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
- Kirk D Ramin, MD
Kirk D Ramin, MD
- Maternal-Fetal Medicine Division, Department of Obstetrics, Gynecology and Women's Health
- Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
- University of Minnesota Medical School
- 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].
- Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120:1029.
- Rattray DD, O'Connell CM, Baskett TF. Acute disseminated intravascular coagulation in obstetrics: a tertiary centre population review (1980 to 2009). J Obstet Gynaecol Can 2012; 34:341.
- Erez O, Novack L, Beer-Weisel R, et al. DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One 2014; 9:e93240.
- Gilbert WM, Danielsen B. Amniotic fluid embolism: decreased mortality in a population-based study. Obstet Gynecol 1999; 93:973.
- Sibai BM, Ramadan MK, Usta I, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169:1000.
- Cunningham FG, Nelson DB. Disseminated Intravascular Coagulation Syndromes in Obstetrics. Obstet Gynecol 2015; 126:999.
- Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol 2015; 213:452.
- Bonnar J, Prentice CR, McNicol GP, Douglas AS. Haemostatic mechanism in the uterine circulation during placental separation. Br Med J 1970; 2:564.
- Bonnar J, McNicol GP, Douglas AS. Coagulation and fibrinolytic mechanisms during and after normal childbirth. Br Med J 1970; 2:200.
- Levi M. Disseminated intravascular coagulation (DIC) in pregnancy and the peri-partum period. Thromb Res 2009; 123 Suppl 2:S63.
- Takai H, Kondoh E, Sato Y, et al. Disseminated intravascular coagulation as the presenting sign of gastric cancer during pregnancy. J Obstet Gynaecol Res 2011; 37:1717.
- Morimatsu Y, Matsubara S, Hirose N, et al. Acute promyelocytic leukemia: an unusual cause showing prolonged disseminated intravascular coagulation after placental abruption. Arch Gynecol Obstet 2008; 277:267.
- Lockwood CJ, Murk W, Kayisli UA, et al. Progestin and thrombin regulate tissue factor expression in human term decidual cells. J Clin Endocrinol Metab 2009; 94:2164.
- Lockwood CJ, Paidas M, Murk WK, et al. Involvement of human decidual cell-expressed tissue factor in uterine hemostasis and abruption. Thromb Res 2009; 124:516.
- Hossain N, Paidas MJ. Disseminated intravascular coagulation. Semin Perinatol 2013; 37:257.
- Gando S. Microvascular thrombosis and multiple organ dysfunction syndrome. Crit Care Med 2010; 38:S35.
- Levi M, Meijers JC. DIC: which laboratory tests are most useful. Blood Rev 2011; 25:33.
- Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for clinicians. Obstet Gynecol 2009; 114:1326.
- Levi M, de Jonge E, van der Poll T, ten Cate H. Disseminated intravascular coagulation. Thromb Haemost 1999; 82:695.
- Murphy N, Broadhurst DI, Khashan AS, et al. Gestation-specific D-dimer reference ranges: a cross-sectional study. BJOG 2015; 122:395.
- Kovac M, Mikovic Z, Rakicevic L, et al. The use of D-dimer with new cutoff can be useful in diagnosis of venous thromboembolism in pregnancy. Eur J Obstet Gynecol Reprod Biol 2010; 148:27.
- Liu J, Yuan E, Lee L. Gestational age-specific reference intervals for routine haemostatic assays during normal pregnancy. Clin Chim Acta 2012; 413:258.
- Taylor FB Jr, Toh CH, Hoots WK, et al. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 2001; 86:1327.
- Toh CH, Hoots WK, SSC on Disseminated Intravascular Coagulation of the ISTH. The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5-year overview. J Thromb Haemost 2007; 5:604.
- Bakhtiari K, Meijers JC, de Jonge E, Levi M. Prospective validation of the International Society of Thrombosis and Haemostasis scoring system for disseminated intravascular coagulation. Crit Care Med 2004; 32:2416.
- Gando S, Iba T, Eguchi Y, et al. A multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients: comparing current criteria. Crit Care Med 2006; 34:625.
- Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth 2010; 19:218.
- Ahmed S, Harrity C, Johnson S, et al. The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage--an observational study. Transfus Med 2012; 22:344.
- Sharma SK, Vera RL, Stegall WC, Whitten CW. Management of a postpartum coagulopathy using thrombelastography. J Clin Anesth 1997; 9:243.
- Huissoud C, Carrabin N, Audibert F, et al. Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG 2009; 116:1097.
- Miall FM, Deol PS, Barnes TA, et al. Coagulation status and complications of pregnancy. Thromb Res 2005; 115:461.
- Burtelow M, Riley E, Druzin M, et al. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion 2007; 47:1564.
- Pavord S, Maybury H. How I treat postpartum hemorrhage. Blood 2015; 125:2759.
- Spahn DR, Spahn GH, Stein P. Indications and Risks of Fibrinogen in Surgery and Trauma. Semin Thromb Hemost 2015.
- Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007; 5:266.
- Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997; 77:761.
- Sagraves SG, Toschlog EA, Rotondo MF. Damage control surgery--the intensivist's role. J Intensive Care Med 2006; 21:5.
- Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure pack for severe pelvic hemorrhage. Obstet Gynecol 2006; 108:1222.
- Martí-Carvajal AJ, Comunián-Carrasco G, Peña-Martí GE. Haematological interventions for treating disseminated intravascular coagulation during pregnancy and postpartum. Cochrane Database Syst Rev 2011; :CD008577.
- Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care 2011; 15:R117.
- Nelson DB, Yost NP, Cunningham FG. Hemostatic dysfunction with acute fatty liver of pregnancy. Obstet Gynecol 2014; 124:40.
- 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