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

International

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

International

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

International

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

International

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

International

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

International

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

International

Management - Initiating Cause

• rapid identification of underlying condition

• appropriate treatment of underlying condition

• removes cause and allows homeostatic

mechanisms to recover

Coagulation Disorders

International

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 Disorders

International

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

International

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

International

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

International

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 Disorders

International

Management 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

Coagulation Disorders

International

Disseminated intravascular coagulation

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 B

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 C

Coagulation Disorders

International

Coagulation Disorders

International

THROMBOPHILIA

D-DIMER DIAGRAM