Can a 24-year-old lady with sickle cell trait (HbAS) who delivered a 2.5 kg baby and had a leukocytosis (White Blood Cell count of 18,000) die from Disseminated Intravascular Coagulation (DIC) due to improper episiotomy stitching and subsequent bleeding?

Death from DIC in a Patient with Sickle Cell Trait Following Improper Episiotomy Repair

Yes, improper episiotomy repair leading to hemorrhage in a patient with sickle cell trait (HbAS) could trigger disseminated intravascular coagulation (DIC) and lead to death.

Pathophysiology and Risk Factors

In this case, several factors likely contributed to the development of fatal DIC:

1. Sickle Cell Trait (HbAS):

   • While generally considered benign, sickle cell trait can become clinically significant under physiologic stress 1
   • During obstetric complications like hemorrhage, patients with sickle cell trait may experience sickling of red blood cells, leading to microvascular occlusion and tissue hypoxia

2. Leukocytosis (WBC 18,000):

   • Elevated white blood cell count suggests an inflammatory or infectious process
   • Infection is a common trigger for DIC 2
   • Postpartum infection from improper episiotomy repair could have initiated the coagulation cascade

3. Hemorrhage from Improper Episiotomy Repair:

   • Uncontrolled bleeding activates the coagulation system
   • Tissue damage releases tissue factor, initiating the extrinsic coagulation pathway
   • Prolonged bleeding leads to consumption of clotting factors and platelets

Diagnostic Considerations

DIC diagnosis requires both clinical and laboratory assessment 3. In this scenario:

• Clinical signs: Excessive bleeding from episiotomy site
• Laboratory findings: Would likely have shown:
  • Prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT)
  • Decreased fibrinogen levels
  • Elevated D-dimer levels
  • Thrombocytopenia
  • Presence of fibrin degradation products

Mechanism of Death

The sequence likely proceeded as follows:

1. Improper episiotomy repair → Bleeding and possible infection
2. Tissue damage and inflammation → Activation of coagulation cascade
3. Widespread microvascular thrombosis → Organ ischemia
4. Consumption of clotting factors and platelets → Hemorrhage
5. Circulatory collapse → Death

Preventive Measures That Should Have Been Taken

1. Proper Surgical Technique:

   • Meticulous episiotomy repair with appropriate suturing technique
   • Adequate hemostasis during the procedure

2. Recognition of High-Risk Status:

   • Patients with sickle cell trait should be considered at higher risk for complications 4
   • Leukocytosis should have prompted evaluation for infection

3. Early Intervention:

   • Prompt recognition and management of bleeding
   • Early administration of blood products for significant hemorrhage

4. Management of DIC:

   • Treatment of the underlying cause (controlling bleeding, addressing infection)
   • Appropriate blood component therapy (fresh frozen plasma, platelets, cryoprecipitate) 3
   • Close monitoring of coagulation parameters

Important Considerations

• DIC is often misunderstood as primarily a bleeding disorder, but it involves both inappropriate clotting and bleeding 2
• Patients with sickle cell trait may be at increased risk for venous thromboembolism and other complications during periods of physiologic stress 1
• Infection and sepsis are among the most common triggers of DIC 2

Conclusion

This case demonstrates how a seemingly routine obstetric procedure can lead to catastrophic outcomes when complications arise in patients with underlying hematologic conditions. The combination of sickle cell trait, possible infection (suggested by leukocytosis), and hemorrhage from improper episiotomy repair created ideal conditions for the development of DIC, ultimately resulting in the patient's death.