Fundamentals of Pathology

Haemostasis

Dr Stephanie Lee
Learning objectives:
Understand
• The haemostatic response to injury
• Vessel wall
• Platelets
• Coagulation
• Fibrinolysis
• Coagulation tests and their interpretation
Haemostasis
• normal haemostatic response to vascular damage
- depends on a closely linked interaction between the blood
vessel wall, circulating platelets and blood coagulation factors

• efficient and rapid mechanism for stopping bleeding from sites

of blood vessel injury
- essential for survival

• response needs to be tightly controlled

• to prevent extensive clots developing
• to be able to break down such clots once damage is repaired
• The haemostatic system thus represents a delicate balance
between procoagulant and anticoagulant mechanisms allied to
a process for fibrinolysis

• five major components involved - platelets, coagulation

factors, coagulation inhibitors, fibrinolysis and blood vessels
Platelets
Platelets

• produced in the bone marrow by fragmentation of the

cytoplasm of megakaryocytes

• circulate for 7–10 days

• Thrombopoietin (TPO) - the major regulator of platelet
formation, 95% is produced by the liver

• main function of platelets - the formation of mechanical

plugs during the haemostatic response to vascular injury
Haemostatic Plug Formation: Overview
Response to injury
Vessel constriction

Formation of an unstable platelet plug

platelet adhesion Primary
platelet aggregation Haemostasis

Stabilisation of the plug with fibrin

blood coagulation Secondary
Haemostasis

Dissolution of clot and vessel repair

fibrinolysis
The involvement of blood vessels, platelets and blood coagulation in haemostasis
Haemostatic response

Vasoconstriction
• Immediate vasoconstriction of the injured vessel and
reflex constriction of adjacent small arteries and arterioles
- responsible for an initial slowing of blood flow to the
area of injury

• reduced blood flow allows contact activation of platelets

and coagulation factors
Platelet reactions and primary haemostatic plug formation

• Following a break in the endothelial lining, there is an initial

adherence of platelets to exposed connective tissue, mediated by
Von Willebrand factor (VWF)

• VWF
• involved in shear‐dependent platelet adhesion to the vessel wall and to
other platelets (aggregation)

• also carries factor VIII

• a large glycoprotein, with multimers made up on average of 2–50
dimeric subunits

• VWF is synthesized both in endothelial cells and megakaryocytes

Platelet reactions and primary haemostatic plug formation – cont’
• Collagen exposure and thrombin
generated through activation of
tissue factor produced at the
site of injury => cause the
adherent platelets to release
their granule contents, and also
activate platelet prostaglandin
synthesis, leading to the
formation of Thromboxane A2
(TXA2).
• TXA2 - important in secondary
amplification of platelet
activation to form a stable
platelet aggregate
Platelet reactions and primary haemostatic plug formation – cont’

• Additional platelets from the

circulating blood are drawn to the
area of injury
• continuing platelet aggregation
promotes the growth of the
haemostatic plug, which soon
covers the exposed connective
tissue
• unstable primary haemostatic
plug produced by these platelet
reactions in the 1st minute or so
following injury - usu sufficient to
provide temporary control of
bleeding
Stabilization of the platelet plug by fibrin
• Biochemical reactions of
coagulation
• Coagulation cascade
• Convert soluble fibrinogen into
a meshwork of insoluble fibrin
• Tightly regulated orchestration
of coagulation factors,
cofactors, and inhibitors
=> result in the controlled
formation of the pivotal
enzyme thrombin which
initiates fibrin formation
Coagulation Factors
Number and/or name Function
Fibrinogen (I) Forms clot (fibrin)
Prothrombin (II) Its active form (IIa) activates I, V, VII, XIII, protein C, platelets
Tissue factor (III) Co-factor of VIIa
Required for coagulation factors to bind to phospholipid (formerly known
Calcium
as factor IV)
V (proaccelerin, labile
Co-factor of X with which it forms the prothrombinase complex
factor)
VI Unassigned - old name of Factor Va
VII (stable factor) Activates IX, X
VIII (antihaemophilic
Co-factor of IX with which it forms the tenase complex
factor)
IX (Christmas factor) Activates X: forms tenase complex with factor VIII

X (Stuart-Prower factor) Activates II: forms prothrombinase complex with factor V

XI (plasma
thromboplastin Activates XII, IX and prekallikrein
antecedent)
XII (Hageman factor) Activates prekallikrein and fibrinolysis
XIII (fibrin-stabilizing
Crosslinks fibrin
factor)
von Willebrand factor Binds to VIII, mediates platelet adhesion 14
Physiological limitation of blood coagulation

• Unchecked, blood coagulation would lead to dangerous occlusion of

blood vessels (thrombosis)

• protective mechanisms - coagulation factor inhibitors, blood flow and

fibrinolysis

• important that the effect of thrombin is limited to the site of injury

• 1st inhibitor to act is tissue factor pathway inhibitor (TFPI) –synthesized
in endothelial cells and is present in plasma and platelets and
accumulates at the site of injury caused by local platelet activation.

