From the Guidelines
Disseminated intravascular coagulation (DIC) in pregnancy is most commonly caused by amniotic fluid embolism, placental abruption, severe preeclampsia, and HELLP syndrome, which trigger widespread clotting activation and consumption of clotting factors and platelets, resulting in paradoxical bleeding. The management of DIC in pregnancy requires treating the underlying cause while providing supportive care with blood products, as early recognition is crucial to reduce maternal mortality, especially when associated with obstetric hemorrhage 1.
Causes of DIC in Pregnancy
- Amniotic fluid embolism: amniotic fluid enters maternal circulation, activating inflammatory and coagulation cascades 1
- Placental abruption: placenta separates prematurely from the uterine wall, releasing tissue factor into maternal circulation
- Severe preeclampsia and HELLP syndrome: cause endothelial damage and platelet activation
- Retained dead fetus syndrome: fetal tissue breakdown products enter maternal circulation
- Severe postpartum hemorrhage: depletes clotting factors
Management of DIC in Pregnancy
- Treat the underlying cause
- Provide supportive care with blood products, including packed red blood cells, fresh-frozen plasma, and platelets at a ratio of 1:1:1 (hemostatic resuscitation) 1
- Early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols (GRADE 1C) 1
- Consider the use of antifibrinolytics such as tranexamic acid or epsilon aminocaproic acid in cases of hyperfibrinolysis 1
Importance of Early Recognition
Early recognition of DIC in pregnancy is crucial to reduce maternal mortality, especially when associated with obstetric hemorrhage 1. Delayed diagnosis and treatment can lead to severe consequences, including organ failure and death. Therefore, it is essential to be aware of the causes and management of DIC in pregnancy to provide timely and effective care.
From the Research
Causes of DIC in Pregnancy
- Obstetrical disorders such as abruptio placentae, eclampsia, retention of a dead fetus, amniotic fluid embolism, placental retention, and bacterial sepsis are common causes of DIC in pregnancy 2
- Acute peripartum hemorrhage, placental abruption, preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count syndrome, retained stillbirth, septic abortion, and intrauterine infection are also associated with DIC 3
- Other causes include amniotic fluid embolism, acute fatty liver of pregnancy, and severe preeclampsia 4, 5
Underlying Mechanisms
- The etiopathogenesis of DIC is complex and currently thought to be initiated by tissue factor or thromboplastin, which is released from trophoblastic or fetal tissue, or maternal decidua or endothelium 5
- Tissue factor activates the coagulation sequence to cause fibrin clotting and its dissolution by the fibrinolysin system, resulting in a range of clinical manifestations from mild laboratory derangements to marked coagulopathy with bleeding 5
Clinical Presentations
- DIC patients can present with uncontrollable bleeding or multi-organ failure, which can be life-threatening 4
- Clinical recognition of DIC varies by disease severity, and several organizations have attempted to standardize the diagnosis through development of scoring systems 5
- A pregnancy-specific DIC score has been developed, which includes fibrinogen concentrations, prothrombin time difference, and platelet count, and has a high sensitivity and specificity for diagnosing DIC in pregnancy 4