Post partum hemorrhage is an
obstetric emergency complicating 1-10% of all deliveries [1].
It continues to be the leading cause (35%) of maternal deaths
[2]. PPH is defined as blood loss of 500 ml or more within 24
hours after birth while severe PPH is defined as a blood loss
of 1000 ml or more within the time frame by the World Health
Organisation. Obstetric hemorrhage and especially DIC is a
leading cause for maternal mortality, often secondary to
maternal and/or fetal complications including placental
abruption, amniotic fluid embolism, HELLP syndrome, retained
stillbirth, acute fatty liver of pregnancy and sepsis [3].
Here, we present to you a young P
1L
2 who
underwent elective LSCS for DCDA twin/IVF conception and the
sequential management.
Introduction
PPH is a complication of delivery and the most common cause of
maternal death accounting for 35% of all maternal deaths
worldwide [4]. Every year 14 million women suffer from PPH.
Primary PPH occurs within first 24 hours after delivery, while
Secondary or late PPH occurs 24 hours to 12 weeks postpartum
[4].
The maternal mortality ratio in developing countries in 2015
is 239 per 100,000 live births vs 12 per 100,000 live births
in developed countries [5]. Thus, 99% of all maternal deaths
occur in developing countries. WHO statistics suggest that 25%
of maternal deaths are due to PPH; which could kill a healthy
women, if left untreated. Shock following severe haemorrhage
and DIC are common life threatening complications of PPH.
DIC is characterised by a concomitant over-activation of
the coagulation and fibrinolytic systems, leading to
widespread microvascular thrombosis, disruption of blood
supply to different organs and thereby leading to multi-organ
failure. Thus extensive activation of coagulation cascade
leads to consumption and depletion of platelets and
coagulation protein, which can provoke concurrent severe
bleeding.ISTH criteria for DIC takes into account the platelet
count, elevated levels of fibrin - related marker, prolonged
prothrombin time and the fibrinogen levels. A score of ≥5 is
compatible with overt DIC.
Case report
A young lady, para one live two (P
1L
2)
who underwent elective LSCS following IVF conception on
presented to the emergency department with features of DIC. 7
hours following elective LSCS, she went into shock where USG
abdomen revealed hemoperitoneum and Hb drop of 7.9 gm/dl. She
was taken up for emergency laparotomy and 1500 ml of
collection was drained. 2 pint PRBC was transfused intra
operatively. It was followed by visual disturbances and
seizures 3 hours post extubation; she was then reintubated and
managed with magnesium sulphate, vitamin K and blood products;
was initiated on ionotropic support and was shifted to our
hospital.
On admission, her level of consciousness was altered but was
opening eyes to command and was responding to painful
stimulus. She was in a state of shock with tachycardia, feeble
pulse and hypotension. Uterus was well contacted and retracted
along with soakage of dressing. Diffuse oozing was noted
from drain site and nostrils. Investigations revealed Hb: 8
gram/dl, platelet: 25,000, prothrombin time: 66.9 seconds, PT
INR 5.24, D dimer > 20,000, elevated fibrinogen: 53.2; a
diagnosis of Disseminated Intravascular Coagulation (DIC) was
made as per the ISTH scoring system. She developed severe
metabolic acidosis (pH 6.903, bicarb 13.8, lactate 8.3).
Vasopressors, ionotropes, Anti-fibrinolytic agent and
hydrocortisone infusion was started. CT brain revealed no
evidence of bleed while CT Abdomen revealed liver and bowel
hyperperfusion changes. An MDT was initiated with the
hematologist, intensivist, neurologist, gynecologist,
nephrologist and infectious disease control. SLED was
initiated and multiple blood products and Octoplex injection
were given accordingly as per the EXTEM report. She then
developed pulmonary edema/ARDS and multiple episodes of
hypoglycemia. Sepsis protocol was activated; started on
ulinastatin, antibiotics were escalated to meropenem and
teicoplanin, and supported with hydrocortisone. Along with the
blood products, she received 3 units of Octoplex injection.
ABG improved to 7.434/110.5/40.9/26.8 on day 3 following
2 sessions of SLED. She had persistent oozing from the drain
site. Peripheral smear revealed schistocytes, platelets:
20,000. She received 34 units of platelets,11 units of packed
red cell, 11 units of plasma, 27 units of cryoprecipitate and
3 units of Octoplex. She received 5 sessions of SLED in
total. She was shifted out of the ICU on post op day 11 and
was discharged on the 20th day.
