DIC in Pregnancy – Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments

Figures & data

Figure 1 The different types of DIC and their clinical presentation. If there is predominance of coagulation pathway activation (denoted as C), in comparison with the fibrinolytic pathways (denoted as F), procoagulant DIC is the result. While the reverse leads to hyperfibrinolytic DIC.

Notes: Reprinted from: Thachil J. The Elusive Diagnosis of Disseminated Intravascular Coagulation: does a Diagnosis of DIC Exist Anymore? Semin Thromb Hemost. 2019;45:100–107.²⁴ With permission. Copyright © Georg Thieme Verlag KG.

Figure 2 Obstetrical complications associated with DIC in pregnancy.

Figure 3 Global distribution of obstetrical complications associated with DIC in pregnancy.

Note: Data was modified from references 4, 5, 26 and 32.

Figure 4 Schematic representation of pathogenic pathways in DIC.

Notes: Adapted from: Levi M. Disseminated intravascular coagulation. Crit Care Med. https://journals.lww.com/ccmjournal/pages/default.aspx. 2007;35(9):2191–2195.⁴⁹ With permission. © 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

Figure 5 Mechanisms of DIC in sepsis involving endothelial dysfunction and platelet activation.

Notes: Reproduced from: Hunt BJ. Bleeding and Coagulopathies in Critical Care. N Engl J Med. 2014;370:847–859.¹⁹⁹ Copyright © 2014 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

Figure 6 Trophoblast deportation and systemic activation of maternal coagulation cascade. Coagulation system is activated in the placental circulation in the normal pregnant state. This activated coagulation can spill into the peripheral circulation in patients who have obstetrical complications like pre-eclampsia. If coagulation activation in the peripheral circulation becomes uncontrolled, it manifests as DIC.

Table 1 Adaptive Changes of the Coagulation System During Pregnancy

Category	Increased	Decreased	No Change
Systemic changes
Procoagulant factors	I, V, VII, VIII, IX, X	XI
Anticoagulation proteins	Soluble TM	PS	PC
Adhesive proteins	vWF
Fibrinolytic proteins	PAI-1, PAI-2	t-PA	TAFI
Microparticles and antiphospholipid antibodies	MP		ALPA
Local placental changes	TF	TFPI

Notes: Reprinted from: Brenner B. Haemostatic changes in pregnancy. Thromb Res. 2004;114(5–6):409—414.¹⁹⁸ With permission from Elsevier. doi: 10.1016/j.thromres.2004.08.004.

Table 2 An Effect of Components of the New DIC Score – Results of Logistic Regression

	Effect of Individual Analytes		Effect of Individual Analytes Adjusted to Other Tests		Assigned Weight^a
	Relative Risk	p-value	Relative Risk	p-value
PT difference (seconds)
<0.5	1.0		1.0		0
0.5–1	12.7	0.031	29.3	<0.001	5
1.0–1.5	27.7	0.005	68.8	<0.001	12
>1.5	60.3	<0.001	558.1	<0.001	25
Platelets (10^9/L)
<50	3.1	0.06	89.2	<0.001	1
50−100	5.2	<0.001	56.2	<0.001	2
100−185	2.9	0.001	12.8	<0.001	1
>185	1.0		1.0		0
Fibrinogen (g/L)
<3.0	59.0	<0.001	662.9	<0.001	25
3.0–4.0	13.4	<0.001	59.1	<0.001	6
4.0–4.5	2.4	0.320	6.8	0.03	1
>4.5	1.00		1.0		0

Notes: ^aWeight was calculated as relative risk of each of the adjusted factors to the relative risk of a factor with minimal effect. Adapted from: Erez O, Novack L, Beer-Weisel R, et al. DIC score in pregnant women–a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9:e93240.⁵ Copyright: © 2014 Erez et al. Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/legalcode)

Figure 7 The changes in the major components of the pregnancy modified DIC score: (A) PT difference: (stands for the difference between the patients PT results and the laboratory control); (B) platelets; (C) fibrinogen, with advancing gestations in women with advancing gestation. (D) ROC curve analysis for the association of the pregnancy specific DIC score with the development of DIC.

Notes: Adapted from: Erez O, Novak L, Beer-Weisel et al. DIC score in pregnant women–a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9(4):e93240.⁵ Copyright: © 2014 Erez et al. Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/legalcode).

Figure 8 Principles of Diagnosis and management of DIC in pregnancy.

Notes: Reproduced from: Erez O. Disseminated intravascular coagulation in pregnancy - Clinical phenotypes and diagnostic scores. Thromb Res. 2017;151203 1:S56-S60.²⁰⁰ With permission. Copyright © 2017 Elsevier Ltd. All rights reserved.

Figure 9 Algorithm for the treatment of obstetrical hemorrhage based on FIBTEM and fibrinogen concentrations.

Notes: Reprinted from: Collins PW, Bell SF, de Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int J Obstet Anesth. 2019;37:106–117.¹⁶⁷ With permission Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.

Figure 10 The ROTEM protocol of the OBS Cymru (the Obstetric Bleeding Strategy for Wales) initiative.

Notes: Reproduced with permission from: ROTEM Protocol (For use in postpartum haemorrhage); 2018. Obstetric Bleeding Strategy for Wales. Available from: https://phw.nhs.wales/services-and-teams/improvement-cymru/improvement-cymru-programmes/maternity-cymru/obs-cymru/obstetric-bleeding-strategy-cymru/rotem-point-of-care-testing.²⁰¹ Copyright © 2016, Public Health Wales.

Thachil J. The Elusive Diagnosis of Disseminated Intravascular Coagulation: does a Diagnosis of DIC Exist Anymore? Semin Thromb Hemost. 2019;45:100–107. doi:10.1055/s-0038-1677042

 PubMed Web of Science ®Google Scholar

Levi M. Disseminated intravascular coagulation. Crit Care Med. 2007;35:2191–2195. doi:10.1097/01.CCM.0000281468.94108.4B

 PubMed Web of Science ®Google Scholar

Hunt BJ. Bleeding and Coagulopathies in Critical Care. N Engl J Med. 2014;370:847–859. doi:10.1056/NEJMra1208626

 PubMed Web of Science ®Google Scholar

Brenner B. Haemostatic changes in pregnancy. Thromb Res. 2004;114(5–6):409–414. doi:10.1016/j.thromres.2004.08.004

 PubMed Web of Science ®Google Scholar

Erez O, Novack L, Beer-Weisel R, et al. DIC score in pregnant women–a population based modification of the International Society on Thrombosis and Hemostasis score. PLoS One. 2014;9:e93240. doi:10.1371/journal.pone.0093240

 PubMed Web of Science ®Google Scholar

Erez O. Disseminated intravascular coagulation in pregnancy - Clinical phenotypes and diagnostic scores. Thromb Res. 2017;151(Suppl 1):S56–S60. doi:10.1016/S0049-3848(17)30069-5

 PubMed Web of Science ®Google Scholar

Collins PW, Bell SF, de Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int J Obstet Anesth. 2019;37:106–117. doi:10.1016/j.ijoa.2018.08.008

 PubMed Web of Science ®Google Scholar

ROTEM Protocol (For use in postpartum haemorrhage); 2018. Obstetric Bleeding Strategy for Wales. Available from: https://phw.nhs.wales/services-and-teams/improvement-cymru/improvement-cymru-programmes/maternity-cymru/obs-cymru/obstetric-bleeding-strategy-cymru/rotem-point-of-care-testing. Accessed September 25, 2021.

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