Disseminated Intravascular Coagulation

August 10, 2011

Disseminated Intravascular Coagulation (DIC) By Prof. Rifaat Al-Shimmy, Al-azhar U.Definition of DIC A pathological condition associated with activation of both: • Coagulation system and • Fibrinolytic one It should be considered as a secondary phenomena of an underlying disease as...Common Obstetric ConditionsAssociated with: • Inadequate replacement of blood loss • Pre-eclampsia-Eclampsia…HELP syndrome • Ante partum hge (abruption placenta and P.P.) • I U F D when prolonged more than 4 weeks • Blood transfusion when massive or incompatible • Septic abortion or massive tissue injury • Amniotic fluid embolism • Saline I U infusionMassive Transfusion Is defined as the replacement of a patient's total blood volume in less than 24 hours,or as the acute administration of more than half the patient's estimated blood volume per hour. DIC is commonly a consequence of delayed or inadequate resuscitation page_break@DIC: Is it Predictable? • It can probably be predicted in all the previously mentioned high risk groups, except amniotic fluid embolism, as it is an unpredictable condition. • However, in AFE, DIC it always occurs only after resuscitation from the primary shocked state. page_break@Is it Preventable? • It can be avoided in most cases by proper ‘in time’ resuscitation and management of the underlying disease in proper time, e.g. Pre-eclampsiaPathogenesis • The most accepted theory is the Cascade theory in which there is activation of both Extrinsic and Intrinsic pathways leading to activation of factor xa leading to formation of thrombin from prothrombin to form fibrin from fibrinogen • With associated activation of fibrinolytic system as a protective mechanism.Pathophysiology, continued Pregnancy is considered as a hypercoagulable state by: • An increase in all coagulation factors except FXI/FXIII. Fibrinogen which increases to 400-650mg/dl in late pregnancy. • The fibrinolytic system is depressed during normal pregnancy and labor but returns to normal one hour after delivery of the placenta.Pathophysiology, continued Decrease in platelets count is a result of: 1. Consumption 2. Aggregation of plateletsPathophysiology, continued • So DIC is a state of increase thrombin activity at first, followed by increased fibrinolytic activity, leading to… • consumption of coagulation factor (source of old name consumptive coagulopathy) and the formation of FDP impairing homeostasis.Pathophysiology, continued • Deposition of fibrin in organs and tissues may lead to ischemic tissue damage. • The decreased number of platelets and elevated FDP increase the problem of homeostasis.Symptoms of DIC It is variable according to the cause, the presentation of the primary cause with: • Generalized or localized hemorrhage • Peticheae • Thromboembolc manifestation, organ failure as: liver, lung, kidneys, brain and frank gangrene have been described. • Chronic DIC, (that occurs with IUFD) may be asymptomatic.Diagnosis Although the definite diagnosis is only by histological finding of fibrin deposits, there are many indirect tests as: • Bedside clot retraction test • Skin puncture test, measure clotting time (fibrinogen) • D. Diamer           (90%) • Platelets count   (90%) • FDP                      (90%) • Thrombin time   (80%) • PTT and PT        (60%)Bedside Clot Retraction Tes(CT) • It simply tests the clotting time - a test of decreased fibrinogen • 2 ml blood in test tube - no clot formed but if occurs it is prolonged, soft and not retracted after half an hour, leaving a clot volume more than serum volume. (the clot doesn't retract)Skin Puncture Test (bleeding time) • Prolonged skin puncture ooze is observed when the platelets count is less than 100,000/ul • Continuous bleeding at puncture site occurs when pl count is less than 30,000 /ulOther laboratory tests • Platelets count decreases in 90% of cases (count less than 100,000/dl) • PT, which measures the time required by extrinsic pathway, elevated in 80% of DIC • PPT which measure the time required by intrinsic pathway - not helpful. • Thrombin time elevated in 80% of casesOther laboratory tests • Fibrinogen level/ less than150mg. This is present in 70% of cases. • Fibrin split product >40ug/dl, 90% of cases • D-Diamer - an antigen formed as a result of plasmin digestion, elevated in 90%of cases.Treatment of DIC • Essentially treat the underlying cause. In most cases prompt termination of pregnancy is required. • Supportive therapy should be directed to the correction of shock, acidosis and tissue ischemia. • Cardiopulmonary support including inotropic therapy, blood transfusion and assisted ventilationGuidelines by the Scottish Executive Committee of the RCOG

Disseminated Intravascular Coagulation (DIC)
By Prof. Rifaat Al-Shimmy, Al-azhar U.

