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doi:10.1111/jog.12426
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1500–1506, June 2014
Obstetrical disseminated intravascular coagulation score Takao Kobayashi Hamamatsu Medical Center, Shizuoka, Japan
Abstract Obstetrical disseminated intravascular coagulation (DIC) is usually a very acute, serious complication of pregnancy. The obstetrical DIC score helps with making a prompt diagnosis and starting treatment early. This DIC score, in which higher scores are given for clinical parameters rather than for laboratory parameters, has three components: (i) the underlying diseases; (ii) the clinical symptoms; and (iii) the laboratory findings (coagulation tests). It is justifiably appropriate to initiate therapy for DIC when the obstetrical DIC score reaches 8 points or more before obtaining the results of coagulation tests. Improvement of blood coagulation tests and clinical symptoms are essential to the efficacy evaluation for treatment after a diagnosis of obstetrical DIC. Therefore, the efficacy evaluation criteria for obstetrical DIC are also defined to enable follow-up of the clinical efficacy of DIC therapy. Key words: clinical symptoms, efficacy evaluation criteria for obstetrical disseminated intravascular coagulation, laboratory findings, obstetrical disseminated intravascular coagulation score, underlying diseases.
Introduction The common causes of maternal death during the perinatal period are postpartum hemorrhage, pulmonary thromboembolism/amniotic fluid embolism (PTE/ AFE) and pre-eclampsia/eclampsia. According to the ‘Annual of Pathological Autopsy Cases in Japan’ from 1989 to 2004, among 193 cases of maternal death due to direct obstetric causes, maternal death was caused by the following: AFE, 24.3%; disseminated intravascular coagulation (DIC) related to pregnancy-induced hypertension, 21.2%; PTE, 13.0%; injury to the birth canal, 11.4%; medical and surgical complications, 9.8%; and atonic bleeding or DIC of unknown cause, 8.3%.1 The incidence of PTE/AFE, which is still difficult to prevent and easily becomes fatal, has increased recently; however, DIC is closely related to the pathogenesis, management and prognosis of these conditions. Therefore, understanding DIC in obstetrics is an essential requirement for obstetricians.2 DIC, known as disseminated intravascular coagulopathy or consump-
tive coagulopathy, is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. As the small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs from the skin (e.g., from sites where blood samples were taken), the gastrointestinal tract, the respiratory tract and surgical wounds. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result. DIC is common in the critically ill, and may participate in the development of multiple organ failure, which may lead to death.3–5 The International Society on Thrombosis and Haemostasis (ISTH)6,7 and the Japanese Association for Acute Medicine (JAAM)8–10 published the diagnostic criteria for DIC after several recent clinical trials. These diagnostic criteria are modified versions of the Japanese Ministry of Health, Labor and Welfare (JMHLW)11 criteria (Table 1).12 These criteria are useful tools for
Received: January 28 2014. Accepted: February 10 2014. Reprint request to: Dr Takao Kobayashi, Hamamatsu Medical Center, 328, Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka 432-8580, Japan. Email: [email protected]
1500
© 2014 The Author Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Obstetrical DIC score
Table 1 Comparison among ISTH overt-DIC diagnostic criteria, the JMHLW DIC diagnostic criteria and JAAM DIC diagnostic criteria Overt-DIC diagnostic criteria by the ISTH
DIC diagnostic criteria by the JMHLW (without leukemia)
JAAM DIC diagnostic criteria
Underlying disease Clinical symptoms
0 points (essential) 0 points
0 points (essential) SIRS score ≥ 3, 1 point
Platelet counts (×103/μL)
>50 but ≤100, 1 point; ≤50, 2 points
1 point Bleeding, 1 point; organ failure, 1 point >80 but ≤120, 1 point; >50 but ≤80, 2 points; ≤50, 3 points
Fibrin-related marker
FDP, D-dimer, SF moderate increase, 2 points; strong increase, 3 points ≤1, 1 point
Fibrinogen (g/L) PT Diagnosis of DIC
Prolonged PT (sec) ≥3 but
doi:10.1111/jog.12426
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1500–1506, June 2014
Obstetrical disseminated intravascular coagulation score Takao Kobayashi Hamamatsu Medical Center, Shizuoka, Japan
Abstract Obstetrical disseminated intravascular coagulation (DIC) is usually a very acute, serious complication of pregnancy. The obstetrical DIC score helps with making a prompt diagnosis and starting treatment early. This DIC score, in which higher scores are given for clinical parameters rather than for laboratory parameters, has three components: (i) the underlying diseases; (ii) the clinical symptoms; and (iii) the laboratory findings (coagulation tests). It is justifiably appropriate to initiate therapy for DIC when the obstetrical DIC score reaches 8 points or more before obtaining the results of coagulation tests. Improvement of blood coagulation tests and clinical symptoms are essential to the efficacy evaluation for treatment after a diagnosis of obstetrical DIC. Therefore, the efficacy evaluation criteria for obstetrical DIC are also defined to enable follow-up of the clinical efficacy of DIC therapy. Key words: clinical symptoms, efficacy evaluation criteria for obstetrical disseminated intravascular coagulation, laboratory findings, obstetrical disseminated intravascular coagulation score, underlying diseases.
