1. DERANGED COAGULATION
PROFILE IN OBSTETRIC PATIENTS
Dr. Kirti S. Ruikar

2.  Obstetrics is "bloody business." Although
medical advances have dramatically reduced
the dangers of childbirth, death from
haemorrhage still remains a leading cause of
maternal mortality
 Hemorrhage is the single most important
cause of maternal death worldwide.
Obstetrical hemorrhage accounts for almost
half of all postpartum deaths in developing
countries

3. Learning objectives
 Refresh about the normal coagulation
cascade mechanisms and its triggers
 To understand the alterations in
coagulations & Fibrinolysis associated
with pregnancy
 Broad line classification of coagulation
failure in pregnancy

4.  To get brief knowledge on some
important causes of deranged
coagulation in pregnancy
 Understanding the pathogenesis of DIC
syndrome, diagnosis, complications &
management outlines

5. Haemostasis balancing act

6. Normal Haemostasis
-Vascular endothelium releases a potent antiplatelet
agent called prostacyclin (PGI2) which limits the size
of any micro thrombi formed , so it prevents overt
thrombus formation.
-On the other hand the platelets release
thromboxane A2 (TxA2) which performs a powerful
platelet aggregation .
-If there is any imbalance between PGI2 & TxA2 , the
result can be a predisposition of either bleeding or
thrombosis.

7. Normal Artery
Endothelium
Smooth
Muscle
Adventitia

8. Vascular Injury
Damage

9. Hemostasis

10. Overview of blood
coagulation
Vessel
Injury
Platelet
Activation
Tissue
Factor
Coagulation
Cascade
Platelet
Aggregation
Platelet
Plug
Thrombin
Clot
Vasocon-
striction

11. HAEMOSTASIS
Primary + Secondary + Tertiary
 Primary Hemostasis
Platelet Plug Formation:dependent on normal
platelet number & function
 Secondary Hemostasis
Activation of Clotting Cascade  Deposition &
Stabilization of Fibrin
 Tertiary Hemostasis
Dissolution of Fibrin Clot:dependent on Plasminogen
Activation

12. Normal haemostasis & the vascular tree
The normal function of coagulation & fibrinolytic
system is to maintain an intact but patent
vascular tree.
Three main components play a part in normal
haemostasis:
1.Vascular constriction
2.Platelet plug
3.Fibrin generation

14. • The fibrinolytic system is complementary to these
activities & is responsible for the removal of fibrin &
the restoration of vascular patency.

15. HOW DOES THE PROCESS OF
NORMAL COAGULATION
TAKES PLACE?

17. Three pathways of blood coagulation are
Extrinsic pathway
Intrinsic pathway
Common pathway

19. Coagulation Inhibitors
In addition to the clotting factors there are
many substances that inhibit coagulation:
-Anti- thrombin III (AT III)
-Alpha 2 globulin inhibits Thrombin & factors Xa, XIIa
,XIa and IXa.
-Protein C (endothelial cell )
-Protein S (endothelial cell & platelets )

24. Coagulation & fibrinolytic
system during pregnancy
-Placental separation during the 3rd stage of labour
represents a major haemostatic challenge to the
mother.
-Physiological adaptations occur during pregnancy
to help the mother meet this haemostatic
challenge .
-Together the change in coagulation & fibrinolysis in
pregnancy represents a hypercoagulable state .

25. Coagulation system during pregnancy
-Plasma fibrinogen concentrations rise during pregnancy by
about 50% , this means that double the amount of
fibrinogen is available to pregnant woman at delivery .
-Concentration of other clotting factors also rise , especially
Prothrombin & factors V ,VII , VIII . IX , X , & XII.
-Notable exception are factors XI & XIII ,whose concentrations
fall during pregnancy.
-Despite the increased potential to form thrombin in
pregnancy , there is no compensatory rise in
anti-thrombin III.
-Platelet count shows little , if any , change.

