Labor and delivery: DIC, HELLP, preeclampsia

Abstract

Hematologists are often needed to assist with the management of microangiopathic emergencies in pregnancy. A firm understanding of the diagnosis and management of preeclampsia with severe features, hemolysis elevated liver enzyme and low platelet syndrome, and disseminated intravascular coagulation, which are the most common causes of microangiopathic emergencies, is critical. However, being able to consider when other microangiopathic emergencies (acute fatty liver of pregnancy, congenital and acquired thrombotic thrombocytopenic purpura, complement mediated microangiopathy, antiphospholipid syndrome) should be considered is imperative. The hematologist and obstetric team should work together to optimize the care of common as well as rare hematologic emergencies.

Graphical abstract

Figure 1.

Spectrum of hypertensive disorders during pregnancy and their prevalence. Gestational hypertension is defined by new-onset elevations in blood pressure (<140/90 mmHg) after 20 weeks of gestation, whereas preeclampsia is also accompanied by proteinuria and/or end-organ dysfunction. Chronic hypertension is present prior to 20 weeks of gestation or continues >12 weeks into the postnatal period and can occur in concert with preeclampsia. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is classified as a subset of preeclampsia, and eclampsia is a complication of preeclampsia characterized by the addition of seizures.

Figure 2.

Management of preeclampsia with severe features.

Figure 3.

Treatment algorithm for clinical management of DIC in obstetric syndromes. ISTH, International Society of Thrombosis and Hemostasis. Reproduced with permission from Cunningham and Nelson, Disseminated intravascular coagulation syndromes in obstetrics, Obstet Gynecol. 2015;126(5):999-1011. Copyright © 2015.

Figure 4.

Algorithm for clinical evaluation of microangiopathy in pregnancy. ADAMTS13; BUN, blood urea nitrogen; CBC, complete blood count; C-TMA, complement-mediated thrombotic microangiopathy; LDH, lactate dehydrogenase; PE, preeclampsia; PT, prothrombin time; PTT, activated partial thromboplastin time; TMA, thrombotic microangiopathy. *Occasionally severe renal failure occurs with HELLP, but the recovery is typically more rapid than in C-TMA.