Can fundal pressure cause Disseminated Intravascular Coagulation (DIC)?

Can Fundal Pressure Cause Disseminated Intravascular Coagulation (DIC)?

Fundal pressure during labor is not directly associated with causing disseminated intravascular coagulation (DIC), but it can potentially contribute to conditions that may lead to DIC in rare circumstances.

Relationship Between Fundal Pressure and DIC

Fundal pressure (also known as the Kristeller maneuver) involves applying manual pressure to the uppermost part of the uterus directed toward the birth canal during the second stage of labor. While fundal pressure itself is not a direct cause of DIC, it can lead to complications that may trigger DIC:

Potential Mechanisms

1. Amniotic Fluid Embolism (AFE)

   • Fundal pressure could theoretically increase the risk of amniotic fluid embolism by disrupting the maternal-fetal interface 1
   • AFE is a known trigger for DIC, as outlined in the SMFM guidelines, which state that "amniotic fluid activates Factor VII and platelets with consequent disseminated intravascular coagulation" 1
   • The pathophysiology involves passage of amniotic fluid into maternal circulation, which can activate the clotting cascade

2. Uterine Trauma

   • Aggressive fundal pressure can potentially cause:
     • Uterine rupture 2
     • Severe tissue trauma
     • These complications can trigger the coagulation cascade and potentially lead to DIC in severe cases

Clinical Considerations

Risk Factors to Consider

When evaluating the potential for DIC in relation to obstetric procedures:

• Pre-existing coagulopathy: Patients with underlying coagulation disorders are at higher risk
• Presence of other DIC triggers: Such as placental abruption, severe preeclampsia, or sepsis
• Method of fundal pressure application: Uncontrolled, aggressive pressure is more likely to cause complications than gentle, standardized pressure 3

Warning Signs of DIC Development

If fundal pressure has been applied and there are concerns about DIC, monitor for:

• Unexplained bleeding from multiple sites
• Thrombocytopenia (platelet count < 150 × 10^9/L) 1
• Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT)
• Decreased fibrinogen levels
• Elevated D-dimer levels

Evidence Quality and Recommendations

The evidence directly linking fundal pressure to DIC is limited. Most concerns about fundal pressure relate to:

• Uterine rupture
• Perineal trauma
• Neonatal injuries
• Rib fractures
• Postpartum complications 2

A Cochrane review found insufficient evidence to draw conclusions on the beneficial or harmful effects of fundal pressure 4, though it remains widely used in some settings with a prevalence of approximately 23.2% globally 5.

Clinical Approach

1. Avoid routine use of fundal pressure

   • Most obstetric guidelines discourage the routine use of fundal pressure due to potential complications
   • Consider alternative approaches to assist vaginal delivery when indicated

2. If fundal pressure has been applied and DIC is suspected:

   • Obtain immediate laboratory tests: complete blood count, coagulation studies (PT, aPTT), fibrinogen, and D-dimer
   • Treat the underlying cause (if AFE or other complications have occurred)
   • Provide supportive care with blood products based on laboratory thresholds 1
   • Consider early consultation with hematology and critical care

3. Prevention:

   • If fundal pressure is deemed necessary, it should only be performed by well-trained and experienced medical staff 2
   • Gentle, firm, and steady pressure at a 30° to 45° angle to the maternal spine is recommended over aggressive pressure 2

Conclusion

While fundal pressure itself is not a direct cause of DIC, it may potentially contribute to rare but serious complications like amniotic fluid embolism that can trigger DIC. The practice of fundal pressure remains controversial, with limited evidence supporting its safety and efficacy. Healthcare providers should be aware of the potential complications and monitor patients closely if this intervention has been used.