26. .
-Plasma plasminogen levels rise in tandem with the
rise of fibrinogen.
-Anti plasmins also rise so that the capacity to
generate plasmin may be reduced in pregnancy .
Fibrinolytic system during pregnancy

27. Coagulation & fibrinolysis during
puerperium
-Following delivery , major changes occur in the coagulation &
fibrinolytic system.
-Rise in plasminogen activator activity which return to non
pregnant range within 30 min of delivery .
-Fibrinogen level & platelets count rise during early
puerperium.
-Anti- thrombin activity increase.
-Following the initial phase o f increased clotting factors in the
puerperium ,the coagulation & fibrinolytic system gradually
revert to normal within 6 weeks after delivery.

28. Coagulation changes in
pregnancy
 Bleeding during labour is dealt with effectively by
- increased production of coagulation
factors during pregnancy
- increased blood volume
- myometrial contraction

29. Classification of
coagulation disorders in
pregnancy

30. Congenital coagulopathies
 Von-willebrand disease
 Haemophilia A and B
 Antithrombin deficiency
Acquired coagulopathies-
 PIH
 Placental abruption
 Retained dead fetus
 Amniotic fluid embolus
 Liver diseases
 Anticoagulants: Aspirin and heparin

31. Platelet Abnormalities
1.QUANTITATIVE (not enough platelets)
-Gestational thrombocytopenia
-Idiopathic/Immunological thrombcytopenic
purpura
-HELLP syndrome
-DIC
2.QUALITATIVE DISORDERS (poor platelet
function)
3. Disorders predisposing to thrombosis
Antiphospholipid syndrome

32. Screening tests for hemostasis
TEST ASSESSMENT
TESTS OF PRIMARY HEMOSTASIS
Bleeding time Platelet and vascular phases
PFA-100 system Platelet function
Platelet count Quantitation of platelets
Blood smear 1.Quantitative and morphological
abnormalities of platelets
2.Detection of underlying haematological
disorder
TESTS OF SECONDARY HEMOSTASIS
Clotting time Crude test of coagulation phase
Prothrombin time Extrinsic and common pathways
Activated partial thromboplastin time Intrinsic and common pathways

33. BLEEDING TIME
PROVIDES ASSESSMENT OF PLATELET
COUNT AND FUNCTION
NORMAL VALUE
2-8 MINUTES

34. PLATELET COUNT
NORMAL 150,000 - 400,000 CELLS/MM3
< 100,000 Thrombocytopenia
50,000 - 100,000 Mild Thrombocytopenia
< 50,000 Severe Thrombocytopenia

35. INR
INR: International normalized ratio
- Established by the WHO and the International Committee on
Thrombosis and Haemostasis for reporting the results of
prothrombin tests
-All PT results are standardized by this calculation:
INR = ( Patient PT / Control PT) ISI
ISI= International sensitivity index
- Given by the manufacturer for each particular thromboplastin
reagent and instrument combination

36. ACTIVATED PARTIAL
THROMBOPLASTIN TIME
Measures Effectiveness
of the Intrinsic
pathway & common pathway
NORMAL VALUENORMAL VALUE
25-40 SECS25-40 SECS

37. APTT prolongs..
1.Intrinsic pathway factor deficiencies (FXII, XI,VIII, IX, HMWK,
prekallikrein )
- Inherited or acquired
- Consumption (DIC)
- PIVKA factors in cumarin therapy
2. Specific inhibitors against FXII, XI, VIII, IX, HMWK, prekallikrein
3. Lupus anticoagulant
4. Non-fractionated heparin therapy

38. THROMBIN TIME
Time for Thrombin To Convert
Fibrinogen Fibrin
A Measure of Fibrinolytic Pathway
NORMAL VALUENORMAL VALUE
9-13 SECS9-13 SECS

39. TT Prolongs..
1.Hypofibrinogenaemia
2. Dysfibrinogenaemia
3.Non fractionated heparin
4.Fibrinogen/ fibrin degradation products
5. Chronic liver disease

