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Tran A, Katz D. Variability of fibrinolytic activity in pregnant patients exposed to tissue plasminogen activator: an in vitro study utilizing rotational thromboelastometry. Int J Obstet Anesth 2024; 59:103994. [PMID: 38632015 DOI: 10.1016/j.ijoa.2024.103994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The investigation into the variability of fibrinolysis in obstetric patients is notably limited despite its relevance to postpartum hemorrhage. We investigate an in vitro model of fibrinolysis measured by rotational thromboelastrometry (ROTEM) in maternal blood samples with lysis stimulated by tissue plasminogen activator (tPA). METHODS Written informed consent was obtained from 19 patients at term pregnancy during admission to the labor and delivery unit. Patients who were taking medication affecting coagulation were excluded. Tissue plasminogen activator was added to whole blood samples to a final concentration of 100 or 220 ng/mL prior to ROTEM testing. RESULTS The addition of tPA produced high intra-individual fibrinolytic variability for clot firmness and lysis parameters. Patients responded differently to each tPA dose ranging from clot lysis within the range of 0 ng/mL tPA group to complete clot lysis. The coefficient of variation (CV) values for the 220 ng/mL tPA group were: EXTEM MCF 0.510, EXTEM LI30 1.601, FIBTEM MCF 0.349, FIBTEM LI30 2.097. CV values for the 100 ng/mL tPA group were: EXTEM MCF 0.144, EXTEM LI30 1.038, FIBTEM MCF 0.096, FIBTEM LI30 1.238. CONCLUSION We demonstrate a wide range of fibrinolytic response in the obstetric population to exogeneous tPA. We found subgroups of patients that were very responsive to tPA and insensitive to tPA. This study represents a preliminary exploration into classifying the obstetric fibrinolytic phenotypes. Further research will integrate relevant coagulation factors to establish a predictive model for testing susceptibility to lysis that can be applied at the point of care.
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Affiliation(s)
- A Tran
- City University of New York School of Medicine, New York, NY 10031, USA; Department of Anesthesiology, Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - D Katz
- Department of Anesthesiology, Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Graves SM, Montemorano L, Rood KM, Costantine MM, Fiorini K, Cackovic M. Viscoelastic Testing in an Obstetric Population at High Risk of Hemorrhage. Am J Perinatol 2024; 41:915-923. [PMID: 35253114 DOI: 10.1055/a-1788-5025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic test used in trauma for goal-directed transfusion. However, there are limited data on baseline ROTEM parameters in the U.S. obstetric population. Obtaining baseline parameters is a first step in implementing a goal-directed massive transfusion protocol in obstetric hemorrhage. OBJECTIVE Our study aimed to establish pre- and postdelivery baseline parameters in a high-risk obstetric population and determine their association with postpartum hemorrhage (PPH). STUDY DESIGN Prospective observational study of patients ≥34 weeks' gestation, at high risk of PPH, admitted for delivery. INTEM, EXTEM, FIBTEM, and APTEM assays were performed at the time of admission to labor and delivery and then 2 hours after delivery. Primary outcome was pre- and postdelivery ROTEM parameters among women without PPH. A sample size of 60 women was needed for >90% power to detect at least 50% correlation between pre- and postdelivery assuming a loss of 10% of participants to follow-up. RESULTS Of 60 women in the study, 10 (17%) had PPH. Baseline characteristics were not different between those with or without PPH. Pre- and postdelivery ROTEM parameters were not significantly different except for APTEM. None of the patients who had PPH, compared with 4 (10%) of those who did not, had shortened clotting time and higher maximum clot firmness in postdelivery APTEM compared with EXTEM, a pattern suggestive of hyperfibrinolysis (p = 0.4). CONCLUSION In this study, we describe baseline ROTEM parameters in women at high risk of PPH. The majority of patients did not have a ROTEM pattern that is suggestive of hyperfibrinolysis, for which tranexamic acid is thought to be beneficial. Based on our findings, previously established obstetric transfusion thresholds for goal-directed massive transfusion protocols are likely valid for the majority of the obstetric population regardless of the presence of comorbidities or pregnancy complications. KEY POINTS · ROTEM parameters do not vary significantly before and after delivery.. · Most patients did not have a hyperfibrinolysis pattern, for which tranexamic acid is thought to be beneficial.. · Previous goal-directed obstetric transfusion thresholds are likely valid in most populations..
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Affiliation(s)
- Stephen M Graves
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lauren Montemorano
- Department of Obstetrics and Gynecology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Kara M Rood
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kasey Fiorini
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Michael Cackovic
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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3
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Katz D, Farber M, Getrajdman C, Hamburger J, Reale S, Butwick A. The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care. Am J Obstet Gynecol 2024; 230:S1089-S1106. [PMID: 38462250 DOI: 10.1016/j.ajog.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 03/12/2024]
Abstract
Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.
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Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Michaela Farber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chloe Getrajdman
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Hamburger
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sharon Reale
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Dibiasi C, Ulbing S, Bancher-Todesca D, Ulm M, Gratz J, Quehenberger P, Schaden E. Concentration-effect relationship for tranexamic acid inhibition of tissue plasminogen activator-induced fibrinolysis in vitro using the viscoelastic ClotPro® TPA-test. Br J Anaesth 2024; 132:343-351. [PMID: 37925268 PMCID: PMC10808820 DOI: 10.1016/j.bja.2023.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Tranexamic acid is an antifibrinolytic drug that is commonly administered for obstetric haemorrhage. Conventional viscoelastic tests are not sensitive to tranexamic acid, but the novel ClotPro® TPA-test can measure tranexamic acid-induced inhibition of fibrinolysis. We aimed to evaluate the TPA-test in pregnant and non-pregnant women. METHODS We performed an in vitro study of whole blood samples spiked with tranexamic acid from pregnant women in the first, second, and third trimester (n=20 per group) and from non-pregnant women (n=20). We performed ClotPro TPA-tests of whole blood sample and ClotPro EX-tests, FIB-tests, and TPA-tests. RESULTS Clot lysis was inhibited in a concentration-dependent manner up to a tranexamic acid concentration of 6.25 mg L-1. At tranexamic acid concentrations of 12.5 mg L-1 and above, clot lysis was completely inhibited. The concentration-effect relationship of tranexamic acid did not differ in a clinically important manner in blood from pregnant women across all three trimesters or from non-pregnant controls. A median maximum lysis cut-off value of at9 least 16% (25-75th percentiles 15-18), a median clot lysis time of 3600 s (25-75th percentiles 3600-3600), or both was associated with a tranexamic acid concentration of least 12.5 mg L-1. CONCLUSIONS The ClotPro® TPA-test is sensitive in detecting inhibition of fibrinolysis by tranexamic acid in whole blood samples of pregnant and non-pregnant women. The concentration-effect relationship of tranexamic acid to inhibit fibrinolysis in whole blood did not differ for women in the first, second, and third trimester or for non-pregnant women.
