DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score

Effectiveness, reliability, and validity of new Japanese diagnostic criteria for obstetrical disseminated intravascular coagulation

Since July 2022, obstetrical disseminated intravascular coagulation (DIC) in Japan has been diagnosed based on the new criteria (tentative version), which assesses the main underlying disease, fibrinogen level, and fibrin/fibrinogen degradation products or D-dimer level. In June 2024, the tentative version underwent minor revision and the final version was released. The previous Japanese criteria assessed underlying disease, clinical symptoms, and various laboratory findings. This study aimed to prove the effectiveness, reliability, and validity of the new criteria (final version). We analyzed 212 women with singleton pregnancies who delivered after 22 gestational weeks and experienced blood loss ≥ 1000 mL during vaginal delivery or ≥ 2000 mL during cesarean section. Those with missing laboratory findings before receiving blood transfusion at delivery were excluded. In the obstetrical DIC group, the frequency of fibrinogen levels < 150 mg/dL was significantly higher than in the control group (90% vs. 5%, p < 0.0001), as was the frequency of scores ≥ 8 according to the previous Japanese criteria (100% vs. 10%, p < 0.0001). Cronbach alpha was 0.757 and Spearman's rank-order correlation was 0.558 between the new and previous criteria. In conclusion, we proved the effectiveness, reliability, and validity of the Japanese new criteria (final version) to diagnose obstetrical DIC.

A novel predictive marker for placental abruption with composite adverse outcomes: creatinine-fibrinogen ratio

PURPOSE

To develop a new cost-effective marker named creatinine-fibrinogen ratio (CFR) for the prediction of composite adverse outcomes (CAO) in placental abruption cases.

METHODS

A total of 109 placental abruption patients (30 with adverse outcomes, 79 without adverse outcomes) were enrolled in this retrospective cohort study. Patients with at least one of the features listed below were included in the abruption with CAO group: requirement of blood product transfusion (erythrocyte suspension, fresh frozen plasma, pooled thrombocyte, thrombocyte apheresis), development of acute kidney injury or disseminated intravascular coagulation, and need for intensive care unit. Laboratory parameters and CFR values at admission to the hospital were compared between the two groups.

RESULTS

Higher creatinine and lower fibrinogen levels were found in the CAO group (p = 0.007 and p < 0.001 respectively). The CFR value of the CAO group was significantly higher (p < 0.001). In the ROC curve analysis performed to investigate the value of CFR in CAO prediction, the area under the curve (AUC) was calculated as 0,802 (95% CI 0.709-0.895, 77% sensitivity, 65% specificity).

CONCLUSION

CFR seems to be a practical marker for the prediction of CAOs in pregnant women with ablatio placenta.

The influence of hematological profiles on the transfusion management and mortality risk of mothers presenting to the obstetric unit of a South African tertiary medical facility

BACKGROUND

Laboratory results are frequently abnormal in pregnant mothers. Abnormalities usually relate to pregnancy or associated complications. Hematological abnormalities and age in pregnancy may increase the likelihood for transfusion and mortality.

STUDY DESIGN AND METHODS

Hematological profiles and transfusion history of pregnant mothers presenting to a tertiary hospital, were evaluated over 2 years. Age, anemia, leukocytosis and thrombocytopenia were assessed for transfusion likelihood. Iron deficiency and coagulation were assessed in transfused patients. Anemia, leukocytosis, thrombocytopenia, human immunodeficiency virus (HIV) and transfusion were assessed for mortality likelihood.

RESULTS

There were 12,889 pregnant mothers included. Mothers <19-years-old had the highest prevalence of anemia (31.5%) and proportion of transfusions (19%). The transfusion likelihood was increased in mothers with anemia (odds ratios [OR] = 6.41; confidence intervals at 95% [95% CI] 5.46-7.71), leukocytosis (OR = 2.35; 95% CI 2.00-2.76) or thrombocytopenia (OR = 2.71; 95% CI 2.21-3.33). Mothers with prolonged prothrombin times received twice as many blood products as their normal counterparts (p = .03) and those with iron deficiency anemia five times more blood products (p < .001). Increased likelihood for mortality was seen in patients with anemia (OR = 4.15, 95% CI 2.03-8.49), leukocytosis (OR = 2.68; 95% CI 1.19-6.04) and those receiving blood transfusion (OR = 3.6, 95% CI 1.75-7.47).

DISCUSSION

Adolescence, anemia, leukocytosis and thrombocytopenia expose mothers to a high risk for transfusion and/or mortality. These risk factors should promptly trigger management and referral of patients. Presenting hematological profiles are strong predictors of maternal outcome and transfusion risk.

Prognostic Role of Initial Thromboelastography in Emergency Department Patients with Primary Postpartum Hemorrhage: Association with Massive Transfusion

BACKGROUND

The early prediction of the need for massive transfusions (MTs) and the preparation of blood products are essential for managing patients with primary postpartum hemorrhage (PPH). Thromboelastography (TEG) enables a thorough evaluation of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. We investigated the role of TEG in predicting the need for MT in patients with primary PPH.

METHODS

A retrospective observational study was conducted in the emergency department (ED) of a university-affiliated, tertiary referral center between November 2015 and August 2023. TEG was performed upon admission. We defined MT as the requirement for transfusion of more than 10 units of packed red blood cells within the first 24 h. The primary outcome was the need for MT.

RESULTS

Among the 184 patients with initial TEG, 34 (18.5%) required MT. Except for lysis after 30 min, the MT and non-MT groups had significantly different TEG values. Based on multivariate analysis, an angle < 60 was an independent predictor of MT (odds ratio (OR) 7.769; 95% confidence interval (CI), 2.736-22.062), along with lactate (OR, 1.674; 95% CI, 1.218-2.300) and shock index > 0.9 (OR, 4.638; 95% CI, 1.784-12.056). Alpha angle < 60 degrees indicated the need for MT with 73.5% sensitivity, 72.0% specificity, and 92.3% negative predictive value.