40. SPECIFIC TESTS
Tests for specific Platelet Functions
1. Platelet aggregation test
2. Flow cytometry
3. Test for platelet secretion
4. Clot retraction test
5. Platelet pro-coagulant activity
Test for Coagulation Phase
1. Quantitative estimation of Fibrinogen
2. Coagulation factor assays
3. F XIII Qualitative assay
Latex agglutination test for Fibrinolysis

41. Von Willebrand Disease

42. Von Willebrand Disease
 Symptomatic patients usually present with evidence
of a platelet defect
 Considered in women with bleeding suggestive of a
chronic disorder of coagulation.
 During normal pregnancy, maternal levels of both
factor VIII as well as vWF antigen increase
substantively .
 Because of this, pregnant women with vWD often
develop normal levels of factor VIII coagulant activity
as well as vWF antigen, Although the bleeding time
still may be prolonged.

43.  If factor VIII activity is very low or if there is
bleeding, treatment is recommended. Desmopressin
by infusion may transiently increase factor VIII and
vWF factor levels.
 Pregnancy outcomes in women with von Willebrand
disease are generally good, but postpartum
hemorrhage is encountered in up to 50 percent of
cases

44. HEMOPHILIAHEMOPHILIA

45.  Patients with hemophilia A or B, because of prior
treatment with factor VIII or IX, may develop antibodies
directed against factor VIII or IX and may lead to life-
threatening hemorrhage.
 Rarely in puerperium, women resent as severe,
protracted, repetitive hemorrhage from the reproductive
tract starting a week or so after an apparently
uncomplicated delivery
 The activated partial thromboplastin time is markedly
prolonged.
 Treatment has included multiple transfusions of whole
blood and plasma and clotting factors.

46. Hypo pro-thrombinemia
-This disorder is a deficiency in Prothrombin, or Factor II, a
glycoprotein formed and stored in the liver.
-Some patients may show no symptoms, and others will suffer
severe hemorrhage.
-Patients may experience easy bruising, profuse nose bleeds,
postpartum hemorrhage, excessively prolonged or heavy
menstrual bleeding, and post-surgical hemorrhage.
-Hypo pro-thrombinemia may also be acquired rather than
inherited, and usually results from a Vitamin K deficiency
caused by liver diseases, newborn hemorrhagic disease, or
a number of other factors.

47. Thrombocytopenia
Thrombocytopenia is a reduction in platelet number below
150000/ul
Causes:
1- Incidental thrombocytopenia of pregnancy
2- Increased consumption
3- Autoimmune thrombocytopenia (ITP)
4- SLE/APS
5-Activated clotting mechanism
- Pre-eclampsia
- HELP syndrome
- DIC
6-Thrombotic thrombocytopenic purpura
7-Decreased platelet production (marrow suppression)
-sepsis
-HIV
8- Malignant marrow infiltration

48. IDIOPATHIC
THROMBOCYTOPENIC PURPURA
-Idiopathic
thrombocytopenic
purpura (ITP) is a
common autoimmune
disorder in which
patients form
antiplatelet
autoantibodies against
platelet-specific
antigens
Payne and colleagues
(1997) studies of
maternal ITP showed
that 12 percent of
newborns of ITP
patients had severe
thrombocytopenia

49. -Major bleeding is rarely seen unless the platelet count is
<10x10/L
-Maternal antibodies may cross the placenta and affect the
fetus , causing neonatal thrombocytopenia.
-four to ten percent of neonates are at risk of having sever
thrombocytopenia at birth or during the 1st
week of life.

50. FEATURES SUGGESTIVE OF
THROMBOCYTOPENIA
 Platelet count < 100,000/mm3
 Increased numbers of megakaryocytes
 Increased platelet volume

51. THROMBOCYTOPENIC
COAGULOPATHIES TREATMENT
Conservative management
• Corticosteriods – if platelet count <20,000/mm3 before
the onset of labor or < 50,000/mm3 at time of deliver
• High dose IV immunoglobulin produces increase in platelet
count
• Significant hemorrhage – immediate postpartum period
platelet transfusion
• The theoretical risk of intracranial haemorrhage in the
thrombocytopenic foetus has not been shown to be reduced
by C/S therefore C/S should be performed for obstetric
reasons