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Affiliation(s)
- Christoph Dibiasi
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute Digital Health and Patient Safety, Vienna, Austria.
| | - Stefan Ulbing
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute Digital Health and Patient Safety, Vienna, Austria
| | | | - Martin Ulm
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute Digital Health and Patient Safety, Vienna, Austria
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Padilla CR, Shamshirsaz AA, Easter SR, Hess P, Smith C, El Sharawi N, Sandlin AT. Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. Am J Perinatol 2023; 40:988-995. [PMID: 37336216 DOI: 10.1055/s-0043-1761638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..
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Affiliation(s)
- Cesar R Padilla
- Division of Obstetric Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology/Surgical Critical Care Texas Children's Hospital, Baylor College of Medicine, Texas
| | - Sarah R Easter
- Department of Obstetrics and Gynecology/Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phillip Hess
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carly Smith
- Department of Anesthesiology and Pain Management, Anesthesiology Institute, Cleveland Clinic, Ohio
| | - Nadir El Sharawi
- Division of Obstetrical Anesthesia, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
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Fiol AG, Yoo J, Yanez D, Fardelmann KL, Salimi N, Alian M, Mancini P, Alian A. Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities. Proc AMIA Symp 2023; 36:562-571. [PMID: 37614857 PMCID: PMC10443986 DOI: 10.1080/08998280.2023.2217534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/21/2023] [Indexed: 08/25/2023] Open
Abstract
Background Point-of-care testing provides a representation of the patient's coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.
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Affiliation(s)
| | - Jin Yoo
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - David Yanez
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nayema Salimi
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marah Alian
- University of New England College of Osteopathic Medicine, Biddeford, Maine, USA
| | - Peter Mancini
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aymen Alian
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
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7
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Jokinen S, Kuitunen A, Uotila J, Yli-Hankala A. Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trial. Br J Anaesth 2023; 130:165-174. [PMID: 36496259 PMCID: PMC9900729 DOI: 10.1016/j.bja.2022.10.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage causes significant mortality among parturients. Early transfusion of blood products based on clinical judgement and conventional coagulation testing has been adapted to the treatment of postpartum haemorrhage, but rotational thromboelastometry (ROTEM) may provide clinicians means for a goal-directed therapy to control coagulation. We conducted a parallel design, randomised, controlled trial comparing these two approaches. We hypothesised that a ROTEM-guided protocol would decrease the need for red blood cell transfusion. METHODS We randomised 60 parturients with postpartum haemorrhage of more than 1500 ml to receive either ROTEM-guided or conventional treatment, with 54 patients included in the final analysis. The primary outcome was consumption of blood products, and secondarily we assessed for possible side-effects of managing blood loss such as thromboembolic complications, infections, and transfusion reactions. RESULTS The median (25th-75th percentile) number of RBC units transfused was 2 (1-4) in the ROTEM group and 3 (2-4) in the control group (P=0.399). The median number of OctaplasLG® units given was 0 in both groups (0-0 and 0-2) (P=0.030). The median total estimated blood loss was 2500 ml (2100-3000) in the ROTEM group and 3000 ml (2200-3100) in the control group (P=0.033). No differences were observed in secondary outcomes. CONCLUSIONS ROTEM-guided treatment of postpartum haemorrhage could have a plasma-sparing effect but possibly only a small reduction in total blood loss. CLINICAL TRIAL REGISTRATION NCT02461251.
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Affiliation(s)
- Samuli Jokinen
- Department of Emergency Medicine, Pain Medicine and Anaesthesiology, Tampere University Hospital, Tampere, Finland.
| | - Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Arvi Yli-Hankala
- Department of Emergency Medicine, Pain Medicine and Anaesthesiology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere, Finland
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8
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Lord MG, Calderon JA, Ahmadzia HK, Pacheco LD. Emerging technology for early detection and management of postpartum hemorrhage to prevent morbidity. Am J Obstet Gynecol MFM 2023; 5:100742. [PMID: 36075527 DOI: 10.1016/j.ajogmf.2022.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Despite advances in hemorrhage detection and management, postpartum hemorrhage remains the single leading cause of maternal death worldwide. Within the United States, hemorrhage is the leading cause of maternal death on the day of delivery and within the first week after delivery. Blood transfusion after hemorrhage represents a large proportion of severe maternal morbidity during and after delivery. Blood loss during delivery has historically been assessed visually by inspecting soiled pads, linens, and laparotomy sponges. These methods underestimate the volume of blood loss by as much as 40%, becoming increasingly inaccurate as blood loss increases. Young, healthy obstetrical patients compensate for blood loss via peripheral vasoconstriction, maintaining heart rate and blood pressure in a normal range until over 1 L of blood has been lost. A significant decrease in blood pressure along with marked tachycardia (>120 bpm) may not be seen until 30% to 40% of blood volume has been lost, or 2.0 to 2.6 L in a healthy term pregnant patient, after which the patient may rapidly decompensate. In resource-poor settings especially, the narrow window between the emergence of significant vital sign abnormalities and clinical decompensation may prove catastrophic. Once hemorrhage is detected, decisions regarding blood product transfusion are routinely made on the basis of inaccurate estimates of blood loss, placing patients at risk of underresuscitation (increasing the risk of hemorrhagic shock and end-organ damage) or overresuscitation (increasing the risk of transfusion reaction, fluid overload, and alloimmunization). We will review novel technologies that have emerged to assist both in the early and accurate detection of postpartum hemorrhage and in decisions regarding blood product transfusion.
