1. Blood coagulation failure

2. Normal blood coagulation
-definition of Haemostasis
the arrest of bleeding, preventing loss of blood from the blood vessels.
- mechanism of coagulation.
- fibrinolysis: dissolving of fibrin clot formation to maintain the patency of the circulation.
-Fibrinolysis is the breakdown of fibrin and occurs as a response to the presence of clotted blood.

3. Stages of blood clotting
When tissues are damaged and platelets break down, thromboplastin is released.
Thromboplastin leads to the conversion of prothrombin into thrombin: a proteolytic (protein-splitting) enzyme.
Thrombin converts fibrinogen into fibrin to form a network of long, sticky strands that entrap blood cells to establish a clot
. The coagulated material contracts and exudes serum, which is plasma depleted of its clotting factors.
This is the final part of a complex cascade of coagulation involving a large number of different clotting factors (simply named Factor I, Factor II etc. in order of their discovery).
It is equally important for a healthy person to maintain the blood as a fluid in order that it can circulate freely.

4. - The coagulation mechanism is normally held at bay by the presence of heparin, which is produced in the liver.
-Unless fibrinolysis takes place, coagulation will continue.
- It is achieved by the activation of a series of enzymes culminating in the proteolytic enzyme plasmin.
- This breaks down the fibrin in the clots and produces fibrin degradation products (FDPs).

5. Disseminated intravascular coagulation (DIC)
definition of DIC :
Inappropriate coagulation occurs within the blood vessels, which leads to the consumption of clotting factors ,a result, clotting fails to occur at the bleeding site
cause of (DIC) is not fully understood.
- reaction to severe tissue trauma
-rarely occurs when the fetus is alive
-starts to resolve after birth.
- DIC is never a primary disease
- occurs as a response to another disease process.

6. Events that trigger DIC include:
placental abruption
intrauterine fetal death, including delayed miscarriage
amniotic fluid embolism
intrauterine infection, including septic miscarriage
pre-eclampsia and eclampsia.

7. A im s o f t he m a na g e m e nt o f DI C
manage the underlying cause and remove the stimulus provoking DIC
maintenance of the circulating blood volume
replace the used up clotting factors

8. -The midwife should be alert for conditions that affect DIC, as well as the signs that clotting is abnormal.
- assessment of the of the clot should be part of the midwife's routine observation during the third stage of labour.
- Oozing from a venepuncture site or bleeding from the mucous membrane of the woman's mouth and nose must be noted and reported.

9. * Blood tests include ; -CBC& blood group -clotting studies
-levels of platelets
- fibrinogen and fibrin degradation products (FDPs).

10. -Treatment of DIC: 1-replacement of blood cells and clotting factors.
2- administration of fresh frozen plasma and platelet concentrates.
3- packed red cells.
- Management by a team of obstetricians, anaesthetists, haematologists, midwives and other healthcare professionals .

11. Care by the midwife
-Frequent and accurate observations to monitor the woman's condition.
- monitor V\S
-Fluid balance is monitored (I&O)for any sign of renal failure.
- client & her partner share them in care with psychological support .

12. Hepatic disorders and jaundice
- disorders are specific to pregnant women, and some pre-existing or co- existing disorders may complicate the pregnancy,.

13. He pa t ic diso r de r s o f pr e g na ncy
Specific to pregnancy
Intrahepatic cholestasis of pregnancy
Acute fatty liver in pregnancy
Pre-eclampsia and eclampsia
Severe hyperemesis gravidarum.
Pre- or co-existing in pregnancy
Gall bladder disease Hepatitis

14. C a use s o f ja undice in pr e g na ncy
Not specific to pregnancy
Viral hepatitis – A, B, C
Cytomegalovirus (CMV), Epstein–Barr virus, toxoplasmosis or herpes simplex
Gall stones Drug reactions
Alcohol/drug misuse Budd–Chiari syndrome

15. Pregnancy-specific causes
Acute fatty liver (AFLP)
HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome
Intrahepatic cholestasis of pregnancy
Hyperemesis gravidarum
Note: Jaundice is not an inevitable symptom of liver disease in pregnancy

16. Obstetric cholestasis (OC)
idiopathic condition may be
1-genetic
2- geographical
3-and environmental factors
in the third trimester of pregnancy
can occasionally present as early as the first trimester.
-resolves spontaneously following birth
-recurrence rate in subsequent pregnancies
It is not a life-threatening condition

17. increased risk of
pre-term labor
fetal compromise
meconium staining
stillbirth risk

18. Clinical presentation
pruritus without a rash
fatigue as a result of the pruritus
insomnia
fever
abdominal discomfort
nausea and vomiting
urine may be darker and stools paler than usual
a few women develop mild jaundice.

19. Investigations
differential diagnoses such as other liver disease or pemphigoid gestations
hepatic viral studies (HBCAg,HCV)
-ultrasound of the hepatobiliary tract
-an autoantibody screen.
Blood tests for bile acids
serum alkaline phosphatase
bilirubin
liver transaminases(ALT,AST)raised.

20. What is pemphigoid gestation :
a rare autoimmune disease of late pregnancy that mimics OC)

21. Management of OC local antipruritic agents, such as antihistamines.
Vitamin K supplements are administered to the woman, 10 mg orally daily, to avoid prothombinaemia which predisposes her to obstetric haemorrhage(APHge,IPHge,PPHge).
Monitor fetal wellbeing by Doppler of the umbilical artery blood flow.
elective birth when the fetus is mature, or fetal condition appears to be compromised, becausev bile acids are
raised, this is associated with impending intrauterine death.
psychological care to the woman.
Advise the woman that her pruritus disappear within 3–14 days of the birth.
use of OCP, advised that her liver function should be monitored.