Coagulation Disorders

International

Coagulation Disorders
in Pregnancy

Coagulation Disorders
International

Objectives
Definition

Causes
Pathophysiology

Clinical Features
Diagnosis

Management

Coagulation Disorders
International

Definition
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 Disorders
International

Causes - Consumptive
Abruptio placentae
Pre-eclampsia/Eclampsia
Sepsis - including septic abortion
Amniotic fluid embolus
Intrauterine Fetal Demise
Sickle Cell Crisis
Trophoblastic Disease

Coagulation Disorders
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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

Coagulation Disorders
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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

Coagulation Disorders
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Coagulation Disorders
International

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 Disorders
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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

Coagulation Disorders
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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

Coagulation Disorders
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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

Coagulation Disorders
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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

Coagulation Disorders
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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, Ringers
RBC replacement - situation specific

Coagulation Disorders
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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

Coagulation Disorders
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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

Coagulation Disorders
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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.

Coagulation Disorders
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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.

Management option
DIC/massive
International
hemorrhage

Coagulation Disorders

Acquired inhibitors
of coagulation

Quality of
evidence

Strength of recommendation

Interdisciplinary
approach
(Obstetrics/hematology)

IV

Treat cause

IV

Resuscitation volume
replacement to maintain
tissue perfusion

IV

Replace fresh frozen

plasma, cryoprecipitate
and platelets on basis of
laboratory results and
clinical condition

IV

Consider heparin in
severe DIC due to
amniotic fluid embolism

IV

Interdisciplinary
approach
(obstetrics/hematology)

IV

Specific clotting factor

concentrates
(individualized
management)

IV

III

Immunosuppressive
therapy

IV
III

C
B

Disseminated intravascular coagulation

Coagulation Disorders

International

Management option

Quality of evidence

Strength 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

Heparin and antithrombolytic

therapy have both been used in
DIC to break the cycle of
consumptive coagulopathy.
Neither has been subjected to
controlled trials

IV

Coagulation Disorders
International

Coagulation Disorders
International

THROMBOPHILIA
D-DIMER DIAGRAM