Disseminated Intravascular Coagulation

DIC By Prof. Rifaat Al-Shimmy Al-azhar U 2010

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 Conditions

Associated with: Inadequate replacement of blood loss
Pre-eclampsia-Eclampsia.HELP syndrome Ante partum hge (abruptio 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

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.

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.

Path physiology, 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.

Path physiology, continued

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

Path physiology, 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.

Path physiology, 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%d) 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) Wies et al2007

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/mm3in 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 RBCs

Whole blood
-Fresh -old
DIVC Massive haemorrhage Major liver trauma Bleeding associated with liver disease

Blood components
Packed red cells platelets Fresh Frozrn Cryopreci Plasma pitate
when PT & when PTT are fibrinogen higher than level is less 1.5 times than 80control levels 100mg/dl
All clotting Initially a tx for factors; no VW Dz, platelets Hemophilia Can Now a source of supplement RBCs when fibrinogen in whole blood notobstetric available for emergencies exchange transfusion

Plasma fractions

-Washed when platelet. count less than RBCs

50000/cmm or when -Leuko- massive blood loss or poor replacement RBCs Pts with febrile, non- has occurred
Pts with allergic reactions to plasma proteins hemolytic reactions to plasma WBCs

Clotting factor concentrates Immunoglobulin preparations Saline albumin solution Salt-poor albumin

Platelet normal dose: 12 dose: 1- 1.5 -2 concentrates - 15ml/ kg packs/ 10 kg (1 pack/10kg) (4-5packs) (8-10 packs) dose : 6units RDP or 1 unit SDP

Clotting disorders Haemophilia Liver disease

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