DIC syndrome in obstetrics: treatment methods
DIC syndrome (disseminated intravascular coagulation syndrome) is a disorder in the functioning of the hemostasis system, which manifests itself primarily in the increased formation of blood clots in small vessels.
This pathology is relevant for various fields of medicine. Obstetricians, resuscitators, and surgeons are involved in the diagnosis and treatment of DIC syndrome. Pathology is found in both adults and children, including newborns. Often, coagulopathies (disorders in the process of blood clotting) are congenital in nature, but can develop throughout life. DIC syndrome in newborns is a form of coagulopathy.
The mechanism of development of the disorder is quite complex, the pathology can have many symptoms. For this reason, doctors face certain difficulties in making a diagnosis. DIC syndrome tends to aggravate the course of other diseases, but it is not an independent disease.
- Thrombosis: when is the norm, and when is the deviation?
- DIC syndrome - what are the causes?
- DIC syndrome: stages and forms
- Symptoms of DIC
- Diagnosis of disseminated intravascular coagulation
- Treatment of disseminated intravascular coagulation
Thrombosis: when is the norm, and when is the deviation?
Throughout life, a person receives various injuries, ranging from minor scratches to serious injuries. The body has its own defense mechanism aimed at stopping blood. To do this, in the damaged area, it begins to roll up, forming a blood clot.
In general, the body has two systems that have a cardinal opposite purpose. One system is called coagulation, and the second is anti-coagulation. If they work without any disturbances, then a balance is maintained in the body. When a threatening situation arises, for example, in case of injury, the blood coagulates, preventing massive bleeding. In the absence of any damage, the blood is in a liquid state.
In order for a blood clot to form at the site of damage to the vessel, the body must launch many complex reactions. They involve a protein called fibrinogen, which is present in blood plasma, as well as platelets, clotting factor, and various enzymes. As a result, the formed clot closes the defect on the vascular wall and prevents blood from flowing out.
If the vessel is not damaged, then the blood circulates through the vessels in a liquid state, preventing blood clots from forming. Antithrombotic mechanisms are responsible for this, which are carried out thanks to substances called anticoagulants. These include plasma proteins, endogenous heparin, and proteolytic enzymes. If fibrinogen begins to accumulate in one place or another of the vessel, then the rapid blood flow "breaks" it and a thrombus does not form. This mechanism is called fibrinolysis. It also involves enzymes that produce leukocytes, platelets and other blood cells. Small particles of fibrin in the future will simply be destroyed by macrophages and leukocytes.
If there is a failure in one or another hemostasis system, or a person develops a disease, the mechanisms that regulate the work of the coagulation and anticoagulation system fail. At the same time, blood clots begin to form in the body, the risk of massive bleeding increases. It is these disorders that underlie the development of DIC. They are extremely dangerous for human health and pose a threat to life.
DIC syndrome - what are the causes?
DIC syndrome is not a disease, but a consequence of certain disorders in the body.
Therefore, its development is influenced by a number of conditions:
- Infectious diseases accompanied by sepsis, or severe viral or bacterial infection.
Shock of any etiology: against the background of an injury, against the background of poisoning of the body, against the background of infection.
- A condition bordering on lethal outcome is clinical death.
- Operations for organ transplantation, for the installation of a prosthetic heart valve. Serious injury.
- Finding a person on the machine and blood circulation during the operation.
- Cancer lesions of internal organs. In terms of the development of DIC syndrome, leukemias are especially dangerous.
- In obstetric practice, DIC syndrome develops against a background of massive bleeding during childbirth, with early placental abruption, and with amniotic fluid embolism.
- During pregnancy, DIC syndrome can accompany severe toxicosis, Rh-conflict, ectopic pregnancy, and more.
- Diseases of the cardiovascular system.
- Inflammation of the internal organs, accompanied by suppuration.
DIC syndrome can develop with clinical death, during resuscitation measures. Against the background of terminal conditions, DIC syndrome either develops or will develop in the near future, if certain therapeutic measures are not taken.
