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Coagulation failure in pregnancy. Dr : Hashmi Hajrai MBBCh , DGO, M’MAS, MRCOG Consultant Obstetrician & Gynaecologist. Learning objectives. The student should understand the alterations in coagulations & fibrinolysis associated with pregnancy

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Coagulation failure in pregnancy

Coagulation failure in pregnancy

Dr : HashmiHajrai


Consultant Obstetrician & Gynaecologist

Learning objectives

Learning objectives

  • The student should understand the alterations in coagulations & fibrinolysis associated with pregnancy

  • Refresh his mind about the normal coagulation cascade mechanisms and its triggers

  • Broad line classification of coagulation failure in pregnancy

Coagulation failure in pregnancy

  • Understanding the pathogenesis of DIC syndrome, diagnosis, complications & management outlines

  • Brief knowledge on some other important causes of coagulation failure in pregnancy

Coagulations changes in pregnancy

Coagulations changes in pregnancy

  • Bleeding during labour is dealt with effectively by

    - increased production of coagulation

    factors during pregnancy

    - increased blood volume

    - myometrial contraction

Coagulation failure in pregnancy

  • this hypercoagulable state with local activation of clotting system is associated with increased risk of not only VTE but also DIC

Coagulation failure in pregnancy

  • The fibrinolytic system is responsible for disposing of fibrin after fulfilling its haemostatic function

  • Plasma proteases are responsible for controlling the speed and extent of coagulation & fibrinolysis

Hemostasis primary secondary tertiary

HEMOSTASISPrimary + Secondary + Tertiary

  • Primary Hemostasis

    • Platelet Plug Formation:dependent on normal platelet number & function

  • Secondary Hemostasis

    • Activation of Clotting Cascade Deposition & Stabilization of Fibrin

  • Tertiary Hemostasis

    • Dissolution of Fibrin Clot:dependent on Plasminogen Activation

Coagulation failure in pregnancy

Normal Artery





Coagulation failure in pregnancy

Vascular Damage

Coagulation failure in pregnancy


Coagulation failure in pregnancy

Overview of blood coagulation

Second step is activation of coagulation

Second step is activation of coagulation

Three phases

  • Intrinsic pathway

  • Extrinsic pathway

  • Common pathway

Coagulation cascade

Coagulation cascade

Intrinsic pathway



Extrinsic pathway










V, Ca, P/L





Classification of coagulation disorders

Classification of coagulation disorders

Congenital coagulation failure disorders

these are uncommon.....examples:

  • Von Willebrand’s disease...will be discussed

  • Haemophilia A & B

Acquired coagulation failure disorders

Acquired coagulation failure disorders

are far more commonly seen

  • Thrombocytopenic coagulopathies

  • Disseminated intravascular coagulation ..DIC

  • Anticoagulant therapy

4 congenital coagulopathies

4. Congenital Coagulopathies

Von Willebrand disease

Factor synthesized by endothelial cells &


Forms a complex with factor VIII

Mediates platelet adhesion and collagen

Inherited as autosomal dominant trait

Congenital coagulopathies

Congenital Coagulopathies

Von Willebrand disease

During pregnancy

Prophylactic treatment factor VIII level below 25%

DDAVP is administered as labor begins –

repeated every 12 hrs.

FFP or cryoprecipitate (500-1,500 units of

factor VIII activity)

Congenital coagulopathies1

Congenital Coagulopathies

Von Willebrand disease

During labor

Factor VIII levels should be maintained at 50%

of normal

CS – factor VIII level to 80%of normal

Check daily during the post partum period

Congenital coagulopathies2

Congenital Coagulopathies

Other coagulation factor deficiencies

Factor VIII ( hemophilia A)

Factor IX ( hemophilia B)

Thrombocytopenic coagulopathies

Thrombocytopenic Coagulopathies

Autoimmune Thrombocytopenic Purpura

Idiopathic thrombocytopenic purpura

Immunoglobulin G (IgG)