Introduction The common causes of maternal death during the perinatal period are postpartum hemorrhage, pulmonary thromboembolism/amniotic fluid embolism (PTE/ AFE) and pre-eclampsia/eclampsia. According to the ‘Annual of Pathological Autopsy Cases in Japan’ from 1989 to 2004, among 193 cases of maternal death due to direct obstetric causes, maternal death was caused by the following: AFE, 24.3%; disseminated intravascular coagulation (DIC) related to pregnancy-induced hypertension, 21.2%; PTE, 13.0%; injury to the birth canal, 11.4%; medical and surgical complications, 9.8%; and atonic bleeding or DIC of unknown cause, 8.3%.1 The incidence of PTE/AFE, which is still difficult to prevent and easily becomes fatal, has increased recently; however, DIC is closely related to the pathogenesis, management and prognosis of these conditions. Therefore, understanding DIC in obstetrics is an essential requirement for obstetricians.2 DIC, known as disseminated intravascular coagulopathy or consump-
tive coagulopathy, is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. As the small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs from the skin (e.g., from sites where blood samples were taken), the gastrointestinal tract, the respiratory tract and surgical wounds. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result. DIC is common in the critically ill, and may participate in the development of multiple organ failure, which may lead to death.3–5 The International Society on Thrombosis and Haemostasis (ISTH)6,7 and the Japanese Association for Acute Medicine (JAAM)8–10 published the diagnostic criteria for DIC after several recent clinical trials. These diagnostic criteria are modified versions of the Japanese Ministry of Health, Labor and Welfare (JMHLW)11 criteria (Table 1).12 These criteria are useful tools for
Received: January 28 2014. Accepted: February 10 2014. Reprint request to: Dr Takao Kobayashi, Hamamatsu Medical Center, 328, Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka 432-8580, Japan. Email: [email protected]
1500
© 2014 The Author Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Obstetrical DIC score
Table 1 Comparison among ISTH overt-DIC diagnostic criteria, the JMHLW DIC diagnostic criteria and JAAM DIC diagnostic criteria Overt-DIC diagnostic criteria by the ISTH
DIC diagnostic criteria by the JMHLW (without leukemia)
JAAM DIC diagnostic criteria
Underlying disease Clinical symptoms
0 points (essential) 0 points
0 points (essential) SIRS score ≥ 3, 1 point
Platelet counts (×103/μL)
>50 but ≤100, 1 point; ≤50, 2 points
1 point Bleeding, 1 point; organ failure, 1 point >80 but ≤120, 1 point; >50 but ≤80, 2 points; ≤50, 3 points
Fibrin-related marker
FDP, D-dimer, SF moderate increase, 2 points; strong increase, 3 points ≤1, 1 point
Fibrinogen (g/L) PT Diagnosis of DIC
Prolonged PT (sec) ≥3 but