In a healthy newborn child who appeared on time, DIC is very rarely diagnosed. It can be accompanied by neonatal hypoxia, which has a severe course, disturbances in the functioning of the respiratory system, and amniotic fluid embolism. In the latter case, the symptoms of DIC syndrome will be diagnosed in both the woman and the child.
Hereditary coagulopathies include hemophilia and von Willebrand disease. In this case, the child has increased bleeding. Thrombohemorrhagic syndrome in children is diagnosed very rarely. It can be provoked by infectious diseases and severe injuries.
DIC syndrome: stages and forms
Depending on the mechanism that triggered the development of DIC, the following stages are distinguished:
Hypercoagulable stage. At the same time, the concentration of thromboplastin in the blood increases, which contributes to its increased coagulability. As a result, blood clots begin to form in a person.
Consumption coagulopathy. In the blood, the level of coagulation factors increases, in response to this, the body increases fibrinolytic activity in order to prevent clogging of blood vessels with blood clots.
Hypocoagulation. During this period, there is a shortage of platelets in the body, since the body has used up their reserves during the previous stages. This situation leads to the fact that blood clotting poorly.
Recovery stage. So, any serious injury or bleeding, or any other damaging factor, entails an increased and uncontrolled consumption of platelets and other blood components responsible for its clotting. This causes their deficiency and further hypocoagulation with increased bleeding. Provided that during this period the patient is provided with high-quality medical care, he will have a recovery phase.
The severity of the lesion is due to the fact that blood clots form in all small vessels, which entails damage to most tissues of organs and systems.
Depending on the nature of the symptoms of DIC and on the severity of their course, the following forms are distinguished:
Acute form. Duration of acute disseminated intravascular coagulation can range from several hours to several days. Most often, this violation is accompanied by injuries, sepsis, surgical interventions, blood transfusion with massive blood loss.
Subacute form. This form of disseminated intravascular coagulation can last for several weeks. It most often accompanies chronic diseases of an infectious origin and autoimmune processes.
Chronic form. This form of disseminated intravascular coagulation can last for several years. Most often, it is diagnosed by therapists who observe patients with diseases of the liver, kidneys, heart, blood vessels, as well as diabetes. As the underlying disease progresses, the symptoms of DIC will increase.
Sometimes DIC can develop in just a few minutes. This form of pathology is called lightning fast. Most often, obstetric practitioners encounter such a variant of DIC.
Symptoms of DIC
If DIC has a subacute or chronic course, then diagnosing it by symptoms can be very problematic. The acute phase, on the other hand, is accompanied by severe clinical manifestations, which are expressed by skin rashes and increased bleeding. At the same time, it is not difficult to make a diagnosis.
Since blood clots form in small vessels against the background of DIC syndrome, organs such as the liver, lungs, skin and brain will be affected first. It is in them that the capillary network is more developed than in other organs. The prognosis for recovery depends on the severity of the DIC.
The main symptoms that make it possible to suspect DIC syndrome include:
- The appearance of a hemorrhagic rash on the skin. Possibly the appearance of foci of necrosis on the face, arms and legs.
- Dyspnea. It occurs as a result of lung damage. With increasing respiratory failure, respiratory arrest with pulmonary edema is possible.
- The accumulation of fibrin in the small vessels of the kidneys leads to malfunctions in their work, up to the development of renal failure. This is manifested by urinary retention and electrolyte imbalance in the body.
- Neurological disorders are the result of brain damage.
Also, DIC syndrome is characterized by the appearance of nosebleeds, uterine bleeding, the appearance of hematomas in the area of soft tissues and internal organs.
If we consider the symptoms of disseminated intravascular coagulation as a whole, then they boil down to the appearance of thrombosis and hemorrhage, as well as to disturbances in the work of most organs, which are life-supporting.