Thrombocytopenic coagulopathies1

Thrombocytopenic Coagulopathies


Platelet count < 100,000/mm3

Increased numbers of megakaryocytes

Increased platelet volume


Thrombocytopenic coagulopathies treatment

Thrombocytopenic Coagulopathiestreatment

Conservative management

Corticosteriods – if platelet count <20,000/mm3 before the onset of labor or

< 50,000/mm3 at time of delivery

High dose IV immunoglobulin produces

increase in platelet count

Significant hemorrhage – immediate

postpartum period platelet transfusion

Coagulation failure in pregnancy

  • The theoretical risk of intracranial haemorrhage in the thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

Coagulation failure in pregnancy



  • An acquired syndrome characterized by systemicintravascularcoagulation

  • Coagulation is always the initial event

Intravascular deposition of fibrin

Depletion of platelets and coagulation factors

Thrombosis of small and midsize vessels



Organ failure

Obstetric causes of dic

Obstetric causes of DIC

Falls into three categories

  • conditions associated with release of tissue thromboplastin that activates extrinsic pathway

    - placental abruption

    - dead foetus

    - molar pregnancy

  • Conditions associated with endothelial damage leading to activation of intrinsic & extrinsic pathways - pre-eclampsia & eclampsia

Coagulation failure in pregnancy

  • Conditions having non-specific or indirect action

    - amniotic fluid embolism

    - gram negative septicaemia

    - saline abortion

Coagulation failure in pregnancy

Mechanism of DIC

Bick et al., 2002

Clinical manifestation of dic

Clinical manifestation of DIC

  • Those of the underlying cause

  • Those due to Complications of DIC

Haemorrhagic manifestations

Haemorrhagic manifestations

Involving skin & mucus membranes

  • Ecchymosis

  • Petechiae

  • Bleeding from the gum

  • Haematuria

  • GIT bleeding

  • Venepunctur oozing

  • Intracranial or intracerebral haemorrhage

Thrombotic manifestations

Thrombotic manifestations

  • Neurologic with multifocal lesions , delirium & coma

  • Dermatologic with focal ischaemia & superficial gangreen

  • Renal with cortical necrosis and ureamia

  • GIT acute ulceration with bleeding

  • Vascular occlusion causing pulmonary infarction or peripheral vascular gangreen

Lab results

Lab results

  • Markedly decreased platelet count

  • Markedly Increased fibrin degradation products FDP’s

  • Fragmented RBCs & microspherocytes in peripheral blood film

  • Low fibrinogen , factor II , V & VII

  • Prolonged PT, PTT & TT

Microscopic findings in dic

Microscopic findings in DIC

  • Fragments

  • Schistocytes

  • Paucity of platelets

Coagulation failure in pregnancy

Fragmented RBC


Coagulation failure in pregnancy

Treatment of DIC

  • Remove underlying cause

  • Replenish depleted factors

  • FFP Provides source of most factors

  • Cryoprecipitate provides fibrinogen

  • Platelet and blood support

  • Cautious use of heparin

Up to date, emedicine



  • Blood coagulation is a major component of haemostasis. Increased Coagulation factors levels in pregnancy is meant to minimize blood loss at time of delivery

  • This haemostatic mechanism could fail risking patient’s life

Coagulation failure in pregnancy

  • Thrombocytopenic coagulation failure and DIC syndrome are the most commonly seen in obstetric practice

  • Congenital causes of coagulation failure are uncommon and usually already diagnosed prior to pregnancy

  • DIC syndrome is always secondary to an underlying pathology

Coagulation failure in pregnancy

  • If diagnosis of DIC is missed or appropriate action is delayed it can cause serious maternal morbidity or even death

  • Platelet transfusion and coagulation factor replacement or fresh blood transfusion are the main stay of treatment besides other supportive therapy

Coagulation failure in pregnancy

  • Use of heparin is controversial . Haematologist opinion should be sought before it’s use

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