1. Prof. M.C.Bansal .
MBBS., MS., MICOG, FICOG.
Founder Principal & Controller ,
Jhalawar Medical College & Hospital Jhalawar
Ex P&C Mahatma Gandhi Medical college and
Hospital , Sitapura, Jaipur.

2. Physiological coagulation Changes
in Pregnancy
 A fine physiological hemostatic balance between
coagulation and fibrinolysis is shifted in favor of pro-
coagulation.
 Thus pregnancy is a hyper coagulation state.
 venous thrombosis disease becomes a potential risk in
pregnancy as Virchow’s triad of coagulation , vessel
wall damage and blood flow rate are affected.
 Bleeding disorders may develop from— (a)
coagulation defect (b) deficiency coagulopathy
(C)reduction or functional Defect in platelets—
Thrombocytopenia .

3. Changes in clotting factors in
Pregnancy
1 . Predominantly pro – hemostatic changes ( shortened
Clotting Time )
Increased Fibrinogen concentration.
Increased factor II , V, VII, VIII , IX, X and XII other
coagulation Factor .
2. reduced platelet count due to low grade intravascular
coagulation.
3. Increased Plasminogen activator inhibitor concentration
( reduced systemic fibrinolytic capacity )
4. reduced Protein S concentration .
5. Increased protein C concentration.

6. Coagulation Disorders
 Inherited Coagulation bleeding disorders 
are more common (20- 100 case /Million )
1. Haemophila A – an linked factor VIII deficiency or
defective condition.
2. Haemophilia B – an X linked factor IX – deficient or
defective condition .
3. Von willebrand’s disease (vWD) , an autosomal
dominant / recessive condition resulting in deficient
or defective VwF ( factor)
Rare are---1case / million  Haemophilia C –factor Xi
deficiency And autosomal recessive conditions
resulting in deficiency of factor x, V, VII, II
, XIII, V+VIII , afribinogenaemia and
dysfibrinogenaemia
.

7. Bleeding Disorders in Pregnancy ---
-
 Acquired
1. DIC .
2. Coagulopathies with Sepsis, acute pro –myelocytic
Leukaemia , massive blood loss, renal and hepatic disease .
3. Acquired inhibitors of coagulation-Anti phspholipid
syndrome .
4. Acquired –Factor VIII antibodies.
5. Thrombocytopenic Purpura .
6. Other thrombotic micro coagulopathies .

8. Thrombocytopathies ( platelet
disorders)
A. Congenital 
-Inherited thrombocytopenia and functional defect.
- Drug / chemical induced .
- Iso- immune ( neonatal alloimmune
thrombocytopenia)
- Bone marrow infiltration ( malignancy
, mucopolysacchardosis)
- Congenital Infections ( cytomeglovirus . Toxoplasma
., rubella )

9. Thrombocytopathies ( platelet
Disorder)
B. Acquired
- Gestational thrombocytopenia .
- Immune Thrombocytopenia.
- Associated with PIH.
- Drug induce – heparin, quinine , sylph drugs , anti
cancer drugs and Zidovudine .
- Anti phospholipid syndrome .
- Associated with HIV infection .
- Other Secondary causes --- DIC, TIP , Hypersplenism
- Dangu fever., falciferum malaria, Septicemia.

10. Clinical Presentation
 Hemophilia A –females are carrier and 50 % may have
low levels of factor Viii ., require replacement therapy
to cover surgery .
 Von willbrand’s disease --- pt has prolonged BT due do
failure of vwF in assisting platelets to adhere to cut
surface hence plate plug is not formed .20% women
with me3norrhagia may have vWD . In pregnancy vWF
rises to normal level .
 Factor XI deficiency -- < 5%in moderate to severe but
6-30% in mild form . Mild bleeding diathesis , with255
developing muscle hematomas and haemorrhoids
, oral or pop bleeding can occur in 505 cases.Patient for
LSCS should be covered with factor XI concentrate or
Fresh Frozen Plasma.

11. Clinical Presentation
 Factor XIII deficiency--- associated with severe
bleeding affecting mucosa and skeletal surfaces . 50%
pregnant women will have abortions .
 Factor X deficiency ---associated with hematomas .
haemarrhosis and bleeding from GIT.
 Acquire coagulopathy
Endothelial Release of Release of
Injury Thromboplastin Phophplipids
PIH,ECLMPSIA , AMNIOTIC Fetomaternal
HELLP Syndrome FLUID Embolism , bleed
Iufd, ABRUPTIO
Septicaemia– PLACENTA , Moer Incompetable
septic abortion , pregnancy , LSCS, Blood transfusion
chorioamnionitis , Intra amniotc
pyelonephritis Hyper tonic saline Haemolysis.
, Shock
Hypovolaemia

12. Simple Laboratory screening tests
in acquired coagulation disorders
Tests Description
Coagulation Reduced Fib
Prothrombin Time (PT ) -Prolong PT, APTT ( perform 50:50 mix
Activated Partial thromboplastin with normal plasma to correct the factor
time(APTT) deficiency)
THROMBIN Time (TT) -Prolong TT ( perform reptilase to exclude
Heparin Effect )
Fibrinogen Assay -Reduced Fibrinogen
Platlets Blood film inspection for clumps , confirm
Absolute Count reduction and altered morphology of
Function platelets , bleeding Time ( pfa 100 or skin
template )
Fibrinolysis
Fibrin Degradation products ( Increased FDPs
FDPs )
Accelerated Clot Lysis -enhanced Euglobulin Clot Lysis Time