Definition of DIC
A pathological condition associated with activation of both:
• Coagulation system and
• Fibrinolytic one
It should be considered as a secondary phenomena of an underlying disease as...

Common Obstetric ConditionsAssociated with:
• Inadequate replacement of blood loss
• Pre-eclampsia-Eclampsia…HELP syndrome
• Ante partum hge (abruption placenta and P.P.)
• I U F D when prolonged more than 4 weeks
• Blood transfusion when massive or incompatible
• Septic abortion or massive tissue injury
• Amniotic fluid embolism
• Saline I U infusion

Massive Transfusion
Is defined as the replacement of a patient's total blood volume in less
than 24 hours,or as the acute administration of more than half the
patient's estimated blood volume per hour.

DIC is commonly a consequence of delayed or inadequate resuscitation
page_break@

DIC: Is it Predictable?
• It can probably be predicted in all the previously mentioned high risk
groups, except amniotic fluid embolism, as it is an unpredictable
condition.
• However, in AFE, DIC it always occurs only after resuscitation from the
primary shocked state.
page_break@

Is it Preventable?
• It can be avoided in most cases by proper ‘in time’ resuscitation and
management of the underlying disease in proper time, e.g. Pre-eclampsia

Pathogenesis
• The most accepted theory is the Cascade theory in which there is activation of both Extrinsic and Intrinsic pathways leading to activation of factor xa leading to formation of thrombin from
prothrombin to form fibrin from fibrinogen
• With associated activation of fibrinolytic system as a protective mechanism.

Pathophysiology, continued
Pregnancy is considered as a hypercoagulable state by:
• An increase in all coagulation factors except FXI/FXIII. Fibrinogen
which increases to 400-650mg/dl in late pregnancy.
• The fibrinolytic system is depressed during normal pregnancy and labor
but returns to normal one hour after delivery of the placenta.

Pathophysiology, continued
Decrease in platelets count is a result of:
1. Consumption
2. Aggregation of platelets

Pathophysiology, continued
• So DIC is a state of increase thrombin activity at first, followed by
increased fibrinolytic activity, leading to…
• consumption of coagulation factor (source of old name consumptive
coagulopathy) and the formation of FDP impairing homeostasis.

Pathophysiology, continued
• Deposition of fibrin in organs and tissues may lead to ischemic tissue
damage.
• The decreased number of platelets and elevated FDP increase the
problem of homeostasis.

Symptoms of DIC
It is variable according to the cause, the presentation of the primary cause with:
• Generalized or localized hemorrhage
• Peticheae
• Thromboembolc manifestation, organ failure as: liver, lung, kidneys, brain and frank gangrene have been described.
• Chronic DIC, (that occurs with IUFD) may be asymptomatic.

Diagnosis
Although the definite diagnosis is only by histological finding of
fibrin deposits, there are many indirect tests as:
• Bedside clot retraction test
• Skin puncture test, measure clotting time (fibrinogen)
• D. Diamer           (90%)
• Platelets count   (90%)
• FDP                      (90%)
• Thrombin time   (80%)
• PTT and PT        (60%)

Bedside Clot Retraction Tes(CT)
• It simply tests the clotting time - a test of decreased fibrinogen
• 2 ml blood in test tube - no clot formed but if occurs it is prolonged, soft and not retracted after half an hour, leaving a clot volume more than serum volume.
(the clot doesn't retract)

Skin Puncture Test (bleeding time)
• Prolonged skin puncture ooze is observed when the platelets count is less than 100,000/ul
• Continuous bleeding at puncture site occurs when pl count is less than 30,000 /ul

Other laboratory tests
• Platelets count decreases in 90% of cases (count less than 100,000/dl)
• PT, which measures the time required by extrinsic pathway, elevated in 80% of DIC
• PPT which measure the time required by intrinsic pathway - not helpful.
• Thrombin time elevated in 80% of cases

Other laboratory tests
• Fibrinogen level/ less than150mg. This is present in 70% of cases.
• Fibrin split product >40ug/dl, 90% of cases
• D-Diamer - an antigen formed as a result of plasmin digestion, elevated in 90%of cases.

