Eight patients were referred from a private clinic between August 2003 and May 2004 for management of severe uncontrolled bleeding after late second trimester termination of pregnancy (TOP). TOP was perfomed at a mean gestation period of 21.4 weeks (median 21 weeks, 21–23 weeks) and was performed in 2 stages. Stage 1 comprised cervical dilatation, rupture of membrane, severing the cord and insertion of laminara. 24 hours later a dilatation and evacuation procedure was carried out. Mean age was 24.25 years (range 17–35). None of the women had any previous bleeding problems. Mean pre-operative Haemoglobin was 10.5 gm/dl (8.7 to 12.2 gm/dl). 1 patient had a preoperative clotting screen and this was normal. The pattern of bleeding was as follows: PV bleed 8/8, generalised bleed 2/8, haemodynamic failure 5/8. Median time to onset of bleeding after the second stage was 1.5 hours and median time to control bleeding was 9.5 hours. Details of coagulation screen and transfusion support are provided in tables 1 and 2. Factor VIIa was not approved for use in the hospital at that time.

table 1

coagulation parameters

UPNnadir fibrinogen (1.8–4.5 g/l)hours to nadir from TOPhours to normal fibrinogenPT (9.6–11.6 secs)APTT (24–32 secs)platelets (150–400 × 109/l)
1 0.44 8 18 16.7 37.2 203 
2 0.19 2 7 22.6 54.8 108 
3 0.67 7 13 16.8 38 44 
4 0.21 5 11 23.4 34.2 145 
5 0.35 5 6 21.5 78 47 
6 0.5 6 12 31 37.2 141 
7 0.57 3 5 15.6 42.7 88 
8 0.94 5  12.8 37.7 144 
UPNnadir fibrinogen (1.8–4.5 g/l)hours to nadir from TOPhours to normal fibrinogenPT (9.6–11.6 secs)APTT (24–32 secs)platelets (150–400 × 109/l)
1 0.44 8 18 16.7 37.2 203 
2 0.19 2 7 22.6 54.8 108 
3 0.67 7 13 16.8 38 44 
4 0.21 5 11 23.4 34.2 145 
5 0.35 5 6 21.5 78 47 
6 0.5 6 12 31 37.2 141 
7 0.57 3 5 15.6 42.7 88 
8 0.94 5  12.8 37.7 144 
View Large
table 2

blood product support

UPNcryoppt (units)FFP(units)RBC(units)platelets(units)
1 12 2 2  
2 20 4 14 1 
3 15 4 9  
4 40 4 12  
5 20 5 17 2 
6 10 3 8  
7 18 4 6 1 
8  2 2  
UPNcryoppt (units)FFP(units)RBC(units)platelets(units)
1 12 2 2  
2 20 4 14 1 
3 15 4 9  
4 40 4 12  
5 20 5 17 2 
6 10 3 8  
7 18 4 6 1 
8  2 2  
View Large

Obstetric interventions included hysterectomy (1), balloon occlusion (2) ERPC (1), hysterotomy (1), cervical tear repair (2) and vaginal pack (2). Obstetric cause of haemorrhage was identified to be uterine atony (4), retained products (2), uterine injury (2) and no identifiable cause (2). All women recovered fully.

Results: The profound coagulopathy in these women was characterised by a reduction in fibrinogen that was out of proportion to the anomalies in other clotting parameters and platelet counts. Treatment with cryoprecipitate reversed this reduction and controlled the haemorrhage although 5/8 patients required significant surgical intervention.

Conclusions:

  1. The coagulation anomalies in these women are indicative of a defibrination syndrome that differs from DIC in the disproportionate reduction in fibrinogen level and the relatively rapid and complete resolution with blood product replacement and treating uterine pathology.

  2. Two stage TOPs in late second trimester is associated with significant morbidity.

Topics:
abortion, induced, bleeding in pregnancy, hemorrhage, fibrinogen, blood coagulation tests, blood products, activated partial thromboplastin time measurement, balloon occlusion, blood coagulation disorders, cryoprecipitate

Disclosure: No relevant conflicts of interest to declare.

Author notes

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Corresponding author

2006, The American Society of Hematology
2006
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