53

Symposium : Newer Diagnostic Tests

Laboratory Studies in Coagulation Disorders

Renu Saxena, Meganathan Kannan and Ved P Choudhry

Department of Hematology, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT
It is important to go in a stepwise approach to diagnose spectrum of bleeding disorders, so that minimum tests are undertaken
to make a definitive diagnosis and to avoid unnecessary tests and laboratory load. Depending on the abnormalities observed
in the short screening, extended screening tests can be performed followed by specialized diagnostic tests. Bleeding time is
prolonged in thrombocytopenia and platelet function disorders (PFD). If platelet count is normal, extended screening tests such
as RVVT, PF3 availability and clot retraction can be performed. Russel viper venom directly activates FX, in presence of PF3,
is an indicator of common pathway of coagulation. However, if there is deficiency of PF3 as obtained in PFD and APTT PT are
normal, its prolongation indicates PFD. These can be tested invitro by performing RVVT with and without inosithin it is highly
suggestive of underlying PFD. In such cases, diagnostic tests for PFD such as platelet aggregation with ADP, ADR, AA,
Collagen and Ristocetin can be performed followed by electron microscopy if possible. Few of the interesting cases also have
been discussed in the text. [Indian J Pediatr 2007; 74 (7) : 649-655]

Key words : Coagulation disorders; Screening tests; Laboratory approach; Case studies

Bleeding disorders constitute an important group of 1. Laboratory Approach to bleeding disorders

disorder in haematology. At AIIMS, over the past five yr,
Since a large number of tests are essential to diagnose
it has been seen that of a total of 600 coagulation
spectrum of bleeding disorders, it is important to go in a
disorders, 70.8% are due to Hemophilia A, 14.1% due to
stepwise approach so that minimum tests are undertaken
Von Willibrand Disease (vWD), 8.4% are due to
to make a definitive diagnosis and to avoid unnecessary
Haemophilia B and the rest due to rare coagulation
tests and laboratory load. In addition, such an
disorders like FX/V/XIII deficiency etc. In diagnosis of
investigative approach becomes cost effective and patient
hemostatic disorders, it is important to have relevant
friendly. A short screening coagulation should be the
clinical information before interpreting the results. From
starting point (Table 1). Depending on the abnormalities
the history, it is important to differentiate hereditary
observed in the short screening, extended screening tests
disorders from acquired. Hereditary disorders generally
can be performed followed by specialized diagnostic
start early in age, or recurrent in nature and may have a
tests. It is essential to understand the coagulation system,
positive family history. On the other hand, acquired
which has extrinsic, intrinsic and common pathways.
disorders occur at any age and have an underlying
Coagulation is a continuous process which has been
predisposing cause. History of medication should
subdivided in to pathways for our better understanding
include replacement therapy or PRP, acitrom or heparin
only. (Fig. 1)
besides intake of analgesics, antibiotics etc. Depending on
the type of bleed, it is important to differentiate between TABLE 1. Short Screening Test
platelet and coagulation factor bleeds. In general, platelet
bleeds present as peticheal hemorrhage, mucosal bleeds, Screening Test Normal Defective
whereas coagulation factor disorder presents as deep Platelet count (PC) 150-450/cumm •P.C.
abdominal bleeds, muscle bleeds, hemostasis, ecchymotic Bleeding time (BT) 205’ • Platelet function
patches. • Vascular function
Prothrombin time (PT) 12-14s • Extrinsic pathway
• (FVII def.)
• Common Path. (FX, V,
II, I def.
Activated Partial 35-45s • Intrinsic
Correspondence and Reprint requests : Dr. Renu Saxena, Professor
Thromboplastin time • Common path (FX, V,
and Head, Department of Hematology, All India Institute of Medical
(APTT) II, I def)
Sciences, Ansari Nagar, New Delhi-110029. India, Phone : 011-
Clot stability (CS) Stable at 2 hr, •F, XIII def.
26594670(off), Fax : 91(0)1126588663, E-mail : renusax@hotmail.com
24 hrs
[Received June 20, 2007; Accepted June 20, 2007]