Treatment of DIC
• Essentially treat the underlying cause. In most cases prompt termination of pregnancy is required.
• Supportive therapy should be directed to the correction of shock, acidosis and tissue ischemia.
• Cardiopulmonary support including inotropic therapy, blood transfusion and assisted ventilation

Guidelines by the Scottish Executive Committee of the RCOG

RESUSCITATE
MONITOR / INVESTIGATE
STOP THE BLEEDING
COMMUNICATE

Help…be ready expecting a catastrophe

Call Help...ALB…
• Set up IV Infusion
• O2 administration
• Airway control; end otracheal intubations
--> maximal ventilation and oxygenation.
A= ANESTHESIA AND INTENSIVE CARE IN DUTY
L= lab group in duty
B= Blood bank in duty

Treatment
• Careful monitoring of fluid balance
• Serial evaluation of coagulation parameters
• If sepsis is suspected, antibiotic is indicated with evacuation of the septic focus

Inform blood bank that it is an emergency

Obtain and send 2 blood samples:

1) To blood bank for grouping and cross
matching
2) To lab to obtain baseline for Hb, Htc, PT, PTT, platelet
count and fibrinogen levels

GENERAL ROLE in Treatment of DIC
• Vaginal delivery if possible is preferable than Cesarean section
• Episiotomy should be avoided if possible
• Central invasive monitoring as pulmonary catheterization is contraindicated
• Failure of response after delivery suggest other cause of coagulopathy or persistent sepsis

DIC Treatment
• Treatment of hypovolemia should be applied according to the guideline of National Institute of Health.
• Crystalloid first
• Plenty blood transfusion
• Treat hypothermia
• Red cell transfusion, if bleeding. (Anticipated)

Treatment of Coagulopathy

1-Fresh Frozen PASMA
• FFP for a prolonged PT - The idea is to keep it 2 to 3 seconds from control, (it contains coagulation factors), each unit volume is 250ml

2-Cryoprecipitate
• For a fibrinogen level less than 100 mg/dL. it is a fresh frozen plasma concentrate, (each bag volume is 10ml), contains 100mg fibrinogen raising f by 10mg/dl.

Platelet Transfusion
• Transfuse platelets for platelet counts less than 20,000/mm3 in active bleeding or less than 50,000 if c s is planned.
• The rate of pl transfusion is one unit to every 10 kg/body w.

Treat Coagulopathy
• Parental vitamin k and folic acid as pt of DICare deficient in these vitamins
• There is much data not in favor of use of the antifibrinolytic drugs
• In DIC 10 UNITES OF CRYOPPT, FOE 2/3 UNITE OF FF PLASMA SHOUID BE READY

Role of Heparin in Low Dose
• Although there is a controversy in regards to giving a low dose of LMWH, its idea is to stop the consumption of coagulation factors, however its role is established in case of chronic DIC, (as in case IUFD of single twin for example or any case of IUFD before termination with follow up with fibrinogen level)
• Full dose if thrombosis is definitely diagnosed

PREPARE AT LEAST:

10 units of cryoprecipitate
4 units of fresh frozen plasma
10 units of platelet concentrate
Blood and packed RBC’s

Prognosis
• Most cases of obstetric DIC will improve with delivery of the fetus or evacuation of the uterus
• This improved prognosis seems to be related to the recent advance in critical care

Conclusion
• DIC is a secondary phenomena, therefore it is mostly predictable
• It occurs in an acute or chronic form, therefore it can be anticipated in the later form.
• The commonest cause is inadequate resuscitation, therefore it is preventable by early intervention.

Take Home Message
DIC can be predicted and even prevented in most of the cases.

Thank-you