CONCLUSIONS

Point-of-care testing of TEG has the potential to be a useful tool in accurately predicting the necessity for MT in ED patients with primary PPH at an early stage.

Report of the ISTH registry on pregnancy and COVID-19-associated coagulopathy (COV-PREG-COAG)

Background

Concerns about COVID-19-associated coagulopathy (CAC) in pregnant individuals were raised in early pandemic.

Methods

An ISTH-sponsored COVID-19 coagulopathy in pregnancy (COV-PREG-COAG) international registry was developed to describe incidence of coagulopathy, VTE, and anticoagulation in this group.

Results

All pregnant patients with COVID-19 from participating centers were entered, providing 430 pregnancies for the first pandemic wave. Isolated abnormal coagulation parameters were seen in 20%; more often with moderate/severe disease than asymptomatic/mild disease (49% vs 15%; p < 0.0001). No one met the ISTH criteria for disseminated intravascular coagulopathy (DIC), though 5/21 (24%) met the pregnancy DIC score. There was no difference in antepartum hemorrhage (APH) with asymptomatic/mild disease versus moderate/severe disease (3.4% vs 7.7%; p = 0.135). More individuals with moderate/severe disease experienced postpartum hemorrhage (PPH) (22.4% vs 9.3%; p = 0.006). There were no arterial thrombotic events. Only one COVID-associated venous thromboembolism (VTE) was reported.

Conclusions

Low rates of coagulopathy, bleeding, and thrombosis were observed among pregnant people in the first pandemic wave.

Differences between Japanese new criteria and pregnancy-specific modified ISTH DIC scores for obstetrical DIC diagnosis

The new Japanese diagnostic criteria for obstetrical disseminated intravascular coagulation (DIC) (tentative version) were released in June 2022. We aimed to demonstrate the differences in characteristics between women with DIC diagnosed using the new Japanese criteria and those diagnosed using the pregnancy-specific modified International Society on Thrombosis and Hemostasis DIC score, also known as the pregnancy-specific modified ISTH DIC score, which was released in 2014. In this retrospective cohort study, all participants were retrospectively diagnosed based on both criteria. Six women were diagnosed with obstetrical DIC based on both criteria (Group A). Of the 43 women diagnosed with obstetrical DIC based on the worldwide criteria, 36 were diagnosed with non-obstetrical DIC based on the new Japanese criteria (Group B). Group A had significantly lower fibrinogen levels and significantly higher prothrombin time differences and scores of underlying diseases (particularly postpartum hemorrhage with coagulopathy) and laboratory findings than Group B. Additionally, Group A had significantly higher rates of platelet concentrate (PC) transfusion therapy for obstetrical DIC and more transfusions of fresh frozen plasma and/or cryoprecipitate, red blood cells and PC than Group B. Thus, the new Japanese criteria detected more severe cases of obstetrical DIC compared with the worldwide criteria.

Investigating gastrointestinal disorders in pregnancy

This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.

Comparative analysis of hyperfibrinolysis with activated coagulation between amniotic fluid embolism and severe placental abruption

Amniotic fluid embolism (AFE) and placental abruption (PA) are typical obstetric diseases associated with disseminated intravascular coagulation (DIC). AFE is more likely to be complicated with enhanced fibrinolysis than PA. AFE may have an additional mechanism activating fibrinolytic cascade. We aimed to compare the coagulation/fibrinolysis factors among AFE, PA, and peripartum controls. We assessed AFE cases registered in the Japanese AFE Registry, and PA cases complicated with DIC (severe PA) and peripartum controls recruited at our hospital. The following factors in plasma were compared: prothrombin fragment 1 + 2 (PF1 + 2), plasmin α2-plasmin inhibitor complex (PIC), tissue factor (TF), tissue plasminogen activator (tPA), annexin A2 (AnnA2), total thrombin activatable fibrinolysis inhibitor (TAFI) including its activated form (TAFIa), and plasminogen activator inhibitor-type 1 (PAI-1). PF1 + 2 and PIC were markedly increased in both AFE (n = 27) and severe PA (n = 12) compared to controls (n = 23), without significant difference between those disease groups; however, PIC in AFE showed a tendency to elevate relative to PF1 + 2, compared with severe PA. AFE had significantly increased tPA and decreased total TAFI levels compared with severe PA and controls, which might be associated with further plasmin production in AFE and underlie its specific fibrinolytic activation pathway.

Hematologic characteristics and coagulopathy in pregnancy with COVID-19 succeeding the first wave: a multicenter retrospective cross-sectional study

Background

Early reports have demonstrated an association of COVID-19 infection during pregnancy and postpartum period with coagulopathy and bleeding complications and indicated that pregnant people with COVID-19 are more likely to experience coagulopathy and venous thromboembolism. A recent report concerning such complications during the first wave of the pandemic was reassuring; however, no publications have evaluated these issues in the context of increased illness severity with the emergence of SARS-CoV-2 variants of concern.

Objectives

We performed a retrospective, multinational cohort study in Canada, Romania, and the United Kingdom, aiming to provide a comprehensive analysis of the hematologic test characteristics of pregnancies affected by COVID-19 after the first wave of the pandemic.

Results

Three-hundred-seventy patients were evaluated. Markers of inflammation and endothelial dysfunction were significantly elevated, in keeping with observations in the nonpregnant population. Reassuringly, despite more severe disease noted in succeeding waves of the pandemic, there was no significant evidence of COVID-19-associated coagulopathy, and overall, no association was demonstrated between isolated coagulation abnormalities and bleeding risk. Notably, fibrinogen below 2g/L was again linked with the risk of postpartum hemorrhage. Finally, venous thromboembolism risk was low but noted more frequently in those with severe illness despite thromboprophylaxis.

