Abstract
ObjectivesThe objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC.Material and MethodsThis is a population based retrospective study, including all women who gave birth at the ‘Soroka University Medical Center’ during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses.Results1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(−) of 0.125 for the diagnosis of DIC.ConclusionWe could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC.
Highlights
The process of labor and delivery is associated with an increased risk for severe maternal hemorrhage [1]
DIC results from a wide spread activation of both clotting and fibrinolysis systems leading to: 1) systemic production of fibrin split products, and thrombi that leads to end-organ ischemia; 2) increased vascular permeability due to activation of the kinin system; and 3) microangiopathic hemolysis, during pregnancy hemorrhage is the leading mechanisms for the development DIC
The leading pregnancy complications associated with DIC were the following: placental abruption (49.4%), post-partum hemorrhage (29.9%), severe preeclampsia (12.6%), and uterine rupture (5.7%) (Table 1)
Summary
The process of labor and delivery is associated with an increased risk for severe maternal hemorrhage [1]. Systemic changes are observed in the maternal plasma including : 1) increased concentrations of clotting factors VII, VIII, IX, X and XII [3,9,10,11,12,13] and fibrinogen; 2) a reduction in the concentration of anticoagulant proteins such as protein S and tissue factor pathway inhibitor (TFPI)-1 [14,15,16,17,18]; 3) acquired resistance to activated protein C sensitivity [18,19,20]; and 4) reduced fibrinolysis as a result of low activation of plasminogen activator inhibitor (PAI) I and II [13,21,22,23,24,25] In spite of these physiologic changes in maternal hemostasis, uncontrolled peripartum bleeding, resulting in consumption coagulopathy and disseminated intravascular coagulation (DIC), is one of the leading causes for maternal mortality worldwide [26]. Aside a clinical assessment, there are no effective tools to identify patients with acute bleeding at risk for DIC
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