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. 2022 Jan;35(2):242-257.
doi: 10.1080/14767058.2020.1716330. Epub 2020 Feb 3.

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion

Ali Alhousseini  1   2   3   4 , Roberto Romero  1   5   6   7   8   9 , Neta Benshalom-Tirosh  1   2 , Dereje Gudicha  1   2 , Percy Pacora  1   2 , Dan Tirosh  1   2 , Doron Kabiri  1   2 , Lami Yeo  1   2 , Jecko Thachil  10 , Chaur-Dong Hsu  1   2   3 , Sonia S Hassan  2   3   11 , Offer Erez  1   2   12
Affiliations

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion

Ali Alhousseini et al. J Matern Fetal Neonatal Med. 2022 Jan.

Abstract

Background: Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy.

Objectives: (1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score.

Study design: This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion.

Results: (1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion.

Conclusion: We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

Keywords: Abruption; packed red blood cells; preterm PROM; thrombin-antithrombin; vaginal bleeding.

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Conflict of interest statement

Disclosure statement: The authors report no conflicts of interest.

Figures

Figure 1.
Figure 1.
The distribution of patients who required blood product transfusion according to clinical criteria (blue) and who were identified by the pregnancy-specific non-overt DIC score (red).
Figure 2.
Figure 2.
The distribution (5th, 10th, 50th, 90th and 95th percentiles) and changes in the concentrations of the different components of the non-overt DIC score with advancing gestation in the maternal plasma of women with a normal pregnancy (n=50): A) Thrombin-antithrombin III complex, B) fibrinogen, C) D-dimer, D) platelet count, E) antithrombin activity, and F) protein C activity.
Figure 3.
Figure 3.
Receiver operating characteristic (ROC) curves comparing the ISTH and pregnancy-specific non-overt DIC scores. (AUC: area under the curve).
See this image and copyright information in PMC

References

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