Conclusion

Our findings add valuable insights into the nature of hematologic test characteristics, bleeding, and thrombotic complications for those affected with COVID-19 in pregnancy, reassuring readers of the low incidence of bleeding and thrombotic complications but inviting further debate as to the degree of thromboprophylaxis that may benefit the subgroup with severe disease.

Transfusion and hematologic indices in cases of stillbirth due to placental abruption

BACKGROUND

Stillbirth because of placental abruption is often associated with maternal hemorrhage and coagulopathy.

OBJECTIVE

This study aimed to describe blood product requirements, hematologic indices, and the overall clinical picture of patients experiencing abruption demise.

STUDY DESIGN

This retrospective cohort included patients with abruption demise at an urban hospital from 2010 to 2020. Outcome data from patients who delivered stillborn infants ≥500 g or with gestational age of ≥24 weeks were included. Abruption was a clinical diagnosis made by a multidisciplinary stillbirth review committee. The overall number and type of blood products given were analyzed. Patients with a stillbirth who required blood transfusion were compared with those that did not. In addition, the hematologic indices of these 2 populations were analyzed and compared with one another. Finally, the overall clinical characteristics of the 2 populations were analyzed. The analysis of data included chi-square, t test, and logistic and negative binomial regression models.

RESULTS

Of 128,252 deliveries, 615 patients (0.48%) experienced a stillbirth, with 76 cases (12%) caused by abruption. Of note, 42 patients (55.2%) required blood transfusion; all received either packed red blood cells or whole blood with a median 3.5 units (2.0-5.5) received. The total units ranged from 1 to 59, with 12 of 42 patients (29%) requiring ≥10 units. Maternal age, gestational age, and mode of delivery were not different, with most (61/76 [80%]) delivering vaginally. Hematocrit level on arrival (odds ratio, 0.80; 95% confidence interval, 0.68-0.91; P=.002) and vaginal bleeding on arrival (odds ratio, 3.73; 95% confidence interval, 1.15-13.40; P=.033) were associated with blood transfusion, as was a diagnosis of preeclampsia (odds ratio, 8.40; 95% confidence interval, 2.49-33.41; P=.001). Those that required a blood transfusion often presented with lower hematologic indices and were more likely to develop disseminated intravascular coagulation (28% vs 0%; P<.001).

CONCLUSION

Most patients experiencing stillbirth because of abruption required blood transfusion, with almost 1 in 3 of those patients consuming ≥10 units of blood products. Hematocrit level on arrival, vaginal bleeding, and preeclampsia were all predictors of the need for blood transfusion. Those requiring blood transfusion were more likely to develop disseminated intravascular coagulation. Blood transfusion should be prioritized when abruption demise is suspected.

Risk of disseminated intravascular coagulation in postpartum hemorrhage associated with intrauterine infection

OBJECTIVE

To evaluate the risk of disseminated intravascular coagulation (DIC) in postpartum hemorrhage (PPH) associated with intrauterine infection.

MATERIAL AND METHODS

A retrospective cohort study of pregnancies complicated by PPH performed at a tertiary academic center in France from 2017 through 2021. Patients giving birth after 22 weeks of gestation with PPH were eligible. Patients with a PPH associated with an intrauterine infection were compared to patients with a PPH without intrauterine infection. Intrauterine infection was defined by a composite criterion available at delivery. DIC was defined by a specific pregnancy DIC score. The association between DIC and intrauterine infection was assessed by logistic regression. The causal effect of intrauterine infection on DIC was estimated by mediation analysis.

RESULTS

Of 2,093 patients with PPH, 49 exposed to a clinical intrauterine infection were compared to 49 unexposed patients. The rate of DIC was higher in patients with than without infection (22 (45.8%) vs. 7 (14.6%), P = .001), and coagulation anomalies occurred sooner in patients with than without infection (7, 2-11 h vs. 14, 9-19 h, P < .001). In the multivariate analysis, intrauterine infection was the only factor independently associated with DIC (adjusted odds ratio 5.01, 95% CI 1.83-13.73). Mediation analysis showed that 14% (95% CI, 0-50%) of this association between intrauterine infection and DIC was mediated by severe PPH, and 86% resulted from the direct effect of intrauterine infection on DIC.

CONCLUSION

In PPH, intrauterine infection had a major direct effect on the occurrence, timing, and severity of DIC.

Characteristics and outcomes of patients undergoing second-trimester dilation and evacuation for intrauterine fetal demise vs induced abortion

OBJECTIVES

Patients with intrauterine fetal demise (IUFD) are at higher risk of complications when undergoing dilation and evacuation (D&E) compared to patients undergoing abortion for other indications. We aimed to compare baseline characteristics and describe outcomes, including frequencies of complications such as disseminated intravascular coagulation (DIC) and hemorrhage, in patients undergoing D&E for IUFD vs induced abortion, with a goal of identifying associated risk factors for complications.

STUDY DESIGN

We conducted a retrospective matched cohort study of patients undergoing nonemergent D&Es for singleton ≥14-0/7-week IUFD January 1, 2019 to May 31, 2021, matched with two patients undergoing induced second-trimester D&Es by cesarean delivery history, patient age, and gestational age (GA). We collected demographics, history, GA, coagulation studies, quantitative blood loss (QBL), and complications. We calculated descriptive statistics and tested for association using chi-square, Fisher's exact, t, and Wilcoxon's rank sum tests.

