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Intrapartum anti-disseminated intravascular coagulation therapy leading to successful vaginal delivery following intrauterine fetal death caused by placental abruption: a case report.

Honda M, Matsunaga S, Era S, Takai Y, Baba K, Seki H - J Med Case Rep (2014)

Bottom Line: To reduce postpartum hemorrhage, 6g of fibrinogen concentrate and tranexamic acid, an antifibrinolytic agent, were administered immediately before extraction of the dead fetus and placenta.Although the amount of intrapartum hemorrhage was 1824g, there was no abnormal bleeding after delivery, and our patient was discharged three days later.In cases of placental abruption complicated with disseminated intravascular coagulation, intrapartum administration of coagulation factors can simultaneously promote effective labor and correct hypofibrinogenemia, enabling minimally invasive vaginal delivery.

View Article: PubMed Central - PubMed

Affiliation: Center of Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan. shige_m@saitama-med.ac.jp.

ABSTRACT

Introduction: Disseminated intravascular coagulation due to placental abruption with intrauterine fetal death is not uncommon. It can result in increased maternal mortality rates and the need for hysterectomy or greater transfusion volumes if the delivery is not completed within six to eight hours. However, consensus is lacking regarding the delivery approach for cases in which delivery is prolonged.

Case presentation: A 37-year-old Japanese woman was transported to our tertiary center two and a half hours after the onset of labor because of a diagnosis of placental abruption with intrauterine fetal death at 40 weeks and three days' gestation. On arrival, although severe hypofibrinogenemia was observed, there was no external hemorrhage. Because her cervical canal dilation was good (Bishop score, 7), labor was induced using oxytocin. Anti-disseminated intravascular coagulation therapy was simultaneously started via transfusion. After her hypofibrinogenemia resolved, delivery progressed rapidly, and the fetus was delivered approximately 10 hours after the onset. To reduce postpartum hemorrhage, 6g of fibrinogen concentrate and tranexamic acid, an antifibrinolytic agent, were administered immediately before extraction of the dead fetus and placenta. Although the amount of intrapartum hemorrhage was 1824g, there was no abnormal bleeding after delivery, and our patient was discharged three days later.

Conclusion: In cases of placental abruption complicated with disseminated intravascular coagulation, intrapartum administration of coagulation factors can simultaneously promote effective labor and correct hypofibrinogenemia, enabling minimally invasive vaginal delivery.

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Clinical course and administration of coagulation factors in placental abruption. DIC, disseminated intravascular coagulation; FDP, fibrinogen degradation products; FFP, fresh frozen plasma.
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Fig3: Clinical course and administration of coagulation factors in placental abruption. DIC, disseminated intravascular coagulation; FDP, fibrinogen degradation products; FFP, fresh frozen plasma.

Mentions: Vaginal delivery was selected because her vital signs were stable, no signs of organ failure were detected with the laboratory tests, and her cervical canal dilation was good. Labor was induced by administering incremental doses of oxytocin at 2mIU/mL every 30 minutes from 5:30 AM. Transfusion of red cell concentrate (RCC) and fresh-frozen plasma (FFP) was also started. Her uterine contractions increased from 6:00 AM, but effective labor was not achieved. At 9:00 AM, her blood fibrinogen level was <70mg/dL with no improvement in DIC although a total of eight units of RCC and 24 units of FFP had been transfused. At this time, amniotomy was performed in anticipation of labor progression, but her cervical os was still 5cm with no remarkable progression at 10:00 AM. At 10:30 AM, her blood fibrinogen level increased to 112mg/dL, and labor progressed rapidly. To reduce the amount of hemorrhaging, 1000mg of the antifibrinolytic agent tranexamic acid and 6g of fibrinogen concentrate were administered immediately before delivery. At 11:47 AM, a dead fetus and placenta, together with 900g of blood and gelosis, were extracted. Oxytocin was administered, and bimanual compression of her uterus was performed. Because slight uterine atony was noted, her uterus was packed with gauze to prevent additional bleeding. No birth canal injury was seen. Her blood fibrinogen level at 2:00 PM was 326mg/dL, and DIC was dissolved quickly with no subsequent abnormal hemorrhaging. The time required for labor was nine hours and 47 minutes from its initial onset, the amount of intrapartum hemorrhage was 1824g, and the total transfused volume was 12 units of RCC, 30 units of FFP, 20 units of platelet concentrate, 6g of fibrinogen concentrate, and 3000 units of human antithrombin concentrate. The weight of the placenta was 420g, and approximately 50% of the placenta appeared to be abrupted. The fetus was a male weighing 3024g with no congenital defect. After the gauze was removed the next morning, day three, our patient was discharged (FigureĀ 3).Figure 3


Intrapartum anti-disseminated intravascular coagulation therapy leading to successful vaginal delivery following intrauterine fetal death caused by placental abruption: a case report.

