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In late pregnancy, there is increased concentration of coagulation factors I (fibrinogen: level is 350-650 mg / dL), VII,VIII,IX and X. Other plasma factors and platelet count (150 000-400 000 / cmm) do not change remarkably. Common causes Massive blood loss with inadequate replacement. Rare causes Sepsis. Retained dead fetus (for more than 3-4 weeks). Autoimmune disease, hematological malign
In late pregnancy, there is increased concentration of coagulation factors I (fibrinogen: level is 350-650 mg / dL), VII,VIII,IX and X. Other plasma factors and platelet count (150 000-400 000 / cmm) do not change remarkably. Common causes Massive blood loss with inadequate replacement. Rare causes Sepsis. Retained dead fetus (for more than 3-4 weeks). Autoimmune disease, hematological malign
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In late pregnancy, there is increased concentration of coagulation factors I (fibrinogen: level is 350-650 mg / dL), VII,VIII,IX and X. Other plasma factors and platelet count (150 000-400 000 / cmm) do not change remarkably. Common causes Massive blood loss with inadequate replacement. Rare causes Sepsis. Retained dead fetus (for more than 3-4 weeks). Autoimmune disease, hematological malign
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Descărcați ca PPT, PDF, TXT sau citiți online pe Scribd
(DIC) or Consumptive Coagulopathy. HYPOFIBRINOGENEMIA PHYSIOLOGICAL BACKGROUND In late pregnancy, there is increased concentration of coagulation factors I (fibrinogen: level is 350-650 mg/dL), VII,VIII,IX and X. Other plasma factors and platelet count (150 000-400 000/cmm) do not change remarkably. DEFINITION A widespread hematological condition characterized by accelerated fibrin formation and lyses. There is consumption of platelets and coagulation factors in variable quantities. Signs of hypofibrinogenaemia develop when its level goes below 100 mg/dL Etiology (Pregnancy related) Common causes Massive blood loss with inadequate replacement. Massive crystalloid or colloid replacement Placental abruption. Severe pre-eclampsia/eclampsia or HELLP syndrome. Rare causes Sepsis. Retained dead fetus (for more than 3-4 weeks). Amniotic fluid embolism. Acute fatty liver of pregnancy. Adult RDS, acute hemolytic transfusion reactions, autoimmune disease, hematological malignancies and solid tumors. MECHANISM Pathologically accelerated coagulation: occurs via the extrinsic pathway (thromboplastin from tissue destruction) or the intrinsic pathway (collagen and other tissue components when endothelial integrity is lost). Finally factor X (Prothrombinase) is activated. The formed thrombin (activated factor II) changes fibrinogen (factor I) to fibrin (monomers and polymers-clot-). Factor X can be activated directly by proteases present in mucin of amniotic fluid or neoplasms.
Fibrinolysis: the fibrin monomers combine with tissue
plasminogen activator and plasminogen which release plasmin. Plasmin lyses the fibrin mono and polymers to form a series of fibrin degradation products (FDPs) including the D-dimer. CLINICAL PICTURE
Postpartum or antepartum hemorrhage.
Persistent bleeding from venipuncture sites or after catheter insertion. Spontaneous bleeding from gums and nose. Generalized oozing in surgical fields. Purpuric areas at pressure sites (thrombocytopenia and incoagulable blood). Investigations
Aiming to detect fibrinolysis.
FDPs and fibrin D-dimer (normally absent). Prolonged PT and PTT(PTT may be normal). Low fibrinogen, falling antithrombin III & low platelet count (CBC should be done). Weiner test (clot observation test): 5-10 cc of blood in a test tube are incubated at 37ºC. A) Normally a clot forms within 3-8 minutes. B) a clot forms after a longer time and dissolves within one hour = hypofibrinogenemia. C) No clot is formed = afibrinogenemia. TREATMENT It must be directed to the underlying cause to reverse defibrination. Two wide-bore IV cannulas are inserted. If PT is > 1.5 times the control value, transfuse fresh frozen plasma (FFP). The goal is to keep PT within 2-3 sec. of the control value. If fibrinogen level is < 100 mg/dL, transfuse cryoprecipitate. Ten units of cryoprecipitate are usually given after every 2 to 3 units of plasma. Each unit of cryoprecipitate increases the fibrinogen by 10 mg/dL. OR give Fibrinogen 4-10 g IV. TREATMENT Platelets should be transfused if the count is < 20 000/cmm or if clinically significant bleeding occurs with a platelet count between 20 000 and 50 000/cmm. Each platelet unit increases count by 10,000/cmm. The usual rate of platelet transfusion is 1-3 U/ 10Kg/ day. Antifibrinolytics as Epsilon Amino Caproic Acid (EACA) 4-6 g IV OR trasylol 2-4 ampules IV ( 5 ml ampoule contains 25 000 U), is not recommended in most types of obstetric coagulopathy to avoid organ ischemia and infarction unless all above mentioned measures fail to control bleeding. Heparin infusion trying to stop coagulation is condemned when the vascular system integrity is compromised.