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[Consensus of Chinese experts on diagnosis and treatment of disseminated intravascular coagulation in obstetrics]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:624-627. [PMID: 37803834 PMCID: PMC10520225 DOI: 10.3760/cma.j.issn.0253-2727.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Indexed: 10/08/2023]
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Sun Q, Lu Y, Zhong J, Yang X, Zhong L, Zhang W, Weng Y, Xu Z, Zhai Y, Cao Z. A Retrospective Case-Control Study on the Diagnostic Values of Hemostatic Markers in Hypertensive Disorder of Pregnancy. Lab Med 2022:6820974. [DOI: 10.1093/labmed/lmac128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
The purpose of this study was to evaluate the diagnostic performance of the following hemostatic markers in hypertensive disorder of pregnancy (HDP): tissue-type plasminogen activator and inhibitor-1 complex (tPAI-C), thrombomodulin, thrombin-antithrombin complex, plasmin inhibitor-plasmin complex, D-dimer, and fibrinogen degradation products.
Methods
A total of 311 individuals diagnosed with HDP and 187 healthy controls (HC) of matched gestational age were admitted, including 175 subjects with gestational hypertension, 94 with mild preeclampsia, and 42 with severe preeclampsia.
Results
Compared with those of the HC group, the plasma concentrations of all the hemostatic markers continuously increased with the clinical severity of the hypertensive disorder, regardless of their statistical significance. In the receiver operating characteristic analysis, tPAI-C displayed the best discrimination performance.
Conclusion
The tPAI-C level was consistently and significantly elevated across the different HDP groups when compared with the HC group, suggesting aggravated fibrinolysis disorder increasing with the severity of the HDP.
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Affiliation(s)
- Qiujin Sun
- Department of Clinical Laboratory, Beijing Chaoyang District Maternal and Child Health Care Hospital , Beijing , China
| | - Yifan Lu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital , Beijing , China
| | - Junhui Zhong
- Peking University School of Public Health , Beijing , China
| | - Xianchun Yang
- Department of Clinical Laboratory, Beijing Chaoyang District Maternal and Child Health Care Hospital , Beijing , China
| | - Lu Zhong
- Department of Clinical Laboratory, Beijing Chaoyang District Maternal and Child Health Care Hospital , Beijing , China
| | - Wenwen Zhang
- Department of Clinical Laboratory, Beijing Chaoyang District Maternal and Child Health Care Hospital , Beijing , China
| | - Yanhua Weng
- Department of Clinical Laboratory, Beijing Chaoyang District Maternal and Child Health Care Hospital , Beijing , China
| | - Zhengwen Xu
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital , Beijing , China
| | - Yanhong Zhai
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital , Beijing , China
| | - Zheng Cao
- Department of Laboratory Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital , Beijing , China
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Yang H, Li J, Liu S, Zhang M, Liu J. An interpretable DIC risk prediction model based on convolutional neural networks with time series data. BMC Bioinformatics 2022; 23:471. [PMID: 36348301 PMCID: PMC9644626 DOI: 10.1186/s12859-022-05004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a complex, life-threatening syndrome associated with the end-stage of different coagulation disorders. Early prediction of the risk of DIC development is an urgent clinical need to reduce adverse outcomes. However, effective approaches and models to identify early DIC are still lacking. In this study, a novel interpretable deep learning based time series is used to predict the risk of DIC. The study cohort included ICU patients from a 4300-bed academic hospital between January 1, 2019, and January 1, 2022. Experimental results show that our model achieves excellent performance (AUC: 0.986, Accuracy: 95.7%, and F1:0.935). Gradient-weighted Class Activation Mapping (Grad-CAM) was used to explain how predictive models identified patients with DIC. The decision basis of the model was displayed in the form of a heat map. The model can be used to identify high-risk patients with DIC early, which will help in the early intervention of DIC patients and improve the treatment effect.
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Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med 2022; 13:21-44. [PMID: 35023983 PMCID: PMC8747805 DOI: 10.2147/jbm.s273047] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/15/2021] [Indexed: 01/04/2023] Open
Abstract
Obstetrical hemorrhage and especially DIC (disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty liver of pregnancy. Various obstetrical disorders can present with DIC as a complication; thus, increased awareness is key to diagnosing the condition. DIC patients can present to clinicians who may not be experienced in a variety of aspects of thrombosis and hemostasis. Hence, DIC diagnosis is often only entertained when the patient already developed uncontrollable bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thrombocytopenia, low fibrinogen, and raised D-dimers. Diagnosis of DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific DIC score including three components: 1) fibrinogen concentrations; 2) the PT difference - relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥26 points, the pregnancy specific DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the hemostatic problem that can be guided by point of care testing adjusted for pregnancy.