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Affiliation(s)
- Megan G Lord
- Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI (Dr Lord).
| | - Joaquin A Calderon
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Luis D Pacheco
- Divisions of Maternal-Fetal Medicine and Surgical Critical Care, University of Texas Medical Branch, Galveston, TX (Dr Pacheco)
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Rotational thromboelastometry for the transfusion management of postpartum hemorrhage after cesarean or vaginal delivery: A single-center randomized controlled trial. J Gynecol Obstet Hum Reprod 2022; 51:102470. [DOI: 10.1016/j.jogoh.2022.102470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/02/2022] [Indexed: 11/21/2022]
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10
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Wells M, Raja M, Rahman S. Point-of-care viscoelastic testing. BJA Educ 2022; 22:416-423. [PMID: 36304915 PMCID: PMC9596284 DOI: 10.1016/j.bjae.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 10/31/2022] Open
Affiliation(s)
- M. Wells
- Barts Health NHS Trust, London, UK
| | - M. Raja
- Royal Free London NHS Foundation Trust, London, UK
| | - S. Rahman
- Royal Free London NHS Foundation Trust, London, UK
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O’Keefe D, Lim HY, Hui L, Ho P. Risk stratification for pregnancy-associated venous thromboembolism: Potential role for global coagulation assays. Obstet Med 2022; 15:168-175. [PMID: 36262814 PMCID: PMC9574445 DOI: 10.1177/1753495x211025397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 09/03/2023] Open
Abstract
Risk assessment for venous thromboembolism in pregnancy and the puerperium is currently limited to stratifying clinical surrogate risk factors without high-quality evidence. While the absolute risk of pregnancy-associated venous thromboembolism is low for the vast majority of women, associated morbidity and mortality remains significant. As guidelines for thromboprophylaxis vary widely, some women may be under- or over-anticoagulated, contributing to poor outcomes. New global coagulation assays provide a holistic view of coagulation and may have the potential to detect hypercoagulability in pregnancy, unlike clinically available coagulation assays. However, there are major technical challenges to overcome before global coagulation assays can be realistically proposed as an adjunct to risk assessment for pregnancy-associated venous thromboembolism. This review summarises the literature and controversies in the prediction and prevention of pregnancy-associated venous thromboembolism and outlines the new tools in haematology that may assist in our future understanding of hypercoagulability in pregnancy.
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Affiliation(s)
- David O’Keefe
- Department of Obstetrics & Gynaecology, The University of
Melbourne, The University of Melbourne, Parkville, Australia
- Department of Obstetrics & Gynaecology, Northern Health,
Epping, Australia
| | - Hui Yin Lim
- Department of Haematology, Northern Pathology Victoria, Epping,
Australia
- Department of Haematology, Northern Health, Epping,
Australia
| | - Lisa Hui
- Department of Obstetrics & Gynaecology, The University of
Melbourne, The University of Melbourne, Parkville, Australia
- Department of Obstetrics & Gynaecology, Northern Health,
Epping, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Pathology Victoria, Epping,
Australia
- Department of Haematology, Northern Health, Epping,
Australia
- Australian Centre for Blood Diseases, Monash University,
Melbourne, Australia
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12
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Phillips AN, Kirkland LL, Wagner WE, Melamed R, Tierney DM. Utilization of point-of-care ultrasound and rotational thromboelastometry (ROTEM) in the diagnosis and management of amniotic fluid embolism presenting as post-partum hemorrhage and cardiac arrest. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
To describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE).
Case presentation
A 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits.
Conclusions
In the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.
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Affiliation(s)
- Angela N. Phillips
- Department of Graduate Medical Education , Abbott Northwestern Hospital, Allina Health , Minneapolis , MN , USA
| | - Lisa L. Kirkland
- Department of Critical Care , Abbott Northwestern Hospital, Allina Health , Minneapolis , MN , USA
| | - William E. Wagner
- Departments of Maternal Fetal Medicine and Critical Care , Abbott Northwestern Hospital, Allina Health , Minneapolis , MN , USA
| | - Roman Melamed
- Department of Critical Care , Abbott Northwestern Hospital, Allina Health , Minneapolis , MN , USA
| | - David M. Tierney
- Department of Graduate Medical Education , Abbott Northwestern Hospital, Allina Health , Minneapolis , MN , USA
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13
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Ogunkua OT, Duryea EL, Nelson DB, Eddins MM, Klucsarits SE, McIntire DD, Leveno KJ. Tranexamic Acid for Prevention of Hemorrhage in Elective Repeat Cesarean Delivery - A Randomized Study. Am J Obstet Gynecol MFM 2022; 4:100573. [PMID: 35038612 DOI: 10.1016/j.ajogmf.2022.100573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists states that data is insufficient to recommend Tranexamic acid (TXA) prophylaxis for postpartum hemorrhage. OBJECTIVE This study's objective was to evaluate if prophylactic TXA reduces calculated blood loss versus placebo in women undergoing elective repeat cesarean delivery. STUDY DESIGN A double-blind, randomized, placebo-controlled trial, examining calculated blood loss with prophylactic doses of 1-gram of TXA given before skin incision and after placental delivery and standard uterotonics in women with singleton pregnancies at least 37 weeks' gestation, presenting for their second or third cesarean delivery under neuraxial anesthesia. The primary outcome was calculated blood loss at 24 hours. The calculation was based on the participant's height, weight, and the difference in hematocrit before the start of surgery and 24 hours after delivery. Prespecified secondary outcomes were quantification of maternal coagulation activity during the perioperative course. A sample size of 50 women per group was planned (N=100), based on a meta-analysis of mean reduction in blood loss after TXA. RESULTS 723 women were screened, and 110 women were randomized as follows: 55 to TXA and 55 to placebo. The primary outcome of mean calculated blood for TXA (2274 ± 469 mL) and the placebo group (2407 ± 388 mL), p > 0.05. In the secondary outcomes, D-dimer levels were lower in the TXA group than the placebo group 24 hours after delivery (2.1 ± 1.2 µg/mL versus 4.3 ± 2.4 µg/mL), p < 0.001. CONCLUSIONS Prophylactic tranexamic acid did not decrease mean calculated blood loss. Significantly less participants had calculated blood loss greater than 2000 mL in the tranexamic acid group compared to the placebo group with lower levels of D-dimer at 24 hours.
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Affiliation(s)
- Olutoyosi T Ogunkua
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX..
