Disseminated Intravascular Coagulation following Midtrimester Abortions

Abstract

PIP: The experience of 3 healthy patients ranging in age from 15-33 years who developed clinical and laboratory evidence of disseminated intravascular coagulation (DIC) after elective, outpatient midtrimester abortions by dilatation and curettage (D and E) under general anesthesia is described. All 3 cases had fetal gestational ages over 20 weeks, difficult fetal and/or placental extractions, and evidence of clinically significant hemorrhage. Coagulation abnormalities included elevated fibrin split products, decreased platelet levels and serum fibrinogen levels, and prolonged prothrombin time and partial thromboplastin time values. In all cases, the generalized oozing abated following administration of coagulation factors, and 2 cases required no further surgery. The apparent mechanism for obstetrically related DIC is release of placental tissue thromboplastin and/or amniotic fluid, which contain a procoagulant, into the maternal venous circulation. Use of larger amounts of pitocin (80-100 U) in patients undergoing late trimester abortion might further increase uterine muscle tone, resulting in more effective constriction of uterine vessels and decreasing the absorption of thromboplastin and amniotic fluid. A minimum of 3 thick lamineria tents should be inserted into the cervical canal 12-24 hours prior to a late midtrimester abortion. The primary therapeutic objective of treating the underlying disorder was achieved by removing all fetal and placental tissues, and procoagulants were given to replace consumed factors. In conclusion, patients undergoing late midtrimester abortions by D and E appear to be at increased risk of DIC. Based on the case reports, it is recommended that the period of recovery room observation be at least 2-3 hours, that coagulation status be assessed early when signs of increased bleeding are noticed, and that therapy with procoagulants be promptly administered if coagulation studies are abnormal. Availability of blood and coagulation factors should be checked before the procedure is initiated.