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Affiliation(s)
- Offer Erez
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women’s Hospital, Wayne State University, Detroit, MI, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Leron
- Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Francesca Gotsch
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata, AOUI Verona, University of Verona, Verona, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Alhousseini A, Romero R, Benshalom-Tirosh N, Gudicha D, Pacora P, Tirosh D, Kabiri D, Yeo L, Thachil J, Hsu CD, Hassan SS, Erez O. Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion. J Matern Fetal Neonatal Med 2022; 35:242-257. [PMID: 31931643 PMCID: PMC9019739 DOI: 10.1080/14767058.2020.1716330] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy. OBJECTIVES (1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score. STUDY DESIGN This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion. RESULTS (1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion. CONCLUSION We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.
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Affiliation(s)
- Ali Alhousseini
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA,Detroit Medical Center, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Miami International University, Miami, Florida, USA
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dereje Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dan Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Maternity Department “D,” Division of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Su J, Yang Y, Cao Y, Yin Z. The predictive value of pre-delivery laboratory test results for the severity of placental abruption and pregnancy outcome. Placenta 2020; 103:220-225. [PMID: 33166877 DOI: 10.1016/j.placenta.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 09/15/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To analyze the relationship between placental abruption severity and maternal pregnancy outcome and to explore the predictive value of pre-delivery laboratory test results for the severity of placental abruption. METHODS The clinical datas of 126 patients with placental abruption diagnosed and treated in our hospital over the past 4 years were retrospectively analyzed. The severity of placental abruption was divided into degrees I to III. The pre-delivery laboratory results of all patients and data on maternal and fetal delivery outcomes were collected. RESULTS The analysis of maternal outcomes showed that the volumes of antepartum, intrapartum and postpartum hemorrhage and the rates of utero-placental apoplexy, uterine compression sutures and vascular embolization significantly increased with increasing placental abruption severity. Fetal delivery data revealed that 1- and 5-min Apgar scores decreased significantly with increasing placental abruption severity. Pre-delivery laboratory findings suggest that the white blood cell count, hemoglobin, hematocrit, platelet count, albumin, aspartate aminotransferase (AST), creatinine, prothrombin time (PT), prothrombin activity, prothrombin time - international standardization ratio (INR), D-dimer, fibrinogen (FIB), and fibrin degradation products (FDP) changed significantly with increasing placental abruption severity. Further analysis by Spearman and Pearson correlation found that the pre-delivery volume of antepartum hemorrhage, D-dimer, FDP and other indicators were correlated with placental abruption severity. CONCLUSIONS The harm of placental abruption to pregnant women and neonates increases with increasing abruption severity. Some laboratory test results can be predictors of placental abruption degree.
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Affiliation(s)
- Jingjing Su
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China; NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract (Anhui Medical University), Hefei, China
| | - Yuanyuan Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China; NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract (Anhui Medical University), Hefei, China; Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - Yunxia Cao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China; Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China; NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract (Anhui Medical University), Hefei, China; Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, Hefei, China; Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China.
| | - Zongzhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China; NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract (Anhui Medical University), Hefei, China; Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China.