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R. Saxena et al

TABLE 2. PPT (N) APTT (High) Hereditary defect (VIII, IX, XI, XII)

Mixing studies (APTT)

NS (corrected) NS (not corrected) NS (not corrected)

Ads(not correct) Ads(corrected) Ads. (not corrected)

Diagn. FIX def. FVIII def. F XI, XII def

VWD (↑BT)

Diagnostic test Factor Assay

Fig. 1. Normal coagulation pathway
Bleeding time is prolonged in thrombocytopenia and
platelet function disorders(PFD). If platelet count is
normal, extended screening tests such as RVVT, PF3
availability and clot retraction can be performed. Russel
viper venom directly activates FX, in presence of PF3, is
an indicator of common pathway of coagulation.
However, if there is deficiency of PF3 as obtained in PFD
and APTT PT are normal, its prolongation indicates PFD.
These can be tested invitro by performing RVVT with
and without inosithin it is highly suggestive of
underlying PFD. In such cases, diagnostic tests for PFD
such as platelet aggregation with ADP, ADR, AA,
Collagen and Ristocetin can be performed followed by
electron microscopy if possible.
Abnormalities in PT/APTT
The following possibilities of the prolongation of PT &
APTT Exist:
• Prolonged PT + Normal APTT
• Normal PT + Prolonged APTT
• Prolonged PT + Prolonged APTT
Isolated prolongation of prothrombin time (PT) may
be hereditary as in FVII deficiency or acquired as in mild
liver disease or warfarin effect.
Isolated prolongation of APTT
This is seen in inherited defects of deficiency of intrinsic
factors like FVIII, IX, XI. In the absence of facilities for
factor assay, mixing studies of APTT with normal serum
or aluminium hydroxide adsorbed plasma (Ads) can be
performed. Normal serum contains factors FIX, X, XI and
XII. Adsorbed plasma contains FV, FVIII, XI, XII. The
interpretation is given in (Table 2).
In case prolonged APTT is accompanied by prolonged
bleeding time, possibilities of VWD is suspected and this
can be conformed using RIPA, VWF Ag and VWF RiCoF
assays and multimeric analysis. Sometimes, however in
VWD variants, BT may not be prolonged. Acquired cause
of isolated prolongation of APTT includes presence of
lupus anticoagulant, intrinsic factor inhibitors and
heparin therapy. Lupus anticoagulant can be confirmed
by Kaolin clotting assay and dilute russel veiper venom
test. Factor inhibitors can be confirmed by screening tests
of APTT followed by inhibitor assay (Bethesda assay).
Prolongation of both PT and APTT
This indicates deficiency in common pathway of
coagulation (FV, FX, FII and FI) or multiple coagulation
factor defects which may be inherited or acquired. When
hemostasis suggests hereditary defects, mixing studies
with normal serum or adsorbed plasma are helpful in
differential diagnosis is given in Table 3.
TABLE 3. PPT (High) APTT (High) Hereditary Defect (V, X, II, I)
Mixing studies (APTT/PT)
NS (corrected) NS (not corrected) NS (not corrected)
Ads (not correct) Ads(corrected) Ads. (not corrected)
Diagn. FIX def. FV def. TT
n ↑
Diagn. test Factor Assay FII Def Hypofibrinogenemia
Dysfibrinogenemia
Acquired conditions like DIC, Fibrinolysis, Liver
disease, vitamin K deficiency may result in prolongation
of both PT and APTT. DIC is confirmed by estimation of
D Dimer, FDP. Fibrinolysis show normal D Dimer but
abonormal FDP. Liver disease can be confirmed by liver
function tests (SGOT/SGPT). Vitamin K deficiency can
be confirmed by repetition of PT, APTT after giving 5mg
of vitamin K injection for 3 days.
Despite such extensive testing, normal screening test
can be obtained in the following conditions.
Disorders with normal screening tests
• Mild clotting factor deficiency/Mild Platelet
functional defects
• Simple purpura
• Senile purpura
• Henoch schonlein purpura
• Scurvy
• Hereditary hemorrhagic telengiectasia
Mild Von Willebrands Disease
If these conditions are suspected strongly, it is suggested