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michelle M Eddins
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Shannon E Klucsarits
- Departments of Anesthesiology and Pain Management (Drs Ogunkua, Eddins, and Klucsarits) and Obstetrics and Gynecology (Drs Duryea, Nelson, McIntire, and Leveno), The University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Ronenson A, Shifman E, Kulikov A, Raspopin Y, Görlinger K, Ioscovich A, Tikhova G. Rotational thromboelastometry reference range during pregnancy, labor and postpartum period: A systematic review with meta-analysis. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_21_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Getrajdman C, Shin DW, Sison M, Katz D. Baseline parameters for non-activated rotational thromboelastometry tests with and without heparinase in healthy pregnant women at term gestation. J Clin Anesth 2021; 75:110484. [PMID: 34500406 DOI: 10.1016/j.jclinane.2021.110484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine the normal values for non-activated thromboelastometry parameters among pregnant women. DESIGN Prospective, observational study. SETTING Tertiary care hospital. PATIENTS Non-laboring women at term gestation without history of bleeding or clotting disorder or anticoagulation use. INTERVENTIONS Venous blood samples were collected and ROTEM® was performed using NATEM and NaHEPTEM assays. MEASUREMENTS Reference ranges were derived by calculating 2.5 and 97.5 percentiles for the following parameters: clotting time (CT), clot formation time (CFT), amplitude at 10 (A10) and 20 min (A20), alpha angle, maximum clot firmness (MCF), and lysis index at 30 (LI30) and 60 min (LI60). The NATEM/NaHEPTEM CT ratio was calculated to determine the baseline ratio in term pregnant women. MAIN RESULTS 146 women were screened and 120 were enrolled. The median age was 34 years [31-36], median gestational age was 39.1 weeks [38.3-39.3], and median parity was 1 [0-2]. Median pre-delivery platelet and hematocrit levels were within the normal ranges. The reference ranges for NATEM parameters were: CT (232-759 (s)), CFT (69-243 (s)), alpha angle (50-77 (°)), A10 (44-69 (mm)), A20 (54-75 (mm)), MCF (57-77 (mm)), LI30 (100-100 (%)), LI60 (90-100 (%)). The reference ranges for NaHEPTEM parameters were: CT (224-717 (s)), CFT (66-210 (s)), alpha angle (53-77 (°)), A10 (44-67 (mm)), A20 (55-73 (mm)), MCF (58-74 (mm)), LI30 (99-100 (%)), LI60 (90-100 (%)). The NATEM to NaHEPTEM CT ratio reference range was 0.73-1.3. CONCLUSIONS This study is the first to our knowledge to report reference ranges for non-activated ROTEM® tests with and without heparinase in non-laboring term pregnant women. These reference ranges may serve as a baseline comparison and may be useful for future research on anticoagulation management in pregnancy.
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Affiliation(s)
- Chloe Getrajdman
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Da Wi Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Matthew Sison
- Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Daniel Katz
- Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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Xie X, Wang M, Lu Y, Zeng J, Wang J, Zhang C, Zhu H, Song Y, Han L, Liu Y, Zhang J, Li L, Chen L, Zhai Y, Cao Z. Thromboelastography (TEG) in normal pregnancy and its diagnostic efficacy in patients with gestational hypertension, gestational diabetes mellitus, or preeclampsia. J Clin Lab Anal 2021; 35:e23623. [PMID: 33067885 PMCID: PMC7891543 DOI: 10.1002/jcla.23623] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Thromboelastography (TEG) provides global assessment of hemostatic function and has been recommended to monitor potential coagulopathies during pregnancy in which hypercoagulable state is favored. In present study, we established the reference intervals (RIs) of the TEG parameters (R, K, MA, and α-angle) with Chinese pregnant women of third trimester. In addition, we examined the diagnostic efficacies of the TEG parameters in the patients diagnosed of gestational hypertension (GH), gestational diabetes mellitus (GDM), or preeclampsia (PE). METHODS With specified including and excluding criteria, non-pregnant controls, healthy pregnant women, and pregnant women with GH, GDM, or PE had their venous blood drawn at Beijing Obstetrics and Gynecology Hospital, followed by TEG tests performed in the clinical laboratory. RESULTS The RIs determined with the healthy pregnant women (in third trimester) for R, K, MA, and α-angle were 4.0-7.7, 1.2-3.2, 51.9-70.1, and 41.4-74.4, respectively. When compared with the healthy pregnancy group, the K value was significantly decreased in GH patients but increased in PE patients; MA was significantly lower in the PE group. In the receiver operating characteristic curve (ROC) analyses, K value was able to efficiently distinguish normal pregnancy from the GH patients, with an AUC of 0.86 which is far better than those of R (AUC = 0.57) and MA (AUC = 0.56). For the PE patients, the AUC of MA (0.69) was significantly greater than that of R (0.50). CONCLUSIONS Thromboelastography may provide more accurate experimental basis for monitoring coagulation functions especially in pregnant women with complications of GH and PE.
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Affiliation(s)
- Xin Xie
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Meng Wang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yifan Lu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jiazi Zeng
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jing Wang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Chunhong Zhang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Hongyuan Zhu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yujie Song
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lican Han
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Ying Liu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jingnan Zhang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lei Li
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lu Chen
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yanhong Zhai
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Zheng Cao
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
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18
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Shamshirsaz AA, Fox KA, Erfani H, Bruzdoski K, Kostousov V, Clark SL, Hensch L, Hui SKR, Teruya J. Trimester-specific thromboelastic values and coagulation activation markers in pregnancy compared across trimesters and compared to the nonpregnant state. Int J Lab Hematol 2021; 43:1216-1224. [PMID: 33496076 DOI: 10.1111/ijlh.13472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Rotational thromboelastometry (ROTEM) rapidly identifies deficits underlying coagulopathy during massive hemorrhage. Prompt coagulopathy correction is balanced with the risk of blood product overutilization, making the ability to quickly target therapy highly desirable. However, data about ROTEM reference ranges in pregnancy are limited. We hypothesized that ROTEM parameters change across trimesters of pregnancy and differ from the nonpregnant state. Also, we sought to identify which hemostatic test best predicts coagulation activation during pregnancy. METHODS A prospective cohort study in healthy pregnant patients in the first (n = 34), second (n = 34), and third trimesters (n = 41) against healthy, nonpregnant controls (n = 33) was performed. Citrated blood was collected, and ROTEM, complete blood count, and plasma-based assays of coagulation were performed. Mean ± SD or median [IQR] were compared across trimesters and between each trimester against the nonpregnant state. ROTEM parameters vs. plasma-based assays were also compared. RESULTS Maximum clot firmness and A10 in FIBTEM correlated strongly with fibrinogen level. INTEM and EXTEM values demonstrated only weak to modest correlation with corresponding tests using plasma assays. Thrombin antithrombin complex (TAT) increased from the first trimester onward, whereas other coagulation activation markers did not show difference compared with control group. CONCLUSION Rotational thromboelastometry parameters differ variably across trimesters of pregnancy and compared with the nonpregnant state. The development and use of pregnancy-specific values are critical to the proper clinical interpretation of ROTEM in women with serious hemorrhage during different stages in pregnancy. TAT was the earliest laboratory marker for coagulation activation among others.