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Gomez-Tolub R, Rabinovich A, Kachko E, Benshalom-Tirosh N, Tirosh D, Thachil J, Besser L, Than NG, Erez O. Placental abruption as a trigger of DIC in women with HELLP syndrome: a population-based study. J Matern Fetal Neonatal Med 2020; 35:3259-3269. [PMID: 32933344 DOI: 10.1080/14767058.2020.1818200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Disseminated Intravascular Coagulation (DIC) is a life-threatening condition. Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome is one of the obstetrical syndromes mostly associated with DIC and thus, high rates of fatal complications. There is a lack of information regarding epidemiologic and clinical characteristics of women who developed HELLP syndrome with and without DIC. Additionally, until now, there is no adapted and widely accepted way to diagnose DIC among pregnant women presenting with HELLP syndrome, despite the evident maternal mortality linked to the disease. Objectives: (1) Address the gaps in knowledge regarding the prevalence, epidemiologic and clinical characteristics of women with HELLP syndrome who develop DIC; and (2) determine the risk factors for the development of DIC among women with HELLP syndrome. STUDY DESIGN This was a population-based retrospective cohort study, including all women who delivered at the Soroka University Medical Center between the years 2001-2017. The study population was divided into three groups: (1) comparison group (n = 207,266 deliveries); (2) HELLP syndrome without DIC (n = 320); (3) HELLP syndrome with DIC (n = 21). The diagnosis of DIC was based on the ICD-9 code as recorded in the obstetrical database of the Soroka University Medical Center. The coding is based on the diagnosis made by the attending physician during hospitalization. RESULTS (1) The rate of HELLP syndrome in the study population was 0.16% (341/207,607), of them 6.16% (21/341) had DIC; (2) among patients with HELLP syndrome, those with DIC had a higher median gravidity and parity; (3) a higher rate of severe maternal morbidity including blood product transfusion, placental abruption, eclampsia, acute renal failure and maternal death was observed in those who had HELLP syndrome and DIC compared to those with HELLP syndrome without DIC and the comparison group (p-value <.001 for comparison among the three groups); (4) among women with HELLP syndrome, those with DIC had a longer median PT difference, higher serum creatinine and lower AST as well as ALT median concentrations than those without DIC; (5) patients with HELLP syndrome and DIC had a higher rate of stillbirth and postpartum death than patients in the other groups (p-value <.001 for comparison among the three groups); and (6) placental abruption was an independent risk factor for the development of DIC in women with HELLP syndrome (p-value <.001). CONCLUSIONS (1) Among women with HELLP syndrome, those who developed DIC had a higher rate of maternal and neonatal morbidity and mortality than those without DIC; and (2) placental abruption, but not abnormal liver function, was an independent risk factor for the development of DIC in women with HELLP syndrome.
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Affiliation(s)
- Rachel Gomez-Tolub
- Faculty of Health Sciences, School of Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eric Kachko
- Center of Clinical Research, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Neta Benshalom-Tirosh
- Department of Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Tirosh
- Department of Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Limor Besser
- Department of Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nandor Gabor Than
- Systems Biology of Reproduction Lendulet Research Group, Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Maternity Clinic, Budapest, Hungary
| | - Offer Erez
- Division of Obstetrics and Gynecology, Maternity Department "D" and Obstetrical Day Care Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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9
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Levi M. Relevance and diagnosis of disseminated intravascular coagulation associated with cardiovascular disease. Eur J Intern Med 2020; 79:27-28. [PMID: 32768159 DOI: 10.1016/j.ejim.2020.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Marcel Levi
- University College London Hospitals NHS Foundation Trust, Department of Medicine (1) and Cardiometabolic Programme-NIHR UCLH/UCL BRC (2), London, UK.
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10
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Amniotic fluid embolism-associated coagulopathy: a single-center observational study. Arch Gynecol Obstet 2020; 301:923-929. [PMID: 32157417 DOI: 10.1007/s00404-020-05466-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Amniotic fluid embolism (AFE) continues to be a rare, enigmatic condition with high maternal mortality. It is characterized by cardiovascular compromise, loss of consciousness or other neurologic symptoms, and coagulopathy. The latter is usually treated according to existing protocols for consumptive coagulopathy. METHODS Serial analyses of a panel of hemostaseological parameters were performed in three consecutive cases of AFE that occurred at our institution. RESULTS All mothers and neonates survived without major sequelae. Disproportionately low levels of fibrinogen and factor five, and exorbitantly elevated D-dimers were present in all cases, whereas markers of consumptive coagulopathy, platelets and antithrombin in particular, were only slightly reduced. DISCUSSION Our results support hyperfibrinolysis as contributing factor of AFE-associated coagulopathy. We, therefore, propose a treatment algorithm which includes early use of tranexamic acid and transfusion of red blood cells and fresh frozen plasma, adding fibrinogen if hemostasis is not readily achieved.
