Disseminated intravascular coagulation during pregnancy
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- Professor of Obstetrics and Gynecology
- Baylor College of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
- Steven Kleinman, MD
Steven Kleinman, MD
- Section Editor — Transfusion Medicine
- Clinical Professor of Pathology
- University of British Columbia, Vancouver
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Deputy Editors
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Jennifer S Tirnauer, MD
Jennifer S Tirnauer, MD
- Deputy Editor — Hematology
Disseminated intravascular coagulation (DIC) is a pathologic disruption of the finely-balanced process of hemostasis. Massive activation of the clotting cascade results in widespread thrombosis, which leads to depletion of platelets and coagulation factors and excessive thrombolysis. This can result in hemorrhage, thrombosis, and/or multiorgan failure.
Any patient with DIC presents a major management challenge, and this challenge is further complicated when the patient is carrying a viable fetus. For example, delaying delivery to transfuse a pregnant woman with DIC who is bleeding heavily may not be in the best interest of a fetus with a category III fetal heart rate tracing, whereas performing an emergency cesarean delivery on a pregnant woman with DIC may not be in her best interest. Even in the setting of fetal demise, labor and delivery of a pregnant woman with DIC carries the potential for catastrophic hemorrhage.
This topic will focus upon DIC related to pregnancy. Broader discussions of the pathogenesis, clinical manifestations, diagnosis, and treatment of DIC can be found separately. (See "Clinical features, diagnosis, and treatment of disseminated intravascular coagulation in adults".)
Other causes of pregnancy-associated thrombocytopenia and obstetrical hemorrhage are also presented separately. (See "Thrombocytopenia in pregnancy" and "Overview of the etiology and evaluation of vaginal bleeding in pregnant women".)
The prevalence of DIC in pregnancy ranges from 0.03 to 0.35 percent in population-based studies [1-3], or 12.5 per 10,000 delivery hospitalizations in one study . Although the overall prevalence of DIC is low in pregnancy, the frequency of DIC in women with specific pregnancy complications can be quite high. In a review of 53 cases of amniotic fluid embolism, DIC was observed in approximately two-thirds, and in a series of 442 pregnancies complicated by hemolysis, elevated liver function tests, and low platelets (HELLP syndrome), 92 had DIC (21 percent), the majority were associated with abruptio placentae [4,5].
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- PREGNANCY-RELATED CAUSES
- CLINICAL FINDINGS
- Laboratory findings
- DIAGNOSTIC TESTING
- Criteria for diagnosis
- Scoring systems
- Differential diagnosis
- Initial management
- - Notify the anesthesia staff
- - Notify the transfusion service
- - Establish intravenous access and begin fluid resuscitation
- - Identify and address the triggering event
- - Insert an arterial line
- - Transfusion
- Blood products
- Transfusion targets
- - Maintain oxygenation
- - Avoid hypothermia
- - Assess blood loss
- - Notify the neonatology service
- Fetal assessment
- Management of delivery
- - Hemodynamically stable mother with dead or nonviable fetus
- - Hemodynamically unstable mother, fetal distress or malpresentation, or contraindication to vaginal delivery
- Hemostatic and anticoagulant therapies
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS