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  1. Home
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  3. Haemorrhage and Thrombosis for the MRCOG and Beyond
  • Edited by Ann Harper, Royal Jubilee Maternity Belfast
Publisher:
Cambridge University Press
Online publication date:
October 2014
Print publication year:
2005
Online ISBN:
9781139924498
DOI:
https://doi.org/10.1017/CBO9781139924498
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Series:
Membership of the Royal College of Obstetricians and Gynaecologists and Beyond
Information

Book description

Although disorders of the coagulation system are uncommon in pregnancy, the two main hazards - haemorrhage and thromboembolism - are leading causes of direct maternal death in the UK and worldwide. Gynaecologists may encounter abnormal haemostasis as a cause of intractable menorrhagia or perioperative haemorrhage, and thromboembolism is a significant risk for women undergoing major gynaecological surgery. This book brings together various aspects of haemostasis in relation to obstetrics and gynaecology to provide practical guidance to clinicians, who may only occasionally encounter these problems. Emphasis is placed on the need for good working relationships and close liaison between obstetricians and gynaecologists, anaesthetists, haematologists and blood transfusion services. The book is primarily designed to provide a comprehensive summary for candidates preparing for the Part 2 MRCOG examination, and as such covers the RCOG curriculum for haemorrhage and thrombosis. It is also a valuable guide for all healthcare professionals working in the field.

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Contents

Contents
  • 1 - The coagulation system in pregnancy
    pp 1-15
  • View abstract

    Summary

    The changes in the coagulation system in normal pregnancy are consistent with a continuing low grade process of coagulant activity. Using electron microscopy, fibrin deposition can be demonstrated in the intervillous space of the placenta and in the walls of the spiral arteries supplying the placenta. Normal pregnancy is accompanied by dramatic changes in the coagulation and fibrinolytic systems, with a marked increase in some of the procoagulant factors, particularly fibrinogen, and suppression of fibrinolysis. Certain disease states specific to pregnancy have profound effects on platelet consumption, lifespan and function. A fall in the platelet count may precede any detectable rise in serum fibrin degradation products (FDP) in women subsequently developing pre-eclampsia. The most common platelet abnormality encountered in clinical practice is thrombocytopenia. During healthy pregnancy there is little change in antithrombin level but there is some decrease at parturition and an increase in the puerperium.
  • 2 - Pregnancy in women with inherited bleeding disorders
    pp 16-26
  • View abstract

    Summary

    This chapter discusses the management of pregnancy and delivery in women suffering from an inherited bleeding disorder such as von Willebrand's disease or haemophilia, or are female partners of affected men. The daughters of men with haemophilia are obligate carriers, with a 50:50 chance of passing on the condition to a son and a similar chance that a daughter will be a carrier of the condition. Chorionic villus sampling, or biopsy, is the principal method used for antenatal diagnosis of haemophilia. Deficiency of von Wille brand factor (VWF) typically results in easy bruising, prolonged bleeding from cuts and scratches, epistaxis and menorrhagia. It is prudent to check the VWF level in all women with von Willebrand's disorder a few days after delivery: an infusion of DDAVP (l-desamino-8-D-arginine vasopressin; desmopressin) may be indicated where the level falls significantly soon after delivery.
  • 3 - Maternal and fetal thrombocytopenia
    pp 27-41
  • View abstract

    Summary

    Thrombocytopenia in the mother and fetus is a common problem. This chapter reviews its causes, clinical significance, investigation and management. Thrombocytopenia complicating hypertensive disorders of pregnancy is responsible for about 20% of cases of maternal thrombocytopenia. The pregnancy-related causes of disseminated intravascular coagulation (DIC) include pre-eclampsia, placental abruption, amniotic fluid embolism and, rarely, retention of a dead fetus. Immune thrombocytopenia is responsible for about 4% of maternal thrombocytopenia. Most cases are due to idiopathic autoimmune thrombocytopenia, but some are drug-related and some associated with HIV infection. Neonatal thrombocytopenia has many causes, and is the most common haematological problem in the newborn infant, and probably the fetus as well. A better understanding of the risks of thrombocytopenia in pregnancy to the mother and fetus has resulted in better targeting of treatment: withholding it in low-risk situations and using intensive therapy where there is high risk.
  • 4 - Massive obstetric haemorrhage
    pp 42-58
  • View abstract

