What should be given to a patient with abortion who develops hypotension and is suspected of having Disseminated Intravascular Coagulation (DIC)?

Management of Hypotension and Suspected DIC in Abortion

In a patient with abortion who develops hypotension and suspected DIC, immediately activate massive transfusion protocol, initiate aggressive blood product replacement (packed RBCs, FFP, platelets in 1:1:1 ratio), administer norepinephrine for persistent hypotension, and treat the underlying cause while avoiding excessive crystalloid resuscitation. 1, 2

Immediate Resuscitation Priorities

Circulatory Support

• Establish large-bore IV access (consider intraosseous line if needed) and begin controlled fluid resuscitation with 500 mL boluses, reassessing after each bolus to avoid fluid overload 1, 2
• Initiate norepinephrine infusion (starting at 0.05-3.3 mcg/kg/min) if hypotension persists after initial fluid bolus, targeting MAP ≥65 mmHg 1, 3
• Avoid excessive crystalloid administration, as this worsens dilutional coagulopathy and can precipitate pulmonary edema in the context of potential cardiac dysfunction 1

Blood Product Replacement

• Activate massive transfusion protocol immediately—do not wait for laboratory confirmation of DIC 1, 2
• Transfuse packed RBCs, fresh frozen plasma, and platelets in a 1:1:1 fixed ratio to prevent dilutional coagulopathy 2
• Prioritize cryoprecipitate over FFP when available to reduce volume overload while correcting fibrinogen deficiency 1
• Consider tranexamic acid 1 g IV over 10 minutes if DIC or hemorrhage develops, as this reduces mortality in obstetric hemorrhage 1

Addressing the Underlying Cause

Obstetric Management

• Aggressively treat uterine atony with oxytocin prophylaxis plus additional uterotonics (misoprostol, carboprost) as needed 1
• Search for anatomic sources of bleeding including retained products of conception, cervical or vaginal lacerations, and uterine perforation 1
• Prepare for potential surgical intervention (dilation and curettage, uterine artery embolization, or hysterectomy) if bleeding is uncontrollable with medical management 2

Differential Diagnosis Considerations

While DIC in the setting of abortion is most commonly due to septic abortion or hemorrhagic shock, consider amniotic fluid embolism in the differential, particularly if the presentation includes sudden cardiovascular collapse, respiratory distress, or seizures preceding the coagulopathy 1

Specific DIC Management

Anticoagulation Considerations

• In DIC with predominant bleeding (most common in obstetric DIC), do NOT routinely administer heparin—reserve anticoagulation only for cases with predominant thrombosis such as purpura fulminans or arterial/venous thromboembolism 4, 5
• If therapeutic anticoagulation is required due to thrombotic complications, use unfractionated heparin via continuous infusion (10 units/kg/h) due to its short half-life and reversibility in case of bleeding 4
• Prophylactic dose heparin or LMWH is recommended once the patient is stabilized and not actively bleeding, to prevent venous thromboembolism 4

Component Therapy Guidelines

• Transfuse platelets if count <50 × 10⁹/L in actively bleeding patients or those requiring invasive procedures 4, 6
• Administer FFP (or prothrombin complex concentrate if volume overload is a concern) for prolonged PT/aPTT in bleeding patients—do not base transfusion decisions on laboratory values alone 4, 5
• Give fibrinogen concentrate or cryoprecipitate if fibrinogen remains <1 g/L despite FFP replacement 4

Hemodynamic Monitoring and Support

Vasopressor Management

• Norepinephrine is the preferred first-line vasopressor, with dosing titrated to maintain MAP ≥65 mmHg 1, 3
• Add vasopressin (0.04 units/min) if MAP remains inadequate despite low-moderate dose norepinephrine (0.1-0.2 mcg/kg/min) 1
• Consider adding epinephrine in patients with cardiac dysfunction and persistent hypoperfusion despite adequate volume status and blood pressure 1
• Initiate low-dose steroids (hydrocortisone 200 mg/day as 50 mg IV every 6 hours) if no response to norepinephrine or epinephrine ≥0.25 mcg/kg/min for at least 4 hours 1

Cardiac Function Assessment

If cardiovascular collapse is severe or refractory to initial management, consider bedside echocardiography to assess for:

• Right ventricular failure (may occur with amniotic fluid embolism or massive pulmonary embolism) requiring inotropes such as dobutamine (2.5-5.0 mcg/kg/min) or milrinone (0.25-0.75 mcg/kg/min) 1
• Left ventricular failure with cardiogenic pulmonary edema requiring careful fluid management 1

Critical Pitfalls to Avoid

• Do NOT administer norepinephrine as the sole intervention without concurrent blood volume replacement—this causes severe peripheral vasoconstriction, decreased renal perfusion, tissue hypoxia, and lactate acidosis 3
• Do NOT use crystalloid alone for volume resuscitation—use blood products to avoid dilutional coagulopathy 2
• Do NOT routinely give antifibrinolytic agents (tranexamic acid) in DIC unless there is confirmed primary hyperfibrinolysis with severe bleeding 4
• Do NOT transfuse blood products based solely on laboratory values in non-bleeding patients—reserve component therapy for active hemorrhage or high bleeding risk situations 4, 6

Monitoring and Ongoing Care

• Monitor serial lactate levels, with repeat measurement within 6 hours if initially elevated 1
• Reassess volume status and tissue perfusion frequently using clinical parameters (urine output, mental status, skin perfusion) 1
• Continue intensive monitoring in ICU setting for at least 24 hours due to potential for ongoing coagulopathy, fluid shifts, and hemodynamic instability 2
• Repeat coagulation studies (PT, aPTT, fibrinogen, platelet count, D-dimer) every 4-6 hours to monitor response to therapy 4, 6