Current research status on obstetric disseminated intravascular coagulation and its scoring system

doi:10.3877/cma.j.issn.1673-5250.2024.05.006

Disseminated intravascular coagulation（DIC）in obstetrics is one of the serious complications，characterized by diverse clinical manifestations，rapid disease progression，and complex of coagulation dysfunction，which greatly increase the difficulty of early diagnosis and treatment of pregnant women with DIC.The diagnosis of obstetrics DIC is mainly relied on a comprehensive assessment of the underlying diseases，characteristic clinical manifestations，and laboratory test results，while the key to a good prognosis of obstetrics DIC pregnant women lies on early identification and appropriate intervention.DIC scoring system in obstetrics came into being as a convenient，accurate，intuitive and quantifiable diagnostic method.At present，there are different obstetric DIC scoring systems both domestically and internationally.The author intends to systematically elaborate the definition of obstetric DIC，incidence and adverse outcomes of pregnant women and puerpera，and their children，physiological hypercoagulability during pregnancy，pathogenesis and pathological characteristics of obstetric DIC，clinical manifestations and laboratory indicators of pregnant women and puerpera，as well as the latest research status of the evolution of diagnostic criteria and scoring system for obstetric DIC，in order to provide reference for clinical diagnosis and treatment of obstetric DIC patients.

Key words: Disseminated intravascular coagulation, Antithrombins, Thrombin time, Fibrinogen, Pregnancy complications, Blood coagulation disorders, Partial thromboplastin time, Scoring system, Pregnant women and puerpera

表1 各国产科DIC评分系统比较

项目	ISTH（Erez）评分系统^［14］		法国Clark评分系统^［25］		日本Takao评分标准^［27-28］a		CDSS产科DIC诊断评分系统^［20］a
项目	评分标准	评分（分）	评分标准	评分（分）	评分标准	评分（分）	评分标准	评分（分）
PLT（×10⁹/L）	＞185	0	＞100	0	≤100	1	≥100	0
	100～185	1	50～100	1			≥80～100	1
	50～100	2	＜50	2			＜80	2
	＜50	1					24 h内下降≥50%	1
凝血相关指标	PT测量值/正常值＜0.5	0	PT延长＜25%正常值	0	PT≥15 s（≤50%）或肝促凝血活酶试验结果≤50%	1	PT延长＜3 s且APTT延长＜10 s	0
	PT测量值/正常值≥0.5～1.0	5	25%正常值≤PT延长≤50%正常值	1			PT延长≥3s或APTT延长≥10 s	1
	PT测量值/正常值≥1.0～1.5	12	PT延长＞50%正常值	2			PT延长≥6 s	2
	PT测量值/正常值＞1.5	25
纤维蛋白水平（g/L）	＞4.5	0	＜2.0	1	≤1.5	1	≥1.0	0
	≥4.0～4.5	1	＞2.0	0			＜1.0	1
	≥3.0～4.0	6
	＜3.0	25
FDP（μg/mL）	—	—	—	—	≥10	1	—	—
D-二聚体（mg/L）	—	—	—	—	—	—	＜5	0
							≥5～9	2
							≥9	3
红细胞沉降率	—	—	—	—	≤4 mm/15 min或≤15 mm/h	1	—	—
出血时间（min）	—	—	—	—	≥5	1	—	—
其他凝血和纤溶因子	—	—	—	—	AT≤180 mg/L或≤60%，前激肽释放酶、α2-PI、纤溶酶原、其他凝血因子≤50%	1	—	—
原发病	—	—	—	—	详见表2	详见表2	—	—
临床特征	—	—	—	—	详见表2	详见表2	—	—
诊断DIC	—	≥26	—	≥3	—	≥8	—	≥7