RESULTS

Of 1390 procedures, 64 patients with IUFD met inclusion criteria and were matched with 128 patients undergoing induced D&E. Eight (12.5%) patients with IUFD and six (4.7%) undergoing induced D&E had hemorrhage (odds ratio [OR] = 2.90, 95% confidence interval [0.96, 8.77]). Six (9.4%) patients with IUFD and none undergoing induced D&E had DIC (OR = 28.56 [1.58, 515.38]). Median QBL was 75.0 mL (50, 162.5) for patients with IUFD vs 110.0 mL (50, 200) for those undergoing induced D&E (p = 0.083). Twelve (18.8%) patients with IUFD vs seven (5.5%) undergoing induced D&E received at least one intervention due to bleeding complications (p = 0.004).

CONCLUSIONS

We found a higher DIC frequency but no significant difference in hemorrhage or QBL in IUFD D&E compared to induced abortion. Our IUFD D&E complication frequency is higher than those previously published.

IMPLICATIONS

Our results affirm current standards of care for D&E in patients with IUFD. Large referral centers may have higher proportions of complications compared to other sites.

Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management

Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.

Thromboprophylaxis in Pregnant Women with COVID-19: An Unsolved Issue

SARS-CoV-2 infection in pregnant women is of growing interest due to controversy over the use of antiplatelet and/or anticoagulant drugs during pregnancy and postpartum. Pregnant women are susceptible to develop severe forms of viral infections due to pregnancy-related immune alterations, changes in lung functions, and hypercoagulability. The association of pregnancy with SARS-CoV-2 infection can cause an increased incidence of thrombotic complications, especially in the case of patients with some genetic variants that favor inflammation and thrombosis. Compared to the general population, pregnant women may be at increased risk of thrombotic complications related to COVID-19. The lack of extensive clinical trials on thromboprophylaxis and extrapolating data from non-pregnant patients lead to major discrepancies in treating pregnant women with COVID-19. Currently, a multidisciplinary team should determine the dose and duration of prophylactic anticoagulant therapy for these patients, depending on the disease severity, the course of pregnancy, and the estimated due date. This narrative review aims to evaluate the protective effect of thromboprophylaxis in pregnant women with COVID-19. It is unknown at this time whether antiplatelet or anticoagulant therapy initiated at the beginning of pregnancy for various diseases (preeclampsia, intrauterine growth restriction, thrombophilia) offers a degree of protection. The optimal scheme for thromboprophylaxis in pregnant women with COVID-19 must be carefully established through an individualized decision concerning gestational age and the severity of the infection.

Echocardiography findings in amniotic fluid embolism: a systematic review of the literature

PURPOSE

Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE.

SOURCES

We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series.

PRINCIPAL FINDINGS

Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases.

CONCLUSIONS

Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE.

STUDY REGISTRATION

PROSPERO (CRD42021271323); registered 1 September 2021.

The role of fibrinogen in postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide (WHO), with almost 60000 deaths annually. Pregnancy is a prothrombotic state with increased levels of several coagulation factors to protect the parturient from bleeding problems during delivery. Fibrinogen has a significant role in coagulation and bleeding. Studies have pointed out that lower fibrinogen levels before delivery, but also at the initiation of PPH, are predictive of major hemorrhage. Early, the goal-directed fibrinogen concentrate therapy might be very useful in a subgroup of patients with serious PPH. This review aims to summarize the current literature on fibrinogen during PPH.

Fetal-neonatal and maternal pregnancy outcomes in women with rheumatoid arthritis: a population-based cohort study

OBJECTIVES

Rheumatoid arthritis (RA) may adversely influence pregnancy and lead to adverse birth outcomes. This study estimated the risk of adverse fetal-neonatal and maternal pregnancy outcomes in women with RA.

DESIGN

This was a retrospective cohort study.

SETTING

We used both the National Health Insurance database and the Taiwan Birth Reporting System, between 2004 and 2014.

PARTICIPANTS

We identified 2 100 143 singleton pregnancies with 922 RA pregnancies, either live births or stillbirths, delivered by 1 468 318 women.

OUTCOME MEASURES

ORs with 95% CIs for fetal-neonatal and maternal outcomes were compared between pregnancies involving mothers with and without RA using an adjusted generalised estimating equation model.

RESULTS

Covariates including age, infant sex, Charlson Comorbidity Index, urbanisation, income, occupation, birth year and maternal nationality were adjusted. Compared with pregnancies in women without RA, pregnancies in women with RA showed that the fetuses/neonates had adjusted ORs (95% CI) of 2.03 (1.66 to 2.50) for low birth weight (n=123), 1.99 (1.64 to 2.40) for prematurity (n=141), 1.77 (1.46 to 2.15) for small for gestational age (n=144) and 1.35 (1.03 to 1.78) for fetal distress (n=60). Pregnancies in women with RA had adjusted ORs (95% CI) of 1.24 (1.00 to 1.52) for antepartum haemorrhage (n=106), 1.32 (1.15 to 1.51) for caesarean delivery (n=398), and 3.33 (1.07 to 10.34) for disseminated intravascular coagulation (n=3), compared with women without RA. Fetuses/neonates born to mothers with RA did not have a higher risk of being stillborn or having fetal abnormalities. Pregnant women with RA did not have increased risks of postpartum death, cardiovascular complications, surgical complications or systemic organ dysfunction.

CONCLUSIONS

Pregnancies in women with RA were associated with higher risks of multiple adverse fetal-neonatal and maternal outcomes; however, most pregnancies in these women were successful.

