Blood coagulation failure

1. Blood coagulation failure

2. Normal blood coagulation • -definition of Haemostasis • the arrest of bleeding, preventing loss of blood from the blood vessels. • - mechanism of coagulation. • - fibrinolysis: dissolving of fibrin clot formation to maintain the patency of the circulation. • -Fibrinolysis is the breakdown of fibrin and occurs as a response to the presence of clotted blood.

3. Stages of blood clotting • When tissues are damaged and platelets break down, thromboplastin is released. • Thromboplastin leads to the conversion of prothrombin into thrombin: a proteolytic (protein-splitting) enzyme. • Thrombin converts fibrinogen into fibrin to form a network of long, sticky strands that entrap blood cells to establish a clot • . The coagulated material contracts and exudes serum, which is plasma depleted of its clotting factors. • This is the final part of a complex cascade of coagulation involving a large number of different clotting factors (simply named Factor I, Factor II etc. in order of their discovery). • It is equally important for a healthy person to maintain the blood as a fluid in order that it can circulate freely.

4. - The coagulation mechanism is normally held at bay by the presence of heparin, which is produced in the liver. • -Unless fibrinolysis takes place, coagulation will continue. • - It is achieved by the activation of a series of enzymes culminating in the proteolytic enzyme plasmin. • - This breaks down the fibrin in the clots and produces fibrin degradation products (FDPs).

5. Disseminated intravascular coagulation (DIC) • definition of DIC : • Inappropriate coagulation occurs within the blood vessels, which leads to the consumption of clotting factors ,a result, clotting fails to occur at the bleeding site • cause of (DIC) is not fully understood. • - reaction to severe tissue trauma • -rarely occurs when the fetus is alive • -starts to resolve after birth. • - DIC is never a primary disease • - occurs as a response to another disease process.

6. Events that trigger DIC include: • placental abruption • intrauterine fetal death, including delayed miscarriage • amniotic fluid embolism • intrauterine infection, including septic miscarriage • pre-eclampsia and eclampsia.

7. A im s o f t he m a na g e m e nt o f DI C • manage the underlying cause and remove the stimulus provoking DIC • maintenance of the circulating blood volume • replace the used up clotting factors

8. -The midwife should be alert for conditions that affect DIC, as well as the signs that clotting is abnormal. • - assessment of the of the clot should be part of the midwife's routine observation during the third stage of labour. • - Oozing from a venepuncture site or bleeding from the mucous membrane of the woman's mouth and nose must be noted and reported.

9. * Blood tests include ; • -CBC& blood group • -clotting studies • -levels of platelets • - fibrinogen and fibrin degradation products (FDPs).

10. -Treatment of DIC: • 1-replacement of blood cells and clotting factors. • 2- administration of fresh frozen plasma and platelet concentrates. • 3- packed red cells. • - Management by a team of obstetricians, anaesthetists, haematologists, midwives and other healthcare professionals .

11. Care by the midwife • -Frequent and accurate observations to monitor the woman's condition. • - monitor V\S • -Fluid balance is monitored (I&O)for any sign of renal failure. • - client & her partner share them in care with psychological support .

12. Hepatic disorders and jaundice • - disorders are specific to pregnant women, and some pre-existing or co- existing disorders may complicate the pregnancy,.

13. He pa t ic diso r de r s o f pr e g na ncy • Specific to pregnancy • Intrahepatic cholestasis of pregnancy • Acute fatty liver in pregnancy • Pre-eclampsia and eclampsia • Severe hyperemesis gravidarum. • Pre- or co-existing in pregnancy • Gall bladder disease Hepatitis

14. C a use s o f ja undice in pr e g na ncy • Not specific to pregnancy • Viral hepatitis – A, B, C • Cytomegalovirus (CMV), Epstein–Barr virus, toxoplasmosis or herpes simplex • Gall stones Drug reactions • Alcohol/drug misuse Budd–Chiari syndrome

15. Pregnancy-specific causes • Acute fatty liver (AFLP) • HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome • Intrahepatic cholestasis of pregnancy • Hyperemesis gravidarum • Note: Jaundice is not an inevitable symptom of liver disease in pregnancy

16. Obstetric cholestasis (OC) • idiopathic condition may be • 1-genetic • 2- geographical • 3-and environmental factors • in the third trimester of pregnancy • can occasionally present as early as the first trimester. • -resolves spontaneously following birth • -recurrence rate in subsequent pregnancies • It is not a life-threatening condition

17. increased risk of • pre-term labor • fetal compromise • meconium staining • stillbirth risk

18. Clinical presentation • pruritus without a rash • fatigue as a result of the pruritus • insomnia • fever • abdominal discomfort • nausea and vomiting • urine may be darker and stools paler than usual • a few women develop mild jaundice.

19. Investigations • differential diagnoses such as other liver disease or pemphigoid gestations • hepatic viral studies (HBCAg,HCV) • -ultrasound of the hepatobiliary tract • -an autoantibody screen. • Blood tests for bile acids • serum alkaline phosphatase • bilirubin • liver transaminases(ALT,AST)raised.

20. What is pemphigoid gestation : • a rare autoimmune disease of late pregnancy that mimics OC)

21. Management of OC • local antipruritic agents, such as antihistamines. • Vitamin K supplements are administered to the woman, 10 mg orally daily, to avoid prothombinaemia which predisposes her to obstetric haemorrhage(APHge,IPHge,PPHge). • Monitor fetal wellbeing by Doppler of the umbilical artery blood flow. • elective birth when the fetus is mature, or fetal condition appears to be compromised, becausev bile acids are • raised, this is associated with impending intrauterine death. • psychological care to the woman. • Advise the woman that her pruritus disappear within 3–14 days of the birth. • use of OCP, advised that her liver function should be monitored.