13. Differential Diagnosis Of Thrombotic Microangiopathy
Condition Specific Tests
DIC Raised FDPs, D-Diamers , Reduce
Fibrinogen , Prolonged PT /APTT
Eclampsia / Hellp Raised SGOT & SGPT, Low platelets
SLE / Scleroderma / vasculiotis / APS Positive ANA , Anti cardiolipin , Lupus
anticoagulant
Evan’ syndrome ( Haemolysis and ITP ) Positive direct coomb’s Test
Haemagglutinin Inhibition Platelet associate and Heparin antibodies
TIP/ HUS ADAMTS-13 Absent
Note-ADAMTS-13 –a disintigration FDPs – Fibrinogen degradation
and metallproteinase with products . HUS –Haemolytic Urimic
thrombospondin motif -13 , ANA ---- syndrome . ITP--- Immune
Antibodies to nuclear antigen . APS -- Trombocytic Purpura. PT ---
-Anti Phospho Antibody syndrome . Prothrombin Time. SLE ---Systemic
Aptt---Activated partial protrombin Lupus erythromatosus. TIP----
Time . Thrombotic thrombocytopenic
purpura

14. Obstetrical Conditions causing DIC
 Sepsis / septicaemia .
 Birth trauma / surgical intervention .
 Obstetricial calamities – Amniotic Fluid embolism
, Abruptio Placenta.
 Toxic / Immunological shock –BT reaction, drug reaction
 Massive Blood loss with In adequate Replacement.
 Co – morbidities ---diabetes, Heart Failure ,Renal /liver
disease Sickle cell disease , underlying Malignancy .
 IUFD, Missed abortion , Molar Pregnancy.
 Eclampsia , HELLP Syndrome .
 Cerebral Malaria .

15. Thrombocytopathies----------
 Reduction in plate let count < 50 ,000/ ml or changes
in function and morphology of platelets is associated
with—
1. Spontaneous or immediate , prolonged bleeding
after even minor trauma .
2. Bleeding from normal mucosa.
3. Petechiae / purpura .
4. Haematoma and Haemorrhasis.

16. Thrombocytopenia in Pregnancy
 Normal platelet counts are increase in pregnancy < 2.4
lacks/ cmm .
 Mild Trombopenia < 1.5-1 lac/ cmm
 Moderate < 1lac /cmm
 Severe < 50 ,000 / cmm
 May be due to --.
1. Increased Platelets destruction –immune factor
, abnormal platelet activation function , consumption
2. Decreased platelet production –leukaemia , aplastic
anaemia , folate deficiency, bone marrow infiltration of
bone marrow , drug induced .

17. Causes of Thrombocytopenia in
Pregnancy
 Gestational --8%
 PIH---1:5 of maternal(21%) Thrombocytopenia
 Hellp Syndrome .
 Pseudothrombocytopenia .
 HIV infection .
 Immune thrombocytopaenic purpura --1: 1000-10,000
pregnancy , presence of IgG antiplatlet antibodies .
 APS syndrome .Hemolytic –Uremic syndrome.
 Congenital Thrombocytopenia.
 Drug induced ( heparin , quinine, guanidine
,Zidovidine ,sulphonamides ).

18. Management of
Thrombocytopenia
 Diagnosis based on clinical observation , suspicion
, confirmation by Peripheral blood film examination and
other necessary haematological tests to find out the cause
and to reach definite diagnosis of its variety.
 Corticosteroid therapy (1mg/Kg/day)is indicated when
Platelet count fall Below 1lac – 80,000 /or falling rapidly .
 Near term, IV immunoglobin( o.4mg/ Kg/day)for more
rapid response .
 Platelet concentration transfusion if platelet count fall as
low 25,000 /cmm .
 Infant of such mother may also have low platelet counts
resulting in intra cranial bleed (3%)

19. Anti Coagulants
Drugs Mode Of Action Dose Side Effects
Heparin(unfractionate Inhibits Thrombin 5-10 Thousand IU SC Maternal–Bleeding,
d) Action , Enhances the DVT& pulmonary urticaria ,
activity of Anti Embolism-- Loading Thrombocytopenia
thrombin III dose 5000 IU osteopenia and
Intravenously followed Hyperkalaemia.
by iv drip 18-20 IU /kg / Fetal –It does not cross
hour as continuous placenta.
infusion.
Pregnancy 5-10
thousand units SC / 12 LMWH---As effective
Low Molecular Weight hrly and monitoring. as unfractionated
Heparin Deltaperin (fregmin) heparin , longer half
2500 IU Sc / 24 hrly life and once a day dose
is convenient .
Warfarin Interferes with 10mg orally / day for 2 Maternal– bleeding
synthesis of Vit K days then 3-9 mg I day Fetal –Contradi’s
dependent factors at same time syndrome ( Skeleton &
II,VII,IX ,X. depending upon facial anomalies) optic
Prothrombin Time atrophy , Microcephaly
(INR) , chondroplasia puncta
.