IUFD --> epidural --> ?DIC

[pgg]

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Recent case, small rural community hospital.

Healthy 30 yo G6P5 @ 32 wks, one prior IUFD, noted loss of fetal movement the day prior to admission, diagnosed fetal demise. This pregnancy uncomplicated until now. Admitted for induction of labor with Cervadil.

Hb 10.0, plt 248.

Epidural placed by CRNA on call - per the note, blood aspirated through catheter, removed, 2nd catheter placed, good. Two needle passes total with a 17g Tuohy, not a CSE / no intrathecal dose. Except for the blood and redo, a routine/easy epidural.

OB hears about the blood and orders coags ... INR 1.0, PT 9.7, PTT 26.4, but fibrinogen 4.8. Repeat fibrinogen 5.2. OB expresses concern about developing DIC in light of the fibrinogen level. No clinical evidence of bleeding, no petechiae, no ecchymosis, and DIC would be pretty amazingly rare just 24 hrs after loss of fetal movement. But they are concerned.

Hospital blood bank carries about a dozen units of red cells, four FFP, no other products.

Induction is making little progress, c-section is on the horizon, I'm 2nd call, and the OB calls and asks for my opinion.

Transfer to a bigger hospital? Use the epidural for the c-section? Pull it now? Leave it but don't use it? GETA? Something else?

 

[proman]

What are the units for the fibrinogen? Also, what about the fibrin degradation products/d-dimer? You could check a TEG but odds of that being available are low.

 

[sevoflurane]

What are the units for the fibrinogen?

beat me to it...

I bet it's g/L vs mg/dl.

Pgg, unless you can get products quickly, it looks like you should punt this off to a place that has more resources (if you are looking at low fibrinogen levels.... less than 150-200 mg/dl).

 

[sevoflurane]

I went through a case like this (and posted it on here I think... ) about a year or so ago. She ended up in DIC and products came in handy. If you catch it early, you are likely to get good results. Late... it can be fatal.

 

[BobBarker]

Since early DIC has been even discussed she needs to be transferred immediately.

 

[sevoflurane]

Aren't d-dimers typically elevated in pregnancy?

 

[proman]

Aren't d-dimers typically elevated in pregnancy?

Yeah, most coagulation values increase in pregnancy, but I think there's still some value in knowing the results.

 

[Idiopathic]

you pretty much have to ship her, i think, since you clearly couldnt handle it where you are if it went south, although i think its unlikely, given that she appears to have mild hypofibrinogenemia which is fairly common in this setting, but rarely progresses to frank DIC. its highly unlikely that you would capture asymptomatic DIC with normal coags and platelets and only an isolated fibrinogen level

edit: wait if those units are g/L, then wouldnt the fibrinogen level be high? (possibly normal finding in pregnancy?)

edit/edit: yes that fibrinogen level is stone cold normal (3.7-6.2 g/L in 3rd trimester)

 

[pgg]

Sorry for the lack of units, our lab reports normal as 200-380.

1st result confirmed by retest, 2nd result equally low.

 

[sevoflurane]

Sorry for the lack of units, our lab reports normal as 200-380.

1st result confirmed by retest, 2nd result equally low.

Dude... 5 mg/dl is INSANELY low.... somethings up here. Lab, patient or otherwise.

What are her platelets?

 

[proman]

Sorry for the lack of units, our lab reports normal as 200-380.

1st result confirmed by retest, 2nd result equally low.

In that case, GTFO. She might bleed to death from the BP cuff.

 

[AirBubble]

Use the epidural for the c-section? Pull it now? Leave it but don't use it? GETA? Something else?

I would leave the epidural catheter in place until I was convinced that her coagulation status was normal. I would use the epidural catheter for labor analgesia. I would explain to the patient and the obstetrician that if she showed any signs of hemodynamic instability that she would receive general anesthesia for a stat c/s. I would otherwise consider using the epidural as the primary anesthetic.

 

[Idiopathic]

theres no way that fibrinogen level is accurate, it its really 5 mg/dL then that patient shouldnt be in the room with a knife or needle and i would wrap her in bubble wrap for transport to someplace with a lot of cryo.

 

[Idiopathic]

I would leave the epidural catheter in place until I was convinced that her coagulation status was normal. I would use the epidural catheter for labor analgesia. I would explain to the patient and the obstetrician that if she showed any signs of hemodynamic instability that she would receive general anesthesia for a stat c/s. I would otherwise consider using the epidural as the primary anesthetic.

id probably let the damn thing granulate in at this point.

 

[pgg]

Dude... 5 mg/dl is INSANELY low.... somethings up here. Lab, patient or otherwise.

What are her platelets?

248 pre-epidural

The fibrinogen was insanely, ridiculously low ... the lab insisted it was correct. Ran the first sample twice, consistent with the 2nd sample.

But given normal platelets, normal PT/PTT, normal INR, absolutely no evidence of coagulopathy/bleeding/bruising/etc outside of a bit of blood from the epidural placement 🙂rolleyes🙂 ... and the fact that this was less than 24 hours since last noted fetal movement, I was dubious that it was DIC. Not impossible, but DIC's more characteristic of an IUFD that goes undetected for weeks. Also ... I haven't seen a lot of patients with DIC, but none of them were diagnosed via incidental lab findings - none of those patients looked right from the doorway, and then lab tests confirmed what we already suspected was going on.

