Coagulopathies in Pregnancy: What an Obstetrician Ought to Know!

Abstract

It is a matter of concern if you read “33 women die every hour from pregnancy and childbirth complications India among 10 nations with highest maternal mortality ratio” (WHO). Complications of pregnancy and childbirth are the leading causes of disability and death amongst women between the ages of 15 and 49. In a study conducted in Mumbai, more than half of the women suffer from various complications and were in the younger age hailing from rural areas [1]. In 1990, the WHO reported the death of 523,000 mothers due to complications in pregnancy and childbirth; in 2013, this number was 45% less indicating that advances in science have helped us achieve this drop in mortality. But we are still falling short as the distribution of health-care talent and mechanisms is discordant between the privileged and the underprivileged. Haematologic emergencies contribute to significant morbidity and mortality in the pregnant population and can be sudden, unprecedented and catastrophic. Certainly, there is an opportunity to prevent haematological emergencies in our community and we owe it to our women, to do our best as thinkers, planners and executors of good health care and safe practices. So are we delivering the same? I feel that awareness of pathophysiology and anticipation or recognition of possible hazardous events are two keys to better therapy and outcome. Coagulopathies in pregnancy can present or lead to obstetric emergencies and can vary from prothrombotic / microangiopathic events such as HELLP (Haemolysis Elevated Liver Enzymes Low Platelets), TTP (thrombotic thrombocytopenia purpura) and other microangiopathies, especially DIC (disseminated Intravascular coagulopathy), to deep venous thrombosis (DVT) and recurrent pregnancy losses and, on the other hand, bleeding events such as antepartum haemorrhage and PPH (postpartum haemorrhage) just to name a few. These could be prevented if we monitor the patient well for warning signs that could warrant tests to diagnose these unwanted events. Unfortunately, a regular ANC follow-up in our clinics is not common and sometimes patients present to us for the first time with an emergency with no documentation of previous adverse events in the earlier pregnancy. So, how can we recognise and prevent such catastrophic events in our patients? Surely, by understanding the pathophysiology we could attempt in all honesty to do so. A good history of past episodes of bleeding along with a family history of bleeding can warn of a bleeding tendency such as a congenital bleeding disorder like von Willebrand disease (prolonged bleeding time, raised APTT (activated partial thromboplastin time) and history of mucosal bleeding from childhood, especially menorrhagia). Simple laboratory tests such as a global coagulation panel including a CBC, PT (prothrombin time), PTT/PTTK (partial thromboplastin time with kaolin) and plasma fibrinogen could predict a coagulopathy. A prolonged PT could suggest underlying liver disease or FVII deficiency, while a prolonged APTT/PTTK could suggest deficiency of the intrinsic pathway (Factor XII, XI, IX, VIII) and a prolongation of both could suggest a defect in the global coagulation system, especially DIC or coagulopathy of PPH or of massive transfusion. A short (less than the control) value of the coagulation tests (PT, APTT/ PTTK) may actually warn us of a prothrombotic state such as preeclampsia or early DIC (disseminated intravascular coagulopathy) in a given clinical situation. TEG (thomboelastogram) is a simple bedside test with a fast turn-around time that may identify and guide appropriate component Dr Abhay A Bhave, Consultant haematologist, Lilavati hospital and Research Centre, Bandra West, Mumbai, Global hospitals, Parel, Mumbai, Empire Haematology Oncology Specialty centre, Bandra west, Mumbai.