37. DIC

Question 1

what are the obstetrical conditions that trigger DIC ?

Answer 1

endothelia injury :
preeclampsia , eclampsia , HELLPsyndrome

septicemia/ endotoxemia through
septic abortion ,chorioamonitis

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release of thromboplastin

*amniotic fluid embolis

dead fetus syndrome

*placental abruption

hyatidiform mole

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release of phospholipids :
fetomaternal baled
incompatible blood transfusion

Question 2

when is chronic DIC observed ?

Answer 2

dead fetus syndrome

lengthy intrauterine retention of a dead fetus usually longer than 4 weeks with occasional disseminated intravascular coagulopathy

Plasma levels of FDP, D-dimers are raised,
aPTT, PT and fibrinogen are within the normal range. There may be mild thrombocytopenia and red cell fragmentation.

Question 3

in placental abruption what is the mechanism in which DIC occurs ?

Answer 3

Thromboplastin liberated from the retroplacental clot, damaged decidua and uterine musculature enters into the circulation and produces DIC via the activation of an extrinsic coagulation cascade

the extend of DIC is the amount which the placenta separates - suggesting like of leakage of thromboplastin materials

Question 4

mechanism of amniotic fluid embolism causing DIC ?

Answer 4

Happen in the late stages of labour and when there is tear in the placental membrane it causes cause amniotic fluid containing fetal cells to enter the blood

it blocks the pulmonary arteries (cardiopulmonary failure) and triggers DIC

Question 5

what are the clinical features observed in DIC ?

Answer 5

if before delivery - signs of bruising , prolonged bleeding at injection sites , gum bleeding , git hemorrhage and hypotension
dyspnea

after delivery - same as above
postpartum hemorrhage in spite of contracted uterus
bleeding from suture sites
hematoma in c section wound or vulval hematoma in vaginal delivery\

in severe- multiple organ failure

Question 6

diagnosis of DC

Answer 6

platelet count decreased

blood fibrinogen level of 100 mg/100 mL

APTT - intrinsic
prolonged

PT - extrinsic
prolonged

thrombin time
prolonged

FDP - fibrin degradation product
(raised

D - dimer
increased

peripheral BLOOD SMEAR - helmet shaped

Question 7

what is the preventive methods in DIC ?

Answer 7

placental abruption - massive blood transfusion

C section

vitamin K dependent factors II, VII, IX, X are consumed in DIC. 5-10 mg of Inj Vit K given (IM), can help to replenish these procoagulants

Question 8

what is the treatment of DIC ?

Answer 8

volume replacement 0 ringer solution

fresh frozen plasma to cryoprecipitate - to replenish the fibrinogen and procoagulants

recombinant activated factors viiA - reverse DIC

platelet concentrates if platelet count below 50,000/ml

intravenous heparin - esp for amniotic fluid embolism
but not given in acute DIC - because it can aggravate bleeding

immediate delivery through c section of placental abruption

respiratory support
hemodynamic support

achieve a platelet count > 50,000/μL and a fibrinogen level > 100 mg/dL.

Question 9

what are the 4 stages of DIC ?

Answer 9

they are continuous and can occur at the same time

1) hypercoaguble
2) secondary fibrinolytic
3) hypocoaguble
4) reperation