Diagnosis of disseminated intravascular coagulopathy in its ACUTE form as described here is simple. A history of obstetric assault related to placenta would be evident
The first time she had a baby it was through a Caesarian Section with prolonged labour and maternal distress as the indication. That was three years ago. This time round the caregivers allowed her to attempt a vaginal delivery in what is generally termed as TRIAL OF SCAR at her insistence. As the day progressed and the chances of her having a normal delivery deemed. She was getting exhausted and finally gave the consent for a surgical delivery. This was successfully carried out.
Twelve hours later, the obstetrician was called back as his patient was bleeding or having a POSTPARTUM HAEMORRHAGE. The commonest cause of this condition is when a patient’s UTERUS (womb) fails to contract after delivery in the process allowing blood to accumulate inside it. It is described as UTERINE ATONY. It should be stated that the mechanism of stopping bleeding from the womb after delivery is through strong contraction of the muscle or the MYOMETRIUM. This process can be hampered in conditions such as a woman who has multiple birth history, where products of conception are still left in the in uterus and ABORTION.
On getting back to the patient, the obstetrician instinctively went and emptied the vagina, uterine cavity of blood clots and packed the vagina with SANITARY PADS. After robbing the uterus to make sure it was contracted, he ordered that MISOPROSTOL and other drugs that enhance uterine contraction be given. Not quite long he noticed that the pads were soaked with blood. He repeated the process and by now the patient was complaining of THIRST. An ominous sign of shock and she really was in HYPOVOLAEMIC shock! He rushed in blood and intravenous fluid with PLASMA EXPANDERS (special fluids used in raising the blood pressure of shocked patients). His patient got round and looked stable.
Just when he was trying to breathe a sigh of relief, the pads were soaked again. The patient had developed DISSEMINATED INTRAVASCULAR COAGULATION (DIC), also known as DISSEMINATED INTRAVASCULAR COAGULOPATHY or CONSUMPTIVE COAGULOPATHY. Or what most clinicians know too well but would rather not want to think about it being incurable optimists – DEATH IS COMING.
DIC is the activation of blood clotting mechanism that occurs when the body is challenged by a variety of diseases. Today we will be restricting ourselves to assaults that have to do with bleeding in childbearing or rather OBSTETRICS.
First let us review the mechanisms involved blood clotting. There are basically two pathways involved in blood clotting – the INTRINSIC, better known as contact activation pathway and the EXTRINSIC or tissue factor pathway. Irrespective of the activated pathway the final outcome is the conversion of FIBRINOGEN to FIBRIN by THROMBIN to form a mesh, which traps blood cells and PLATELETS commonly, described as blood dusts.
The clotting of blood in the body is a continuous process, which the body uses to maintain a steady state or HOMEOSTASIS. This is also complimented by FIBRINOLYSIS or breakdown of fibrin/ clots by another system involving the protein PLASMIN. In all there are about thirteen blood clotting factors in the blood that has to be activated in a cascade manner leading eventually to the formation of clots.
READ ALSO: Abruptio placenta
Blood clotting is a complex chain reaction, but can easily be visualized by imaging oneself standing on top of a 13 steps staircase and gently dropping a ball and allowing it to roll down. As the ball rolls down, gravity increases the speed, and as it gets to the bottom it drops into a bucket and goes nowhere. This is what happens in the intrinsic pathway to the continuous wear and tear of daily living resulting from the damage of the inner lining or ENDOTHELIUM of blood vessels. Remember that the electrical charge distribution in the endothelium helps to make sure that the blood flow in the vessels is lamina thus avoiding contact except when there is a disruption.
In the EXTRINSIC or tissue factor pathway, the chain is a little bit shortened and the trigger is a GLYCOPROTEIN (sugar and protein) molecule known as the tissue factor. Tissue factor is present on the surface of many cells but NOT in contact with the general blood circulation. It is exposed to the circulation following damage to the blood vessels from trauma, infections, cancer and other disease conditions. Tissue factor is very abundant in the PLACENTA.
Under normal circumstances, there is a maintained balance between coagulation and fibrinolysis facilitated by PLASMIN. The final product of this breakdown of clots is known FIBRIN DEGRADATION PRODUCT (FDP) or FIBRIN SPLIT PRODUCT (FCP). In DIC, this delicate balance of clotting and clot breakdown is uncontrolled resulting in WIDESPREAD clotting phenomenon with BLEEDING!
The bad news about clotting in DIC, is that more clotting leads even to more clotting and more fibrinolysis in the process CONSUMING factors involved in both clotting and fibrinolysis. This leads to the production of excess fibrinogen degradation products, which have powerful anti-clotting properties. It is like everything going haywire just to sustain bleeding with an imminent death.
Also associated with this deranged clotting is the blockage of organs with small (micro)and large (macro) clots leading to their damage. This is followed by severe INFLAMMATORY response in the body that will result in shock due to the production of substances that make the production of substances that make the blood vessels to lose their tone and dilate causing low blood pressure.
In the case of the patient presented earlier, she had a total of five litres of blood, which is equivalent to the total blood volume transfused during the crisis and still went into shock twice! The pints of intravenous fluid she received were more than twenty. That gives you an insight on the magnitude and the desperation of the challenge.
The Diagnosis of disseminated intravascular coagulopathy in its ACUTE form as described here is simple. Commonly a history of obstetric assault related to placenta would be evident; like abortion and ABRUPTIO placenta (a condition where the placenta or afterbirth separates while the baby is still in the womb). The uncontrolled vaginal bleeding easily gives it away. Other features that also give it away are prolonged clotting time, low platelet count, and elevated products of fibrin breakdown.
As the bleeding continued the Obstetrician in desperation had to go in again to remove the womb, an operation known as HYSTERECTOMY. This didn’t stop the bleeding. He looked dejected, looked at his patient for the last time and walked away without leaving any instructions. When the phone rang again two hours later, he didn’t bother to pick the call because he knew the patient was dead.