So both the OB and I were suspicious of the lab despite the confirmed and retested result. He had already decided to send a recheck to another hospital ...

In the meantime, despite not really believing it was a real value, I told the OB I would
a) transfer the patient (epidural in place) only if she developed any other signs of DIC
b) do frequent neurologic checks
c) leave the epidural in place, especially if she developed other signs of DIC, because at that point the hematoma risk would come from removal
d) go GETA & not use the epidural if DIC abruptly kicked in and LTCS was deemed necessary to 'fix the cause' because she'd bleed a lot, and bloody OB/GYN cases are less fun if you start off with a sympathectomy and an awake patient


The recheck fibrinogen that was sent to another hospital came back >500 mg/dL. Everyone scowled at our lab, spun down, and the rest of the case went without incident.

edit/edit: yes that fibrinogen level is stone cold normal (3.7-6.2 g/L in 3rd trimester)

😉

BFE lab strikes again.

When the day crew arrived, they discovered that the tech mixed up units when transcribing the machine output to the EMR. Whoops.

As you point out, fibrinogen levels increase in pregnancy. By the 3rd trimester, a low normal fibrinogen may really be consistent with early DIC. That wasn't the case here, the patient was totally normal.

I was less amused at 4 AM when they called me, but in retrospect it was a good thought exercise.


Last time we had a thread about this subject the discussion was mostly 'Should epidurals be offered to patients with IUFD?' in light of the non-zero risk of DIC. This patient, who was thought to be heading toward DIC, but already had an epidural, reminded me of that thread.

 

[Idiopathic]

again, mild hypofibrinogenemia is common in 3rd trimester (up to 1/3 of patients) and clearly is not associated with DIC. severe hypo-FIB is associated with it.

 

[gclax30]

Was the 'bloody' epidural catheter aspirate the impetus for checking coags in the first place? Couldn't this happen just from being intravascular or from placement of the Touhy?

With the lack of any other clinical signs (or even just plain old extremely low probability) of DIC, seems like a stretch to me. Now you're stuck acting on a possibly aberrant lab value.

 

[Idiopathic]

Was the 'bloody' epidural catheter aspirate the impetus for checking coags in the first place? Couldn't this happen just from being intravascular or from placement of the Touhy?

With the lack of any other clinical signs (or even just plain old extremely low probability) of DIC, seems like a stretch to me. Now you're stuck acting on a possibly aberrant lab value.

sounds like it, yes, yes, and agreed.

 

[cincincyreds]

248 pre-epidural

The fibrinogen was insanely, ridiculously low ... the lab insisted it was correct. Ran the first sample twice, consistent with the 2nd sample.

But given normal platelets, normal PT/PTT, normal INR, absolutely no evidence of coagulopathy/bleeding/bruising/etc outside of a bit of blood from the epidural placement 🙂rolleyes🙂 ... and the fact that this was less than 24 hours since last noted fetal movement, I was dubious that it was DIC. Not impossible, but DIC's more characteristic of an IUFD that goes undetected for weeks. Also ... I haven't seen a lot of patients with DIC, but none of them were diagnosed via incidental lab findings - none of those patients looked right from the doorway, and then lab tests confirmed what we already suspected was going on.

So both the OB and I were suspicious of the lab despite the confirmed and retested result. He had already decided to send a recheck to another hospital ...

In the meantime, despite not really believing it was a real value, I told the OB I would
a) transfer the patient (epidural in place) only if she developed any other signs of DIC
b) do frequent neurologic checks
c) leave the epidural in place, especially if she developed other signs of DIC, because at that point the hematoma risk would come from removal
d) go GETA & not use the epidural if DIC abruptly kicked in and LTCS was deemed necessary to 'fix the cause' because she'd bleed a lot, and bloody OB/GYN cases are less fun if you start off with a sympathectomy and an awake patient


The recheck fibrinogen that was sent to another hospital came back >500 mg/dL. Everyone scowled at our lab, spun down, and the rest of the case went without incident.




😉

BFE lab strikes again.

When the day crew arrived, they discovered that the tech mixed up units when transcribing the machine output to the EMR. Whoops.

As you point out, fibrinogen levels increase in pregnancy. By the 3rd trimester, a low normal fibrinogen may really be consistent with early DIC. That wasn't the case here, the patient was totally normal.

I was less amused at 4 AM when they called me, but in retrospect it was a good thought exercise.


Last time we had a thread about this subject the discussion was mostly 'Should epidurals be offered to patients with IUFD?' in light of the non-zero risk of DIC. This patient, who was thought to be heading toward DIC, but already had an epidural, reminded me of that thread.

They need to fire that tech working in the lab. I am so tired of the arrogance of people working in my hospital who asssume they can do no wrong. I had one nurse actually bring the wrong patient to my room one time. I was so mad, I complained, and not one person did anything about it. I always check bracelets against my medical record before starting a case.