Disseminated Intravascular Coagulation: The Past, Present, and Future Considerations

Disseminated intravascular coagulation (DIC) has been understood as a consumptive coagulopathy. However, impaired hemostasis is a component of DIC that occurs in a progressive manner. The critical concept of DIC is systemic activation of coagulation with vascular endothelial damage. DIC is the dynamic coagulation/fibrinolysis disorder that can proceed from compensated to decompensated phases, and is not simply impaired hemostasis, a misunderstanding that continues to evoke confusion among clinicians. DIC is a critical step of disease progression that is important to monitor over time. Impaired microcirculation and subsequent organ failure due to pathologic microthrombi formation are the pathophysiologies in sepsis-associated DIC. Impaired hemostasis due to coagulation factor depletion from hemodilution, shock, and hyperfibrinolysis occurs in trauma-associated DIC. Overt-DIC diagnostic criteria have been used clinically for more than 20 years but may not be adequate to detect the compensated phase of DIC, and due to different underlying causes, there is no "one-size-fits-all criteria." Individualized criteria for heterogeneous conditions continue to be proposed to facilitate the diagnosis. We believe that future research will provide therapeutics using new diagnostic criteria. Finally, DIC is also classified as either acute or chronic, and acute DIC results from progressive coagulation activation over a short time and requires urgent management. In this review, we examine the advances in research for DIC.

Changes of new coagulation markers in healthy pregnant women and establishment of reference intervals in Changsha

OBJECTIVES

There is a high coagulation state in pregnant women, which is prone to coagulation and fibrinolysis system dysfunction. This study aims to explore the latest coagulation markers-thrombomodulin (TM), thrombin-antithrombin complex (TAT), plasmin-α2 plasmin inhibitor complex (PIC), and tissue plasminogen activator/plasminogen activator inhibitor compound (tPAI-C) in different stages of pregnancy, establish reference intervals (RIs) for healthy pregnant women of Chinese population, and to provide an effective and reliable reference for clinicians.

METHODS

A total of 492 healthy pregnant women, who underwent pregnancy examination and delivery in the Department of Obstetrics, Second Xiangya Hospital of Central South University from October 2019 to October 2020, were enrolled for this study. They were assigned into the first trimester group, the second trimester group, the third trimester group, and the puerperium group according to the pregnancy period, and 123 healthy non-pregnant women were selected as the controls. Plasma levels of TM, TAT, PIC and tPAI-C were analyzed by automatic chemiluminescence immunoassay analyzer. The RIs for TM, TAT, PIC, and tPAI-C were defined using non-parametric 95% intervals, determined following Clinical and Laboratory Standards Institute Document C28-A3c (CLSI C28-A3c), and Formulation of Reference Intervals for the Clinical Laboratory Test Items (WS/T402-2012).

RESULTS

TM and TAT levels increased gradually in the first, second, and third trimester women and decreased in the puerperium women (P<0.05 or P<0.01). PIC level of healthy non-pregnant women was lower than that of pregnant women (P<0.05 or P<0.01), but PIC level of pregnant and puerperium women did not differ significantly (P>0.05). tPAI-C level in healthy non-pregnant women was lower than that of pregnant women (P<0.05 or P<0.01), and tPAI-C level was significantly decreases in the puerperium women (P<0.01). The RIs for TM were as follows: Healthy non-pregnant women at 3.20-4.60 TU/mL, the first and second trimester at 3.12-7.90 TU/mL, the third trimester at 3.42-8.29 TU/mL, puerperium at 2.70-6.40 TU/mL. The RIs for TAT were as follows: Healthy non-pregnant women at 0.50-1.64 ng/mL, the first and second trimester at 0.52-6.91 ng/mL, the third trimester at 0.96-12.92 ng/mL, puerperium at 0.82-3.75 ng/mL. The RIs for PIC were as follows: Healthy non-pregnant women at 0.160-0.519 ng/mL, pregnant women at 0.162-0.770 μg/mL. The RIs for tPAI-C were as follows: Healthy non-pregnant women at 1.90-4.80 ng/mL, the first and second trimester at 2.03-9.33 ng/mL, the third trimester at 2.80-14.20 ng/mL, puerperium at 1.10-8.40 ng/mL.

CONCLUSIONS

The levels of 4 new coagulation markers TM, TAT, PIC, and tPAI-C in pregnant women are increased significantly during pregnancy and gradually return to normal after delivery. The RIs for TM, TAT, PIC, and tPAI-C in pregnant women by trimester are established according to CLSI C28-A3c, thus providing a clinical reference for clinician in judgement of thrombotic risk.

COVID-19 Infection Complicated by Disseminated Intravascular Coagulation during Pregnancy—Two Cases Report

Coagulopathies are one of the obstetric complications affecting the period of pregnancy, childbirth, and puerperium. One of the more severe and complex disorders of the haemostatic system is the disseminated intravascular coagulation syndrome (DIC), in which generalised activation of the coagulation system and activation of inflammatory cells occurs. DIC syndrome was observed in patients whose pregnancy was complicated by SARS-CoV-2 infection. Both the course of these cases and literature review indicate that particular notice should be paid to laboratory parameters of the coagulation system, closely monitoring the well-being of the foetus and, in the situation of acute DIC development, it is advised to deliver a baby and initiate intensive therapy.

Point-of-Care Viscoelastic Tests in the Management of Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Thromboelastography and rotational thromboelastometry are laboratory methods of assessing the kinetics of blood clot formation through real-time measurement of viscoelastic clot strength and may aid in management of severe hemorrhage. Although first described more than 70 years ago, viscoelastic testing devices are now available that allow for rapid point-of-care use of this technology to aid in real-time management of blood product replacement in cases of severe hemorrhage. These devices can be used to visually estimate multiple facets of hemostasis-coagulation, platelet function, and fibrinolysis-within 10-20 minutes. They have been used successfully in cardiac surgery, trauma, and liver transplantation and have potential for use in management of obstetric hemorrhage. Goals with their use include targeted transfusion of blood and its components for specific coagulation deficiencies. To date, however, published experiences with the use of these viscoelastic tests for obstetric hemorrhage have been limited. Because of the increasing use of the point-of-care tests by anesthesiologists, surgeons, and intensivists, the purpose of this report is to familiarize obstetricians with the technology involved and its use in severe hemorrhage complicating pregnancy.

DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments

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.

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

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.

