- by Dr Sahana K P
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- Feb 08 2017
Coagulation Disorders In Pregnancy
The coagulation system undergoes significant change during pregnancy. The caregiver for the pregnant woman must understand these changes, particularly when the woman has a preexisting hematological condition. Because many hematological conditions are rare, there often is limited information to guide the obstetric and anesthetic management of these parturient.
Physiological changes to coagulation during pregnancy
Pregnancy is associated with changes in hemostasis, including an increase in the majority of clotting factors, a decrease in the quantity of natural anticoagulants and a reduction in fibrinolytic.
Physiological changes in pregnancy affect the coagulation and fibrinolytic systems. Many of the clotting factors increase and anticoagulation factors decrease causing augmented coagulation and decreased fibrinolysis. Pre-existing coagulopathies may affect the course of pregnancy and nature of coagulopathy may also be modified by pregnancy. Changes in coagulation affect the mode of delivery and the approach to analgesia and anesthesia in patients with hypercoagulable disorders.
Disorders of coagulation in pregnancy can be classified as:
A. Clotting factor abnormalities
1. Congenital coagulopathies:
a) Von Willebrands disease
b) Haemophilia A and B
c) Antithrombin deficiency
2. Acquired coagulopathies:
a) Pregnancy induced hypertension
b) Placental Abruption
c) Retained dead fetus
d) Amniotic fluid embolus
e) Liver disease
f) Anticoagulants: Aspirin and Heparin
B. Platelet abnormalities:
1. Quantitative abnormalities (Not enough platelets)
a) Gestational thrombocytopenia
b) Idiopathic/immunological thrombocytopenic purpura
c) HELLP Syndrome
d) Disseminated intravascular coagulation (DIC)
2. Qualitative disorders (Poor platelet function)
Pregnancy is a hypercoagulable state due to the physiological changes of pregnancy.
The platelet count is decreased at term compared to pre-pregnant states in normal pregnancy.
Most coagulation factors increase during pregnancy but some do not.
Parturients with inherited factor deficiencies may require treatment during pregnancy.
Thromboembolism is the leading cause of maternal mortality and is increased in women with inherited thrombophilia.
Provision of neuraxial anaesthesia in parturients with coagulation abnormalities is dependent on the condition and the current status of coagulation.
In summary, pregnancy is associated with major changes in haemostasis including increases in the majority of clotting factors, decreases in the quality of natural anticoagulants and a reduction in fibrinolytic activity. These changes are greatest at the time of delivery. Platelet counts may be lower in pregnancy most commonly due to gestational thrombocytopaenia or ITP. Haemostasis is normal in gestational thrombocytopaenia and often in ITP despite low platelet numbers.
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