Disseminated Intravascular Coagulation (DIC) PDF

Disseminated Intravascular Coagulation Heather Helen NU3115 AY2024  ▪ Definition ▪ Predisposing factors ▪ Haemostasis Content ▪ Clinical findings ▪ Lab investigations ▪ Treatment ▪ Summary ...

Disseminated Intravascular Coagulation Heather Helen NU3115 AY2024  ▪ Definition ▪ Predisposing factors ▪ Haemostasis Content ▪ Clinical findings ▪ Lab investigations ▪ Treatment ▪ Summary  ▪ Disseminated intravascular coagulation (DIC) during pregnancy is a unique entity. ▪ It is always secondary to an underlying disease or complication ▪ Subsides only when underlying disease/condition Introduction resolves (Elez 2017) ▪ ‘Thrombo-haemorrhagic condition’ ▪ Incidence 0.03%-0.35% (Erez et al 2022)  ▪ DIC can results from complications unrelated to pregnancy such as sepsis or trauma, but it is also associated with specific pregnancy complications including: Acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); Predisposing Placental abruption; Pre-eclampsia/eclampsia/HELLP syndrome; factors IUD/Retained stillbirth; Septic abortion and intrauterine infection; Amniotic fluid embolism Acute fatty liver of pregnancy (Erez 2017, Erez et al 2022, Nelson Piercy 2021)  ▪ In a normal situation blood flows freely in a blood vessel Haemostasis ▪ When damage occurs to the wall of the blood vessel, a reaction occurs to prevent loss of blood. (Rankin 2017)  ▪ Three events occur; 1. Vascular spasm Haemostasis 2. Platelet plug formation 3. Coagulation of blood (Rankin 2017)  ▪ Vasoconstriction results after injury occurs as a result of Injury to vascular smooth tone 1) Vascular Compression of vessel by blood spasm Chemical release Platelets and reflexes stimulated by pain receptors (Rankin 2017)  ▪ In normal situations platelets do not stick together ▪ When a blood vessel wall has been damaged underlying collagen fibres are exposed 2) Platelet plug ▪ This causes platelets to stick to exposed areas formation ▪ Lipids in the platelets release thromboxane A2. ▪ Other chemicals are then released enhancing vascular spasm and attract more platelets (Rankin 2017)  ▪ Prothrombin activator is formed ▪ This converts prothrombin to thrombin ▪ Thrombin causes fibrinogen to form fibrin threads 3) Coagulation ▪ Thus trapping fibrin, red and white blood cells and stops bleeding. of Blood (Rankin 2017) In DIC procoagulation substances are released in excess DIC  ▪ Obstetric DIC presents more usually with bleeding than Clinical Signs clotting complications (Erez et al 2022)  ▪ Unfortunately, in the majority of the cases the diagnosis of DIC is based on the clinical assessment of the woman Review of history Clinical situation Diagnosis ▪ Early diagnosis is essential to prevent ▪ Multi-organ failure ▪ Uncontrollable haemorrhage Both of which carry high mortality (Erez et al 2022)  ▪ May be asymptomatic Clinical Findings ▪ Haemorrhage – extent depends on the degree (Nelson Piercy 2021)  ▪ Full examination of clinical condition ▪ Lab tests results confirm: Thrombocytopenia (low platelet count) - identifies increased destruction Laboratory Prolonged prothrombin time (PT) Investigations Partial thromboplastin time (PTT), Low fibrinogen level, Rising D- dimer (Erez et al 2022)  The basic principles for treating obstetrical DIC are: ▪ Treatment and resolution of the underlying condition leading to DIC ▪ Fast and prompt delivery or termination of pregnancy (before the threshold of viability). The delivery options should discussed by a multidisciplinary team and consider the safest mode of delivery to the mother, how fast she is expected to deliver, what are the resources of blood products and other Treatment supportive mechanisms available ▪ Supportive treatment with blood product transfusion, surgical care and related measures ▪ Treatment of coagulopathy Fresh Frozen Plasma Red cells – only to replace blood loss Platelets Fibrinogen  ▪ Rigorous clinical and laboratory surveillance – Consideration for point of care testing (TEG/ROTEM) ▪ Prompt involvement of senior MDT such as hematologists, gynaecological surgeons, anesthesiologists and others Treatment ▪ In small health care facilities consider transfer. Important to estimate whether their blood bank can support a massive blood transfusion and, if necessary, contact regional or larger hospitals for assistance or for transfer Erez et al 2022  ▪ DIC is a life-threatening situation ▪ Can arise from a variety of obstetrical and non- obstetrical causes. ▪ Prompt diagnosis and understanding the underlying Summary mechanisms of disease leading to this complication in essential for favorable outcome. ▪ Team work and prompt treatment are essential for the successful management of women with DIC.  ▪ Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, & Thachil J (2022). DIC in pregnancy – pathophysiology, clinical characteristics, diagnostic scores, and treatments. Journal of Blood Medicine, 13, 21-44. ▪ Erez O (2017) Disseminated Intravascular Coagulation in Pregnancy – Clinical Phenotypes and Diagnostic References Scores. Thrombosis Research 151 S56-60. Web. ▪ Nelson Piercy C (2021) Handbook of Obstetric Medicine, 56h ed. CRC Press ▪ Rankin, J (2017) The haematological systemphysiology of the blood. In Rankin, J. (Ed.). Physiology in Childbearing with Anatomy and Related Biosciences, 4th edn. Elsevier, London, 155-166.