Disseminated intravascular coagulation syndrome - a severe obstetric complication: what should be done? how to prevent it?

• Devyatova E.A.

Abstract

Maternal pregnancy-associated complications are the major factor of maternal morbidity. Postpartum hem­orrhage (PPH) is the most often reason of maternal mortality and is up to 30% in the structure [2]. PPH leading disseminated intravascular coagulation (DIC) syndrome occupies the 2nd place in the structure of maternal mortality. DIC development because of forming predisposing conditions is able to transform into a life-threat­ening complication quickly. DIC should be accepted as one of the leading reasons of potentially lethal compli­cations and maternal mortality. Due to this fact we should differentiate a high-risk group, work out quick and reliable diagnostic and curative approach.

Placenta accretа appears in a set of predisposing conditions and is considered to be a severe obstetric com­plication; maternal mortality is up to 7%. Prophylactic preoperative balloon occlusion of iliac arteries is aimed at blood loss control and has become a part of multidiscipline approach to the delivery, but the evaluation of use of this procedure is needed.

Routine prophylaxis of PPH is potentially useful by the reason of DIC - a severe lethal complication of PPH. At the moment misoprostol administration is considered to become a safe alternative to parenteral prophylaxis of PPH. Misoprostol administration will form a reserve in a number of cases possibly, but estimation of its ef­fectiveness is desirable.

Objective - discussion of pathophysiology, modern diagnostic and therapeutic approach to DIC; as­sessment of use of prophylactic balloon occlusion of iliac vessels before operative delivery in the cases of expected placenta accretа; evaluation of efficacy of administration of sublingual misoprostol for PPH pro­phylactics.

Conclusion. DIC syndrome is caused with a number of obstetric and other reasons and is a life-threatening complication. It is implemented with endothelial and platelet dysfunction, activation of coagulation system. Understanding of basic mechanisms of DIC, its immediate diagnostic and treatment are essential for good prog­nosis. The scale of risk assessment which was modified for pregnancy demonstrates high reliability in detecting obstetric patients with DIC.

Application of TEG and ROTEM can be useful in getting the results quickly, which helps to evaluate the severity of DIC and take a decision about an immediate intervention. Basic therapeutic approach to DIC in obstetric practice is concluded in immediate removal of predisposing to DIC conditions and complications of pregnancy, adequate supporting treatment, including haemotransfusion. Clinical and laboratory monitor­ing, specialists' cooperation and instant start of treatment are the main steps of successful therapy of DIC and favorable clinical outcome.

The question of prophylactic balloon occlusion of iliac vessels before operative delivery in the cases of expected placenta accretа is staying controversial and requires further studying.

Administration of sublingual misoprostol during the III stage of labor (if active clinical approach) for de­creasing of PPH risk is comparable to intramuscular oxytocin administration.

Keywords:postpartum hemorrhage, PPH, bleeding, disseminated intravascular coagulation syndrome, DIC, score, endothelial dysfunction, trophoblast, acute fatty liver of pregnancy, HELLP syndrome, placenta previa, placenta accretа, balloon occlusion of iliac arteries, sublingual misoprostol, oxytocin

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