Intrapartum anti-disseminated intravascular coagulation therapy leading to successful vaginal delivery following intrauterine fetal death caused by placental abruption: a case report
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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.
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.
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.
KeywordsDIC Intrauterine fetal death Placental abruption Vaginal delivery
Minimally invasive vaginal delivery with appropriate anti-DIC therapy is considered first-line therapy, except when external hemorrhage cannot be controlled even with transfusion or when vaginal delivery is difficult because of obstetric complications . Hemorrhage from an abdominal wall wound or uterine wound may actually foster DIC in a Cesarean section, particularly with coagulopathy. In vaginal delivery, massive hemorrhage from the abruption surface can be avoided by appropriate postpartum treatment, such as oxytocin administration and uterine compression .
However, there is still insufficient evidence supporting the benefits of vaginal delivery, and consensus regarding the appropriate mode of delivery has not been reached . In the presence of DIC, vaginal delivery presents two clinical problems. First, delivery should be completed within six to eight hours after the onset of placental abruption. Otherwise, DIC may worsen, massive hemorrhage may occur, and the risk of shock and organ damage may increase . Second, with IUFD that is a result of placental abruption, effective labor occasionally does not occur . If delivery is prolonged, DIC may become more severe, and a larger volume of blood transfusion or a hysterectomy may be required .
Here, we report the case of a patient in whom vaginal delivery was selected after placental abruption with IUFD. With the simultaneous correction of hypofibrinogenemia, effective labor was achieved, and DIC was quickly controlled after vaginal delivery approximately 10 hours after onset.
A 37-year-old Japanese woman with a history of five pregnancies and three full-term vaginal deliveries with no co-morbidities or diseases was examined by her obstetrician because of amenorrhea lasting 14 months after her previous delivery. She did not smoke and had no history of abruption or thromboembolism. Her gestational age was estimated at 28 weeks and two days based on the biparietal diameter of her fetus. No placental or fetal abnormalities were detected on ultrasonography. Hypertensive disease was not observed prior to or during the pregnancy.
Consensus regarding the mode of delivery in cases of placental abruption associated with IUFD has not yet been reached . In Japan, obstetricians are more likely to choose a Cesarean section and eliminate the cause of DIC, compared with those in western countries, because blood coagulation factor preparations such as fibrinogen concentrate and cryoprecipitates are not covered by the Japanese national health insurance system. However, safe and successful vaginal deliveries have been increasingly reported in cases of placental abruption with IUFD in Japan. In 506 cases of placental abruption with IUFD extracted from the Japan Society of Obstetrics and Gynecology Perinatal Registration Database between 2002 and 2008, Cesarean sections accounted for 87.5% and 66.6% of the deliveries in 2002 and 2008, respectively , suggesting an increase in the number of obstetricians opting for vaginal delivery.
Delivery should be completed within six to eight hours after the onset of placental abruption to avoid worsening of DIC and organ damage . Effective labor is required for prompt vaginal delivery, but there are occasional cases of placental abruption with IUFD in which labor is not initiated . Imanaka et al. suggested that immediate amniotomy is the key to successful vaginal delivery . In our case, the delayed amniotomy may have prolonged the labor. However, we also noted that effective labor was observed at the same time as the improvement in our patient’s blood fibrinogen level. Therefore, the coagulation factors in the FFP may have promoted effective uterine contractions, similar to uterine atony caused by DIC.
Furthermore, in our case, hypofibrinogenemia was quickly corrected by fibrinogen concentrate immediately before extraction of the dead fetus and placenta. Because of the increase in the levels of FDP, which is considered a cause of uterine atony, the antifibrinolytic agent tranexamic acid was administered after extraction [13, 14], and sufficient uterine compression was performed, preventing massive hemorrhage after delivery. With the intrapartum and postpartum replacement of coagulation factors, a safe vaginal delivery may be accomplished even if the labor is prolonged slightly more than the recommended six to eight hours. However, our patient did not experience shock or organ failure such as renal failure. If these occur, labor induction should be ceased and a Cesarean section should be performed immediately because these conditions are improved only by delivery. Because the effect of delayed delivery on the outcomes is not fully known, further investigation is needed in additional cases.
Intrapartum anti-DIC therapy may help the onset of effective labor with minimal hemorrhage in cases of DIC-complicated placental abruption.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank all people who contributed to this study, especially Dr YO for obtaining consent from the patient for publication.
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