Clotting Disease in Pregnancy

What is D-Dimer?

D-dimeris afibrin degradation product(or FDP)

FDP: Small Protein fragments that result once clot is

broken up (i.e. fragments of the fibrin mesh)

D-dimer is so named due to it being a dimer of to D domains,

connected to an E domain of Fibrin

D-dimer concentration may be determined by

ablood testto help diagnosethrombosis.

Not normally in the blood, unless the coagulation

pathway is active
High Levels indicate clotting disorder favoring
thrombosis

Used as diagnostic criteria for: deep venous

thrombosis,pulmonary embolismor disseminated
intravascular coagulation

Causes of schistocytes (aka Helmet Cells)

Schistocytes are present in

microangiopathic hemolytic anemia

This is a form of anemia caused by damage to the

endothelial walls of small blood vessels
Clotting and irregularity of the cell walls damage
the RBCs

The fibrin mesh (loose fibrin that extends into the

vessel) damages the RBCs, causing their irregular shape

Specifically, this damage arises from the fibrin sticking to

the RBCs, which are then pulled away by the blood
pressure, causing some of the cells to tear

Causes of microangiopathic hemolytic anemia during

pregnancy

Pre-eclampsia/Eclampsia

HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome,

which is characterized by hemolysis, elevated liver enzymes, and
low platelets.

Linked to pre-existing hypertension (due to rushing of cells

through damaged/very small vessels), which also is present
in pre-eclampsia/eclampsia

Possible link to Gestational diabetes

Glycosylation damages the endothelial walls, resulting in clotting

and formation of microangiopathic hemolytic anemia

Has to be very high ( >220 Systolic or >130 dystolic at rest), known as malignant
hypertension

Not confirmed. Link exists in traditional diabetes that has gone unmanaged
but seems to mostly hypothetical in gestational diabetes

SLE (Lupus)- Will have appeared as a pre-existing condtion in

most cases, and our patient lacks the rash or other
associated symptoms

Causes of microangiopathic hemolytic

anemia during pregnancy
So, what else could it be?
Disseminated intravascular coagulation (DIC)
syndrome
Thrombotic thrombocytopenic purpura (TTP)

Disseminated intravascular coagulation (DIC) syndrome

The DIC syndrome is the most

common cause of an abnormal
hemorrhage tendency during
pregnancy.

Rapid clotting results in depletion of clotting factors,

resulting in lack of normal clotting

Diagnosis of the DIC syndrome:

Also common during child birth or

immediately following

In pregnancy it is an indicator of an
underlying issue with the pregnancy:

Placental Abruption
Eclampsia
Retention of a dead fetus
Amniotic fluid embolism,
Placental retention
Bacterial sepsis

Caused by systemic activation of

the coagulation cascade by
circulating clotting factors, with
secondary activation of the
fibrinolytic (clot breaking) system.

reduced levels of fibrinogen

and platelets,
prolongation of the thrombin,
prothrombin and partial
thromboplastin times
The presence of
fibrin/fibrinogen degradation
products (FDP) in the serum.

Treatment:

Prompt removal of the source

of pro-coagulant material
Replacement of depleted
clotting factors
in some cases, anticoagulation with heparin.

Thrombotic thrombocytopenic purpura (TTP)

TTP has two forms: Primary

and secondary

Symptoms:

Secondary is associated with

pregnancy

Time during pregnancy with

greatest risk for
development of TTP
hemolytic uremic syndrome
is near term and during the
postpartum period.
Rare: 1/25000 Pregnancies
Cause is unknown for
secondary TTP, beyond that
pregnancy can trigger it

Fatigue
Fever
Bleeding (from nose, gums)
Diarrhea
Chest pain
Kidney failure (dark urine,
jaundice)
Neurologic Symptoms
(confusion, headaches,
visual changes)
Thrombocytopenia
microangiopathic hemolytic
anemia

Treatment: Plasmaphoresis and Prednisone

My hypothesis:

Fetal death occurred at 30 weeks. However,

fetus was not expelled

This triggered the patient to suffer DIC syndrome

Alternative cause: Placenta Abruption

Patient lacks any confusion or other symptoms

of TTP, has no history or signs of lupus, and
their blood pressure is relatively low

Though the low blood pressure could be due to

blood loss.