Honda M, Matsunaga S, Era S, Takai Y, Baba K, Seki H - J Med Case Rep (2014)

Clinical course and administration of coagulation factors in placental abruption. DIC, disseminated intravascular coagulation; FDP, fibrinogen degradation products; FFP, fresh frozen plasma.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4307188&req=5

Fig3: Clinical course and administration of coagulation factors in placental abruption. DIC, disseminated intravascular coagulation; FDP, fibrinogen degradation products; FFP, fresh frozen plasma.
Mentions: Vaginal delivery was selected because her vital signs were stable, no signs of organ failure were detected with the laboratory tests, and her cervical canal dilation was good. Labor was induced by administering incremental doses of oxytocin at 2mIU/mL every 30 minutes from 5:30 AM. Transfusion of red cell concentrate (RCC) and fresh-frozen plasma (FFP) was also started. Her uterine contractions increased from 6:00 AM, but effective labor was not achieved. At 9:00 AM, her blood fibrinogen level was <70mg/dL with no improvement in DIC although a total of eight units of RCC and 24 units of FFP had been transfused. At this time, amniotomy was performed in anticipation of labor progression, but her cervical os was still 5cm with no remarkable progression at 10:00 AM. At 10:30 AM, her blood fibrinogen level increased to 112mg/dL, and labor progressed rapidly. To reduce the amount of hemorrhaging, 1000mg of the antifibrinolytic agent tranexamic acid and 6g of fibrinogen concentrate were administered immediately before delivery. At 11:47 AM, a dead fetus and placenta, together with 900g of blood and gelosis, were extracted. Oxytocin was administered, and bimanual compression of her uterus was performed. Because slight uterine atony was noted, her uterus was packed with gauze to prevent additional bleeding. No birth canal injury was seen. Her blood fibrinogen level at 2:00 PM was 326mg/dL, and DIC was dissolved quickly with no subsequent abnormal hemorrhaging. The time required for labor was nine hours and 47 minutes from its initial onset, the amount of intrapartum hemorrhage was 1824g, and the total transfused volume was 12 units of RCC, 30 units of FFP, 20 units of platelet concentrate, 6g of fibrinogen concentrate, and 3000 units of human antithrombin concentrate. The weight of the placenta was 420g, and approximately 50% of the placenta appeared to be abrupted. The fetus was a male weighing 3024g with no congenital defect. After the gauze was removed the next morning, day three, our patient was discharged (FigureĀ 3).Figure 3

Bottom Line: To reduce postpartum hemorrhage, 6g of fibrinogen concentrate and tranexamic acid, an antifibrinolytic agent, were administered immediately before extraction of the dead fetus and placenta.Although the amount of intrapartum hemorrhage was 1824g, there was no abnormal bleeding after delivery, and our patient was discharged three days later.In cases of placental abruption complicated with disseminated intravascular coagulation, intrapartum administration of coagulation factors can simultaneously promote effective labor and correct hypofibrinogenemia, enabling minimally invasive vaginal delivery.

View Article: PubMed Central - PubMed

Affiliation: Center of Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan. shige_m@saitama-med.ac.jp.

ABSTRACT

Introduction: Disseminated intravascular coagulation due to placental abruption with intrauterine fetal death is not uncommon. It can result in increased maternal mortality rates and the need for hysterectomy or greater transfusion volumes if the delivery is not completed within six to eight hours. However, consensus is lacking regarding the delivery approach for cases in which delivery is prolonged.

Case presentation: A 37-year-old Japanese woman was transported to our tertiary center two and a half hours after the onset of labor because of a diagnosis of placental abruption with intrauterine fetal death at 40 weeks and three days' gestation. On arrival, although severe hypofibrinogenemia was observed, there was no external hemorrhage. Because her cervical canal dilation was good (Bishop score, 7), labor was induced using oxytocin. Anti-disseminated intravascular coagulation therapy was simultaneously started via transfusion. After her hypofibrinogenemia resolved, delivery progressed rapidly, and the fetus was delivered approximately 10 hours after the onset. To reduce postpartum hemorrhage, 6g of fibrinogen concentrate and tranexamic acid, an antifibrinolytic agent, were administered immediately before extraction of the dead fetus and placenta. Although the amount of intrapartum hemorrhage was 1824g, there was no abnormal bleeding after delivery, and our patient was discharged three days later.

Conclusion: In cases of placental abruption complicated with disseminated intravascular coagulation, intrapartum administration of coagulation factors can simultaneously promote effective labor and correct hypofibrinogenemia, enabling minimally invasive vaginal delivery.

Show MeSH
Related in: MedlinePlus