Diagnosis of disseminated intravascular coagulation
Diagnosis of DIC is impossible only on the basis of its clinical manifestations. Performing laboratory tests is a mandatory diagnostic measure. They make it possible not only to confirm the presence of DIC, but also to determine its stage and form.
The basic research method is a blood coagulogram, which makes it possible to detect a decrease in the number of platelets, an increase in fibrinogen (at the initial stage of the development of pathology) or its fall (at the subsequent stages of the development of DIC). Also, a coagulogram will determine an increase in blood clotting time and other disorders.
If a person died, then it is possible to conduct a postmortem diagnosis of DIC. For this, his tissues are sent for histological examination. They will contain blood cells that accumulate in the capillaries, as well as blood clots that clog them. The internal organs of a person are subject to multiple hemorrhages, covered with areas of necrosis.
If you suspect DIC, it is necessary to monitor blood counts, since at the initial stages of the development of pathology, they may be within normal limits. You also need to monitor electrolyte imbalance in the body, the level of urea and creatinine in the blood, urine output and blood pH.
Treatment of disseminated intravascular coagulation
There is simply no single regimen that could be used to treat any form of DIC. However, based on the stage of development of the pathological process, doctors have developed certain approaches to therapy.
First, you need to establish the cause of DIC.
Depending on this, the following approaches can be implemented:
- Prescribing antibiotics if DIC syndrome develops against a background of purulent conditions.
- Replenishment of blood with massive blood loss.
- Stabilization of the work of the heart and blood vessels, blood pressure during the development of a state of shock.
- Providing adequate obstetric care.
- Conducting pain relief in the development of shock against the background of trauma or other damage.
To eliminate the symptoms and manifestations of DIC syndrome, it is necessary to carry out the following therapy:
- Anticoagulant treatment. For this purpose, heparin is most often used, which allows to normalize blood coagulation processes, prevents blood clots from forming, and accelerates the process of their dissolution. As a result, the work of organs and tissues is normalized.
- Appointment of fibrinolytics and antifibrinolytics, which depends on the stage of disseminated intravascular coagulation. To make up for the lack of blood clotting factors, the patient is prescribed infusion therapy. For this, frozen plasma is used. It can be administered with Heparin, with the drug Gordox or Contrikal, which interfere with hypercoagulability.
- Improving blood flow, prescribing drugs to normalize blood microcirculation in blood vessels. To achieve these goals, Aspirin, Trental, Curantil and rheological solutions, for example, Voluven and Reopolyglyukin, are used.
- Extracorporeal detoxification. In this case, the patient undergoes hemodialysis, plasmapheresis, cytapheresis.
Sometimes the decision on the choice of a therapeutic regimen has to be made very quickly, since there are only seconds to save a person's life. It is imperative to take into account the stage of development of the DIC syndrome, since some drugs are indicated at one time, and at another point in time they can be categorically contraindicated. In parallel, the state of the blood coagulation system, its electrolyte and acid-base balance should be monitored.
Also, it is impossible to allow a person to endure pain, it is necessary to carry out anti-shock measures. At the first stage of the development of the pathological condition, the patient is injected with Heparin.
All patients who are at risk of developing thrombohemorrhagic syndrome, or have already been diagnosed, are delivered to the intensive care unit. If this syndrome has reached stage 3, then the probability of death is 70%. The chronic course of thrombohemorrhagic syndrome always ends with the death of the patient.
In order to prevent the development of DIC syndrome, it is necessary to diagnose it in a timely manner and select the appropriate therapy for the situation. The sooner hemostasis is normalized, the faster the person will recover.
Video: lecture by A. I. Vorobyov on DIC:
The author of the article: Shutov Maxim Evgenievich | Hematologist
Education: In 2013 he graduated from the Kursk State Medical University and received a diploma "General Medicine". After 2 years, completed residency in the specialty "Oncology". In 2016 completed postgraduate studies at the National Medical and Surgical Center named after N. I. Pirogov.