Bleeding from injection needles and surgical incisions
Introduction
Introduction Hemorrhage due to injection needle and surgical incision is a concomitant symptom of obstetric disseminated intravascular coagulation. Obstetric disseminated intravascular coagulation is not an independent disease, but an intermediate morbidity or complication characterized by extensive intravascular coagulation and hemorrhagic tendencies associated with certain clinically diagnosed diseases. Obstetric DIC occurs mostly in obsessive complications and complications of obstetrics. Such as infectious abortion, expired abortion, fetal death, early placental stripping, amniotic fluid embolism, shock and severe hypertensive disorder complicating pregnancy.
Cause
Cause
Obstetric DIC occurs in severe complications of obstetrics and common comorbidities found in:
1. Infectious abortion. In the case of illegal abortion and intrauterine injection of drugs in the middle of pregnancy, the infection causes bacterial and bacterial toxins to enter the blood to cause chorioamnionitis, and amnion causes sepsis to damage vascular endothelial cells, platelet aggregation, tissue necrosis and release of blood clotting. Live enzyme.
2, expired abortion fetus in the death palace, Pritchard (1959) reported that about 25% of pregnant women in the fetal death of more than 4 weeks of low-fibrous egg yolkemia, almost no coagulation was delivered before 4 weeks. The occurrence of hypoproteinemia is caused by the retention of dead fetus to release tissue thrombin and trigger DIC.
3, early exfoliation of the placenta, is an obstetric emergency that endangers the mother's life, the incidence rate in China is 0.46% to 2.1%, and the reported rate in the southern United States is 0.46% to 1.3%. There are differences due to different diagnostic criteria. The fetal death is 1.2% and 9.2%, respectively. The cause of placental abruption is unknown, but most of them occur in patients with hypertension, due to the contraction of spiral arterioles, decidual ischemia and hypoxia, necrosis, release of thromboplastin, placenta After the hematoma consumption fibrinogen, showing low fibrinogenemia, fibrinogen <1 ~ 1.5g / L bleeding tendency and organ embolism.
4, amniotic fluid embolism, amniotic fluid containing epithelial cells, keratin, fetal fat meconium, mucus and other particulate matter amniotic fluid into the blood circulation can trigger the internal and external source of coagulation system, can cause platelet aggregation damage, promote blood coagulation and activate coagulation factor VII, through The surface of the vascular endothelium contacts to form endogenous thromboplastin, which has a strong procoagulant effect. Amniotic fluid not only contains procoagulant substances, but also contains fibrinolytic enzymes, activates the fibrinolytic system, converts plasminogen to plasmin, and dissolves fibrin into fibrin degradants (HDP), which is also soluble. Fibrinogen, which consumes a large amount of clotting factors, especially platelets and fibrinogen. On the other hand, fibrin dissolves, and the blood is rapidly changed from a hypercoagulable state to a low-condensation and high-solubility. Therefore, amniotic fluid embolism leads to DIC, and the disease is developing rapidly and falls into deep shock or even death within a few minutes.
5, shock, shock microcirculation in the late stage of blood, slow blood flow, increased blood viscosity, increased red blood cells are easy to aggregate and severe ischemia, hypoxia and accumulation of a large number of acidic metabolites can damage vascular endothelial cells, activate endogenous coagulation The system causes DIC. Traumatic shock injury tissue can also activate the exogenous coagulation system.
6. Pathophysiological changes of severe hypertensive disorder complicating pregnancy, severe vasospasm and blood concentration, ischemia and hypoxic endothelial cell damage in various organs of the body, resulting in decreased epoprostenol (prostacyclin) synthase, thromboxane ( tromboxaneXA2) The relative increase of synthetase, the decrease of PGI2/TXA2 ratio, the increase of collagen, which activates platelets to induce platelet adhesion and aggregation, and the release of adenosine monophosphate (ADP), serotonin (5-HT) and catecholamines further increase platelet aggregation. .
Therefore, severe hypertensive disorders of pregnancy have conditions for activating the endogenous coagulation system. Clinical manifestations of hemorrhagic symptoms, hematemesis, hematuria, but laboratory tests for low fibrinogenemia, but hemolytic anemia and thrombocytopenia, so hemolytic anemia is not secondary to fibrinolysis and high pregnancy Blood pressure disease complicated by microvascular disease hemolysis, non-consumptive coagulopathy should distinguish hemolytic anemia from DIC, thrombocytopenia and liver enzyme increase are collectively known as Hellp syndrome, and whether there is a causal relationship with DIC needs further observation.
Examine
an examination
Related inspection
Blood routine clotting factor activity assay
1, hemorrhage obstetrics DIC with uterine bleeding is the most common, and often mistaken for postpartum hemorrhage of uterine contraction, delaying rescue time. Uterine bleeding is characterized by continuous vaginal bleeding, and the amount of bleeding is not a blood clot. Severe can be accompanied by skin bleeding spots, bleeding gums, hemoptysis, hematemesis, hematuria, and injection needles and surgical incision bleeding.
2, circulatory disorders due to microcirculation thrombosis, venous return flow decreased sharply combined with blood loss, circulation disorders, blood pressure decreased, shock occurred, and a large number of platelet destruction, histamine and 5-tryptamine release, microvascular contraction, aggravation Hypoxia, severely affect the heart, liver and adrenal function of the main organs. Myocardial contraction is inhibited by a decrease in cardiac function. Kidney due to renal cortical embolism, ischemia and hypoxia can cause necrosis leading to acute renal failure. In the lungs, respiratory embedding syndrome (ARDS) occurs due to extensive embolization of the pulmonary capillaries. Therefore, there may be symptoms such as confusion, lack of speed, difficulty in breathing, cyanosis, oliguria or no urine.
3, the onset of the disease generally onset quickly and suddenly developed rapidly, with amniotic fluid embolism, early exfoliation of the placenta, severe pregnancy-induced hypertension. A small number of clotting factors are slowly consumed, and the disease develops slowly and the bleeding is lighter, such as expired abortion and stillbirth.
Diagnosis
Differential diagnosis
Injection needle and surgical incision bleeding should be identified as follows.
1, severe viral hepatitis, severe hepatitis in clinical and laboratory tests and DIC have many similarities, such as bleeding tendency, kidney damage, liver damage consciousness, change the level of blood coagulation factors and thrombocytopenia. Whether severe hepatitis has DIC complications is particularly important in the development of treatment plans and evaluation of prognosis.
2, thrombotic thrombocytopenic purpura (TTP), the disease clinical and laboratory tests and DIC, there are many similarities, such as bleeding tendency kidney damage, disturbance of consciousness, thrombosis, thrombocytopenia and increased platelet activation metabolites.
3, primary fibrinolysis, the disease is extremely rare, can be expressed as bleeding tendency, fibrinogen is extremely reduced and a variety of fibrinolytic experimental indicators are abnormal, must be differentiated from secondary fibrinolysis caused by DIC Have:
1 microcirculatory failure and embolization performance is rare.
2 The reduction of other coagulation factors was not obvious except for the extremely low fibrinogen.
3 thrombocytopenia is not obvious, its activation and metabolites do not increase.
4D-dimer is mostly negative in primary fibrinolysis.
5 In addition to FPA, other coagulation factor activation molecular markers such as TAT, F1+2 and AT-III are generally normal.
