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
• Uterine Rupture
• 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
• Phospholipid release
– sepsis, transfusion reactions
 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