Disseminated Intravascular Coagulation in Pregnancy

Disseminated Intravascular Coagulation (DIC)

• DIC is a unique entity during pregnancy, secondary to an underlying disease or complication.
• It subsides when the underlying condition resolves.
• Incidence is 0.03%-0.35%.
• DIC can result from pregnancy complications or unrelated issues like sepsis or trauma.

Predisposing Factors

• Acute peripartum hemorrhage (uterine atony, cervical/vaginal lacerations, uterine rupture)
• Placental abruption
• Pre-eclampsia/eclampsia/HELLP syndrome
• IUD/Retained stillbirth
• Septic abortion & intrauterine infection
• Amniotic fluid embolism
• Acute fatty liver of pregnancy

Haemostasis

• Normal blood flow occurs freely in a blood vessel.
• When a vessel wall is damaged, a reaction occurs to prevent blood loss.
• This reaction involves three events:
  • Vascular spasm: Vasoconstriction resulting from vessel injury, blood compression, and chemical release (pain receptors stimulate platelets).
  • Platelet plug formation: Platelets aggregate at exposed areas of the vessel wall. Platelets release thromboxane A2 and other chemicals to promote vascular spasm and attract more platelets.
  • Coagulation of blood: Prothrombin activator is formed, converting prothrombin to thrombin. Thrombin causes fibrinogen to form fibrin threads, trapping red/white blood cells and stopping bleeding.

DIC Pathophysiology

• In DIC, procoagulation substances are released in excess leading to:
  • Excess coagulation (widespread clotting)
  • Disruption of blood flow, ischemia, and multi-organ failure
  • Consumption and depletion of platelets
  • Severe bleeding

Clinical Signs

• Obstetric DIC often presents more with bleeding than clotting complications.

Diagnosis

• Diagnosis is usually based on clinical assessment of the patient (review of history, clinical situation).
• Early diagnosis is essential to prevent multi-organ failure and uncontrolled hemorrhage, which have high mortality rates.

Clinical Findings

• DIC can be asymptomatic.
• Haemorrhage severity depends on the extent of the process.

Laboratory Investigations

• Full examination of clinical condition.
• Lab tests confirm:
  • Thrombocytopenia (low platelet count) - identifies increased destruction
  • Prolonged prothrombin time (PT)
  • Partial thromboplastin time (PTT)
  • Low fibrinogen level
  • Rising D-dimer

Treatment

• Treatment focuses on resolving the underlying condition, especially before the threshold of viability, through fast and prompt delivery or termination.
• Delivery options discussed among a multi-disciplinary team.
• Supportive treatment with blood products (plasma, red blood cells, platelets, fibrinogen) and surgical care as needed.
• Continuous clinical and lab surveillance.
• For small health facilities, consider possible referral to larger facilities for blood bank support and massive blood transfusion when appropriate.

Summary

• DIC is a life-threatening condition arising from varied obstetric and non-obstetric causes.
• Prompt diagnosis and understanding the underlying mechanisms are crucial for favourable outcomes.
• Teamwork and rapid treatment are essential for successful management.

This quiz covers the essential aspects of Disseminated Intravascular Coagulation (DIC) during pregnancy, including its causes, predisposing factors, and the mechanism of hemostasis. Understanding DIC is crucial for managing pregnancy complications effectively. Test your knowledge on this critical topic.