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Wu HD, Song ZK, Cao HY, Xu XY, Tang ML, Yang S, Liu Y, Qin L. Successful treatment of amniotic fluid embolism complicated by disseminated intravascular coagulation with rivaroxaban: A case report. Medicine (Baltimore) 2020; 99:e18951. [PMID: 31977912 PMCID: PMC7004698 DOI: 10.1097/md.0000000000018951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
RATIONALE An amniotic fluid embolism (AFE) is a rare, lethal syndrome that is commonly associated with disseminated intravascular coagulation (DIC). Anticoagulation therapy is the most important strategy to inhibit excessive activation of the coagulation cascade in patients with AFE and DIC. At present, treatment of AFE with rivaroxaban has not been reported. PATIENT CONCERNS We report a 37-year-old woman (gravida 2, para 1) at 39 weeks' gestation with irregular contractions of the uterus was admitted to the obstetrical department. Ten minutes after the spontaneous rupture of the membranes, the patient complained of dyspnea and dysphoria and exhibited cyanosis of her lips. The patient's blood pressure decreased and heart rate increased rapidly, and 2100 mL of unclotted blood flowed from her vagina within 1 hour. Her platelet count dropped to 21 × 10/L, and the results from routine coagulation tests, and D-dimer and fibrin degradation product tests were obviously abnormal. DIAGNOSES According to the current research consensus, AFE with DIC should be considered immediately when sudden cardiovascular collapse occurs around the time of labor and delivery, followed by the development of coagulopathy and hemorrhage. INTERVENTIONS In addition, the variety of supportive treatments, rivaroxaban was used in anticoagulant therapy. OUTCOMES At follow-up 30 and 60 days, there were no complaints of discomfort or abnormal laboratory assays. The patient recovered completely. LESSONS This case highlights that rivaroxaban, as a direct inhibitor of activated factor Xa, demonstrates a good therapeutic efficacy for treating AFE with DIC.
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Miyagi Y, Tada K, Yasuhi I, Maekawa Y, Okura N, Kawakami K, Yamaguchi K, Ogawa M, Kodama T, Nomiyama M, Mizunoe T, Miyake T. New method for determining fibrinogen and FDP threshold criteria by artificial intelligence in cases of massive hemorrhage during delivery. J Obstet Gynaecol Res 2019; 46:256-265. [PMID: 31762151 DOI: 10.1111/jog.14166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/10/2019] [Indexed: 02/06/2023]
Abstract
AIM To investigate the feasibility of a novel method using artificial intelligence (AI), in which the fibrinogen criterion was determined by the quantitative relation between the distributions of fibrin/fibrinogen degradation products (FDPs) and fibrinogen. METHODS A dataset of 154 deliveries comprising more than 2000 g of blood lost due to hemorrhage, excluding disseminated intravascular coagulation (DIC), among patients from eight national perinatal centers in Japan from 2011 to 2015 were obtained. The fibrinogen threshold criterion was identified by using the function that best fit the distributions of FDP as determined by AI. FDP production was described by differential equations using a dataset containing fibrinogen levels less than the fibrinogen criterion and solved numerically. RESULTS A fibrinogen level of 237 mg/dL as the threshold criterion was obtained. The FDP threshold criteria were 2.0 and 8.5 mg/dL for no coagulopathy and a failed coagulation system, respectively. CONCLUSION The fibrinogen threshold criterion for patients with massive hemorrhage excluding DIC at delivery were obtained by selecting the functions that best fit the distributions of FDP data by using AI.
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Affiliation(s)
- Yasunari Miyagi
- Medical Data Labo, Okayama, Japan.,Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama, Japan.,Miyake Ofuku Clinic, Okayama, Japan
| | - Katsuhiko Tada
- Department of Obstetrics and Gynecology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Ichiro Yasuhi
- Department of Obstetrics and Gynecology, National Hospital Organization Nagasaki Medical Center, Omura, Japan
| | - Yuka Maekawa
- Department of Obstetrics and Gynecology, National Hospital Organization Mie Chuo Medical Center, Tsu, Japan
| | - Naofumi Okura
- Department of Obstetrics and Gynecology, National Hospital Organization Kokura Medical Center, Kitakyushu, Japan
| | - Kosuke Kawakami
- Department of Obstetrics and Gynecology, National Hospital Organization Kokura Medical Center, Kitakyushu, Japan
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masanobu Ogawa
- Research Center for Environment and Developmental Medical Sciences, Kyusyu University, Fukuoka, Japan.,Department of Obstetrics and Gynecology/Clinical Research Institute, National Hospital Organization Kyusyu Medical Center, Fukuoka, Japan
| | - Takashi Kodama
- Department of Obstetrics and Gynecology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization Saga National Hospital, Saga, Japan