Discussion
DIC is a dynamic situation that requires a continuous
assessment of clinical and laboratory parameters including
decreasing concentration of fibrinogen and platelet count,
prolongation of prothrombin time and increased concentration
of fibrin split products or D-dimers until it resolves. The
hallmark of successful management depends on the prompt and
accurate recognition of DIC. Bedside tests like bleeding time,
coagulation time, clot retraction time, peripheral smear and
circulatory fibrinolysis test helps in the diagnosis. Standard
laboratory tests have limitations including absence of real
time data and incapacity to determine the functionality of the
hemostatic system of whole blood. Viscoelastic tests or TG and
rotational thromboelastography (ROTEM) are the most widely
used viscoelastic tests which provide rapid assessment of in
vivo. A shorter R&K, higher alpha angle and maximum
amplitude suggest that clot formation is faster and bigger (as
in pregnancy; especially in the 3rd trimester). Consumptive
Coagulopathy is a serious complication of massive PPH.
Management should be concentrated on removing the trigger. It
involves maintenance of circulatory blood volume with
appropriate fluid replacement. Volume replenishment by massive
blood transfusion is the sheet anchor of treatment to
replenish fibrinogen and other pro-coagulants. Platelet
transfusion is recommended to maintain platelet count above
50,000/cubic mm and cryoprecipitate to be administered if
fibrinogen levels fall less than one gm/dl.
OCTAPLEX is a plasma derived, virally inactivated concentrate
of clotting factors II, VII, IX and X. It also contains the
naturally occurring anticoagulants, Protein C and S.The dosing
is adjusted according to the INR value. Use of recombinant
activated factor 7 or RF 7A to start with low dose of 40 to 60
microgram/kilogram requires correction of metabolic
acidosis, hypothermia, hypofibrinogenemia and
thrombocytopenia. A volume of 500 ml fresh blood raises the
fibrinogen level by 12.5 milligram/ml. 1 unit of platelet
transfusion raises platelet count by 5000 to 10,000 per cubic
millimeter. Cryoprecipitate is rich in fibrinogen and factor
VIII, XIII. Tranexamic acid, an anti-fibrinolytic agent
prevents the activation of plasminogen by plasmin. Human
fibrinogen concentrate have been used for substitution therapy
in hypofibrinogenemia. Recombinent Human Soluble
Thrombomodulin decreases excessive thrombin activation and
regulates the imbalance of coagulation system which improves
platelet count, D-dimer, fibrinogen concentrations,
prothrombin time and decreases the need for platelet
transfusion.
Conclusion
The basic principles of treatment of obstetric DIC include:
a) Identifying & treatment of the underlying condition
leading to DIC,
b) Fast and prompt delivery or termination of pregnancy
options should be discussed by MDT and consider the fastest
mode of delivery to the mother,
c) Treatment with blood product transfusion, surgical care and
related matters,
d) Rigorous clinical and laboratory patient surveillance,
e) Prompt involvement of needed consultants such as
hematologist, gynecologist, anesthesiologist and others,
f) Shifting the patient to a higher center where blood bank
can support massive blood transfusion.
References
1. Borovac-Pinheiro A, Pacagnella RC,
Cecatti JG, et al Postpartum
hemorrhage: new insights for definition and diagnosis. Am J
Obstet Gynecol. 2018;219:162-168.
2. Taran Deol. Postpartum haemorrhage remains leading cause of
maternal deaths in Kerala[Internet]. 2022 Mar 09; available
from
https://www.downtoearth.org.in/news/health/amp/postpartum-haemorrhage-remains-leading-cause-of-maternal-deaths-in-kerala-report-81873.
3. Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil
J. DIC in Pregnancy - Pathophysiology, Clinical
Characteristics, Diagnostic Scores, and Treatments. Journal of
Blood Medicine. 2022 Jan 6:21-44.
4. WHO postpartum summit [Internet]. 2022 September 29;
available from :
https://www.who.int/publications/m/item/who-postpartum-hemorrhage-(pph)-summit
5. Mehboob R, Amir Gilani S, Khalid S, Hassan A, Alwazzan A.
Maternal Mortality Ratio in Low Income Developing Countries.
Global Women's Health [Internet]. 2021 Dec 22; Available from:
http://dx.doi.org/10.5772/intechopen.95258.