Disseminated Intravascular Coagulation In Patients With Fatty Liver Of Pregnancy. Onset Of Dic Prior To Labor

Fatty liver of pregnancy (FLP) is a rare syndrome with a high maternal mortality. Bleeding complications are frequent and are associated with disseminated intravascular coagulation (DIC). We have previously demonstrated that DIC in this syndrome can be persistent, lasting 2 to 6 days, and is associated with severe depressions of functional and antigenic antithrombin III (AT III). The severe depression of AT III in this syndrome is believed to secondary to decreased hepatic synthesis and increased consumption from DIC. We have hypothesized that DIC is initiated by active labor, persists because of the low levels of AT III and may be controlled by transfusion of fresh frozen plasma or AT III concentrate. Recently we saw a patient with FLP proven by biopsy who presented with jaundice, nausea, and emesis. The patient was not in active labor. In preparation for surgical delivery, coagulation studies were done which revealed DIC (abnormal screening tests, fibrinogen of 70mg/dl, fibrin split products of 320-640 ng/dl, depressed factors V ᶓ VIII and a positive protamine sulfate test). The patient was given 1500 cc of fresh frozen plasma and viable twins were surgically delivered on the second hospital day. Following delivery DIC subsided, but infusions of plasma were continued until the fourth hospital day.

Subsequently we measured AT III using a fluorometric synthetic substrate (Protopath-see table above). From our observations on this patient we conclude (1) active labor is not necessary for the initiation of DIC in FLP (2) DIC in FLP can be associated with non-detectable functional AT III (3) transfusions of fresh frozen plasma can significantly increase functional AT III and may control DIC.