SIMPLE GUIDELINE FOR MANAGEMENT OF SEVERE DIC in Obstetric/ICU setting

  • DIC (Disseminated intravascular coagulation) can occur following medical, surgical or obstetric catastrophe. The list of causes are enumerated in standard text books.
  • In general, in addition to the obstetric complications such as aminiotic fluid embolism, abruption placenta, dead foetus etc, overhelming sepsis, acute shock due to any condition esp. major trauma, snake bite etc can produce severe DIVC.
  • DIC can be symptomatic and can present with acute massive bleeding or bleeding from multiple sites. It can also cause multiorgan damage due to microvascular thrombosis. Sometimes DIVC is detected by laboratory investigation without manifestations of bleeding or thrombosis.<
  • Investigations reveal prolonged APTT (Activated Partial Thromboplastin Time), PT (Prothrombin time) and low platelets. The fibrinogen level drops in massive DIVC. Even though the D Dimers will be strongly positive, in a critically ill and in patients with trauma, this alone is not an indication of DIVC.
  • In the rural and semi urban set up where there are no facilities for APTT and PT, sudden or rapid drop in a platlelet count (measured in automated cell counter) in the clinical setting of DIC is sufficient to diagnose and initiate treatement. Remember platelet counts done manually can be falsely high (The reasons are beyond the scope of discussion here).
  • The treatment of DIVC is directed towards the cause which initiated the DIC.
  • Even when there is ongoing DIVC, if there is no active bleeding, treatment should be directed towards treating the primary cause. For example in snake bite, treatment with anti-venom is the treatment of choice and replacement with blood products to correct the coagulation and platelet defects are not needed in the absence of bleeding. (In a patient with high risk of bleeding, support with blood products may be needed even in the absence of bleeding but these cases are to be individualized)
  • Treatment with blood products should be initiated immediately in the presence of severe bleeding or if there is any surgical intervention such as ceaessarean section is needed immediately.
  • If the fibrinogen is low, it is advisable to give 8-12 bags of cryoprecipitate followed by 15-20ml/kg of FFP. Platelets should be transfused after replacement of the coagulation factors with FFP or cryoprecipitate. 6-8 units of platelets can be transfused rapidly if the platelet count is less than 50,000. In an ongoing DIVC, where it takes a longer time to correct the primary cause or if the DIC persists even after correcting the primary cause, continued support with blood products may be necessary if the patient is bleeding.
  • Use of epsilon amino caproic acid (iv) may be indicated in the presence of severe bleeding, but care should be taken as these patients are prone for thrombosis.
  • This is only a guideline for practioners and since various other newer therapeutic agents are available, please contact the nearest major blood bank or hematology centre for advice.
 
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