650 Indian Journal of Pediatrics, Volume 74—July, 2007

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Laboratory Studies in Coagulation Disorders
that above tests are repeated to confirm the diagnosis
2. Collection of blood samples from patients and control
As in all laboratory testing, ‘the results are only as good as
the samples’. In coagulation , this cannot be stressed
enough.
Blood should not be collected through cannulae if they
have been indwelling for more than 30 minutes or if
heparin has been used to keep them patent.
Venous blood should be taken by means of a clean
venepuncture, with minimum stasis(remove tourniquet
as soon as the needle is in the vein) using a 21 gauge
number needle(length not 3.5cms) and a plastic syringe
and transferred rapidly in a plastic(polypropylene) or
siliconized glasstube (13x100mm), containing 3.2%
trisodium citrate solution. The blood should be allowed to
run down by the side of the tube, it should never be
squirted into the test tube, the tube should be screw
capped and quickly but gently mixed by inverting at least
5-7 times without producing frothing.
The blood specimen should be transported to the
laboratory as quickly as possible. Centrifuge within 30
minutes after venepuncture and carry out actual test with
in 4 hrs. Centrifuge the sample at 3500 to 4000 rpm for 15
minutes at 4°C in a refrigerated centrifuge
Keep the samples in a box. Containing small saturated
with water to eliminate air spaces, until tested or during
testing
3 Tests For coagulation disorders
3.1 Bleeding Time(Template method)
Principle: The bleeding time test measures the time that
elapses after infliction of a standard wound and the
arrest of bleeding. It depends largely on the rate of
formation of platelet plug and is mostly independent of
fibrin forming coagulation mechanisms.1-3
METHODS
The patient is seated comfortably at a warm ambient
temperature with one forearm resting horizontally on a
table with the flexor surface upper most. A scalpel blade
is so arranged on the holder (with the help of gauge) that
the tip protrudes 1mm through the template.A
sphygnomano-meter cuff is placed round the patient’s
upper arm and inflated to 40mm Hg.Skin of the forearm
is cleaned with spirit and allowed to dry.Template is
pressed firmly on the forearm with the slit placed in
cephalo-caudal direction and about 5 cm distal to the
crease of the elbow, taking care of superficial veins.With
the help of the scalpel blade an incision 9 mm in length
and 1 mm in depth is made with a quick movement.
Immediately a stop watch started. The sides of the
Indian Journal of Pediatrics, Volume 74—July, 2007
incision are gently blotted with a filter paper every 30
seconds to remove the blood oozing out, until the incision
is dry (avoid touching the wound itself with the filter
paper). Stop the stop watch and note the reading. Clean
the wound with spirit. Oppose wound edges and put
adhesive plaster for at least 48 hr.
Normal Range: 2-5 minutes
Each laboratory should establish its own normal range.
Interpretation: Bleeding time is a measure of capillary
function, platelet number and Platelet function. It is
prolonged in conditions such as Thrombocytopenia and
Platelet function defectsVon Willebrand’s Disease,
Capillary defect
3.2 Prothrombin Time (PT)
Principle: The prothrombin time test belongs to a group
of blood tests that assess the clotting ability of blood.4, 5
The test is also known as the pro time or PT test. The
blood is collected in a tube that contains sodium citrate to
prevent the clotting process from starting before the test.
The blood cells are separated from the liquid part of
blood (plasma). The PT test is performed by adding the
patient’s plasma to a protein in the blood
(thromboplastin) that converts prothrombin to thrombin.
The mixture is then kept in a warm water bath at 37°C for
one to two minutes. Calcium chloride is added to the
mixture in order to counteract the Sodium citrate and
allow clotting to proceed. The test is timed from the
addition of the calcium chloride until the plasma clots.
This time is called as the prothrombin time.
Normal value : The normal prothrombin time is 11-15
seconds. A prothrombin time within this range indicates
that the patient has normal amounts of clotting factors VII
and X. A prolonged PT time is considered abnormal.
Abnormal value: The prothrombin time will be
prolonged if the concentration of any of the tested factors
is 10% or more below normal plasma values. A prolonged
prothrombin time indicates a deficiency in any of factors
VII, X, V, prothrombin, or fibrinogen. It may mean that
the patient has a vitamin K deficiency, a liver disease, or
disseminated intravascular coagulation (DIC). The
prothrombin time of patients receiving warfarin therapy
will also be prolonged-usually in the range of one and
one half to two times the normal PT time. PT time that
exceeds approximately two and a half times the control
value (usually 30 seconds or longer) is ground for
concern, as abnormal bleeding may occur.
Limitations: Spurious results may occur if the blood to
anticoagulant ratio is not 9:1. The PT clotting times may
be prolonged by substances including corticosteroids,
EDTA, oral contraceptives, asparaginase, clofibrate,
erythromycin, ethanol, Tetracycline and anticoagulants
such as heparin and coumarin. The PT may be shortened
by substances including antihistamines, butabarbital,
651

