From the Guidelines
Disseminated intravascular coagulation (DIC) in pregnancy is most strongly associated with risk factors such as amniotic fluid embolism, severe hemorrhage, and uterine atony, which can trigger a coagulopathy that may be managed with blood products and surgical interventions 1. The risk factors for DIC in pregnancy can be categorized into several key areas, including:
- Placental abruption
- Amniotic fluid embolism, which is known to cause DIC in most cases, with variable onset and requiring aggressive management of coagulopathy 1
- Severe preeclampsia or HELLP syndrome
- Sepsis, particularly from intrauterine infection
- Retained dead fetus syndrome
- Acute fatty liver of pregnancy
- Severe postpartum hemorrhage
- Intrauterine growth restriction
- Gestational trophoblastic disease These conditions can trigger DIC through various mechanisms, including tissue factor release, endothelial damage, and activation of the coagulation cascade, leading to widespread clot formation and subsequent consumption of clotting factors and platelets, resulting in a paradoxical bleeding tendency. Healthcare providers should prioritize the early assessment of clotting status and aggressive management of clinical bleeding with standard massive transfusion protocols, including the administration of blood products to maintain a platelet count above 50,000/mm3 and normal (or close to normal) activated partial thromboplastin time and international normalized ratio 1. In the setting of massive hemorrhage, blood product administration should not be delayed while awaiting the results of laboratory tests, and early aggressive resuscitation with packed red blood cells, fresh-frozen plasma, and platelets at a ratio of 1:1:1 (hemostatic resuscitation) results in improved outcomes 1. Routine prenatal care should include screening for these risk factors, and women with identified risks should be managed in high-risk obstetric units with access to blood products and intensive care facilities if needed. Prompt treatment of the underlying condition, along with supportive care and replacement of blood components, is essential in managing DIC in pregnancy.
From the Research
Risk Factors for Disseminated Intravascular Coagulation (DIC) in Pregnancy
The following are risk factors for DIC in pregnancy:
- Acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture) 2
- Placental abruption 2, 3
- Pre-eclampsia/HELLP syndrome 2, 3
- Retained stillbirth 2
- Sepsis 2, 3
- Amniotic fluid embolism 2, 3
- Acute fatty liver of pregnancy 2, 3
- Massive obstetric hemorrhage 3
- Thrombophilia (acquired and genetic) 4, 5
- History of venous thromboembolism (VTE) 5, 6
- Older age, increased weight, and emergency Caesarean section 4
- Uteroplacental thrombosis, which provides a common pathophysiological link between various poor pregnancy outcomes, including recurrent miscarriage, stillbirth, placental abruption, fetal growth restriction, and pre-eclampsia 4
Hypercoagulability and Thrombosis in Pregnancy
Pregnancy is a hypercoagulable state that affects both the coagulation and fibrinolytic systems, increasing the risk of thrombosis three-fold to four-fold 6. This hypercoagulability is present as early as the first trimester and is thought to have evolved to protect women against the bleeding challenges associated with miscarriage and childbirth 6. Factors that further increase the risk of thromboembolism in pregnancy include a history of thrombosis, inherited and acquired thrombophilia, certain medical conditions, and complications of pregnancy and childbirth 6.