Toward an endothelium-centered framework for obstetric disseminated intravascular coagulation: Harmonizing pathophysiology, diagnosis, and treatment

BACKGROUND: Obstetric disseminated intravascular coagulation (DIC) is a life-threatening coagulopathy triggered by placental abruption, amniotic fluid embolism, HELLP syndrome, and postpartum hemorrhage. Although rapid hemostasis and transfusion are central to management, growing evidence implicates endothelial injury, particularly endothelial glycocalyx (eGCX) degradation, in amplifying coagulopathy and organ dysfunction. This review integrates endothelial pathophysiology into modern diagnostic and therapeutic frameworks for obstetric DIC. METHODS: We conducted a narrative synthesis of studies and guidelines published through 2025, examining (1) the pathophysiologic interplay among coagulation, fibrinolysis, and endothelial injury; (2) clinical utility of endothelial biomarkers; and (3) diagnostic criteria updates, including the 2024 revised Japanese obstetric DIC score. RESULTS: eGCX degradation, indicated by elevated syndecan-1, heparan sulfate, and hyaluronic acid levels, has been associated with disease severity and may reflect early endothelial dysfunction in obstetric DIC. Crystalloid overload, ischemia-reperfusion injury, and inflammatory cytokines promote glycocalyx shedding, exacerbating vascular permeability and consumption coagulopathy. The 2024 revised Japanese obstetric DIC criteria showed high sensitivity for pregnancy-specific coagulopathy and highlighted fibrinogen decline and fibrin-related markers as key diagnostic variables. Integrating endothelial biomarkers with these laboratory parameters may enhance early risk stratification and inform personalized resuscitation strategies addressing hemostasis and endothelial protection. CONCLUSIONS: Preservation of endothelial integrity represents a new therapeutic paradigm in obstetric DIC. Alongside optimized transfusion practices, timely fibrinogen replacement, and interventional hemostasis, targeting eGCX protection and endothelial recovery may redefine management goals. The 2024 Japanese obstetric DIC score provides a foundation for this integrative, endothelium-centered approach to improving maternal outcomes.