How should disseminated intravascular coagulation occurring after a hysterectomy be treated?

Treatment of DIC Post-Hysterectomy

Treat the underlying cause immediately while providing aggressive transfusion support for active bleeding: maintain platelets >50 × 10⁹/L, administer fresh frozen plasma 15–30 mL/kg, and replace fibrinogen if <1.5 g/L; initiate prophylactic anticoagulation with heparin once bleeding is controlled unless the DIC phenotype is hyperfibrinolytic. 1, 2

Immediate Priorities

1. Identify and Treat the Underlying Trigger

• Surgical source control is paramount: inspect for retained products, uterine atony, cervical/vaginal lacerations, or ongoing surgical bleeding that requires re-exploration. 3
• In post-hysterectomy DIC, consider occult bleeding, infection/sepsis, or amniotic fluid embolism (if peripartum hysterectomy) as potential triggers. 3, 2
• Treat any identified infection aggressively with appropriate antibiotics and source control. 2

2. Determine the DIC Phenotype

• Bleeding-predominant DIC (most common post-operatively): characterized by diffuse oozing from surgical sites, IV sites, and mucosal surfaces with laboratory evidence of factor consumption. 1, 2
• Thrombosis-predominant DIC (less common): presents with arterial/venous thromboembolism, purpura fulminans, or vascular skin infarction. 1, 2
• Hyperfibrinolytic DIC (rare post-hysterectomy): massive bleeding with rapid fibrinogen depletion; may benefit from tranexamic acid but heparin is contraindicated. 1, 2

Management of Bleeding-Predominant DIC (Most Relevant Post-Hysterectomy)

Transfusion Support

• Platelets: Transfuse to maintain count >50 × 10⁹/L in actively bleeding patients or those requiring re-operation. 1, 4
• Fresh frozen plasma (FFP): Administer 15–30 mL/kg for prolonged PT/aPTT with active bleeding; dose based on clinical response rather than isolated laboratory values. 1, 2
• Fibrinogen replacement: If fibrinogen remains <1.5 g/L despite FFP, give two pools of cryoprecipitate or fibrinogen concentrate. 1, 2
• Massive transfusion protocol: Consider 1:1:1 ratio of packed red cells:FFP:platelets for hemostatic resuscitation in severe hemorrhage. 3

Critical Transfusion Pitfalls

• Transfused platelets and clotting factors have shortened survival in active DIC due to ongoing consumption; expect to require repeated dosing. 1
• Do not transfuse based solely on laboratory abnormalities in non-bleeding patients; clinical bleeding or procedural risk must drive decisions. 1, 4
• Avoid prothrombin complex concentrate (PCC) in DIC—it causes thromboembolism and can worsen DIC by providing unbalanced pro-coagulant factors without natural anticoagulants. 5

Surgical Considerations

• Perform thorough inspection of cervix and vagina for lacerations contributing to bleeding. 3
• For diffuse bleeding not amenable to surgical control, consider pelvic packing with delayed closure and ICU transfer for continued medical therapy. 3
• Manage any persistent uterine atony (if supracervical hysterectomy or retained cervical stump) with uterotonics, though this is uncommon post-total hysterectomy. 3

Anticoagulation Strategy

Once Bleeding is Controlled

• Initiate prophylactic heparin in all post-hysterectomy DIC patients once active bleeding stops, unless contraindications exist (platelets <20 × 10⁹/L or hyperfibrinolytic phenotype). 1, 2
• Low molecular weight heparin (LMWH) is preferred for most patients. 1, 2
• Unfractionated heparin (UFH) is preferred if high bleeding risk persists and renal impairment exists, due to rapid reversibility. 1, 2

If Thrombosis Develops

• Escalate to therapeutic-dose anticoagulation if arterial/venous thromboembolism, severe purpura fulminans, or vascular skin infarction occurs. 1, 2, 4
• Prolonged PT/aPTT alone should not preclude anticoagulation in the absence of bleeding—DIC represents a rebalanced hemostatic state with simultaneous loss of pro- and anticoagulant factors. 1, 2

Agents to Avoid

• Tranexamic acid: Not recommended routinely; reserve only for refractory bleeding with documented hyperfibrinolysis on thromboelastography. 3, 1, 2
• Recombinant factor VIIa: Not recommended; uncertain benefit with definite thrombotic risk. 2
• Corticosteroids: No established benefit in DIC. 1
• Antiplatelet agents: Not indicated and may increase bleeding. 1

Monitoring

• Serial laboratory assessment: Monitor CBC, PT/aPTT, fibrinogen, and D-dimer at intervals appropriate to severity (hourly to every 6 hours in acute severe DIC). 1, 2
• Clinical vigilance: Watch for new bleeding sites, thrombotic events, or organ dysfunction. 2
• A ≥30% drop in platelet count can indicate worsening DIC even if absolute values remain normal. 2

Special Consideration: Amniotic Fluid Embolism

If post-peripartum hysterectomy, consider amniotic fluid embolism in the differential, which presents with the classic triad of hypotension, hypoxia, and subsequent coagulopathy. 3 Management principles remain the same: aggressive hemostatic resuscitation and treatment of the underlying trigger. 3

Common Pitfalls to Avoid

• Do not delay surgical re-exploration if ongoing bleeding suggests a surgical source rather than pure coagulopathy. 3
• Do not use PCC to "quickly correct" elevated INR in DIC—this worsens thrombotic risk without addressing the consumptive process. 5
• Do not withhold prophylactic anticoagulation once bleeding stops solely because coagulation tests remain abnormal. 1, 2
• Do not assume all post-hysterectomy bleeding with coagulopathy is DIC—rule out surgical bleeding, dilutional coagulopathy from massive transfusion, and other causes. 3