Bleeding caused by a violation of the blood coagulation system during childbirth and during pregnancy. DIC syndrome and its phases.
It is now generally accepted that the gestational process causes changes in the hemostasis system aimed at ensuring the functioning of the mother-placenta-fetus system.
Pregnancy is regarded as a hypercoagulable condition, with changes taking place in all parts of the hemostasis system: subnitrombocytic, procoagulation, clotting inhibitors and proteolytic: the platelet count increases, but their aggregation activity decreases slightly, the concentration and activity of the main procoagulants and fibrinogen level increases, fibrinolytic activity decreases. These changes are regarded as physiological, conditioned by the adaptive-protective reaction of the organism, which contributes to rapid and reliable stopping of postpartum hemorrhage.
Investigation of the hemostatic system in pregnant women and parturient women before bleeding indicates a more pronounced hypercoagulation: along with an increase in the number of platelets their aggregation activity increases, with the increase in the level and concentration of fibrinogen, its quality also changes. In blood plasma, fibrinogen B appears in increasing amounts, as indicated by positive paracoagulation tests. Its appearance indicates the activation of intravascular coagulation of blood and possibly the development of DIC syndrome. To block the contractile activity of the uterus leads to an elevated concentration of fibrin degradation products, this can cause the uterine hypotonia refractory to the action of endo- and exogenous oxytetics.
Thus, changes in the system of hemostasis during pregnancy and childbirth before bleeding are regarded as potential hypercoagulation in the chronic form of DIC syndrome.
The content of this phenomenon consists in excessive activation of plasma and platelet clotting factors, their inclusion in the process of intravascular coagulation in the microcirculation system, depletion of natural inhibitors of clotting and substrates of fibrinolysis, when hypocoagulation develops as a result of consumption of coagulation factors, but increased thromboplastin activity.
Acute bleeding caused by violations of the blood coagulation system, arise at the following states:
- Complicated pregnancy and childbirth (premature detachment of the normally located placenta, embolism of the amniotic fluid, birth of the dead fetus, rupture of the body or cervix, infection, rough uterine massage);
- Congenital diseases of the blood system (thrombocytopenic purpura, angiogemophilia, etc.)
- Dysadaptation of the hemostasis system, when hypocoagulation takes place instead of physiological adaptive hypercoagulation at the end of the third trimester of pregnancy.
Under these conditions, active thromboplastin substances can enter the general circulatory system, which leads to intravascular coagulation of the blood. In this case, there is a progressive decrease in the concentration of fibrinogen, prothrombin and other factors of coagulation with subsequent deterioration of blood coagulation.
The clinical picture with coagulopathic hemorrhage depends on the form and phase of the DIC syndrome.
The phases of ICE
Phase I - hypercoagulation (Lee-White time less than 4 min).
II phase - gradual depletion of hemostasis (Lee-White time is more than 10-12 minutes), there is general bleeding, microcirculation in organs is disturbed, the content of antithrombin III sharply decreases.
III phase - decompensation of hemostasis (shock III degree of severity). The blood does not clot.
IV phase - thrombotic-embolic complications (from 1 to 3 weeks).
DIC-syndrome can occur in acute, subacute and chronic forms.
Treatment of the DIC syndrome depends on the phase of the process: when hypercoagulable - heparin 2500 ED after 5-10 minutes 2-4 times, transfusion of heparinized blood, but this stage is very difficult to determine and bleeding with ICE syndrome is diagnosed already with the hypocoagulant phase. At present, fresh frozen plasma is required. It is recommended to transfuse erythrocyte mass, svizho-citrate blood, dry plasma, albumin, protamine sulfate, dicinone, cryoprecipitate, gelatin solution, volekamu, vikasol, calcium chloride solution. Introduce inhibitors of proteolysis: countercranial, gordoks, or trasilol.
In a number of cases there is no normalization of blood coagulation, afribnogenemia develops, profuse bleeding, as a result of which a woman dies