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Affiliation(s)
- Amir A Shamshirsaz
- The Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,The Department of Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Karin A Fox
- The Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Hadi Erfani
- The Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Karen Bruzdoski
- The Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Vadim Kostousov
- The Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Steven L Clark
- The Department of Obstetrics and Gynecology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Lisa Hensch
- The Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Shiu-Ki Rocky Hui
- The Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,The Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Jun Teruya
- The Department of Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,The Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.,The Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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19
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Fudge JM, Page B, Mackrell A, Lee I, Jeffery U. Blood loss and coagulation profile in pregnant and non-pregnant queens undergoing elective ovariohysterectomy. J Feline Med Surg 2020; 23:487-497. [PMID: 33030098 PMCID: PMC8151557 DOI: 10.1177/1098612x20959610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aims of this study were to determine if there is increased risk of intraoperative bleeding in pregnant cats undergoing elective ovariohysterectomy (OHE), and to compare coagulation in queens in various stages of estrus and pregnancy subjected to elective OHE using a whole-blood viscoelastic assay. METHODS Intraoperative blood loss was compared between non-pregnant and pregnant cats undergoing elective OHE. Viscoelastic evaluations of whole blood drawn pre- and postoperatively were performed using a point-of-care device measuring clot time (CT), clot formation time (CFT), alpha angle, maximum clot formation (MCF), amplitude at 10 and 20 mins (A10 and A20, respectively), and lysis index at 30 and 45 mins after MCF (LI30 and LI45, respectively). RESULTS One hundred and ninety-three cats underwent OHE by a ventral midline approach. Median blood loss was greater for pregnant cats (2.0 ml, range <0.5-13 ml) than non-pregnant cats (<0.5 ml, range <0.5-15 ml; P <0.0001). Preoperatively, pregnant cats had a shorter median CFT (165 s vs 190.5 s), increased median A10 (31 from 25.5 VCM units) and A20 (38 from 35 VCM units), and a lower median LI45 (99% from 100%) than non-pregnant cats. Postoperatively, A10 and A20 increased, and LI30 and LI45 decreased in both non-pregnant and pregnant queens. In pregnant queens, mean CT also increased postoperatively. CONCLUSIONS AND RELEVANCE Pregnant cats were relatively hypercoagulable and had an increased rate of clot lysis than non-pregnant cats. Intraoperative blood loss was increased in pregnant vs non-pregnant cats, but no clinically relevant bleeding conditions occurred.
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Affiliation(s)
| | - Bernie Page
- Surgery, Hill Country Animal League, Boerne, TX, USA
| | - Amy Mackrell
- Surgery, Hill Country Animal League, Boerne, TX, USA
| | - Inhyung Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, Republic of Korea
| | - Unity Jeffery
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biological Sciences, Texas A&M University, College Station, TX, USA
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20
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Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020; 18:1813-1838. [PMID: 32356929 DOI: 10.1111/jth.14882] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.
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Affiliation(s)
| | - Terrence Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Abstract
Fibrinogen is one of the first factors to fall to critically low levels in the blood in many coagulopathic events. Patients with hypofibrinogenemia are at a significantly greater risk of major hemorrhage and death. The rapid replacement of fibrinogen early on in hypofibrinogenemia may significantly improve outcomes for patients. Fibrinogen is present at concentrations between 2 and 4 g/L in the plasma of healthy people. However, hypofibrinogenemia is diagnosed when the fibrinogen level drops below 1.5-2 g/L. This review analyses different types of fibrinogen assays that can be used for diagnosing hypofibrinogenemia. The scientific mechanisms and limitations behind these tests are then presented. Additionally, the current state of clinical major hemorrhage protocols (MHPs) is presented and the structure, function and physiological role of fibrinogen is summarized.
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Affiliation(s)
- Marek Bialkower
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, Australia
| | - Gil Garnier
- BioPRIA and Department of Chemical Engineering, Monash University, Clayton, Australia
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22
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise. Case Rep Anesthesiol 2020; 2020:9642438. [PMID: 32724681 PMCID: PMC7364204 DOI: 10.1155/2020/9642438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/17/2020] [Indexed: 11/17/2022] Open
Abstract
A 39-year-old G2P1001 female presented from an outside hospital following an eclamptic seizure in the setting of HELLP syndrome. This condition was complicated by intrauterine fetal demise and disseminated intravascular coagulation, which required an emergent cesarean section. We report the work-up and intraoperative and postoperative management of this complex patient with multiple medical needs. We focus on the hemostatic abnormalities in this patient and describe how our management would differ from that of a similar, nonpregnant patient.
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24
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Fiol AG, Fardelmann KL, McGuire PJ, Merriam AA, Miller A, Alian A. The Application of ROTEM in a Parturient With Antiphospholipid Syndrome in the Setting of Anticoagulation for Cesarean Delivery: A Case Report. A A Pract 2020; 14:e01182. [DOI: 10.1213/xaa.0000000000001182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Lee J, Eley VA, Wyssusek KH, Kimble RM, Way M, Cohen J, Zundert AA. The influence of obesity on coagulation in healthy term pregnancy as assessed by rotational thromboelastometry. Aust N Z J Obstet Gynaecol 2020; 60:714-719. [DOI: 10.1111/ajo.13141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/28/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Julie Lee
- Department of Anaesthesia and Perioperative Medicine The Royal Brisbane and Women’s Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
| | - Victoria A. Eley
- Department of Anaesthesia and Perioperative Medicine The Royal Brisbane and Women’s Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
| | - Kerstin H. Wyssusek
- Department of Anaesthesia and Perioperative Medicine The Royal Brisbane and Women’s Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
| | - Rebecca M.N. Kimble
- The University of Queensland Brisbane Australia
- Department of Obstetrics and Gynaecology The Royal Brisbane and Women’s Hospital Brisbane Australia
| | - Mandy Way
- QIMR Berghofer Medical Research Institute Brisbane Australia
| | - Jeremy Cohen
- The University of Queensland Brisbane Australia
- Department of Intensive Care Medicine The Royal Brisbane and Women’s Hospital Brisbane Australia
| | - André A. Zundert
- Department of Anaesthesia and Perioperative Medicine The Royal Brisbane and Women’s Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
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26
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Lee J, Eley VA, Wyssusek KH, Kimble R, Way M, Coonan E, Cohen J, Rowell J, van Zundert AA. Baseline parameters for rotational thromboelastometry in healthy labouring women: a prospective observational study. BJOG 2020; 127:820-827. [PMID: 31943696 DOI: 10.1111/1471-0528.16094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to establish rotational thromboelastometry (ROTEM® ) baseline parameters in labouring women at term gestation. The secondary aim was to compare these reference ranges with those from previous studies on labouring women and from the manufacturer. DESIGN A prospective, observational study. SETTING Tertiary referral hospital. PARTICIPANTS Healthy women in labour. METHODS Ethics approval was granted for an opt-out recruitment approach. ROTEM® testing was performed in labouring women at term gestation. Women with any condition affecting coagulation were excluded. ROTEM® Delta reference ranges were derived by calculating the 2.5% and 97.5% centiles for INTEM/EXTEM/FIBTEM parameters including amplitude at 5 minutes (A5), coagulation time (CT) and maximum clot firmness (MCF). MAIN OUTCOME MEASURES ROTEM® parameters were measured in labouring women before delivery. The following tests were performed: FIBTEM, EXTEM and INTEM. RESULTS One hundred and twenty-one women met the inclusion criteria, with a mean (± SD) age of 29.6 ± 5.4 years and median (interquartile range) gestation of 39.4 weeks (37.4-40.4 weeks). Seventy-five (62.0%) women were nulliparous and 71 (58.7%) delivered vaginally. The median and interquartile ranges for selected ROTEM® parameters were: FIBTEM A5, 21 mm (IQR 18-23 mm); EXTEM A5, 55 mm (52-58 mm); and EXTEM CT, 52 seconds (48-56 seconds). CONCLUSIONS The FIBTEM/EXTEM/INTEM amplitudes were higher than the manufacturer's reference ranges for non-obstetric patients. The FIBTEM MCF upper and lower limits were higher and the EXTEM/INTEM CT was shorter and narrower in range. This study provides reference ranges for ROTEM® values in healthy labouring women at term gestation with uncomplicated pregnancies. TWEETABLE ABSTRACT This is the first study to report on ROTEM® reference ranges with over 120 healthy labouring women of normal weight at term gestation.
