Coagulation defects in pregnancy


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Coagulation defects in pregnancy

  1. 1. Coagulation Defects in Pregnancy<br />
  2. 2. Coagulation Disorders in Pregnancy<br />1.Disseminated intravascular coagulation:<br />2. Others:<br />Inherited: <br />b. Non-inherited:<br />
  3. 3. Disseminated Intravascular Coagulation (DIC)<br />Pathogenesis<br /> Extensive vessels and tissues damage ? release of thromboplastins ? utilisation of the fibrinogen and other clotting factors in an aimless coagulation process ? fibrin .? stimulates fibrinolytic system ? breaks fibrin and fibrinogen into FDP which have an anticoagulant effect ? aggravates haemorrhage and shock ? ischaemia ? more tissue damage ? viscious circle.<br />
  4. 4. The anticoagulant effect of FDP is due to:<br /> a. Inhibition of platelet function.<br />b.Interference with thrombin/ fibrinogen reaction.<br />c. Interference with fibrin polymerisation.<br />d. Interference with myometrial contraction.<br />
  5. 5. Predisposing factors<br />a. Abruptioplacentae.<br />b.Amniotic fluid embolism.<br />c. Endotoxic shock.<br />d. Eclampsia and pre-eclampsia.<br />e. Hydatidiform mole.<br />f.. IUFD and missed abortion.<br />g. Intra amniotic hypertonic saline or urea for induction of abortion.<br />h. Incompatible blood transfusion or transfusion of massive banked <br />blood which is deficient in factor V and VIII.<br />i. Prolonged shock of whatever the cause.<br /> g. Placenta accreta.<br /> h. Rupture uterus.<br />
  6. 6. Clinical features<br />a. oozing of blood,<br />b. bruising,<br />c epistaxis,<br />d. haematuria,<br />e. haematoma formation especially at wound and venepuncture site,<br />f. postpartum haemorrhage.<br />
  7. 7. Investigations<br />a. Clot observation test:<br /> + 5-10 C.C. of blood in a test tube will be clotted normally within 10 minutes. In case of DIC no clot will be formed or a clot is formed but it undergoes dissolution within one hour in 37oC.<br />b. Fibrindex test:<br /> + 0.5 C.C. of fibrindex which contains thrombin is added to 0.5 C.C. of plasma in a test tube. Normally, a visible clot will be formed within 5-10 seconds. In DIC, clot formation is delayed up to 30 seconds (hypofibrinogenaemia) or it will not form at all (afibrinogenaemia).<br />
  8. 8. c. Schneider test:d. Thrombin is added to serial dilutions of the patient’s plasma 1:2, 1: 4, 1:8,......1:128.<br />> Clot formation in all tubes: Normal.<br />> No clot in all tubes: Afibrinogenaemia.<br />> No clot in dilutions 1: 16 onwards: Hypofibrinoginaemia.<br />
  9. 9. Laboratory tests<br />a. Plasma fibrinogen level:<br /> > During pregnancy the normal level is 4-6 gm/L. Failure of coagulation occurs when its level drops to 1 gm/L.<br /> b. Fibrinogen degradation products FDP: increased.<br /> c. Platelet count: decreased.<br />
  10. 10. Management<br /> a Elimination of the underlying cause.<br />b. Fresh blood transfusion: contains clotting factors particularly F II, V and VIII.<br />c. Fresh frozen plasma: contains 3 gm fibrinogen/L in addition to FV and VIII.<br />d. Fibrinogen: 4-6 gm IV may be given if there is no fresh frozen plasma. However, it is not recommended as it may aggravate the coagulation process (fuel on fire) and cause hepatitis B.<br />
  11. 11. e. Heparin: to inhibit fibrin production and consumption of the clotting factors but it is contraindicated if there is current bleeding.<br />f. Antifibrinolytic agents: as EACA, trasylol or tranexamic acid may be given to suppress the fibrinolytic process. However, this may enhance thrombosis formation.<br />
  12. 12. DEEP VEIN THROMBOSIS (DVT)<br />