1 coagulation disorderin pregnancy ch06 --dic

7/25/2019 1 Coagulation Disorderin Pregnancy CH06 --DIC

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Coagulation Disorders

International


in Pregnancy




International

Objectives

• Definition

• Causes

• Pathophysiology

• Clinical Features

• Diagnosis

• Management




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Definition

• Abnormal coagulation

– consumptive - disseminated intravascular coagulation (DI

- increased split products and fibrinolysis

– dilutional - secondary to massive volume replacement

- crystalloid or PRBC without clotting

factors




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Causes - Consumptive

• Abruptio placentae

• Pre-eclampsia/Eclampsia

• Sepsis - including septic abortion• Amniotic fluid embolus

• Intrauterine Fetal Demise

• Sickle Cell Crisis

• Trophoblastic Disease




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Causes - Dilutional

• Massive resuscitation due to hypovolemia

– post-partum hemorrhage

– placenta abruption

– placenta previa – uterine rupture

– ectopic pregnancy / incomplete abortion

– trauma

– non-pregnancy related bleeding




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Activation of Clotting System

• Thromboplastin release

– acute - abruption, AF embolus, uterine rupture

– sub-acute - intrauterine death, missed abortion

• Endothelial cell injury

– pre-eclampsia, sepsis

• Uterine Rupture

• Phospholipid release

– sepsis, transfusion reactions




International TABLE – Couses and Pathophysiology of

Disseminated Intravascular Coagulation




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Clinical Features• signs and symptoms of underlying cause

• bleeding

– bruising, purpura, epistaxis, venipunctureoozing

– operative sites, PPH

• hypotension and hypoperfusion

• thrombotic complications are rare




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Diagnosis• recognize triggering conditions

• high index of suspicion

• Clot Test - simple bedside test – abnormal if no clot formed in 10 -12 minutes

– clot occupies 50% of blood sample volume

–clot withstands inversion of tube after 30

minutes

– no clot lysis within 1 hour




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Diagnosis

• decreased platelets

• prolonged INR and PTT may not be seen initially

• thrombin time usually prolonged

• fibrinogen level decreased

– normally increased to 4 - 8 mM in pregnancy

– levels < 2 mM may indicate coagulopathy

• increase in fibrin split products• evidence of RBC damage - blood smear




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Management - Principles

• rapidly developing and evolving condition

• lab results may not reflect current situation

• serious threat to life

• rapid and rational treatment essential

• multi-specialty approach




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Management - Initiating Cause

• rapid identification of underlying condition

• appropriate treatment of underlying condition

• removes cause and allows homeostatic

mechanisms to recover




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Management - Resuscitation• oxygen

• maintain organ perfusion

–

promotes clearance of anticoagulants – prevents ischemic injury - liver, kidney

– allows clotting factor synthesis

• rapid crystalloid infusion - saline, Ringer’s

• RBC replacement - situation specific




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Management - Procoagulant Replacement

• component replacement - situation specific

– Fresh whole blood

– Fresh Frozen Plasma

– Fresh Plasma

– Cryoprecipitate - infection risk

– Platelets

• management aided by hematologist

• anticoagulants not indicated




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Summary

• identify and treat underlying cause

• rapid resuscitation

• airway and oxygen

• volume replacement

• RBC replacement

• clotting factor replacement

• multi-specialty approach in severe cases




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Replacement of procoagulants

- Fresh frozen plasma replaces most clotting factors and has the least risk

of transmitting hepatitis.

1 unit after the initial 4-6 units of whole blood and thereafter 1 unit for

every 2 units of wholeblood required.

- Cryoprecipitates may be necessary if fibrinogen levels are low.

- Platelets can be transfused in severe cases of thrombocytopenia.

1 unit of platelets can raise the number of platelets to about

5000-10 000.




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Inhibition of the DIC and fibrinolysis

The use of heparin has been advocated as a method of blocking DIC. It is

especially recommended in cases of chronis DIC, as is the intrauterine

death syndrome. It is not recommended if the patient is bleeding

profusely.

Epsilon aminocaproic acid (EACA) inhibits the conversion of plasminogen

to plasmin and its use has been suggested as a means to counteract

secondary fibrinolysis. It is not recommended in these cases.




Internationalanagement option

Quality of

evidence

Strength of recommendation

DIC/massive

hemorrhage

Interdisciplinary approach

Obstetrics/hematology)

IV C

Treat cause IV C

Resuscitation volume

replacement to maintain

tissue perfusion

IV C

Replace fresh frozen

plasma, cryoprecipitate and

platelets on basis of

laboratory results and

clinical condition

IV C

Consider heparin in severe

DIC due to amniotic fluid

embolism

IV C

Acquired inhibitors of

coagulation

Interdisciplinary approach

obstetrics/hematology)

IV C

Specific clotting factor

concentrates individualized

management)

IV

III

C

B

Immunosuppressive therapy IV

III

C

B




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Disseminated intravascular coagulation

Management option Quality of evidenceStrength of

recommendation

Involve hematologist and support

services (blood transfusion etc.) early- √

Treat/remove cause (e.g.empty uterus,antibiotics for sepsis) - √

Hematological priorities are to replace

blood constituents and coagulation

factors

III B

Heparin and antithrombolytic therapy

have both been used in DIC to break thecycle of consumptive coagulopathy.

Neither has been subjected to controlled

trials

IV C




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1 coagulation disorderin pregnancy ch06 --dic

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