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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

MBBCh, DGO, M’MAS, MRCOG

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



Coagulations changes in pregnancy
Coagulations changes in pregnancy complications & management outlines

  • Bleeding during labour is dealt with effectively by

    - increased production of coagulation

    factors during pregnancy

    - increased blood volume

    - myometrial contraction




Hemostasis primary secondary tertiary
HEMOSTASIS fibrin after fulfilling its haemostatic functionPrimary + 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


Normal Artery fibrin after fulfilling its haemostatic function

Endothelium

Smooth

Muscle

Adventitia


Vascular Damage fibrin after fulfilling its haemostatic function


Hemostasis fibrin after fulfilling its haemostatic function


Overview of blood coagulation fibrin after fulfilling its haemostatic function


Second step is activation of coagulation
Second step is activation of coagulation fibrin after fulfilling its haemostatic function

Three phases

  • Intrinsic pathway

  • Extrinsic pathway

  • Common pathway


Coagulation cascade
Coagulation cascade fibrin after fulfilling its haemostatic function

Intrinsic pathway

XII

XI

Extrinsic pathway

IX

VII

APTT

VIII

X

PT

thrombin

Prothrombin

(II)

V, Ca, P/L

fibrin

fibrinogen

XIII

STABILISED FIBRIN


Classification of coagulation disorders
Classification of coagulation disorders fibrin after fulfilling its haemostatic function

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 fibrin after fulfilling its haemostatic function

are far more commonly seen

  • Thrombocytopenic coagulopathies

  • Disseminated intravascular coagulation ..DIC

  • Anticoagulant therapy


4 congenital coagulopathies

4. Congenital Coagulopathies fibrin after fulfilling its haemostatic function

Von Willebrand disease

Factor synthesized by endothelial cells &

megakaryocytes

Forms a complex with factor VIII

Mediates platelet adhesion and collagen

Inherited as autosomal dominant trait


Congenital coagulopathies

Congenital Coagulopathies fibrin after fulfilling its haemostatic function

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 fibrin after fulfilling its haemostatic function

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 fibrin after fulfilling its haemostatic function

Other coagulation factor deficiencies

Factor VIII ( hemophilia A)

Factor IX ( hemophilia B)


Thrombocytopenic coagulopathies

Thrombocytopenic fibrin after fulfilling its haemostatic functionCoagulopathies

Autoimmune Thrombocytopenic Purpura

Idiopathic thrombocytopenic purpura

Immunoglobulin G (IgG)


Thrombocytopenic coagulopathies1

Thrombocytopenic fibrin after fulfilling its haemostatic functionCoagulopathies

Diagnosis

Platelet count < 100,000/mm3

Increased numbers of megakaryocytes

Increased platelet volume

Diameter


Thrombocytopenic coagulopathies treatment

Thrombocytopenic fibrin after fulfilling its haemostatic functionCoagulopathiestreatment

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



DIC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

SYSTEMIC ACTIVATION OF COAGULATION

  • 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

Bleeding

DEATH

Organ failure


Obstetric causes of dic
Obstetric causes of DIC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

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



Mechanism of DIC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

Bick et al., 2002


Clinical manifestation of dic
Clinical manifestation of DIC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • Those of the underlying cause

  • Those due to Complications of DIC


Haemorrhagic manifestations
Haemorrhagic manifestations thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

Involving skin & mucus membranes

  • Ecchymosis

  • Petechiae

  • Bleeding from the gum

  • Haematuria

  • GIT bleeding

  • Venepunctur oozing

  • Intracranial or intracerebral haemorrhage


Thrombotic manifestations
Thrombotic manifestations thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • 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 thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • 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 thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • Fragments

  • Schistocytes

  • Paucity of platelets


Fragmented RBC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

T. TATU


Treatment of DIC thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • 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


Conclusion
conclusion thrombocytopenic foetus has not been shown to be reduced by C/S therefore C/S should be performed for obstetric reasons

  • 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





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