Pemeriksaan hemostasis

pada trombosis
Pemeriksaan laboratorium pada
trombosis

♦ Membantu diagnosis

♦ Memantau terapi trombosis

♦ Mencari faktor risiko

Membantu diagnosis
♦ Bukti aktivasi koagulasi :
• Fragmen protrombin (F1.2)
• Thrombin-antithrombin complex (TAT)
• Fibrin monomer
• Fibrinopeptida A (FPA)
• D dimer
♦ Bukti aktivasi trombosit :
• Platelet factor 4
• β thromboglobulin
 Pemantauan terapi trombosis
Heparin :
Meningkatkan aktivitas antitrombin
Monitoring : TT, APTT, WBCT, plasma heparin
(titrasi protamin, anti Xa)
3 jam setelah suntikan terakhir atau 30 menit
sebelum suntikan berikut
Target : 1.5 – 2.5 x baseline (0.3 – 0.8 IU/ml)
 Low molecular weight heparin
♦ Perdarahan kurang
♦ Pemberian 1 – 2 x dengan cara sc
♦ Monitoring tak perlu kecuali pada kehamilan
dan fungsi ginjal terganggu
♦ Monitoring : - Anti Xa (0.2 – 0.4 IU/ml)

- 3 jam setelah suntikan

- Tidak bisa dengan APTT

Antikoagulan oral gol. coumarin
♦ Menghambat vitamin K ( II, VII, IX, X turun)
♦ PIVKA : protein induced by vitamin K absence
or antagonist
♦ Monitoring :
– INR (International Normalised Ratio)
target 2 – 3 (DVT, PE)
3 - 4.5 (emboli, atrial fibrilasi)
– Thrombotest 5 – 10%
15 – 25% Jika mau operasi
Deteksi faktor risiko trombosis

♦ ACA, LA ♦ Profil lipid

♦ Antitrombin ♦ Glukosa darah
♦ Protein C ♦ Lipoprotein a
♦ Protein S ♦ Agregasi trombosit
♦ Viskositas ♦ Homosistein
♦ Fibrinogen
Antiphospholipid antibody

♦ Reagin

♦ Lupus anticoagulant

♦ Anticardiolipin

♦ Antiphosphatidylserin

♦ Antiphosphatydilethanolamin
 Antiphospholipid-thrombosis
syndrome

LAT syndrome ACLAT syndrome

Primer Sekunder Primer Sekunder

Vena Arteri Arteri Arteri

Vena Vena Vena
Lupus anticoagulant (LA)
♦ Misnomer
♦ Primer : tanpa penyakit dasar
♦ Sekunder : ada penyakit dasar misal SLE,
RA, keganasan, infeksi (HIV)
♦ Obat-obatan : phenytoin, phenotiazine,
fansidar, quinidine, quinine, hydralazine,
procainamide
Lupus anticoagulant (LA)
♦ Tidak perdarahan kecuali ada kelainan
hemostasis lain
♦ Dihubungkan dg. trombosis vena dan arteri
♦ Mekanisme trombosis
– menghambat pelepasan PGI2
– menghambat aktivasi protein C
– mengganggu aktivitas antitrombin
– menghambat pelepasan t-PA
– interaksi dan aktivasi trombosit
LA-Thrombosis syndrome
♦ Primer:
• Tanpa penyakit dasar
• Terutama trombosis vena
• Sering tanpa ACA
♦ Sekunder :
• Ada penyakit dasar
• Trombosis vena maupun arteri
• Sering ACA positif
LA-Thrombosis syndrome

♦ DVT, PE, recurrent fetal wastage, renal

vascular thrombosis, thrombocytopenia
♦ Thrombosis : 10% pasien SLE

♦ Thrombosis : 50% pasien SLE dengan LA +

♦ Pada 6 – 8% pasien thrombosis dijumpai LA

ACA-Thrombosis Syndrome
♦ Type I : DVT, PE
♦ Type II : Coronary thrombosis, peripheral
thrombosis
♦ Type III : Retinal artery/vein thrombosis,
cerebrovascular thrombosis
♦ Type IV : mixtures of type I, II, III
♦ Type V : Fetal wastage syndrome
♦ Type VI : no clinical manifestations
Antiphospholipid syndrome and
thrombocytopenia
♦ Trombositopenia dijumpai pada:
– 50% APL-T syndrome sekunder
– 10% APL-T syndrome primer
♦ Patofisiologi : autoimmune, sensitisasi
trombosit oleh antibodi yang melekat pada
permukaan fosfolipid
♦ Manifestasi : trombosis bukan perdarahan
Preliminary Classification Criteria for
Antiphospholipid Antibody Syndrome
(International Consensus Workshop 1998)
♦ Vascular thrombosis :
– One or more episodes
– Arterial, or
– venous, or
– Small vessel thrombosis in any tissue or
organ
– Confirmed by imaging or Doppler
– Histopathologic confirmation : thrombosis
without inflammation in the vessel wall
Preliminary Classification Criteria (cont)
Pregnancy morbidity
– Three or more unexplained miscarriages with anatomic,
genetic, or hormone causes excluded or,
– One or more unexplained deaths of a morphologically
normal fetus at or after the10th week of gestation with
fetal morphology documented by ultrasound or by direct
examination of the fetus or
– One or more premature births of a morphologically
normal neonate at or before the 34th week of gestation
associated with severe preeclampsia or severe placenta
insufficiency
Laboratory Criteria

Anticardiolipin antibody :
♦ IgG and/or IgM present in
♦ Medium or high titer
♦ On two or more occasion, 6 weeks or more
apart, and
♦ Measured by standardized ELISA for β2-
glycoprotein I-dependent anticardiolipin
antibody
Laboratory Criteria
Lupus anticoagulant :
♦ Two or more occasions 6 weeks or more apart and
♦ Detected according to the guidelines of the SSC
subcommittee on lupus anticoagulant/phospholipid
dependent antibodies in the following steps:

• prolonged phospholipid-dependent coagulation screening test

• failure to correct the prolonged test by mixing with normal PPP
• correction of the prolonged test by the addition of excess
phospholipid
• exclusion of other coagulopathies as clinically indicated and
heparin
Skrining untuk deteksi LA
♦ APTT

♦ Kaolin clotting time

♦ Textarin time

♦ Dilute Russell Viper Venom Test

♦ Tissue Thromboplastin Inhibition (TTI)