Pregnancy

Hypercoagulability
ALLEN OCTAVIANO CUDIAMAT

COAGULATION AND FIBRINOLYSIS

During normal pregnancy, both coagulation and fibrinolysis are
augmented but remain balanced to maintain hemostasis.
increased concentrations of all clotting factors, except factors
XI and XIII, and increased levels of high-molecular-weight
fibrinogen complexes.
clotting time of whole blood does not differ significantly in
normal pregnant women
The percentage of high-molecular-weight fibrinogen is
unchanged

 CLOTTING FACTORS
COAGULATION
CASCADE
FIBRIN FORMATION

PLASMIN
CLOT
DEGRADATION
FIBRINOLYSIS

PLASMINOGEN

ACTIVATED BY:
TISSUE
PLASMINOGEN
ACTIVATOR (tPA)

PLASMIN

FIBRINOLYSIS

PRODUCT: FIBRINDEGRADATION
PRODUCTS

PLASMINOGEN

ACTIVATOR: tPA

ACTIVITY
DECREASES

INHIBITED BY
PAI-1 AND PAI-2

PLASMIN
DECREASED LEVELS

FIBRINOLYSIS
impaired

fibrinolytic activity is reduced in

normal pregnancy
tPA activity gradually decreases
over the course of normal
pregnancy.
plasminogen activator inhibitor
type 1 (PAI-1) and type 2 (PAI-2)
(which inhibit tPA and regulate
fibrin degradation by plasmin)
increase during normal pregnancy.
These changes indicate that the
fibrinolytic system is impaired, but
countered by
increased levels of plasminogen
and
decreased levels of another
plasmin
inhibitor,
alpha
2
antiplasmin.
SUCH CHANGES SERVE TO ENSURE
HEMOSTATIC BALANCE DURING
NORMAL PREGNANCY.

Increased
PLASMINOGEN

ACTIVATOR: tPA

PLASMIN

DECREASED ALPHA 2
ANTIPLASMIN LEVELS

FIBRINOLYSIS
Balanced

PLATELETS
the average platelet count was decreased slightly during pregnancy to
213,000/L compared with 250,000/L in nonpregnant control women.
thrombocytopenia - below the 2.5th percentile (platelet count of
116,000/mL).
Decreased platelet concentrations are partially due to the effects of
HEMODILUTION.
INCREASED PLATELET CONSUMPTION, leading to a greater proportion
of younger, and larger platelets.
beginning in midpregnancy, production of thromboxane A2, which
induces platelet aggregation, progressively increases.

REGULATORY PROTEINS
natural inhibitors of coagulation
proteins C, S, and Z and antithrombin
thrombophilias
Inherited or acquired deficiencies of natural regulatory proteins
account for many thromboembolic episodes during pregnancy
Between the first and third trimesters, levels of activated PROTEIN C decrease
from about 2.4 to 1.9 U/mL, and free PROTEIN S decreases from 0.4 to 0.16
U/mL
PROTEIN Z is a vitamin-K dependent glycoprotein that inhibits activation of factor
X.
20-percent increase across pregnancy.
ANTITHROMBIN remain relatively constant throughout gestation and the early
puerperium