Question 24.2

A 38-year-old female presents to the Emergency Department with complaints of lower abdominal pain and vaginal bleeding. On examination, she is confused and, with cool peripheral perfusion and patchy ecchymoses over her extremities. Vaginal examination reveals clots, with tissue resembling products of conception. She is tachypneic, tachycardic with a non-invasive blood pressure of 88/42 mmHg.

(Parts 24.1 and 24.2 of the question are related to the initial blood results obtained from this patient.)

Full blood count and coagulation results are shown below:

Parameter Patient Value Adult Normal Range
Haemoglobin 93 g/L* 120 – 160
Mean Cell Volume 85 fL 80 – 100
Mean Corpuscular
Haemoglobin (MCH)     
28.0 pg 27.5 – 33.0
White Cell Count 24.0 x 109/L* 4.0 – 11.0
Platelet count 25 x 109/L* 150 – 350
Parameter Patient Value      Adult Normal Range
Prothrombin time 24.0 sec* 12.0 – 16.5
INR 2.2* 0.9 – 1.3
APTT > 200.0 sec* 27.0 – 38.5
Fibrinogen < 0.4 g/L* 2.0 – 4.0

a)    Explain the abnormalities for the full blood count and coagulation parameters, and list one likely pathological diagnosis.    (20% marks)

b)    This patient continues to have ongoing vaginal bleeding along with ooze from invasive lines. Outline your principles of management.    (20% marks)

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College answer

Not available.


Explain the abnormalities:

  • The FBC is boring:
    • There is anaemia
    • Normocytosis suggests this has nothing to do with iron deficiency
    • Normal cell volume suggests that vitamin deficiency is not to blame
    • The raised WCC suggests that some sort of infection is occurring
  • The coags are hideous:
    • All of the parameters are markedly deranged
    • The extremely low fibrinogen and profound thrombocytopenia suggests that there is a consumptive coagulopathy occurring
    • It would have been nice to have a quantitative D-dimer, but let's face it, we all know it would have been raised.

List one likely pathological diagnosis: 

  • Disseminated intravascular coagulation (DIC); or, to use a more modern redefinition of the term, "sepsis-induced coagulopathy (SIC)".

Principles of management of DIC(SIC):

  • Treat the cause:
    • Evacuate the retained products
    • Treat the polymicrobial sepsis with antibiotics
  • Limit clotting factor replacement
    • Give blood instead to maintain haemoglobin
    • Only administer blood products if the patient is having life-threatening (eg. intracerebral) bleeding
    • Consider supplementing fibrinogen until it is over 1g/L
    • Though there is a theoretical concern that replacing clotting factors will increase the risk of microthrombosis and microemboli, these appear to be largely unfounded  
  • Theoretical therapies


Slofstra, Sjoukje, Arnold Spek, and Hugo ten Cate. "Disseminated intravascular coagulation." The Hematology Journal 4.1 (2013): 295-302.

Levi, Marcel, and Hugo Ten Cate. "Disseminated intravascular coagulation."New England Journal of Medicine 341.8 (1999): 586-592.

Letsky, Elizabeth A. "Disseminated intravascular coagulation." Best Practice & Research Clinical Obstetrics & Gynaecology 15.4 (2001): 623-644.

Carr, J. Meehan, M. McKinney, and J. McDonagh. "Diagnosis of disseminated intravascular coagulation. Role of D-dimer." American journal of clinical pathology 91.3 (1989): 280-287.

Adam, Soheir S., Nigel S. Key, and Charles S. Greenberg. "D-dimer antigen: current concepts and future prospects." Blood 113.13 (2009): 2878-2887.