Goals for Collaborative Management of Obstetric Hemorrhage

Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.

Consumptive Coagulopathy Involving Amniotic Fluid Embolism: The Importance of Earlier Assessments for Interventions in Critical Care

Supplemental Digital Content is available in the text.

Objectives:

Amniotic fluid embolism is a rare disease that induces fatal coagulopathy; however, due to its rarity, it has not yet been examined in detail. The strict diagnostic criteria by Clark for amniotic fluid embolism include severe coagulopathy complicated by cardiopulmonary insufficiency, whereas the Japanese criteria also include postpartum hemorrhage or Disseminated Intravascular Coagulation in clinical practice. Amniotic fluid embolism cases with preceding consumptive coagulopathy may exist and are potential clinical targets for earlier assessments and interventions among amniotic fluid embolism cases fulfilling the Japanese, but not Clark criteria. The present study was performed to compare coagulopathy in the earlier stage between the amniotic fluid embolism patients diagnosed by Clark criteria (Clark group, n = 6), those by the Japanese criteria (Non-Clark group, n = 10), and peripartum controls and identify optimal clinical markers for earlier assessments of amniotic fluid embolism-related consumptive coagulopathy.

Design:

Retrospective case-control study.

Setting:

A single university-based center. Our amniotic fluid embolism registry program has accumulated clinical information and blood samples since 2003.

Patients:

Amniotic fluid embolism patients in the Clark and Non-Clark groups between 2009 and 2017 and peripartum controls.

Interventions:

None.

Measurements and Main Results:

Clinical information was collected on hemoglobin levels, platelet counts, and coagulation- and fibrinolysis-related variables. Fibrinolytic parameters were also measured and compared among the three groups before blood transfusion. Fibrinogen levels in all patients in the Clark group and most in the Non-Clark group decreased earlier than hemoglobin levels, which was consistent with the high hemoglobin/fibrinogen ratio and, thus, is a promising clinical marker for the earlier assessment of amniotic fluid embolism-related consumptive coagulopathy.

Conclusions:

Earlier evaluations of consumptive coagulopathy and hyperfibrinolysis using the hemoglobin/fibrinogen ratio following preemptive treatment may reduce the occurrence or prevent the aggravation of severe coagulopathy in amniotic fluid embolism patients.

When does obstetric coagulopathy occur and how do I manage it?

Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy 'in or out', decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.

Effect of hypofibrinogenemia on obstetrical disseminated intravascular coagulation in Japan in 2018: a multicenter retrospective cohort study

Japanese obstetrical hemorrhage recommendations state that not only pregnant women with an obstetrical disseminated intravascular coagulation (DIC) score ≥ 8 points but also those with fibrinogen levels ≤ 1.5 g/L have a high risk of maternal death and warrant blood transfusion. Our aim was to demonstrate the potential of fibrinogen levels ≤ 1.5 g/L as predictors of a Japanese obstetrical DIC score of ≥ 8. We included 595 participants with blood loss ≥ 1000 mL during vaginal delivery or ≥ 2000 mL during cesarean delivery. The frequency and volume of red blood cell (RBC), fresh-frozen plasma, platelet concentrate (PC), and fibrinogen administration in women with a DIC score of ≥ 8 and fibrinogen levels of ≤ 1.5 g/L were significantly higher than controls (P < 0.0001). Multivariate analysis demonstrated that a score of ≥ 3 was associated with RBC or fibrinogen administration and a score of ≥ 5 was associated with PC transfusion. Fibrinogen levels ≤ 1.89 g/L and ≤ 2.44 g/L were associated with PC transfusion and fibrinogen administration, respectively. Fibrinogen levels ≤ 1.5 g/L may have similar potential to a DIC score of ≥ 8 points for detecting obstetrical DIC in Japan.

Disseminated intravascular coagulation: epidemiology, biomarkers, and management

Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.

Haemostatic and thrombo-embolic complications in pregnant women with COVID-19: a systematic review and critical analysis

BACKGROUND

As pregnancy is a physiological prothrombotic state, pregnant women may be at increased risk of developing coagulopathic and/or thromboembolic complications associated with COVID-19.

METHODS

Two biomedical databases were searched between September 2019 and June 2020 for case reports and series of pregnant women with a diagnosis of COVID-19 based either on a positive swab or high clinical suspicion where no swab had been performed. Additional registry cases known to the authors were included. Steps were taken to minimise duplicate patients. Information on coagulopathy based on abnormal coagulation test results or clinical evidence of disseminated intravascular coagulation (DIC), and on arterial or venous thrombosis, were extracted using a standard form. If available, detailed laboratory results and information on maternal outcomes were analysed.

RESULTS

One thousand sixty-three women met the inclusion criteria, of which three (0.28, 95% CI 0.0 to 0.6) had arterial and/or venous thrombosis, seven (0.66, 95% CI 0.17 to 1.1) had DIC, and a further three (0.28, 95% CI 0.0 to 0.6) had coagulopathy without meeting the definition of DIC. Five hundred and thirty-seven women (56%) had been reported as having given birth and 426 (40%) as having an ongoing pregnancy. There were 17 (1.6, 95% CI 0.85 to 2.3) maternal deaths in which DIC was reported as a factor in two.

CONCLUSIONS

Our data suggests that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Detection of the former may be useful in the identification of women at risk of deterioration.

COVID-19 coagulopathy in pregnancy: Critical review, preliminary recommendations, and ISTH registry-Communication from the ISTH SSC for Women's Health

BACKGROUND

Novel coronavirus (SARS-CoV-2), which causes COVID-19, has thus far affected more than 15 million individuals, resulting in more than 600 000 deaths worldwide, and the number continues to rise. In a large systematic review and meta-analysis of the literature including 2567 pregnant women, 7% required intensive care admission, with a maternal mortality ~1% and perinatal mortality below 1%. There has been a rapid increase in publications on COVID-19-associated coagulopathy, including disseminated intravascular coagulopathy and venous thromboembolism, in the non-pregnant population, but very few reports of COVID-19 coagulopathy during pregnancy; leaving us with no guidance for care of this specific population.