• TFPI inhibits Xa and VIIa and tissue factor to limit the main in vivo
pathway.
• There is also direct inactivation of thrombin and other serine
protease factors by other circulating inhibitors, of which
antithrombin is the most potent

• Heparin potentiates its action markedly

Fibrinolysis

• Fibrinolysis (like coagulation) is a normal haemostatic

response to vascular injury

• the process whereby fibrin is degraded by plasmin

• Main function
• clot limiting mechanism
• repair and healing mechanism
Haemostatic Plug Formation: summary
Response to injury
Vessel constriction

Formation of an unstable platelet plug

platelet adhesion
platelet aggregation Primary
Haemostasis

Stabilisation of the plug with fibrin

blood coagulation Secondary
Haemostasis
Dissolution of clot and vessel repair
fibrinolysis
Thrombosis
• the pathological process whereby platelets and fibrin
interact with the vessel wall to form a haemostatic plug to
cause vascular obstruction

• may be arterial, causing ischaemia

• or venous, leading to stasis
• underlies ischaemic heart, cerebrovascular and peripheral
vascular diseases, venous occlusion and pulmonary
embolism
Haemostasis and Thrombosis: a Balance
Normal haemostasis: a state of equilibrium

Fibrinolytic factors, Coagulation factors,

anticoagulant proteins platelets
 Thrombosis

Fibrinolytic factors, Coagulation

anticoagulant proteins factors,
platelets
Thrombosis
 Bleeding

Coagulation factors,
Platelets
Fibrinolytic
factors,
Anticoagulant
proteins

August
August 3,
3, 2021
2021 Haemostasis
Haemostasis Principals
Principals
Easy bruising
(ecchymosis)

August
August 3,
3, 2021
2021 Haemostasis
Haemostasis Principals
Principals
Tests of haemostatic function
• Defective haemostasis with abnormal bleeding may result from:
• A vascular disorder
• Thrombocytopenia or a disorder of platelet function
• Defective blood coagulation
• Simple tests are employed to assess the platelet, vessel wall
and coagulation components of haemostasis

• E.g. Blood count and blood film examination, screening tests of

blood coagulation, individual coagulation factor assays, assay of
von Willebrand factor
Screening tests used in the diagnosis of coagulation disorders

• prothrombin time (PT)

• measures factors VII, X, V, prothrombin (II) and fibrinogen
• Tissue thromboplastin (a brain extract) or [synthetic] tissue
factor with lipids and calcium is added to citrated plasma

• activated partial thromboplastin time (APTT)

• Measures factors VIII, IX, XI and XII in addition to factors X, V,
prothrombin (II) and fibrinogen.

• Three substances – phospholipid, a surface activator (e.g.

kaolin) and calcium are added to citrated plasma
• thrombin (clotting) time (TT)
• sensitive to a deficiency of fibrinogen or inhibition of
thrombin

• Diluted bovine thrombin is added to citrated plasma

Screening tests used in the diagnosis of coagulation disorders

DIC, disseminated intravascular

coagulation; FDPs, fibrin degradation
products.
N.B. Platelet count and the tests of
platelet function are also used in
screening patients with a bleeding
disorder
Principles of clotting tests
• Incubate plasma with reagents necessary for
coagulation
• Phospholipid, co-factors
• Trigger or activator
• Calcium
• Measure time taken to form fibrin clot

29
Manual Coagulation
Automated Coagulation
Summary
Haemostatic Plug Formation:
Response to injury
Vessel constriction

Formation of an unstable platelet

plug
platelet adhesion
Primary
platelet aggregation Haemostasis

Secondary
Stabilisation of the plug with fibrin
blood coagulation Haemostasis

Dissolution of clot and vessel repair

• Haemostasis and Thrombosis: a Balance
• Coagulation tests and their interpretation