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Affiliation(s)
- J Lee
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,The University of Queensland, St Lucia, QLD, Australia
| | - V A Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,The University of Queensland, St Lucia, QLD, Australia
| | - K H Wyssusek
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,The University of Queensland, St Lucia, QLD, Australia
| | - Rmn Kimble
- The University of Queensland, St Lucia, QLD, Australia.,Department of Obstetrics and Gynaecology, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - M Way
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - E Coonan
- The University of Queensland, St Lucia, QLD, Australia.,Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - J Cohen
- The University of Queensland, St Lucia, QLD, Australia.,Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - J Rowell
- The University of Queensland, St Lucia, QLD, Australia.,Department of Haematology, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - A A van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,The University of Queensland, St Lucia, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia
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Brearton C, Rushton A, Parker J, Martin H, Hodgson J. Performance Evaluation of a New Point of Care Viscoelastic Coagulation Monitoring System in Major Abdominal, Orthopaedic and Vascular Surgery. Platelets 2020; 31:1052-1059. [DOI: 10.1080/09537104.2019.1704719] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Chris Brearton
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Andrew Rushton
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jane Parker
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Hannah Martin
- Thornton Science Park, Medtechtomarket Consulting Ltd, Chester, UK
| | - Jake Hodgson
- Thornton Science Park, Medtechtomarket Consulting Ltd, Chester, UK
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Guimicheva B, Roberts LN, Patel JP, Subramanian D, Arya R. Mode of Delivery Does Not Influence Postpartum Hypercoagulability Measured by Thrombin Generation or Thromboelastometry. TH OPEN 2020; 4:e1-e11. [PMID: 31915751 PMCID: PMC6946610 DOI: 10.1055/s-0039-3402807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/19/2019] [Indexed: 01/28/2023] Open
Abstract
Introduction
Venous thromboembolism (VTE) is a significant cause of maternal mortality with the greatest risk postpartum. Mode of delivery influences VTE risk, with emergency caesarean section (CS) associated with the highest risk (CS). Thromboprophylaxis is recommended for selected women to reduce the risk of VTE.
We aimed to investigate the impact of mode of delivery and thromboprophylaxis on hypercoagulability as measured by thromboelastometry (TEM) and thrombin generation (TG) in women at high VTE risk. Materials and Methods
Blood was collected from 99 pregnant women with VTE risk factors at up to five time points from pre- (T1) and post (T2)-delivery to 6 weeks postpartum (T5). Multiple linear regression was utilised to compare TG and TEM between those with vaginal delivery (VD) and CS at each time point. Paired sample
t
-test with post hoc Bonferroni correction was utilised to compare laboratory markers over time.
Results
Women in both groups had a median of three postpartum VTE risk factors, with higher body mass index and parity post-VD. In both the groups, TG and TEM parameters suggested hypercoagulability at T2 compared with T1, with resolution at T5. There were minimal differences between groups, apart from T2 with shorter clot formation time and higher maximum clot firmness in the VD group.
Conclusion
TG and TEM illustrate hypercoagulability associated with pregnancy and delivery. The pattern of postpartum hypercoagulability seen in women with VTE risk factors was similar irrespective of mode of delivery. Further research is required to establish the effect of labour on TG/TEM in the absence of low molecular weight heparin use.
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Affiliation(s)
- Boriana Guimicheva
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Women's Health, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jignesh P Patel
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Institute of Pharmaceutical Science, King's College London, London, United Kingdom
| | - Devi Subramanian
- Women's Health, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Lee J, Wyssusek KH, Kimble RMN, Way M, van Zundert AA, Cohen J, Rowell J, Eley VA. Baseline parameters for rotational thromboelastometry (ROTEM®) in healthy pregnant Australian women: a comparison of labouring and non-labouring women at term. Int J Obstet Anesth 2019; 41:7-13. [PMID: 31831279 DOI: 10.1016/j.ijoa.2019.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 10/03/2019] [Accepted: 10/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM®) is a point-of-care coagulation test. Reference ranges in non-labouring women have recently been established from a cohort of women presenting for elective caesarean delivery using the recommended minimum sample size of 120. This study aimed to present baseline parameters for labouring and non-labouring women and to compare the mean values of these ROTEM® parameters. METHODS Ethical approval was granted for an opt-out recruitment approach for labouring women and written consent was obtained from non-labouring women (data published previously). ROTEM® testing was performed in these two cohorts at term gestation. Women with any condition affecting coagulation were excluded. ROTEM® Delta reference ranges were derived by calculating the 2.5 and 97.5 percentiles for INTEM/EXTEM/FIBTEM amplitude at 5 min (A5), coagulation time (CT), maximum clot firmness (MCF) and clot formation time (CFT). RESULTS One hundred and twenty-one labouring and 132 non-labouring women met inclusion criteria. The mean values for selected ROTEM® parameters for labouring and non-labouring women respectively were: FIBTEM A5, 21.05 and 19.7 mm (P=0.008); EXTEM A5, 54.8 and 53.2 mm (P=0.025); and EXTEM CT, 52.2 and 53.7 s (P=0.049). Significant differences between the groups were observed in measures of clotting onset and clot firmness. CONCLUSIONS We demonstrated a significant decrease in the mean time-to-clotting onset in labouring women compared with non-labouring women. Mean values for measures of clot firmness were greater in labouring women. In comparison to previously established ROTEM® baseline parameters for non-labouring women, this study provides evidence that there is greater hyper-coagulability in labouring women.