METHODS

This is a collaborative effort conducted by a group of experts that was reviewed, critiqued, and approved by the International Society on Thrombosis and Haemostasis Subcommittee for Women's Health Issues in Thrombosis and Hemostasis. A structured literature search was conducted, and the quality of current and emerging evidence was evaluated. Based on the published studies in the non-pregnant and pregnant population with a moderate to high risk of bias as assessed by Newcastle-Ottawa scale and acknowledging the absence of data from randomized clinical trials for management of pregnant women infected with SARS-CoV-2, a consensus in support of a guidance document for COVID-19 coagulopathy in pregnancy was identified.

RESULTS AND CONCLUSIONS

Specific hemostatic issues during pregnancy were highlighted, and preliminary recommendations to assist in the care of COVID-19-affected pregnant women with coagulopathy or thrombotic complications were developed. An international registry to gather data to support the management of COVID-19 and associated coagulopathy in pregnancy was established.

Prenatal Plasma Fibrinogen Level Predicts Postpartum Hemorrhage of Patients With HELLP Syndrome

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a serious complication of pregnancy. Postpartum hemorrhage indicates poor prognosis of pregnant women with HELLP syndrome. The aim of our study is to investigate the predictive value of coagulation markers for postpartum hemorrhage of pregnant women with HELLP syndrome. In a retrospective cohort study, 106 patients who were diagnosed as pregnant women with HELLP syndrome in Peking University Third Hospital from August 2010 to January 2017 were analyzed. The demographic characters of maternal and fetus, days of hospital stay, postpartum complications, and the laboratory tests of coagulation markers within 3 days before delivery were collected. In addition, 100 healthy pregnant women were collected as a control group. The result showed that the incidence of preeclampsia in pregnant women with postpartum hemorrhage was higher than that in pregnant women without hemorrhage (P = .011). The level of fibrinogen (FIB) in postpartum hemorrhage pregnant women with HELLP syndrome was lower than that in nonpostpartum hemorrhage pregnant women with HELLP syndrome and healthy pregnant women (2.3 [1.68-2.81] vs 3.64 ± 0.95, P = .000; 2.3 [1.68-2.81] vs 4.48 ± 0.62, P = .000). Multivariate analysis showed that decreased FIB levels independently predicted the postpartum hemorrhage of pregnant women with HELLP syndrome (odds ratio = 7.374, 95% confidence interval [CI], 1.551-35.05, P = .012). The receiver operating characteristic curve showed that the area under the curve of FIB level when predicting postpartum hemorrhage is 0.841 (95% CI, 0.708-0.976). When the cutoff value of FIB was 3.04 g/L, the sensitivity was 90.90% and the specificity was75.80%. Therefore, the low level of prenatal FIB is a reliable biomarker to predict postpartum hemorrhage of pregnant women with HELLP syndrome, which make it useful for pregnant women with HELLP syndrome in guiding surveillance therapy and prognosis assessment.

The predictive value of pre-delivery laboratory test results for the severity of placental abruption and pregnancy outcome

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.

Potential predictors for prognosis and postpartum recovery time of acute fatty liver of pregnancy

BACKGROUND

Acute fatty liver of pregnancy (AFLP) is a potentially lethal condition of pregnant women with a high mortality rate. Potential predictors related to postpartum recovery time and prognostic factors of AFLP are still unclear. This study aimed to evaluate potential predictors for prognosis and postpartum recovery time of AFLP.

METHODS

We retrospectively analyzed the clinical data of 76 AFLP patients in our hospital from 2002 to 2017 and investigated potential predictors using univariate analysis and multivariate logistic regression analysis.

RESULTS

Hepatic encephalopathy (HE) was found to be associated with prognosis in AFLP patients (P = 0.005, OR = 26.844). The postpartum recovery time analysis showed that AFLP patients with a age < 25 had the shortest recovery time, but no significant difference (P = 0.134, OR = 5.952). The postpartum recovery time of patients with liver failure (LF) was significantly prolonged compared to those without LF (P = 0.036, OR = 10.052). Cryoprecipitate, and plasma infusion showed no significant effect on prognosis or recovery time. Artificial liver support therapy (ALST) had no effect on prognosis, but it might affect postpartum recovery time with no statistical significance (P = 0.128, OR = 5.470).

CONCLUSION

HE is a potential predictor for prognosis of AFLP. LF is a potential predictor for postpartum recovery time.

Placental abruption as a trigger of DIC in women with HELLP syndrome: a population-based study

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.

Underlying disorders of disseminated intravascular coagulation: Communication from the ISTH SSC Subcommittees on Disseminated Intravascular Coagulation and Perioperative and Critical Care Thrombosis and Hemostasis

BACKGROUND

Disseminated intravascular coagulation (DIC), a systemic activation of coagulation, presents with multiple clinical and laboratory manifestations. In this International Society on Thrombosis and Haemostasis (ISTH) communication, we examined the importance of identifying the underlying disorder causing DIC to help physicians in the diagnosis and management of this common and severe condition.

METHODS

Eight DIC experts participated in a three-step consensus process that searched for published guidelines and diagnostic scores on DIC to create a preliminary list of DIC underlying disorders from those reported in the literature Overall, 13 papers were identified, including three guidelines, one harmonization paper by the ISTH, one ISTH recommendation paper on cancer-associated DIC, five general diagnostic scores, two scores specific for pregnancy, and one specific for children. We then assessed the strength of the evidence on the association between the disease and DIC as many postulated DIC-associated disorders are rare.

