Abstract
Disseminated intravascular coagulation (DIC) is a life-threatening event that is the endpoint of a pathologically activated cascade leading to excessive consumption of platelets culminating in bleeding. Several diseases are known to be associated with DIC, some of which may also occur during pregnancy or the puerperium. One of the potential risk factors that have been considered as a potential trigger for DIC is the retention of a highly macerated fetus after intrauterine fetal death (IUFD). However, sparse evidence exists on its clinical implication on hemostasis parameters. In this retrospective single-center study, we investigated the role of fetal maceration grades 0-III on the risk of DIC in 91 women following IUFD between gestational weeks (+days) 22 + 0 and 41 + 6 between 2003 and 2017. We calculated the Erez DIC-score after consideration of maternal platelet count (PC), prothrombin time (PT) and fibrinogen (Fib) and correlated the findings with fetal maceration grade. Mean (±SD) age of women was 32.1 ± 6.7 years. Neither maternal hemostasis parameters (PC, PT, Fib), nor the Erez score showed a statistically significant difference between maceration grades 0-III with median values of 1 for all four grades (maceration grade I: range 0 to 27; I: 0 to 51; II: 0 to 52; III: 0 to 39). We therefore conclude, that the pathophysiology of DIC in women after singleton IUFD is unrelated to the degree of fetal maceration.
Highlights
Disseminated intravascular coagulation (DIC) is a clinicopathological syndrome characterized by the formation of fibrin clots with concomitant consumption of platelets and coagulation factors that leads to organ failure and contributes to a high mortality if left untreated[1,2,3]
Obstetrical conditions associated with DIC include placental abruption due to a large amount of released collagen[6,7,8,9], amniotic fluid embolism with circulating mucin cells causing rapid defibrinolysis in maternal circulation[10,11], maternal septic shock with hematogenous spread of exotoxins, endotoxins and tissue damage accompanied by acidosis[12,13,14,15,16], as well as preeclampsia and HELLP syndrome due to hypercoagulation and endothelial injury
In this study our aim was to explore the impact of fetal maceration grade on the risk of maternal coagulopathy after singleton intrauterine fetal death (IUFD), as expressed by pathophysiological changes in biochemical markers and the clinical picture of the patient
Summary
Disseminated intravascular coagulation (DIC) is a clinicopathological syndrome characterized by the formation of fibrin clots with concomitant consumption of platelets and coagulation factors that leads to organ failure and contributes to a high mortality if left untreated[1,2,3]. More recent evidence shows that women after IUFD are found to have increased in-vivo thrombin generation and platelet activation when compared to healthy mothers[25] Their amniotic fluid contains higher levels of tissue factor concentrations indicating higher thrombin generation. Despite anecdotal case-reports on establishment of DIC in women during or after prolonged retention of a dead fetus, there is a lack of evidence to verify this association. We designed this retrospective cohort study to prove the hypothesis, whether higher grades of fetal maceration, as denominator for prolonged fetal retention, elicit hematological changes in the maternal system and therewith increase the risk of DIC in this population after IUFD. We calculated the Erez score[26] in all eligible women from our institution between 2003 and 2017 and correlated these results with the fetal maceration grades 0 to III, as obtained from the pathology reports following fetal post-mortem autopsy
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