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Affiliation(s)
- J Lee
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; The University of Queensland, QLD, Australia.
| | - K H Wyssusek
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; The University of Queensland, QLD, Australia
| | - R M N Kimble
- The University of Queensland, QLD, Australia; Department of Obstetrics and Gynaecology, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - M Way
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - A A van Zundert
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; The University of Queensland, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia
| | - J Cohen
- The University of Queensland, QLD, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - J Rowell
- The University of Queensland, QLD, Australia; Department of Haematology, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - V A Eley
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; The University of Queensland, QLD, Australia
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30
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Markley JC, Carusi DA. Postpartum Hemorrhage: What’s New? CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2019. [DOI: 10.1007/s13669-019-00273-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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31
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Managing coagulopathy following PPH. Best Pract Res Clin Obstet Gynaecol 2019; 61:106-120. [DOI: 10.1016/j.bpobgyn.2019.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
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32
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Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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33
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Rabinovich A, Abdul-Kadir R, Thachil J, Iba T, Othman M, Erez O. DIC in obstetrics: Diagnostic score, highlights in management, and international registry-communication from the DIC and Women's Health SSCs of the International Society of Thrombosis and Haemostasis. J Thromb Haemost 2019; 17:1562-1566. [PMID: 31218838 DOI: 10.1111/jth.14523] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
- University College, London, UK
| | - Jecko Thachil
- Department of Hematology, Manchester Royal Infirmary, Manchester, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, Ontario, Canada
| | - Offer Erez
- Maternity Department, University Soroka, Gynecology and Obstetrics Division, Soroka University Medical Center, School of Medicine Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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34
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Othman M, Han K, Elbatarny M, Abdul-Kadir R. The use of viscoelastic hemostatic tests in pregnancy and puerperium: review of the current evidence - communication from the Women's Health SSC of the ISTH. J Thromb Haemost 2019; 17:1184-1189. [PMID: 31127695 DOI: 10.1111/jth.14461] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/28/2019] [Accepted: 04/11/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Canada
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Canada
| | - Katharina Han
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Canada
| | | | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation hospital, London, UK
- University College, London, UK
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35
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Point-of-care coagulation testing for obstetric hemorrhage: time for a theranostic approach? Int J Obstet Anesth 2019; 38:1-3. [DOI: 10.1016/j.ijoa.2019.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 12/13/2022]
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36
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Lee J, Eley V, Wyssusek K, Coonan E, Way M, Cohen J, Rowell J, van Zundert A. Baseline parameters for rotational thromboelastometry (ROTEM®) in healthy women undergoing elective caesarean delivery: a prospective observational study in Australia. Int J Obstet Anesth 2019; 38:10-18. [DOI: 10.1016/j.ijoa.2019.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/20/2018] [Accepted: 01/11/2019] [Indexed: 01/22/2023]
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37
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Hill JS, Devenie G, Powell M. Point-of-Care Testing of Coagulation and Fibrinolytic Status during Postpartum Haemorrhage: Developing a Thrombelastography®-Guided Transfusion Algorithm. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000612] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J. S. Hill
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - G. Devenie
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
- Operations and Project Administrator, LabPlus, Auckland City Hospital
| | - M. Powell
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
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38
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Sharp G, Young CJ. Point‐of‐care viscoelastic assay devices (rotational thromboelastometry and thromboelastography): a primer for surgeons. ANZ J Surg 2018; 89:291-295. [DOI: 10.1111/ans.14836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 05/28/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Gary Sharp
- Department of Colorectal SurgeryRoyal Prince Alfred Hospital Sydney New South Wales Australia
| | - Christopher J. Young
- Department of Colorectal SurgeryRoyal Prince Alfred Hospital Sydney New South Wales Australia
- Discipline of SurgeryThe University of Sydney Sydney New South Wales Australia
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39
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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40
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Samama CM, Ickx B, Ozier Y, Steib A, Susen S, Godier A. The place of fibrinogen concentrates in the management of perioperative bleeding: A position paper from the Francophone Working Group on Perioperative Haemostasis (GIHP). Anaesth Crit Care Pain Med 2018; 37:355-365. [DOI: 10.1016/j.accpm.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023]
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Abstract
Haemostatic abnormalities are common in the critically ill or bleeding patient, including haemorrhage-related coagulopathies, disseminated intravascular coagulation and thrombocytopenia, among other pathologies. In this article we aim to outline some of the causes of these clotting abnormalities, highlighting recent advancements in knowledge and new insights into their clinical management, with the aim of optimising diagnostic and therapeutic strategies.
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Affiliation(s)
- Divyansh Gulati
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Novak
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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42
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Novak A, Stanworth SJ, Curry N. Do we still need cryoprecipitate? Cryoprecipitate and fibrinogen concentrate as treatments for major hemorrhage - how do they compare? Expert Rev Hematol 2018; 11:351-360. [PMID: 29584463 DOI: 10.1080/17474086.2018.1458610] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Major hemorrhage is a source of significant mortality and morbidity worldwide. Identification and characterization of coagulation impairment associated with major hemorrhage has suggested a key role for fibrinogen deficiency, however the optimum mode of replacement of fibrinogen remains unclear, and standardized major hemorrhage protocols may overlook context-dependent variations in individual patients' clotting derangement. Areas covered: This paper examines the current practice and evidence regarding the role of different modes of fibrinogen replacement in major hemorrhage in 3 distinct clinical settings: trauma, obstetric hemorrhage, and gastrointestinal hemorrhage with associated liver disease. A literature search was carried out electronically using Athens access to the National Health Service evidence health information resources, primarily PubMed and Google Scholar. Expert commentary: Two key questions need to be addressed. First, what is the role of concentrated fibrinogen (by comparison to no fibrinogen), and second, which concentrated source or product is more effective (or cost-effective)? Current practice and concept is derived largely from small pilot trials in the trauma setting, but results from larger studies are awaited. More comparative data on changes to clotting profiles in different groups of bleeding patients are needed to help delineate differences and guide interventional treatment studies.