52. HELLP SYNDROME
The acronym HELLP was coined by Weinstein in 1982 to
describe a syndrome consisting of Hemolysis, Elevated liver
enzymes and Low platelet count.
DEFINITION-
It is a syndrome that is characterized by hepatic endothelial
disruption followed by platelet activation, aggregation and
consumption, ultimately resulting in ischemia and hepatocyte
death.
The findings of this multisystem disease are attributed to-
Abnormal vascular tone
Vasospasm
Coagulation defects

53.  1) Classical histological lesion in LIVER
 2) Haemolysis
 3) Thrombocytopenia
 HELLP Syndrome - 0.2 to 0.6% of all pregnancies.
In a multicenter study conducted on women with
HELLP syndrome 40 percent had adverse outcomes
such as subcapsular liver hematoma
,eclampsia,placental abruption, acute kidney injury,
and pulmonary edema,stroke, coagulopathy, acute
respiratory distress syndrome, and sepsis.

54. Laboratory findings
Laboratory criteria for diagnosis —
1. Low platelets - < 100,000/µL
2. Elevated liver enzymes – AST > 70 IU/L
- LDH > 600 IU/L
3. Haemolysis – Abnormal peripheral smear
- Total bilirubin > 1.2mg%
 Leukocytosis
 Coagulation factors
 S. uric acid – raised
 Hypoglycemia-

55.  Peripheral smear shows-
Spherocytosis
Schizocytes
Reticulocytosis
Anisocytosis
Triangular cells
Helmet cells
Burr cells
Polychromasia HELLP syndrome - Schizocytes
(vertical arrows), spherocytes,
stomatocytes, and
spheroacanthocyte (oblique arrow)

56. MANAGEMENT
1) Immediate delivery - at or more than 34 weeks gestation.
2) Delivery within 48 hours after evaluation and stabilization of
the maternal clinical condition and Steroid treatment-27 to
34 weeks of gestation,
3) Expectant (conservative) management -before 27 weeks
gestation
Platelet transfusion
PCV and FFP
ROLE OF TRANSFUSION

57. DIC
 An acquired syndrome
characterized by
systemic
intravascular
coagulation
 Coagulation is always
the initial event
 DIC is the most
common maternal
complication with a
reported frequency
varying from 4-38%
SYSTEMIC ACTIVATION
OF COAGULATION
Intravascul
ar
deposition
of fibrin
Depletion of
platelets and
coagulation
factors
Thrombosis of
small and
midsize
vessels
Bleeding
Organ failure DEATHDEATH

59. Obstetric causes of DIC
Falls into three categories
 conditions associated with release of tissue
thromboplastin that activates extrinsic pathway
- placental abruption
- dead foetus
- molar pregnancy
 Conditions associated with endothelial damage
leading to activation of intrinsic & extrinsic pathways
- pre-eclampsia & eclampsia
 Conditions having non-specific or indirect action
- amniotic fluid embolism
- gram negative septicaemia
- saline abortion

60. Clinical manifestations of
DIC
 Those of the underlying cause
 Those due to Complications of DIC

61. Haemorrhagic
manifestations
Involving skin & mucus membranes
 Ecchymosis
 Petechiae
 Bleeding from the gum
 Haematuria
 GIT bleeding
 Venopunctur oozing
 Intracranial or intracerebral haemorrhage

62. Thrombotic manifestations
 Neurologic with multifocal lesions ,
delirium & coma
 Dermatologic with focal ischemia &
superficial gangrene
 Renal with cortical necrosis and uraemia
 GIT acute ulceration with bleeding
 Vascular occlusion causing pulmonary
infarction or peripheral vascular
gangrene

63. Lab results
 Markedly decreased platelet count
 Markedly Increased fibrin degradation products
FDP’s
 Fragmented RBCs & microspherocytes in
peripheral blood film
 Low fibrinogen , factor II , V & VII
 Prolonged PT, PTT & TT