R. Saxena et al
caffeine, oral contraceptives, phenobarbital and vitamin
K.
3.3 Activated Partial Thromboplastin Time (APTT)
Principle : APTT is the time required for plasma to be
clotted when maximal surface contact activation and
optimal phospholipid and calcium concentration are
provided.
Results are expressed as time seconds or as ratio.
Normal range: Every laboratory should determine its
own normal range. In our laboratory with commercial
reagents it is 29-35 seconds.
Interpretation : APTT is sensitive to the deficiencies or
abnormalities of both intrinsic and common coagulation
factors i.e. Factors I, II, V, X, VIII, IX, XI, XII, Fletcher
factor and Fitzgerald factor. The test is more sensitive to
an abnormality occurring in the early stage of coagulation
mechanism i.e. factors leading upto the generation of
Factor Xa and less sensitive to later stage i.e. Factor II
fibrinogen. A deficiency levels < 20-50% of Factor XII, XI,
IX, XIII, X or V would give prolonged APTT. Where as a
deficiency upto 10% of Prothrombin and 0.5-1g/litre of
fibrinogen or less would give an abnormal APTT.
APTT is also prolonged when there is an inhibitor
present in patient’s plasma. Therefore whenever a
prolonged APTT is detected, screening test for inhibitor
must be performed. It is also an important test for the
control of heparin therapy. Therapeutic range-60-100
seconds.
3.4 Clot Stability
Principle : Clot formed in the presence of factor XIII and
Ca2+ are stable for at least 1 hr in 1% monochloracetic acid
solution and in 5 mol/litre urea, whereas clots formed in
the absence of factor XIII dissolve rapidly.6
Normal – Clot stable
If clot dissolves : Factor XIII deficiency
3.5 Thrombin Time (TT)
Principle : Thrombin is added to the plasma and clotting
time measured. The clotting of citrated plasma is affected
by the concentration and reaction of fibrinogen, and also
by the presence of inhibitory substances. The normal
range is 15 – 17 seconds.
Interpretation : Thrombin time is prolonged in the
presence of heparin, hypofibrinogenemia,
dysfibrinogenemias and fibrin degradation products.
3.6 D-Dimer Test
Principle : The latex particles provided in the D-Di Test
are coated with mouse anti-human D-dimer monoclonal
antibodies. Test samples containing D-dimers when
mixed with the latex particle suspension make the
652
56
particles agglutinate. At a predetermined concentration
of D-dimers that the D-di test is designed for, the
agglutination of the latex particles produces macroscopic
clumps that can be visualized by the naked eye.7-9
Results: D-Dimer test results are expressed in initial
fibrinogen equivalent units (FEU), which are exactly the
same units, used for the FDP assay. By definition, as FEU
is the quantity of fibrinogen initially present that leads to
the observed level of D-dimer. In general, the actual
quantity of D. -dimer is approximately half of an FEU.
For practical purposes that positive cut-off value of 0.5
ug/ml (FEU) is approximately 0.25 ug/ml (actual D-
dimer). Either unit may be used as preferred. For
consistency, all results discussed in this insert are in FEU.
Normal : The d-dimer levels are <0.5 ug/ml (expressed in
FEU). The D-dimer level increases during pregnancy. It
also rises with age ( >70 yr)
Limitations : Rheumatoid factor (RF), if present, may
lead to false positive d-dimer test result. When
suspected, RF presence should be confirmed with an
independent procedure for RF.Do not test suspect
samples, especially those in which the coagulation
process may already have started, since these tend to
produce false positive reaction with the D-Dimer test.
3.7 APTT Mixing Study with normal serum / adsorbed
plasma
Principle : Plasma samples found to have a prolonged
APTT are further investigated to define the abnormality
by performing mixing or correction tests. Correction of
the abnormality by the additive indicates that the reagent
must contain the substance deficient in the test sample.
An abnormal APTT is repeated on 50:50 mixtures of a
known congenitally deficient plasma and the test plasma,
or on 50:50 mixtures of aged/adsorbed plasma and test
plasma until correction is obtained and the missing factor
identified.
3.8 Factor VIII assay
ONE STAGE F VIII CLOTTING ASSAY
Principle : The assay is based o the ability of the patient’s
plasma to shorten the abnormal activated partial
thromboplastin time of a severe F VIII deficient plasma as
compared to the corrections obtained from normal pool
plasma.
Normal Range : Factor VIII concentration range from 50
to 200% but varies widely in a given population and also
in the same subject at different times, therefore normal
range must be established in each laboratory.
Interpretation : Decreased values of F VIII activity may
be due to
A. Congenital deficiencies
1. Haemophilia A
Indian Journal of Pediatrics, Volume 74—July, 2007
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Laboratory Studies in Coagulation Disorders