表1 各国产科DIC评分系统比较

项目	ISTH（Erez）评分系统^［14］		法国Clark评分系统^［25］		日本Takao评分标准^［27-28］a		CDSS产科DIC诊断评分系统^［20］a
项目	评分标准	评分（分）	评分标准	评分（分）	评分标准	评分（分）	评分标准	评分（分）
PLT（×10⁹/L）	＞185	0	＞100	0	≤100	1	≥100	0
	100～185	1	50～100	1			≥80～100	1
	50～100	2	＜50	2			＜80	2
	＜50	1					24 h内下降≥50%	1
凝血相关指标	PT测量值/正常值＜0.5	0	PT延长＜25%正常值	0	PT≥15 s（≤50%）或肝促凝血活酶试验结果≤50%	1	PT延长＜3 s且APTT延长＜10 s	0
	PT测量值/正常值≥0.5～1.0	5	25%正常值≤PT延长≤50%正常值	1			PT延长≥3s或APTT延长≥10 s	1
	PT测量值/正常值≥1.0～1.5	12	PT延长＞50%正常值	2			PT延长≥6 s	2
	PT测量值/正常值＞1.5	25
纤维蛋白水平（g/L）	＞4.5	0	＜2.0	1	≤1.5	1	≥1.0	0
	≥4.0～4.5	1	＞2.0	0			＜1.0	1
	≥3.0～4.0	6
	＜3.0	25
FDP（μg/mL）	—	—	—	—	≥10	1	—	—
D-二聚体（mg/L）	—	—	—	—	—	—	＜5	0
							≥5～9	2
							≥9	3
红细胞沉降率	—	—	—	—	≤4 mm/15 min或≤15 mm/h	1	—	—
出血时间（min）	—	—	—	—	≥5	1	—	—
其他凝血和纤溶因子	—	—	—	—	AT≤180 mg/L或≤60%，前激肽释放酶、α2-PI、纤溶酶原、其他凝血因子≤50%	1	—	—
原发病	—	—	—	—	详见表2	详见表2	—	—
临床特征	—	—	—	—	详见表2	详见表2	—	—
诊断DIC	—	≥26	—	≥3	—	≥8	—	≥7

表2 日本Takao评分标准、CDSS产科DIC诊断评分系统中，产科DIC原发病及临床表现评分细则及标准

评分细则	日本Takao评分（分）	CDSS产科DIC诊断评分（分）
原发病
胎盘早剥		2
子宫僵硬，死胎	5
子宫僵硬，活胎	4
超声发现或有CTG证据确诊胎盘早剥	4
羊水栓塞		2
急性肺源性心脏病	4
人工通气	3
辅助呼吸	2
吸氧	1
DIC型PPH		—
宫腔来源不凝血	4
≥2 000 mL（开始出血后24 h内）	3
1 000～2 000 mL（开始出血后24 h内）	1
子痫发作	4	—
严重感染	—	—
伴随休克的发热、菌血症和脓毒症	4	—
稽留热和弛张热	1	—
HELLP综合征、宫内感染、死胎滞留	—	2
其他原发病	1	—
临床表现
出血倾向		1
肉眼可血尿和黑便，紫癜，黏膜、牙龈及注射部位出血等	4
PPH，止血困难，产道或手术创面出血、渗血、止血困难	—
多器官脏器功能衰竭		1
心脏（啰音、泡沫痰等）	4
肝脏（黄疸等）	4
脑（意识模糊、震颤等）	4
消化道（坏死性肠炎等）	4
其他严重的器官衰竭	4
急性肾衰竭		—
无尿（≤5 mL/h）	4
少尿（5～20 mL/h）	3
急性呼吸衰竭（除外羊水栓塞）
人工通气或辅助呼吸	4	—
吸氧	1	—
休克表现	—	1
脉搏≥100次/min、收缩压≤90 mmHg或血压下降≥40%、冷汗、苍白	各为1分	—
血氧饱和度≤90%	—	—

表2 日本Takao评分标准、CDSS产科DIC诊断评分系统中，产科DIC原发病及临床表现评分细则及标准

评分细则	日本Takao评分（分）	CDSS产科DIC诊断评分（分）
原发病
胎盘早剥		2
子宫僵硬，死胎	5
子宫僵硬，活胎	4
超声发现或有CTG证据确诊胎盘早剥	4
羊水栓塞		2
急性肺源性心脏病	4
人工通气	3
辅助呼吸	2
吸氧	1
DIC型PPH		—
宫腔来源不凝血	4
≥2 000 mL（开始出血后24 h内）	3
1 000～2 000 mL（开始出血后24 h内）	1
子痫发作	4	—
严重感染	—	—
伴随休克的发热、菌血症和脓毒症	4	—
稽留热和弛张热	1	—
HELLP综合征、宫内感染、死胎滞留	—	2
其他原发病	1	—
临床表现
出血倾向		1
肉眼可血尿和黑便，紫癜，黏膜、牙龈及注射部位出血等	4
PPH，止血困难，产道或手术创面出血、渗血、止血困难	—
多器官脏器功能衰竭		1
心脏（啰音、泡沫痰等）	4
肝脏（黄疸等）	4
脑（意识模糊、震颤等）	4
消化道（坏死性肠炎等）	4
其他严重的器官衰竭	4
急性肾衰竭		—
无尿（≤5 mL/h）	4
少尿（5～20 mL/h）	3
急性呼吸衰竭（除外羊水栓塞）
人工通气或辅助呼吸	4	—
吸氧	1	—
休克表现	—	1
脉搏≥100次/min、收缩压≤90 mmHg或血压下降≥40%、冷汗、苍白	各为1分	—
血氧饱和度≤90%	—	—

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