and is the most common type of ITP. Acute ITP often occurs after
a viral infection.
 Chronic ITP lasts 6 months or longer and mostly affects adults. However, some
teenagers and children do get this type of ITP. Chronic ITP affects women two to
three times more often than men.
 Symptoms:
 Abnormally heavy menstruation.
 Bleeding into the skin causes a characteristic skin rash that looks like pinpoint red
spots. (petechial rash)
 Easy bruising.
 Nosebleed or bleeding in the mouth.

25. Lab diagnosis
 Status of platelet & coagulation process can be screened by using
the following simple lab test:
 Bleeding Time
 Clotting time
 Activated partial thromboplastin time (APTT)
 Prothrombin time (PT)
 Full Blood Count
 Peripheral Blood Film
 May-Grünwald-Giesma stain

26. Bleeding time
 Function:
 Basic screening test of platelet function
 Procedure:
 Place a blood pressure cuff on the arm and inflare it to 40mm Hg
 Clean the area of the fore arm below the anticubital fossa with 70% alcohol. There
should be no superficial veins in the area selected
 Make 2 skin punctures in rapid succession, each 3mm deep, by using disposable
lancets
 Start the stop-watch as soon as bleeding starts. Wipe off the blood at 15 seconds
interval by touching lightly with a blotting paper
 Record the time taken for the blood to stop flowing in the both punctures and
determine the mean time.
 Remove the blood pressure cuff and cover the puncture site with plaster
 Result:
 Normal range : 2-6 minutes
 Borderline : 6-10 minutes (Test should be repeated)

27. Bleeding time:

28. Clotting time:
 Function:
 To measure he time required for a sample of blood to coagulate in vitro under
standard conditions
 Procedure:
 Make a clean venipuncture with minimum trauma to the connective tissue
 Start stop-watch as soon as the blood enters the glass syringe.
 Draw 4ml of blood and deliver 1ml each into 4 glass tubes previously warmed to
37ºC
 Place the tube immediately at 37ºC water bath
 At the end of each minutes, gently tilt one tube to see if the blood is clotted.
 Continue tilting the tube one after the other at one minute interval till one of them
can be tilted at 90º without the blood flowing out.
 Note the time
 Continue with the remaining tubes and take the average of the clotting time in all
the 4 tubes
 Reference values:
 Normal values : 5-10 minutes
 Prolonged clotting time is a marked deficiency in one of the coagulation factors of
intrinsic pathway.
 Replaced by APTT

29. Activated partial thromboplastin time
 Function:
 Evaluate intrinsic pathway
 Measure all coagulating factor except factor VII and XIII
 Monitor heparin therapy
 Procedure:
 Pre-warmed APTT reagent at 37ºC for at least 10 minutes.
 Collect blood specimen in blue top tube
 Centrifuge and separate the plasma from blood
 Add 100µl of APTT reagent into a test tube, then add 100µl of plasma into the test
tube and incubate for 2-3 minutes
 Then add 100µl calcium chloride reagent to the plasma
 Start stop-watch until clot formed
 Record the time at which clot form
 Reference value:
 Normal range : 35-45 seconds

30. Prothrombin time
 Function:
 Used to evaluate the extrinsic pathway (factor 1,2,5,7, and 10)
 Also used to monitor warfarin therapy
 Procedure:
 Collect blood in blue top tube.
 Centrifuge blood and separate plasma from blood
 Make sure to pre-warmed PT reagent 37ºC for at least 10 minutes before use.
 Place 100µl plasma into test tube. Pre-warm plasma for 2-3 minutes at 37ºC
 Then add 200µl of PT reagent to the tube, simultaneously start the stop-watch and
record the time required for clot formation.
 Reference value:
 Normal range : 11-14 seconds

31. Coagulation pathway:

32. Other lab test:
 Full blood count:
 Normal range : 150,000 – 400,000 /ul
 Those with coagulation / platelet disorder : thrombocytopenia
 PBF:
 Giant platelet may present
 thrombocytopenia
 Special staining:
 MGG stain for Gray platelet syndrome

33. Giant Platelet Giant Platelet
Thrombocytosis Thrombocytopenia