2. Von Willebrand’s Disease

B. Acquired deficiencies
1. DIC
2. F VIII Inhibitors
Ristocetin
Increased values may be found in: Ristocetin
AA 400uM Correction
1. Physical exercises
2. Pregnancy ADR 20uM
3. Stress ADP 2.5uM
4. After DDAVP administration
5. Liver disease etc. Fig. 3. Aggregation chart showing Bernard Soulier Syndrome

3.9 Screening for FVIII inhibitors

The acquired coagulation disorders occur, by definition,
in previously normal individuals, secondary to
underlying disease which are associated with loss of
coagulation factors, due to circulating inhibitors. An
unexplained abnormal PTT that is not corrected by
addition of normal plasma indicates the presence of a
circulating anticoagulant.
3.10 Platelet aggregation tests
Principle: Platelets are disk-shaped blood cells that are
also called thrombocytes. They play a major role in the
blood-clotting process. The platelet aggregation test is a
measure of platelet function. The platelet aggregation test
aids in the evaluation of bleeding disorders by measuring
the rate and degree to which platelets form a clump
(aggregate) after the addition of a chemical that
stimulates clumping (aggregation).
Diagnosis : Absent aggregation with all agonist -
Glanzmann Thrombasthenia (Fig. 4), afibrinogenemia.
Reduced aggregation with Ristocetin : vWD, Bernard
Soulier (Figs. 2 and 3)
Fig. 2. Aggregation chart showing von Willebrand disease
Reduced aggregation with all agonist : Storage pool
disease, Arachidonic acid pathway defect.
Reduced aggregation with any one or 2 agonist only:
Unclassified PFD
3.11 Tests for vWD
ADP 1.25 ADF ADP AA collagen
Fig. 4. Aggregation chart showing Glanzmann Thrombasthenia
a. Platelet Aggregation with Ristocetin (RIPA)
Principle: A sample of platelets rich plasma is stirred at a
constant speed in a thermostatically heated block and an
aliquot of ristocetin is added. The pattern of aggregation
is followed on a potentiometric chart recorder which
traces the change in optical density of the plasma sample
which occurs when platelets aggregate.
Interpretation : An antibiotic ristocetin derived from the
bacterium Nocardia purida was withdrawn from clinical
use because of the high incidence of thrombocytopenia in
patient’s treated with the drug. It was found that
ristocetin causes platelet aggregation in vitro and in vivo,
and later it was shown that platelets from a majority of
patient’s with von Willebrand’s Disease fail to aggregate
with this chemical.
(b) Von Willebrand’s Factor (vWF) Antigen
Principle of the test VWF: Ag assay is a sandwich ELISA.
A capture antibody specific for human vWF is coated to
96-microwell polystyrene plates. Diluted patient plasma
is incubated in the wells, allowing any available vWF: Ag
to bind to the anti-human vWF antibody on the microwell
surface. The platelets are washed to remove unbound
proteins or other plasma molecules. Bound vWF:Ag is
quantitated using horseradish peroxidase (HRP)
conjugated anti-human vWF detection antibody.
Following incubation, unbound conjugate is removed by