    Summary

    Massive obstetric haemorrhage is usually due to placenta praevia, premature placental separation or postpartum causes and is often associated with coagulopathy. Most maternal deaths associated with ectopic pregnancy, which is the most common cause of death in early pregnancy, are due to haemorrhage. Many women who have died from ectopic pregnancy presented with symptoms of urinary or gastrointestinal conditions. The main causes of antepartum haemorrhage are placenta praevia and placental abruption. A high incidence of false positive diagnosis of placenta praevia is associated with second-trimester transabdominal ultrasound scans. The most common cause of primary postpartum haemorrhage is uterine atony. The signs and symptoms of secondary postpartum haemorrhage include a rising pulse rate, falling blood pressure, pallor, sweating, restlessness and oliguria. Haemorrhage can occur suddenly and unexpectedly in any woman. However, some women are at increased risk of bleeding.
  • 5 - Disseminated intravascular coagulation
    pp 59-71
  • View abstract

    Summary

    Disseminated intravascular coagulation (DIC) is characterised by an imbalance between prothrombotic and antithrombotic activities. It may complicate a wide range of clinical disorders, including tissue destruction associated with surgery or trauma, serious bacterial or non-bacterial infection, malignancy and a variety of obstetric mishaps. Increased consumption/degradation and reduced production result in low levels of the most important natural inhibitor of thrombin, antithrombin. The clinical presentation of DIC is variable. Sometimes there is little obvious apart from oozing from venepuncture sites but some patients present with serious bleeding. Obstetric complications are frequently associated with clinically severe DIC. The basis of the diagnosis of DIC is an appreciation of the underlying disorders in which DIC can develop. Acute DIC is a serious complication which carries with it a high risk of mortality. It is generally accepted that the cornerstone of management of DIC is treatment of the underlying cause.
  • 6 - Gynaecological problems in women with bleeding disorders
    pp 72-89
  • View abstract

    Summary

    Excessive or abnormal vaginal bleeding are the most common symptoms when women present to a gynaecologist. Undiagnosed bleeding disorders, especially Von Willebrand's disorder, can be the under-lying cause of menorrhagia in a significant proportion of women. This chapter aims to increase awareness and provide basic information about these relatively uncommon disorders. Immune idiopathic thrombocytopenic purpura (lTP) in adults is usually a chronic disorder with an insidious onset of minor bleeding symptoms. Menorrhagia and dysmenorrhoea adversely affect women's quality of life and may have a major influence on lifestyle and employment. DDAVP (1-desamino-8-D-arginine vasopressin) nasal spray increases von Willebrand factor (VWF) and FVIII and can be used as a home treatment for some women with bleeding disorders. Increased awareness among clinicians of these problems and the treatment options available are essential to improve quality of life and avoid unnecessary surgical intervention.
  • 7 - Venous thromboembolism in obstetrics and gynaecology
    pp 90-110
  • View abstract

    Summary

    Venous thromboembolism (VTE) remains the major cause of mortality in association with pregnancy and childbirth and a source of morbidity. Many therapeutic agents may be used in the management of VTE. The choice of the agent and dosage is determined by the setting, balance of risks and benefit, and individual patient factors such as allergy or co-morbidity. Certain therapeutic agents include heparin, warfarin, dextran 70, aspirin and hirudin. The identification of risk factors for VTE provides an opportunity for prevention. The symptoms and signs of deep veins of lower limbs (DVT) include leg pain, swelling, tenderness, oedema, pyrexia, lower abdominal pain and elevated white cell count. Traditionally, unfractionated heparin (UFH) has been used in the initial management of VTE as such treatment reduces the risk of further thromboembolism compared with no treatment. Thromboprophylaxis is effective in reducing the incidence of VTE.
  • 8 - Genetic thrombophilias and antiphospholipid antibodies
    pp 111-127
  • View abstract

    Summary

    Venous thromboembolism (VTE) is a common cause of morbidity and mortality and has been implicated in the pathophysiology of a number of obstetric complications. This chapter provides an overview of the more common genetic thrombophilias and the acquired thrombophilia associated with the presence of antiphospholipid antibodies. A limited number of genetic variants are proven to be independent risk factors for VTE. These include mutations in the genes controlling the function of both pro- and anticoagulant factors. The main benefit in screening thrombophilia is to prevent a first VTE in affected relatives rather than secondary prevention of recurrent VTE. Oral contraceptives increase the risk of VTE, particularly in the first year of use. Women with thrombophilic defects are at greater risk. Improved pregnancy outcomes in women with antiphospholipid syndrome can be achieved with the use of aspirin and low-dose heparin.

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