PostpartumDisseminatedIntravascularCoagulation

Running head: POSTPARTUM DISSEMINATED INTRAVASCULAR COAGULATION 1
Postpartum Disseminated Intravascular Coagulation
Tonsina Wells
SUU
Care of Family
N4330
Becky Rasmusson
April 21, 2014

POSTPARTUM DISSEMINATED INTRAVASCULAR COAGULATION 2
Postpartum Disseminated Intravascular Coagulation
Disseminated intravascular coagulation (DIC) is a series of processes that occur after
massive loss of blood products during a surgical, infectious or traumatic event. During the
postpartum period, there is an increased risk for DIC due to the initial blood loss of the event and
can be further complicated by a high-risk pregnancy category, uterine atony, and ineffective
suture closure or generalized system stressors. This paper will investigate the causes of DIC,
evaluate the associated laboratory values and diagnostic tests that identify the disease process
and associated interventions and medications to slow, stop or reverse the process.
Pregnancy is typically a time of great changes in the body systems and processes which
allow for the creation and development of a new entity. However, the process of carrying and
delivering the fetus can be complicated by difficulties that lead to excessive blood loss and
associated coagulopathies. In typical instances of DIC, the coagulation system is over stimulated
and then rapidly depleted; allowing for system wide bleeding which deteriorates into
hypovolemic shock, impaired consciousness, organ failure, respiratory failure and death
(Elsevier, 2012). Understanding the preceding risk factors and associated disorders is important
to understanding the development of DIC in pregnant patients.
Pregnancy Disease Processes
Several disorders that complicate pregnancy can lead to alteration in the coagulation
cascade. According to Francois & Foley, in pregnancy “DIC may occur as a result of acute
antepartum hemorrhage (APH) or postpartum hemorrhage (PPH), abruptio placentae, amniotic
fluid embolism, dead fetus syndrome, severe preeclampsia, sepsis, saline abortion and acute fatty
liver of pregnancy” (as cited by Perry, Hockenberry, Lowdermilk, & Wilson, 2009). Other
causes of potential hemorrhage include prolonged third stage of labor, multiple delivery,

episiotomy, fetal macrosomia, and previous history of postpartum hemorrhage (Anderson &
Etches, 2007). In order to fully understand the individual disease processes, it is important to
understand the specific processes involved in each disorder that can lead to DIC.
Definitions
 Antepartum hemorrhage is any bleeding that occurs during pregnancy prior to
delivery. Instances of placenta previa, which is an improper implantation of the
ovum, leads to painless bleeding (typically in the third trimester), fluid loss and
possible miscarriage, if left untreated.
 Postpartum hemorrhage is blood loss greater than 500 mL within twenty-four
hours following delivery and can be attributed to lacerations of the vaginal tract,
surgical complications in a cesarean section, uterine atony or retained placenta
(Children’s hospital of Wisconsin [CHW], 2014).
 Abruptio placentae is a separation of the placenta before delivery of the infant and
occurs when there is trauma to the abdomen (fall or car accident) which can be
occult, incomplete, or complete and can also occur in abrupt loss of amniotic fluid
(MedlinePlus, 2014).
 Amniotic fluid embolism occurs when amniotic fluid or fetal material moves into
the maternal bloodstream causing the coagulation cascade to come into effect
(Mayo Clinic, 2014).
 Dead fetus syndrome occurs when the fetus has died in utero, but has not been
expelled from the uterus for an extended period of time; eventual delivery leads to
massive overt bleeding (MediLexicon, 2014).

