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The Harbinger of DIC- Hypofibrinogenemia in a patient with IUFD and Pre-eclampsia
Abstract Number: RF4AD-416
Abstract Type: Case Report Case Series
We present a patient with disseminated intravascular coagulopathy (DIC) secondary to intrauterine fetal demise (IUFD), with hypofibrinogenemia as sole indicator prior to massive hemorrhage.
A 24 year old G1P0 female at 37 weeks and 2 days presented with abdominal pain and no fetal movement for 1 day. IUFD was diagnosed due to absent fetal heart tones, leading to induction for vaginal delivery. Labs were positive for cocaine, fibrinogen 145 mg/dL, and platelets 166x103/µL. She completed vaginal delivery with EBL of 1500cc, receiving misoprostol, oxytocin, and Hemabate. Postdelivery labs showed fibrinogen 52 mg/dL and platelets 91x103/µL, with new gingival bleeding. We initiated massive transfusion protocol (MTP) with concern for coagulopathy.
She received 2 units pRBC, 1 of FFP, 1 of pooled platelets, 5 of cryoprecipitate, and 1g TXA. After transfusion, fibrinogen rose to 303 mg/dL. Platelets and hemoglobin/hematocrit levels reached nadirs 43x103/µL and 7.6/22 respectively 8h post delivery. The postpartum course was complicated by pre-eclampsia with severe features, elevated creatinine, and endometriosis. Magnesium, Ca+ channel blockers, and antibiotics were administered. She was stabilized by postpartum day 1 and discharged 3 days after initial presentation.
Placental abruption was the suspected etiology of fetal demise in the setting of known active cocaine use, and is responsible for 10-20% of IUFD (1). There is no laboratory test both specific and sensitive for DIC; diagnosis is based on history, risk factors, clinical presentation, and lab data. Third-trimester fibrinogen levels are typically >300mg/dL and levels <200 mg/dL had 100% positive predictive value for progression to severe post-partum hemorrhage in a study of 128 patients (2). Our patient experienced severe PPH, consistent with that study. Thrombocytopenia is typically the first finding in DIC (3). Our patient presented with normal third-trimester platelet levels. Per literature, platelets typically fall to <100x103/µL before critical fibrinogen drops. In our case, however, fibrinogen drop preceded acute thrombocytopenia. Patients with suspected abruption or IUFD should be screened for coagulopathy at admission. Fibrinogen < 200 should alert the physician to a possible impending hemorrhage or DIC.
(1) Fretts RC et al. The changing pattern of fetal death, 1961-1988. Obstet Gynecol 1992;79:35-9.
(2) Charbit B et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5:266-73.
(3) Erez O et al. Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management. Am J Obstet Gynecol. 2015;213:452-63.