"Sir, this patient came to us with placental abruption early morning" the Registrar informed me during the round of the labor ward. "She had DIC. She delivered two hours ago."
"So what did you do?" I asked. DIC is short for disseminated intravascular coagulation. It is a serious condition in which the patient's blood does not clot and she bleeds profusely, sometimes to death unless treated in time.
"We are going to transfuse her with six units of fresh frozen plasma."
"You are going to? You mean she delivered without correction of her DIC?" I asked.
"Yes, Sir. There was some problem with getting fresh frozen plasma. But now we will get it."
"But she did not bleed after delivery?" I asked.
"No, Sir. The uterus is well contracted and retracted. There is no bleeding at all."
"If she has not bled for two hours after delivery, she is not going to bleed now. Her body will correct whatever coagulopathy she has got, if any. She does not require and treatment" I said. "The diagnosis was probably wrong. She did not have any DIC."
"Sir, her PT-INR was 1.72, and plasma fibrinogen was 56 mg%."
"That sounds terrible. But believe me, she is OK. Where did you get the tests done?"
"In the private lab outside the hospital, except PT-INR which was done in the hospital's emergency lab" the Registrar said.
"Sir, I think we should treat her" the Associate Professor said. "She could bleed later."
"But the uterine vessels must have thrombosed by now. How will she bleed?" I asked.
"Suppose she does?"
"Yes, medicolegally that could pose a problem" I agreed. "Treat her."
At that time I saw doctors of another unit in the labor ward, taking round of their patients. I had an idea. I stopped their chief and said, "Can I ask you an academic question?"
"Yes."
So I explained the situation and asked, "Will you give such a patient fresh frozen plasma even if she has not bled for 2 hours after delivery?"
"Yes. She could bleed elsewhere, say in the brain?"
"Hmm...." I said.
"What are you going to do?"
"We will treat her because we do not medicolegal claim of negligence. But if I were that patient, I would not take this treatment myself." I said.
Our Registrar had send that patient's DIC tests again that morning, before starting treatment, but after she had delivered and not bled. These tests were sent to our routine lab in the hospital.
"I want to see the results of those tests" I told the Registrar" I said, "because I am sure there is an error in the diagnosis."
I was shown the results the next day and they were as shown below.
"The reports after delivery are normal, which cannot happen in two hours. She had no DIC" I said. "The private lab has given you wrong reports, and you believed them, rather than the clinical evidence that she had no bleeding problem. I hope you learn to believe what you find in a patient clinically rather than what some laboratory says."
"So what did you do?" I asked. DIC is short for disseminated intravascular coagulation. It is a serious condition in which the patient's blood does not clot and she bleeds profusely, sometimes to death unless treated in time.
"We are going to transfuse her with six units of fresh frozen plasma."
"You are going to? You mean she delivered without correction of her DIC?" I asked.
"Yes, Sir. There was some problem with getting fresh frozen plasma. But now we will get it."
"But she did not bleed after delivery?" I asked.
"No, Sir. The uterus is well contracted and retracted. There is no bleeding at all."
"If she has not bled for two hours after delivery, she is not going to bleed now. Her body will correct whatever coagulopathy she has got, if any. She does not require and treatment" I said. "The diagnosis was probably wrong. She did not have any DIC."
"Sir, her PT-INR was 1.72, and plasma fibrinogen was 56 mg%."
"That sounds terrible. But believe me, she is OK. Where did you get the tests done?"
"In the private lab outside the hospital, except PT-INR which was done in the hospital's emergency lab" the Registrar said.
"Sir, I think we should treat her" the Associate Professor said. "She could bleed later."
"But the uterine vessels must have thrombosed by now. How will she bleed?" I asked.
"Suppose she does?"
"Yes, medicolegally that could pose a problem" I agreed. "Treat her."
At that time I saw doctors of another unit in the labor ward, taking round of their patients. I had an idea. I stopped their chief and said, "Can I ask you an academic question?"
"Yes."
So I explained the situation and asked, "Will you give such a patient fresh frozen plasma even if she has not bled for 2 hours after delivery?"
"Yes. She could bleed elsewhere, say in the brain?"
"Hmm...." I said.
"What are you going to do?"
"We will treat her because we do not medicolegal claim of negligence. But if I were that patient, I would not take this treatment myself." I said.
Our Registrar had send that patient's DIC tests again that morning, before starting treatment, but after she had delivered and not bled. These tests were sent to our routine lab in the hospital.
"I want to see the results of those tests" I told the Registrar" I said, "because I am sure there is an error in the diagnosis."
I was shown the results the next day and they were as shown below.
|
Parameter
|
Before delivery,
before treatment
|
After delivery,
before treatment
|
|
Plasma Fibrinogen
|
56 mg%
|
220 mg%
|
|
PT-INR
|
1.72
|
0.98
|
|
D-dimer
|
More than 10
|
0 – 5
|
|
aPTT
|
44/28
(Patient/control)
|
30.5/28.5
(Patient/control)
|
"The reports after delivery are normal, which cannot happen in two hours. She had no DIC" I said. "The private lab has given you wrong reports, and you believed them, rather than the clinical evidence that she had no bleeding problem. I hope you learn to believe what you find in a patient clinically rather than what some laboratory says."