KEY RESULTS

Eight main subgroups - 'severe infection', 'solid tumour', 'haematological neoplasia', 'pregnancy complication', 'vascular disease', 'newborn-complication', 'tissue damage due to internal or external insult', and 'chemical and biological agent' - and a detailed list of specific causes of DIC were provided.

CONCLUSIONS & INFERENCES

Our results suggest more data are needed to determine the association between DIC and specific diseases such as malignant lymphoma, colorectal cancer, or vasculitis, for which the evidence remains limited. When a patient develops a coagulopathy consistent with DIC, the first step is to immediately search for an underlying disorder, including specific causes that are rarely associated with DIC and to consider that patients may have more than one cause of DIC to identify the principal precipitating disorder to prioritize treatment.

To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise

A 39-year-old G2P1001 female presented from an outside hospital following an eclamptic seizure in the setting of HELLP syndrome. This condition was complicated by intrauterine fetal demise and disseminated intravascular coagulation, which required an emergent cesarean section. We report the work-up and intraoperative and postoperative management of this complex patient with multiple medical needs. We focus on the hemostatic abnormalities in this patient and describe how our management would differ from that of a similar, nonpregnant patient.

Amniotic fluid embolism-associated coagulopathy: a single-center observational study

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.

New method for determining fibrinogen and FDP threshold criteria by artificial intelligence in cases of massive hemorrhage during delivery

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.

Thrombosis and hemostasis health in pregnancy: Registries from the International Society on Thrombosis and Haemostasis

Online patient registries are used to collect data on clinical conditions with rare occurrence or unclear diagnostic and management practices. The success of these registries depends on clear definition of goals, correct identification of patient population/inclusion criteria, availability of appropriate setup and maintenance tools, and the quality of dissemination. The Scientific and Standardization Committee (SSC) for Women's Health Issues in Thrombosis and Hemostasis, one of 20 committees of the International Society on Thrombosis and Haemostasis (ISTH) has developed 6 registries for women's bleeding and thrombotic conditions over the past 2 years and are currently in various stages of progress. Here, we provide information about these registries, including rationale, objectives, and methods for data collection. The aim is to enhance worldwide participation and thus promote the success of these registries. We used ISTH REDCap, a mature and secure Web application for building and managing online surveys and databases, and the ISTH advertising platform to maximize participation. Registries (links and project details available on ISTH and Women's SSC Web sites) include: (1) WiTEAM, project on thrombophilia and placenta-mediated obstetric complications; (2) a registry for disseminated intravascular coagulation in pregnancy; (3) severe congenital protein C deficiency-an obstetric study; (4) obstetric and gynecologic outcomes of women with platelet function disorders; (5) thrombolysis and invasive treatments for massive pregnancy-related pulmonary embolism; (6) pregnancy and exposure to direct oral anticoagulants. The ISTH promotes online registries on women's issues to enhance understanding of current practices, identify knowledge gaps, promote research, and ultimately improve patient safety and quality of life.

Coagulopathy in surgical management of placenta accreta spectrum

BACKGROUND

One of the major complications of the placenta accreta spectrum (PAS) is the development of coagulopathy. The detection, prevention and prompt treatment of coagulopathy may be lifesaving.

OBJECTIVE

Our objective was to study selected factors associated with coagulopathy in the management of PAS by a well-established multidisciplinary team.

STUDY DESIGN

This is a retrospective review of all patients with pathologically proven PAS (including placenta accreta, increta or percreta) who underwent surgery by our multidisciplinary team between January 2011 and February 2017. Coagulopathy in this setting was defined as a platelet count of <100,000/mm³, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL based on institutional protocols developed by our Division of Transfusion Medicine & Coagulation. The outcomes of those patients with and without coagulopathy were compared with appropriate adjustments. Receiver operating characteristics curves (ROCs) were constructed to assess the ability of select variables to discriminate between women with and without coagulopathy, and the area under the curves (AUCs) were calculated.

RESULTS

Of 123 singleton patients with PAS, 37 (30.1%; 95%CI 22.1-39.0) developed coagulopathy and 86 (69.9%; 95%CI 61.0-77.9) did not. Baseline patient demographic characteristics did not differ significantly between these groups. Estimated blood loss (median and Inter-quartile range) was 2100cc (1800, 400) and 1400 (1000, 2500) in the presence and absence of coagulopathy, respectively (P < 0.01). The overall number of units of red blood cells (RBC) transfused was greatest in the coagulopathy group [3 (2, 9) vs. 1 (0, 4); P < 0.01]. Univariate regression analysis confirmed the association between coagulopathy and (i) the number of units of RBC's transfused, and (ii) the estimated blood loss. ROC curves showed that an estimated blood loss ≥ 1500 mL had the best discriminating power. Depth and/or severity of placental invasion were not associated with coagulopathy in patients with PAS.

CONCLUSIONS

Coagulopathy in patients with PAS undergoing hysterectomy is strongly associated with blood loss and replacement. It may be prudent to establish protocols that aggressively monitor for, and treat, coagulopathy when EBL exceeds 1500 mL in such surgeries, prior to the development of clinical coagulopathy which if uncorrected may lead to massive blood loss.

Vaginal Bleeding in Late Pregnancy

Bleeding in late-term pregnancy can present as an innocuous start to parturition or a catastrophic maternal-fetal hemorrhage masked by the physiologic adaptations of pregnancy. The emergency management of late-term bleeding can be challenging, especially when providing stabilizing care in a limited-resource environment. Early recognition of life-threatening vaginal bleeding, potential causes, and emergency management of maternal-fetal distress is reviewed. Maternal resuscitation with balanced versus targeted blood products replacement is presented for low-resource versus high-resource environments. Emergency department readiness for such a patient, in combination with appropriate consultation or transfer, is essential to the effective management of late-term vaginal bleeding.