| | - Tomoya Mizunoe
- Department of Obstetrics and Gynecology, National Hospital Organization Kure Medical Center, Kure, Japan
| | - Takahito Miyake
- Department of Obstetrics and Gynecology, Miyake Clinic, Okayama, Japan
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Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017; 119:411-421. [DOI: 10.1093/bja/aex181] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/25/2022] Open
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14
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Collins P, Cannings-John R, Bruynseels D, Mallaiah S, Dick J, Elton C, Weeks A, Sanders J, Aawar N, Townson J, Hood K, Hall J, Harding K, Gauntlett R, Collis R. Viscoelastometry guided fresh frozen plasma infusion for postpartum haemorrhage: OBS2, an observational study. Br J Anaesth 2017; 119:422-434. [DOI: 10.1093/bja/aex245] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/22/2022] Open
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15
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Disseminated intravascular coagulation in pregnancy – Clinical phenotypes and diagnostic scores. Thromb Res 2017; 151 Suppl 1:S56-S60. [DOI: 10.1016/s0049-3848(17)30069-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Riddell A, Chuansumrit A, El-Ekiaby M, Nair SC. Diagnostic laboratory for bleeding disorders ensures efficient management of haemorrhagic disorders. Haemophilia 2017; 22 Suppl 5:90-5. [PMID: 27405683 DOI: 10.1111/hae.12988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
Abstract
Haemorrhagic disorders like Postpartum haemorrhage and Dengue haemorrhagic fever are life threatening and requires an active and efficient transfusion service that could provide the most appropriate blood product which could be effective in managing them. This would essentially require prompt identification of the coagulopathy so that the best available product can be given to the bleeding patient to correct the identified haemostatic defect which will help control the bleeding. This would only be possible if the transfusion service has a laboratory to correctly detect the haemostatic defect and that too with an accuracy and precision which is ensured by a good laboratory quality assurance practices. These same processes are necessary for the transfusion services to ensure the quality of the blood products manufactured by them and that it contains adequate amounts of haemostasis factors which will be good to be effective in the management of haemorrhagic disorders. These issues are discussed in detail individually in the management of postpartum haemorrhage and Dengue haemorrhagic fever including when these can help in the use of rFVIIa in Dengue haemorrhagic fever. The requirements to ensure good-quality blood products are made available for the management of these disorders and the same have also been described.
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Affiliation(s)
- A Riddell
- KD Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - A Chuansumrit
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - M El-Ekiaby
- Shabrawishi Blood Bank, Shabrawishi Hospital, Cairo, Egypt
| | - S C Nair
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India
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18
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19
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Sonoclot coagulation analysis: a useful tool to predict mortality in overt disseminated intravascular coagulation. Blood Coagul Fibrinolysis 2016; 27:77-83. [PMID: 26703984 DOI: 10.1097/mbc.0000000000000345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Disseminated intravascular coagulation (DIC) contributes to high mortality. The study was performed to investigate Sonoclot as a potential predictor of 30-day survival in overt DIC. This cohort included 237 consecutive critically ill patients with overt DIC, admitted to a 15-bed multidisciplinary ICU between July 2010 and July 2013. Hemostasis was analyzed with Sonoclot, including activated clotting time (ACT), clot rate, and platelet function, as well as routine clotting test at admission to the critical care center. Sonoclot variables differed in survivors and nonsurvivors. Mean ACT was prolonged (289.9 ± 200.5 vs. 194.8 ± 126.6 s; P < 0.001) and platelet function (1.2 ± 0.9 vs. 1.6 ± 1.2; P = 0.010) was reduced in nonsurvivors. The clot rate was not different. Cox proportional-hazard model showed that ACT and platelet function correlated independently with survival (P < 0.05). Kaplan-Meier survival curve analysis suggested that patients with one pathological Sonoclot findings have better outcome (P < 0.05). After ACT and platelet function were introduced, the receiver-operating characteristic area under the curve of model achieved 0.876 (P < 0.05), with a specificity of 82.6% and a sensitivity of 80.5% in prediction of 30-day survival by multivariate analyses. Our data suggest that the Sonoclot can predict mortality in critically ill patients with overt DIC.