 Severe preeclampsia occurs when maternal hypertension combines with proteins
in the urine and edema after twenty (20) weeks of pregnancy. Generally,
treatment for preeclampsia involves bed rest, diet modification, medications for
high blood pressure, intravenous magnesium, and ultimately delivery of the fetus
(Venes, 2013). If preeclampsia is left unmonitored or untreated, it can devolve
into DIC.
 Sepsis leads to an “overwhelming inflammatory host response … leading to the
over expression of inflammatory mediators.” The infection puts out cellular
components that exacerbate the inflammation process which eventually result in
cell apoptosis or necrosis, causing further inflammation, coagulation, cell death
and organ failure (Semeraro et al., 2010).
 Saline abortion is related to DIC in the same way that amniotic embolism occurs;
during the abortion saline fluid or other products from the fetus pass into the
maternal circulation, which if left untreated, can lead to DIC and death.
 Acute fatty liver of pregnancy (AFLP) leads to “microvesicular fatty infiltration
of hepatocytes without any inflammation or necrosis hemolysis,” according to Ko
and Yoshida “elevated liver enzymes and low platelets (HELLP) syndrome, pre-
eclampsia, thrombotic thrombocytopenia purpura and AFLP may all be a
spectrum of the same illness” (2006, para. 3).
All of the conditions discussed begin with different precursors, but have the similar outcome of
wide spread coagulation. This process is followed by destruction of coagulation components,
with the end result of severe internal and external hemorrhage and organ failure, termed DIC.

Treatment initially depends on the type of pathology that leads up to DIC, however confirmation
and treatment for each condition is much the same.
Diagnostic Tests & Confirmation of DIC
In order to eliminate other coagulation pathologies, it is important to conduct laboratory
tests to determine the specific cause of widespread bleeding. In instances of DIC, a standard
blood draw for complete blood count (CBC) will be performed and a complete metabolic panel
(CMP) may be ordered to ascertain the extent of liver and kidney involvement or damage. From
the same blood draw prothrombin time (PT), partial prothrombin time (PTT) and activated
prothrombin time (aPTT) will also be assessed for blood coagulation times. Results of the tests
(PT, PTT, aPTT) could possibly show delayed clotting times, decreased platelet counts, high
serum fibrinogen, and the CMP will show elevated liver enzymes ALT and AST. However, not
all of the tests may definitively show altered results enough to be able to diagnose DIC and must
be periodically repeated to reveal declining or increasing trends in blood products and
coagulation times. Due to the difficulty in determining DIC, The International Society on
Thrombosis and Haemostasis (ISHT) has developed a scoring tool to assist in the process, shown
below in Figure 1 (Levi & Schmaier, 2012).

Figure 1
A score greater than five (5) indicates the presence of DIC, a score of less than five (5) does not
rule out DIC and further testing and assessment must be completed (Levi & Schmaier, 2012).
Once DIC has been determined to be present, immediate intervention must be performed to
prevent further decline in health.

Nursing Interventions & Treatments
The primary responsibility of a nurse in any situation is assessment, which is vital for
identification and the prevention of further complications. This is especially true in the instance
of any postpartum situation from an uncomplicated, natural, vaginal birth, up to and including a
high-risk, emergent cesarean section. The greatest risk to any postpartum woman according to
the World Health Organization (WHO) is hemorrhage (2012). Ensuring that the fundus is firm,
contracting and midline prevents unchecked bleeding that begins rapid depletion of blood
products. The second greatest risk to the postpartum woman is infection due to the altered
immune function following delivery, which needs to be monitored to avoid introduction of an
infectious process that can quickly develop into sepsis. This is accomplished by strict adherence
to standard precautions, with medical asepsis during vaginal exams (before and after birth), with
surgical asepsis maintained during any surgical procedure. This goal is furthered by immediate
evaluation after delivery, routine vital sign checks post-delivery and through the first twenty-four
to forty-eight hours during recovery. Vital signs are initially performed every thirty minutes for
the first hour postpartum, once an hour for the next two hours, twice in every four hours, and
then a minimum of every eight hours until discharge. At each vital sign check, signs of
hemorrhage, infection and clotting should be scanned for; including checking lochia flow,
vaginal region for excess bleeding and hematoma, legs for deep vein thrombosis (DVT),
temperature for fever, IV insertion site for complications and altered level of consciousness that
could signal blood loss or infection. According to Levi & Schmaier, standardized treatments
include determining cause of DIC
“…assessing and documenting extent of hemorrhage, correcting hypovolemia and
administering basic hemostatic procedures when indicated. Specific blood products