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R. Saxena et al

washing. A chromogeneic substrate of tetramethy- Inhibitor assay: >5 Bethesda Units

benzidine (TMB) and hydrogen peroxide (H2O2) is added
Diagnosis: Haemophilia A with Inhibitors
to develop a colored reaction. The intensity of the color is
measured in optical density (OD) units with a Case 2
spectrophotometer at 450nm. Platelet vWF:Ag in relative
percent concentration is determined against a curve made A 15-yr female presented with history of menorrhagia,
from the reference plasma. gum bleeding off and on, for 8 years. History of recurrent
epistaxis and menorrhagia i was present in her mother
Expected values Examination revealed mild pallor and systemic
examination was essentially normal. There were few
Normal Range : Plasma VWF:Ag values are generally
ecchymotic spots only.
expressed in relative percent (%) as compared to pooled
normal plasma. The normal range when normal plasma Investigations
samples were tested by REAADS vWF:Ag assay was 47-
197% (mean 105.8% SD 39%). Available assays (50-160%). • Hb: 9.3 g/dl
Sample with values above the range of the reference • TLC: 9800
curve may need to be diluted and retested for accurate • Platelet count: 240x103/ul,
results. • Bleeding Time: > 15’
• Prothrombin Time: 15”/12”
C Assay of VWF: RCo (von Willebrand Ristocetin
• APTT: 65”/ 30”
cofactor activity)
• CS: Normal
Principle: The degree of aggregation of washed platelets • RIPA: Absent
induced by ristocetin is related to the vWF level present • vWF Ag: 3% (low) (Normal 50 to 150%)
in the system. The level of vWF in the plasma that are • RiCoF: 0.3% (low) (Normal 60 to 150%)
being tested at the appropriate dilution is obtained by
comparing the speed of platelet aggregation in the test Diagnosis: Type II vWD
plasma with that of the standard obtained from a diluted Case 3
normal human plasma pool.
Normal range: of vWF RCo (in adults = 60-150%) A 7-yr-old female child presented with history of
epistaxis off and on since birth, along with peticheal
4. Case Studies hemorrhages . Her elder sister had similar complaints
Case 1 from early childhood