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Abstract
Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation that can be caused by infectious insults (such as sepsis) and non-infectious insults (such as trauma). The main pathophysiological mechanisms of DIC are inflammatory cytokine-initiated activation of tissue factor-dependent coagulation, insufficient control of anticoagulant pathways and plasminogen activator inhibitor 1-mediated suppression of fibrinolysis. Together, these changes give rise to endothelial dysfunction and microvascular thrombosis, which can cause organ dysfunction and seriously affect patient prognosis. Recent observations have pointed to an important role for extracellular DNA and DNA-binding proteins, such as histones, in the pathogenesis of DIC. The International Society on Thrombosis and Haemostasis (ISTH) established a DIC diagnostic scoring system consisting of global haemostatic test parameters. This scoring system has now been well validated in diverse clinical settings. The theoretical cornerstone of DIC management is the specific and vigorous treatment of the underlying conditions, and DIC should be simultaneously managed to improve patient outcomes. The ISTH guidance for the treatment of DIC recommends treatment strategies that are based on current evidence. In this Primer, we provide an updated overview of the pathophysiology, diagnosis and management of DIC and discuss the future directions of basic and clinical research in this field.
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Jones RM, de Lloyd L, Kealaher EJ, Lilley GJ, Precious E, Burckett st Laurent D, Hamlyn V, Collis RE, Collins PW. Platelet count and transfusion requirements during moderate or severe postpartum haemorrhage. Anaesthesia 2016; 71:648-56. [DOI: 10.1111/anae.13448] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R. M. Jones
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - L. de Lloyd
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. J. Kealaher
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - G. J. Lilley
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. Precious
- Institute of Infection and Immunity; School of Medicine; Cardiff University; Cardiff UK
| | - D. Burckett st Laurent
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - V. Hamlyn
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - R. E. Collis
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - P. W. Collins
- Institute of Infection and Immunity; School of Medicine; Cardiff University; Cardiff UK
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Collins P, Abdul-Kadir R, Thachil J. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. J Thromb Haemost 2016; 14:205-10. [PMID: 27028301 DOI: 10.1111/jth.13174] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/11/2015] [Indexed: 08/31/2023]
Affiliation(s)
- P Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - R Abdul-Kadir
- The Royal Free Foundation Hospital, University College London, London, UK
| | - J Thachil
- Haemostasis and Thrombosis Unit, Manchester Royal Infirmary, Manchester, UK
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23
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Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol 2015; 213:452-63. [PMID: 25840271 DOI: 10.1016/j.ajog.2015.03.054] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/26/2015] [Accepted: 03/29/2015] [Indexed: 01/04/2023]
Abstract
Disseminated intravascular coagulation (DIC) is a life-threatening situation that can arise from a variety of obstetrical and nonobstetrical causes. Obstetrical DIC has been associated with a series of pregnancy complications including the following: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count syndrome; (4) retained stillbirth; (5) septic abortion and intrauterine infection; (6) amniotic fluid embolism; and (7) acute fatty liver of pregnancy. Prompt diagnosis and understanding of the underlying mechanisms of disease leading to this complication in essential for a favorable outcome. In recent years, novel diagnostic scores and treatment modalities along with bedside point-of-care tests were developed and may assist the clinician in the diagnosis and management of DIC. Team work and prompt treatment are essential for the successful management of patients with DIC.
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Takahashi N, Nishijima K, Orisaka M, Tsuyoshi H, Kurokawa T, Kato K, Shirafuji A, Arakawa K, Hisazaki K, Tada H, Yoshida Y. Amniotic Fluid Embolism Triggered By Hypertensive Crisis Due to Undiagnosed Pheochromocytoma in a Pregnant Subject With Neurofibromatosis Type 1. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14108.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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26
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Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage. Anaesthesia 2014; 70 Suppl 1:78-86, e27-8. [DOI: 10.1111/anae.12913] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/26/2022]
Affiliation(s)
- R. E. Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine; Cardiff and Vale University Health Board; Cardiff UK
| | - P. W. Collins
- Institute of Infection and Immunity; Critical Illness Research Group; Cardiff University School of Medicine; Cardiff UK
- Department of Haematology; Cardiff and Vale University Health Board; Cardiff UK
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27
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DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One 2014; 9:e93240. [PMID: 24728139 PMCID: PMC3984105 DOI: 10.1371/journal.pone.0093240] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/04/2014] [Indexed: 01/26/2023] Open
Abstract
Objectives The objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC. Material and Methods This is a population based retrospective study, including all women who gave birth at the ‘Soroka University Medical Center’ during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses. Results 1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(−) of 0.125 for the diagnosis of DIC. Conclusion We could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC.
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