64. Microscopic findings in DIC
 Fragments
 Schistocytes
 Paucity of platelets

65. ๓ ธันวาคม ๒๕๕๑ T. TATU 65
Fragmented RBC

66. Treatment of DIC
• Remove underlying cause
• Replenish depleted factors
• FFP Provides source of most factors
• Cryoprecipitate provides fibrinogen
• Platelet and blood support
• Cautious use of heparin

67. Thrombophilia :
Is defined as a predisposition to thrombosis, secondary to any
persistent or identifiable hypercoagulable state.
Although these disorders are collectively present in about 15
percent of population, they are responsible for more than 50
percent of all thromboembolic events during pregnancy
DVT alone - more common antepartum whereas
pulmonary embolism - more common in the first 6 weeks
postpartum.
It can be inherited or acquired:
It should also be considered, in patients who have recurrent
pregnancy loss, unexplained IUFD's and early severe IUGR.

68. Causes of thrombophilia
Inherited causes
1.Anti thrombin III deficiency:
-Anti thrombin III is a naturally occurring anticoagulant.
-It inactivate thrombin and factors IXa, Xa, XIa and XIIa.
-This is an autosomal-dominant condition.
-The clinical manifestation is thrombosis.
-The risk of thrombosis during pregnancy among antithrombin-
deficient women without a personal or family history is 3 to
7 percent, and it is 11 to 40 percent with such a history .
-It may be an acquired deficiency in patients who have DIC,
nephrotic syndrome, liver disease, pre-eclampsia, during
oral contraceptive use and during heparin therapy.

69. 2. Protein C deficiency
-is also autosomal dominant
-This is the next thrombophilia.
3-Protein S deficiency is also autosomal dominant.
4-Factor V Leiden mutation.
5.Prothrombin gene mutation.
Acquired causes of thrombophilia - most common is
Antiphospholipid syndrome

70. ANTIPHOSPHOLIPID SYNDROME
 The antibodies are directed against cardiolipin(s) or
against phospholipid-binding proteins such as B2-
glycoprotein
 Women with moderate-to-high levels of these
antibodies may have antiphospholipid syndrome,
which is defined by a number of clinical features such
as thromboembolism or recurrent early trimester
unexplained fetal deaths.
 It is found to be associated with 3.4% of early
pregnancy loss

71.  It is postulated that they may interfere with the
normal function of phospholipids or phospholipid-
binding proteins involved in coagulation regulation,
including prothrombin, protein C, annexin V, and
tissue factor. Many of these antibodies are directed
against b2-glycoprotein I, which may itself function
as a natural anticoagulant

72. CONCLUSION
 Blood coagulation is a major component of
haemostasis. Increased Coagulation factors
levels in pregnancy is meant to minimize blood
loss at time of delivery
 This haemostatic mechanism could fail risking
patient’s life
 Thrombocytopenic coagulation failure and DIC
syndrome are the most commonly seen in
obstetric practice
 Congenital causes of coagulation failure are
uncommon and usually already diagnosed prior
to pregnancy

73.  DIC syndrome is always secondary to an
underlying pathology
 If diagnosis of DIC is missed or appropriate
action is delayed it can cause serious
maternal morbidity or even death
 Platelet transfusion and coagulation factor
replacement or fresh blood transfusion are
the main stay of treatment besides other
supportive therapy
 Use of heparin is controversial .
Haematologist opinion should be sought
before it’s use.

74. References
 Robbins and Cotran 8th
edition
 Dacie and Lewis Practical Hematology 10th
edition
 Williams Obstetrics 23rd
edition
 Uptodate, emedicine
 Various Websites

75. Thank You

78. ITP
 it is certainly not unusual for women who have been
in clinical remission for several years to have
recurrent thrombocytopenia during pregnancy.
Although this may be from closer surveillance,
hyperestrogenemia has also been suggested as a
cause
 Platelet-associated IgG antibodies cross the placenta
and may cause thrombocytopenia in the fetus-
neonate
 Payne and colleagues (1997) studies of maternal ITP
showed that 12 percent of newborns had severe
thrombocytopenia