What causes coagulation disorders in patients with postpartum hemorrhage (PPH)?

Updated: Jan 02, 2018
  • Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Answer

During the third stage of labor (after delivery of the fetus), hemostasis is most dependent on contraction and retraction of the myometrium. During this period, coagulation disorders are not often a contributing factor. However, hours to days after delivery, the deposition of fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the postpartum period.

Potential causes include the following:

  • Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura (ITP) or, less commonly, functional platelet abnormalities. Platelet dysfunction can also be acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).

  • Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor X deficiency or familial hypofibrinogenemia

  • Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin, aspirin, or postpartum warfarin.

  • Disseminated intravascular coagulation (DIC): This can occur, such as from sepsis, placental abruption, amniotic fluid embolism, HELLP syndrome, or intrauterine fetal demise.

  • Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/or packed red blood cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage from other causes.

  • Physiologic factors: These factors may develop during the hemorrhage such as hypocalcemia, hypothermia, and acidemia.


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