include platelet and factor replacement; heparin can be used in instances where there is
extensive fibrin deposition without evidence of substantial hemorrhage and is appropriate
to treat the thrombosis with DIC. Administration of activated protein C (APC) has
shown benefit in subgroups of patients with sepsis who have DIC, with consideration
given to the anticoagulant effects of this agent” (2012, Treatment).
Medications that assist in preventing postpartum hemorrhage are classified as uterotonic agents,
include oxytocin (Pitocin), methylergonovine (Methergine) and prostaglandins like carboprost
that enhance uterine contractility and cause vasoconstriction. These medications should be used
cautiously in instances of hypertension and have side effects of nausea and vomiting (Anderson
& Etches, 2007).
Medications
Oxytocin
Indications – induction of labor at term; facilitation of threatened abortion; postpartum
control of bleeding after expulsion of placenta.
Action – stimulated uterine smooth muscle, producing uterine contractions with
vasopressor and antidiuretic effects.
Adverse Reactions/Side Effects – central nervous system (CNS) – maternal coma,
seizures; cardiovascular (CV) – maternal hypochloremia, hyponatremia, water
intoxication; other – increased uterine motility, painful contractions, abruptio placentae,
decreased uterine blood flow, hypersensitivity.
Assessment (Postpartum) – monitor BP and pulse during administration, monitor for
water intoxication, notify physician if signs and symptoms occur.

Methylergonovine
Indications – prevention and treatment of postpartum or postabortion hemorrhage caused
by uterine atony or subinvolution.
Action – Directly stimulated uterine and vascular smooth muscle for contraction.
Adverse Reactions/Side Effects – CNS – stroke, dizziness, headache; eye ear nose throat
(EENT) – tinnitus; Respiratory – dyspnea; (CV) – hypertension, arrhythmias, atrial-
ventricular block, chest pain, palpitations; gastric-intestinal (GI) – nausea, vomiting;
genito-urinary (GU) – cramping; dermatology (DERM) – diaphoresis; neurological –
paresthesia; other – allergic reactions.
Assessment – monitor BP, heart rate, uterine response frequently during medication
administration. Notify physician if uterine relaxation becomes prolonged or if character
of vaginal bleeding changes.
Carboprost
Indications – induction of mid-trimester abortion, treatment of postpartum hemorrhage
that has not responded to conventional therapy.
Action – causes uterine contractions by directly stimulating myomentrium.
Adverse Reactions/Side Effects – CNS – dizziness, headache; Respiratory – wheezing;
GI – diarrhea, nausea, vomiting, abdominal pain, cramps; GU – uterine rupture; DERM –
flushing; other – fever, chills, shivering.
Assessment – monitor frequency, duration and force of contractions and uterine resting
tone, notify physician if contractions are absent or last more than one (1) minute.
Monitor temperature, pulse and BP periodically throughout course of therapy, observe for
hypertension and elevated temperature up to sixteen hours after administration.

Auscultate breath sounds, check for sensation of chest tightening for allergic reactions.
Assess for nausea, vomiting and diarrhea; medicate with antiemetic or antidiarrheal prior
to prostaglandin administration. Monitor amount and type of vaginal discharge, notify
physician immediately for symptoms of hemorrhage (Vallerand, Sanoski, & Deglin,
2013).
Other interventions include replacement of blood volume with transfusion of red blood cells
(RBCs), platelets and clotting factors, monitoring blood pressure and utilizing vasopressors as
needed. While continuing to monitor progress, surgical necessity can be determined and utilized
to correct any uncontrolled bleeding from lacerations.
Nursing Care Plan
Table 1
Nursing Care Plan
Assessment Nursing
Diagnosis
Outcomes Nursing
Interventions
Rational Evaluation
Postpartum
VS
At risk for
bleeding for a
decrease in
blood volume
r/t postpartum
period
(Sparks &
Taylor,
2014).
Patient will
receive
adequate
screening/mo
nitoring to
alert
clinicians of
existing risk
factors for
bleeding.
Interview/scree
n each
individual for
risk factors for
bleeding.
Some individuals
know of their risks
for bleeding (high-
risk pregnancies,
other concurrent
health issues) others
do not, clinical tests
and evaluation by
expert clinicians
allows for
preventative or
corrective
intervention
measures.
Patient receives
careful monitoring
of existing risk
factors.

