Approach To Bleeding Disorder

Approach to bleeding disorder
Dr.Keerthy
Overview
• Approach to bleeding disorder
- Symptoms & definition
- History
- Sample collection & transport
- Variables
- Lab tests
platelet count
bleeding time
PFA-100
• Primary hemostasis
- Vascular
- Platelets
• Secondary hemostasis
- Coagulation factors
Introduction
• Presents with hemorrhagic symptoms.
-range from easy bruisability to life-
threatening hemorrhage.
• Severity of blees is generally proportional to
severity and type of hemostatic defect.
• Bleeding from subcutaneous blood vessels
(capillaries) into intact skin can be visualized
- Petechiae,
- Purpura, ecchymoses, or
- Hematomas
Types of Bleeding in Disorders
of Primary Hemostasis
• Type of bleeding can indicate which
component of the hemostatic system is
defective.
• Defect in a component of primary hemostasis
vasculature, platelets- bleeding from the skin
or mucous membranes, such as epistaxis
(nose bleeds), gingival mucosa (gums), or
menorrhagia (abnormal menstrual bleeding).
• Bleeding symptoms in patients with
coagulation factor abnormalities - internal,
involving deeper tissues and joints.
Petechiae
• Petechiae are small red to purple spots skin < 3 mm in
diameter
-resulting from blood leakage through endothelial lining of
capillaries.
Petechiae usually occur

-extremities because of the high venous pressure.
• When occurring spontaneously without trauma, they are
painless.
• Several petechiae can merge into a larger bruised area.
• Petechial lesions are characteristic of abnormalities of
platelets and blood vessels.
• Usually are not seen in coagulation factor disorders
Ecchymoses
• Larger than 1 cm in diameter
-caused by blood escaping through the endothelium into
subcutaneous tissue, commonly from a vessel larger than a
capillary.
• They are red or purple when first formed and become

yellowish green as they heal and hemoglobin degrades into
bilirubin and biliverdin.
• Ecchymoses can appear spontaneously or with trauma and

can be painful and tender.
• Occur when abnormalities of blood vessels, platelets, or

coagulation factors exist
Purpura & Hematoma
• Intermediate lesions (>3 mm but < 1 cm) are
called Purpura.
• Hematoma is formed when blood leaks from
an opening in a vessel
-collects beneath intact skin, forming a blue
or purple slightly raised area.
• Hematomas can occur in any organ or tissue

• Easy bruisability -ecchymoses and purpura
are found in higher than normal and with less
than usual trauma.
• Bleeding disorders characterized by excess
bleeding, which occurs from superficial cuts
and scratches when platelets fail to form an
effective primary hemostatic plug.
• Frank bleeding is characteristic of both
platelet and coagulation abnormalities.
Evaluation of a Patient with Abnormal
Bleeding
Divided into two parts:
• Clinical evaluation–history, physical
examination, family history
• Laboratory evaluation–screening tests, specific
tests.
Patient history
• Age of onset of hemorrhagic symptoms

• Type of symptoms
• Family history
• Presence of other diseases
• Complete drug history (including over-the-
counter drugs and herbal supplements)
• Exposure to toxins
Common drugs which can impair haemostasis
and cause bleeding
• Platelet phase
-Aspirin, other nonsteroidal anti-inflammatory
drugs, heparin, antibacterials, thiazides,
chloroquine, quinine, cytotoxic drugs, ethyl
alcohol
• Coagulation phase
-Oral anticoagulants, heparin
Inherited vs Acquired condition
• Bleeding occurring at birth or shortly

thereafter often indicates an inherited
disorder, although onset later in life does not
rule this out.
• Bleeding from the umbilical cord stump
and/or from the circumcision site suggests a
coagulation factor defect.
Clinical differentiation between platelet/vascular
and coagulation disorders
Pre -analytical variables
Laboratory Evaluation of
Abnormal Bleeding
Screening tests for haemostasis
Significant Laboratory Tests in Defects of Primary
Hemostasis
Manual counting
• Platelet count can be made by
8–20 platelets per oil-immersion field ( X
1000), or
one platelet present for every 20
erythrocytes
Pitfalls!
• Platelet overlies an erythrocyte on a
peripheral blood smear and can be mistaken
for an erythrocyte inclusion.
• Differentiation -Superimposed platelet has a
halo surrounding it and displays the classic
morphologic characteristics of a normal
platelet (e.g., azurophilic granules.
Practical point!
• Platelet count was more difficult to automate
- because of their small size (potentially
difficult to differentiate from cellular debris)
- tendency to aggregate (size of aggregated
platelets can overlap size parameter for
erythrocytes).
• Large platelets—megathrombocytes or giant
platelets (75 mcM diameter):
-MPN or
-during recovery from severe
thrombocytopenias.
PFA-100
• PFA-100 is an alternative to the bleeding time
test.
-provides automated assessment of platelet
dysfunction by aspirating a blood sample
through a capillary tube at high shear flow to
simulate the hemodynamic conditions of
platelet adhesion and aggregation at a
vascular lesion
• Abnormality of the PT and/or APTT denotes a
coagulation factor disorder .
• Numerous confirmatory tests are available to
specify the diagnosis
General approach for investigation of a bleeding
disorder
THANK YOU

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Approach to bleeding disorder

Petechiae usually occur

• They are red or purple when first formed and become

• Ecchymoses can appear spontaneously or with trauma and

• Occur when abnormalities of blood vessels, platelets, or

• Hematomas can occur in any organ or tissue

• Age of onset of hemorrhagic symptoms

• Bleeding occurring at birth or shortly

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