•A 5-yr-old male child presented with history of Examination revealed mild pallor, few peticheal
spontaneous swelling of right calf for 2 days, Recurrent hemorrhages over the high. Systemic examination was
joint swelling, past 2 years, and Prolonged bleed in elder essentially normal.
brother. Earlier patient responded to FVIII but now no Investigations
effect on swelling was seen.
• Hb: 9.9 g/dl
Examination revealed that he had mild Pallor , diffuse • TLC: 11 000 /ul
swelling of right calf. Contracture of left knee joint with • Platelet: 5.5 lakh
marked restriction of joint movements Wasting of Left • Bleeding Time: > 15’
thigh muscle was present • PT: 14”/13”
Investigations • APTT: 32”/30”
• CS: Normal
• Hb: 12g/dl • Platelet aggregation study: Absent with all agonists
• TLC: 9000/uL except with Ristocetin
• Platelet count 5.3 lac/uL
• Flow Cytometery: Absent GPIIb/IIIa
• Bleeding Time: 3’ (Normal 2- 5’)
• Diagnosis: Glanzmann Thrombasthenia
• Prothrombin Time : 15”/12”
• Activated partial prothrombin time: 90”/30” Case 4
• Clot Solubility: Normal
• Factor VIII level: <1% normal pooled plasma A 10-yr-female presented with history of recurrent gum
• Screening for FVIII Inhibitor: bleeds and high grade fever of 5 days duration. She
complained of breathlessness and bodyaches.
0’ 120’ Examination revealed that she had moderate pallor along
NP 30” 35” with gum bleeds and generalized oozing from multiple
NP+PP (1:1) 50” 120” puncture sites. She had sternal tenderness and no lymph
PP 90” 95” node enlargement Hepatosplenomegaly of 2 and 3 cms

654 Indian Journal of Pediatrics, Volume 74—July, 2007

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Laboratory Studies in Coagulation Disorders

were present • Plt: 2.3 lakhs

Investigations • PT: 20”/13”
• APTT: 40”/30”
• Hb: 5.3 g/dl
• TLC: 600/ul • CS: Normal
• DLC: P20 L17 Promyelocytes 60 Myeloblasts 3% • Injection vitamin K 2mg IV given
• Platelet count: 5000/ul • Repeat PT, APTT after 72 hr of vitamin K
• PT: 23”/12” PT 14”/13”
• APTT 45”/30” APTT: 33”/30”
• TT: 23”/17”
•Diagnosis: Vitamin K deficiency
• Fibrinogen: 100mg/dl
• D dimer: >0.5 ug/ml REFERENCES
• Peripheral blood smear revealed : Micro angiopathic 1. Mielke CH, Jr., Kaneshiro MM, Maher IA et al. The
Haemolytic anemia bone marrow was compatible with standardized normal Ivy bleeding time and its prolongation
AML M3 by aspirin. Blood 1969; 34 : 204-215.
• Diagnosis: DIC secondary to AML M3 2. Mielke C. H. Measurement of the bleeding time. Thrombosis
and Haemostasis 1984; 52 : 210-211.
Case 5 3. Bowie, EJW et al. Mayo clinic laboratory manual of hemostasis,
Philadelphia; W.B. Saunders and Co., 1971; 29-33.
• One month male child presented with history of 4. Miale JB, Laboratory Medicine: Hematology, 4th ed. St. Louis, C.V.
spontaneous ecchymosis following intramusculor Mosby Co., 1972; 1268-1269.
injection for past 10 days. This baby was born premature 5. Rizza, Charles R and Walker, William. One stage Prothrombin
time techniques. In Bang NU, et al. eds. Thrombosis and Bleeding
in village and was delivered by village dai. Baby was in
Disorders, New York, Academic press, 1971; 92- 100.
breast fed. There was no history of fever joint swelling, 6. Sirridge M. Laboratory evaluation of the bleeding patient. Clin
hematuria or prolonged bleeding from umbilical stump Lab Med 1984 Jun;4(2) : 285-301.
during first week of life. Examination revealed only 7. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C,
ecchymotic patches, while rest of examination, was Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ.
Evaluation of D-dimer in the diagnosis of suspected deep-vein
essentially normal.
thrombosis. N Engl J Med 2003 Sep 25; 349(13) : 1227-1235.
Investigations 8. Gupta PK, Gupta M, Chatterjee T, Saxena R. Comparative
evaluation of whole blood D-dimer test to plasma D-dimer
• Hb: 11.9 g/dl test for diagnosis of disseminated intravascular coagulation.
Indian J Exp Biol 2005 Apr;43(4) : 382-384.
• TLC: 12000/ ul 9. Saxena R, Gupta PK, Ahmed R, Vinita B, Suresh K D – dimer
test :Diagnostic role in clinical and sub – clinical DIC. IJPM
2003; 46(3) : 425-426.

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