Patient will
experience no
bleeding
episodes.
Patient and
clinicians will
identify and
avoid risk
situations
with the
potential for
trauma injury.
Monitor for
frank and occult
bleeding at
incision site,
lochia flow,
through
assessment of
dressings,
eliminated body
fluids by visual
inspection, etc.
Examine
surgical wound
dressings,
lochia and
chucks pads for
excess
bleeding.
Early recognition of
excessive bleeding
is important to
ensure early
intervention.
Assessment of
bleeding and
seepage should be
compared to
expected blood loss
for similar
conditions.
Patient receives
appropriate
intervention to
protect from
bleeding episodes.
Patient experiences
no incidence of
excessive bleeding.
Excessive
bleeding,
fluid &
electrolyte
balance
Deficient
fluid volume
r/t postpartum
hemorrhage
(Sparks &
Taylor,
2014).
Patient’s vital
signs will
remain stable.
Patient’s
uterus will
remain firm.
Medical
personnel will
quickly
Monitor and
record vital
signs every 15
minutes for 1
hour, then every
4 hours for 24
hours, then
every shift until
discharge.
Gently massage
a boggy fundus,
avoid
overstimulation.
Evaluate
postpartum
hematology
Early detection for
signs of
hemorrhage and
shock, such as
increased pulse and
respiratory rates
and decreased
blood pressure.
Gentle stimulation
can help fundus
become firm;
overstimulation can
cause relaxation.
Comparison of post
delivery Hb and
Hct with previous
Patient’s vital signs
remain stable.
Patient’s uterus
remains firm.
Results of patient’s
hematology studies
are within normal

identify signs
of possible
shock and
initiate
treatment.
studies and
report abnormal
results.
Consider
whether patient
needs typing
and cross
matching for
transfusion.
results provides
information about
the amount of blood
loss and allows
time to plan
interventions, such
as requesting blood
from a blood bank.
range.
Post-DIC
recognition
At risk for
shock r/t
inadequate
blood flow to
the body’s
tissues in the
postpartum
period.
(Sparks &
Taylor,
2014).
Patient will
maintain
adequate
blood
pressure to
maintain
tissue
perfusion.
Patient will
not
experience
hemodynamic
complications
from
underlying
medical
condition.
Patient will
verbalize
signs and
symptoms of
possible
hypotension
and
hypoperfusio
n.
Monitor
hemodynamics
status
frequently,
including blood
pressure, heart
rate and oxygen
saturation.
Collaborate
with other
members of the
health care
team.
Administer
blood products,
as needed.
Educate patient
and family of
reportable signs
and symptoms
of inadequate
perfusion,
including
dizziness,
confusion,
restlessness and
dyspnea.
Trending of vital
signs will provide
database for early
intervention and
treatment.
Effective
management of
underlying medical
condition prevents
complications.
Early detection and
intervention is
essential in
preventing
permanent organ
damage.
Patient’s blood
pressure was
adequate to
maintain tissue
perfusion.
Patient did
experience any
complications
related to
hypoperfusion due
to aggressive
management of
underlying medical
condition.
Patient was able to
verbalize reportable
signs and
symptoms of
possible
hypoperfusion and
shock.

Summary
Disseminated intravascular coagulation is a complex series of occurrences that can be
caused by numerous disease and injury processes. In high-risk pregnancies the instance and
likelihood of DIC is increased greatly. Careful monitoring during a post-partum situation
includes regular vital signs to establish downward trends, regular assessment of bleeding and
lochia to note excesses, with awareness of increases in temperature and changes in level of
consciousness to ascertain warning signs of DIC. Medications are utilized to counteract the
uterine atony and decrease bleeding and prevent DIC. Once DIC has been noted, replacement of
blood products, and utilization of heparin occurs to counteract excess clotting and loss of clotting
factors. Surgical intervention should be considered in instances of excessive bleeding from
incision sites and it is vital to keep the physician informed of all progress and declination in
physical or mental patient status. Assessment, intervention and follow up are paramount to
prevent and note conditions that lead up to and cause disseminated intravascular coagulation.

References
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World Health Organization. (2012). WHO recommendations for the prevention and treatment of
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