Importance of Appropriate Coagulation Evaluation in a Peripartum Patient with a Complex Medical History

Abstract

Background Peripartum patients have physiologic changes affecting coagulation. Patients with complex disease states may have additional coagulopathy risks and have a higher risk of bleeding complications. It is important during the prenatal work-up to evaluate coagulation appropriately to prevent the risk of bleeding events such as postpartum hemorrhage. Case Description We present a 34-year-old G4P0121 patient at 37 weeks gestation, with a history of immune thrombocytopenia (ITP), hepatitis C, and repaired Tetralogy of Fallot. Her pregnancy was complicated by coagulopathy, necessitating medical optimization prior to delivery. On admission, the patient demonstrated thrombocytopenia, hypofibrinogenemia, increased von Willebrand activity with unremarkable multimer studies, and abnormal TEG results, prompting the initiation of Intravenous immunoglobulin (IVIG), prednisone, vitamin K, cryoprecipitate, and platelet transfusions in preparation of delivery. Despite medical management she suffered post-partum hemorrhage which was managed with uterotonic and antifibrinolytic agents. The remainder of the postpartum course was uncomplicated. Clinical Significance The patient’s complex medical background portends multiple effectors of her coagulation status. Pregnant patients have dilutional anemia, and increased prothrombotic factors, Factors V, VII, VIII, IX, XII, and fibrinogen, and positive D-dimer results. Patients with liver disease are affected by decreased and dysregulated coagulation factors and prothrombotic factors. Congenital heart disease can lead to high velocity gradients across abnormal heart valves leading to increased sheering stress. This leads to nonfunctional von Willibrand Factor (vWF) multimers that can’t function as effectively causing impaired platelet aggregation and adhesion. Conclusions A multifactorial approach with early, comprehensive coagulation workup and attention to less common differentials in high-risk PPH patients can provide targeted coagulation management before labor, thus significantly reducing the risk of bleeding complications.