Coagulation
International Disorders
CoagulationDisorders
in Pregnancy
Coagulation
International Disorders
Objectives
• Definition
• Causes
• Pathophysiology
• Clinical Features
• Diagnosis
• Management
Coagulation
International Disorders
Defnitio
n• Abnormal coagulation
– consumptive - disseminated intravascular coagulation (DIC)
- increased split products and fibrinolysis
– dilutional - secondary to massive volume replacement
- crystalloid or PRBC without clotting
factors
Coagulation
International Disorders
Causes -
Consumptive
• Abruptio placentae
• Pre-eclampsia/Eclampsia
• Sepsis - including septic
• abortion
• Amniotic fluid embolus
• Intrauterine Fetal Demise
• Sickle Cell Crisis
Trophoblastic Disease
Coagulation
International Disorders
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
Coagulation
International Disorders
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
Coagulation
Disorders
TABLE – Couses and Pathophysiology of
International
Disseminated Intravascular Coagulation
Coagulation
International Disorders
Clinical Features
• signs and symptoms of underlying cause
• bleeding
– bruising, purpura, epistaxis, venipuncture
oozing
– operative sites, PPH
• hypotension and hypoperfusion
• thrombotic complications are rare
Coagulation
International Disorders
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
Coagulation
International Disorders
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
Coagulation
International Disorders
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
Coagulation
International Disorders
Management - Initiating Cause
• rapid identification of underlying condition
• appropriate treatment of underlying condition
• removes cause and allows homeostatic
mechanisms to recover
Coagulation
International Disorders
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
Coagulation
International Disorders
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
Coagulation
International Disorders
Summary
• identify and treat underlying cause
• rapid resuscitation
• airway and oxygen
• volume replacement
• RBC replacement
• clotting factor replacement
• multi-specialty approach in severe cases
Coagulation
International Disorders
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.
Coagulation
International Disorders
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.
Coagulation Quality
Management Disorders
International option of Strength of recommendation
evidence
DIC/massive Interdisciplinary approach IV C
hemorrhage (Obstetrics/hematology)
Treat cause IV C
Resuscitation volume IV C
replacement to
maintain tissue
perfusion
Replace fresh frozen IV C
plasma, cryoprecipitate
and platelets on basis of
laboratory results and
clinical condition
Consider heparin in IV C
severe DIC due to
amniotic fluid embolism
Acquired inhibitors Interdisciplinary approach IV C
of coagulation (obstetrics/hematology)
Specific clotting factor IV C
concentrates
(individualized III B
management)
Immunosuppressive therapy IV C
III B
Coagulation
International Disorders
Disseminated intravascular
coagulation Strength of
Management option Quality of evidence
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 III B
factors
Heparin and antithrombolytic therapy
have both been used in DIC to break the
cycle of consumptive coagulopathy. IV C
Neither has been subjected to controlled
trials
Coagulation
International Disorders
INTRINSIC EXTRINSIC PATHWAY
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Coagulation
International Disorders
THROMBOPHILIA
D-DIMER DIAGRAM
