Case report: New clinical clue of hyper-endogenous heparinization provides an imperative guideline for Treatment of Postpartum Hemorrhage with DIC via TEG guides and protamine intervention

BackgroundPostpartum hemorrhage (PPH) is a leading cause of maternal mortality and severe maternal morbidity worldwide and involves disseminated intravascular coagulation (DIC) secondary to cause massive blood loss. The coagulation abnormality in response to severe trauma or infection is a latent cause that may aggravate PPH.Case presentationA 26-year-old puerpera with 39 weeks of menolipsis case lacks amniotic fluid and uterus infection was examined. During the cesarean section, the patient presented fever and massive hemorrhage that she became the DIC and shock. The low coagulation of this PPH patient was diagnosed by Thromboelastography (TEG) guiding with heparinase (type I). The patient appeared a critical condition admitted in emergency room. According the continuous detection via TEG guides assay, she was observed in coagulopathy and hyper-heparinization. And subsequently the protamine correction for the patient's coagulation abnormality, the patient who became a stable condition after 4 hours of urgent treatment.ConclusionTEG-guided determination of endogenous heparin and subsequent infusion of protamine effectively reversed the syndrome of PPH with DIC. This is the first case report that infection and bleeding might be major causes of hyper-endogenous heparinization without exogenous heparin intervention. The hyper-endogenous heparinization is clinically taken into consideration for the syndrome of PPH with low coagulation.

Chronic Localized Intravascular Coagulation in a Case of Sporadic Multifocal Venous Malformations with Phleboliths

ABSTRACT Aim The aim of this article is to report a case of chronic localized intravascular coagulation in widespread sporadic multifocal venous malformations (VMs) associated with phleboliths, presenting with pathological femur fracture with very high D-dimer level and deranged coagulation profile hampering the surgical management of the patient. Background Disseminated intravascular coagulation (DIC) is a well-known cause of raised D-dimer. It leads to derangement of coagulation profile with very poor management outcome and needs intensive care. A very high level of D-dimer present in localized intravascular coagulopathy (LIC) can be misleading to diagnosis of DIC. Localized intravascular coagulopathy is seen in few VMs and they show abnormally high D-dimer levels. Venous malformations are the most frequent slow-flow vascular malformations referred to specialized centers. Most of the VMs are sporadic, and unifocal, while 1% are multifocal VMs. Multifocal sporadic VMs are rare and associated with phleboliths. High D-dimer is associated with various types of VMs like cutaneomucosal VMs and capillarovenous malformations. We reported the case of a 22-year-old female with congenital multifocal VMs presenting with fracture shaft of left femur on trivial trauma with deranged coagulation profile as prolonged prothrombin time, activated partial thromboplastin time, thrombocytopenia, and persistently high D-dimer level along with the presence of multiple phleboliths. Review In the view of deranged coagulation profile with raised D-dimer level in presence of trauma, patient was initially managed as a case of DIC and her surgical procedure for fracture femur was delayed for the correction of her coagulation abnormality. She was transfused 16 units of fresh frozen plasma, 18 units of platelets, and 3 units of packed red blood cells, but her D-dimer level remained high. Persistently raised D-dimer level without any hemorrhagic manifestation along with the presence of multiple phleboliths in his X-rays clinched the diagnosis of LIC. Low molecular weight heparin was started and after stabilization of coagulation profile, the patient got shifted to orthopedics department for the management of fracture femur. Conclusion This case describes a unique presentation of sporadic multifocal VMs as coagulation abnormality mimicking DIC. It emphasizes prompt diagnosis and workup when multiple VMs are present to prevent morbidity during surgical excision secondary to intravascular coagulopathy. Clinical significance Multifocal VMs have been associated with an increased risk of spontaneous thrombosis and thrombolysis because of stasis of blood, a condition termed LIC. Severe LIC has potential to progress to DIC during surgical excision so this mandates preoperative evaluation. How to cite this article Chaurasia AK, Gupta P, Purwar N. Chronic Localized Intravascular Coagulation in a Case of Sporadic Multifocal Venous Malformations with Phleboliths. J Postgrad Med Edu Res 2017;51(3):144-149.