Obstetrical
hemorrhage and especially
DIC (
disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including
placental abruption,
amniotic fluid embolism,
HELLP syndrome (
hemolysis, elevated liver
enzymes and low platelets), retained
stillbirth and
acute fatty liver of pregnancy. Various obstetrical disorders can present with
DIC as a complication; thus, increased awareness is key to diagnosing the condition.
DIC patients can present to clinicians who may not be experienced in a variety of aspects of
thrombosis and hemostasis. Hence,
DIC diagnosis is often only entertained when the patient already developed uncontrollable
bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with
DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in
DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT),
thrombocytopenia, low
fibrinogen, and raised D-dimers. Diagnosis of
DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific
DIC score including three components: 1)
fibrinogen concentrations; 2) the PT difference - relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥26 points, the pregnancy specific
DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of
DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the
hemostatic problem that can be guided by point of care testing adjusted for pregnancy.