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Affiliation(s)
- Alex Novak
- a Emergency Department , Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Simon J Stanworth
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,c NHS Blood and Transplant , John Radcliffe Hospital , Oxford , UK.,d Radcliffe Department of Medicine , University of Oxford , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
| | - Nicola Curry
- b Department of Haematology , Oxford University Hospitals NHS Foundation Trust , Oxford , UK.,e Oxford Biomedical Research Centre , NIHR Blood Theme , Oxford , UK
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Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-944. [DOI: 10.1213/ane.0000000000002530] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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Platelet Aggregometry Testing: Molecular Mechanisms, Techniques and Clinical Implications. Int J Mol Sci 2017; 18:ijms18081803. [PMID: 28820484 PMCID: PMC5578190 DOI: 10.3390/ijms18081803] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 12/18/2022] Open
Abstract
Platelets play a fundamental role in normal hemostasis, while their inherited or acquired dysfunctions are involved in a variety of bleeding disorders or thrombotic events. Several laboratory methodologies or point-of-care testing methods are currently available for clinical and experimental settings. These methods describe different aspects of platelet function based on platelet aggregation, platelet adhesion, the viscoelastic properties during clot formation, the evaluation of thromboxane metabolism or certain flow cytometry techniques. Platelet aggregometry is applied in different clinical settings as monitoring response to antiplatelet therapies, the assessment of perioperative bleeding risk, the diagnosis of inherited bleeding disorders or in transfusion medicine. The rationale for platelet function-driven antiplatelet therapy was based on the result of several studies on patients undergoing percutaneous coronary intervention (PCI), where an association between high platelet reactivity despite P2Y12 inhibition and ischemic events as stent thrombosis or cardiovascular death was found. However, recent large scale randomized, controlled trials have consistently failed to demonstrate a benefit of personalised antiplatelet therapy based on platelet function testing.
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45
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Muirhead B, Weiss ADH. Massive hemorrhage and transfusion in the operating room. Can J Anaesth 2017; 64:962-978. [DOI: 10.1007/s12630-017-0925-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/11/2017] [Accepted: 06/20/2017] [Indexed: 12/01/2022] Open
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Kaufner L, Henkelmann A, von Heymann C, Feldheiser A, Mickley L, Niepraschk-von Dollen K, Grittner U, Henrich W, Bamberg C. Can prepartum thromboelastometry-derived parameters and fibrinogen levels really predict postpartum hemorrhage? J Perinat Med 2017; 45:427-435. [PMID: 27442353 DOI: 10.1515/jpm-2016-0009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/19/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Decreased postpartum rotational thromboelastometric parameters of coagulation (ROTEM®) and fibrinogen levels have been associated with postpartum hemorrhage (PPH). However, the predictive power of prepartum ROTEM® parameters and fibrinogen levels (Fbgpre) for PPH remains unknown. METHODS This prospective observational pilot study included 217 healthy pregnant women. Maximum clot firmness (FIBTEM-MCF), fibrinogen levels and standard coagulation parameters were measured upon admission to the delivery room for labor and within 1 h after vaginal delivery. Blood loss was measured with a calibrated collecting drape during the third stage of labor. PPH was defined as blood loss ≥500 mL. Predictors for bleeding were identified via receiver operating characteristic analyses and bivariate and multivariate regression analyses. RESULTS Women with and without PPH did not differ in median FIBTEM-MCF [23 mm (25th percentile 20 mm, 75th percentile 26 mm) vs. 23 mm (19 mm, 26 mm), respectively; P=0.710] or mean Fbgpre (4.57±0.77 g/L vs. 4.45±0.86 g/L, respectively; P=0.431). Blood loss and prepartum coagulation parameters were not correlated (FIBTEM-MCF, rs=-0.055, P=0.431; Fbgpre, rs=-0.017, P=0.810). The areas under the curves (predictive power for PPH) for FIBTEM-MCF and Fbgpre and were 0.52 (0.41-0.64, P=0.699) and 0.53 [95% confidence interval (95% CI) 0.40-0.65, P=0.644], respectively. Neither FIBTEM-MCF nor Fbgpre was associated with PPH. However, primiparity [odds ratio (OR) 4.27, 95% CI 1.32-13.80, P=0.015) and urgent cesarean section (2.77, 1.00-7.67, P=0.050) were independent predictors of PPH. CONCLUSIONS ROTEM® parameters, Fbgpre and postpartum blood loss were not associated, nor did these factors predict PPH. Sufficiently powered prospective studies are needed to confirm these results.
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Ahmadzia HK, Lockhart EL, Thomas SM, Welsby IJ, Hoffman MR, James AH, Murtha AP, Swamy GK, Grotegut CA. Using antifibrinolytics in the peripartum period - concern for a hypercoagulable effect? J Neonatal Perinatal Med 2017; 10:1-7. [PMID: 28304315 DOI: 10.3233/npm-16139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Although antifibrinolytic agents are used to prevent and treat hemorrhage, there are concerns about a potential increased risk for peripartum venous thromboembolism. We sought to determine the impact of tranexamic acid and ɛ-aminocaproic acid on in vitro clotting properties in pregnancy. METHODS Blood samples were obtained from healthy pregnant, obese, and preeclamptic pregnant women (n = 10 in each group) prior to delivery as well as from healthy non-pregnant controls (n = 10). Maximum clot firmness (MCF) and clotting time (CT) were measured using rotation thromboelastometry in the presence of tranexamic acid (3, 30, or 300 μg/mL) or ɛ-aminocaproic acid (30, 300, or 3000 μg/mL). ANOVA and regression analyses were performed. RESULTS Mean whole blood MCF was significantly higher in healthy pregnant vs. non-pregnant women (66.5 vs. 57.5 mm, p < 0.001). Among healthy pregnant women, there was no significant difference between mean MCF (whole blood alone, and with increasing tranexamic acid doses = 66.5, 66.1, 66.4, 66.3 mm, respectively; p = 0.25) or mean CT (409, 412, 420, 424 sec; p = 0.30) after addition of tranexamic acid. Similar results were found using ɛ-aminocaproic acid. Preeclamptic women had a higher mean MCF after the addition of ɛ-aminocaproic acid and tranexamic acid (p = 0.05 and p = 0.04, respectively) compared to whole blood alone. CONCLUSIONS Pregnancy is a hypercoagulable state, as reflected by an increased MCF compared to non-pregnant women. Addition of antifibrinolytic therapy in vitro does not appear to increase MCF or CT for non-pregnant, pregnant, and obese women. Whether antifibrinolytics are safe in preeclampsia may require further study.
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Affiliation(s)
- H K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - E L Lockhart
- Department of Pathology, Division of Pathology Clinical Services, Duke University, Durham, NC, USA
| | - S M Thomas
- Department of Biostatistics, Duke University, Durham, NC, USA
| | - I J Welsby
- Department of Anesthesiology, Division of Cardiac Anesthesiology, Duke University, Durham, NC, USA
| | - M R Hoffman
- Department of Pathology, Division of General Pathology, Duke University Durham, NC, USA
| | - A H James
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - A P Murtha
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - G K Swamy
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - C A Grotegut
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
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O'Brien KL, Uhl L. How do we manage blood product support in the massively hemorrhaging obstetric patient? Transfusion 2016; 56:2165-71. [DOI: 10.1111/trf.13753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/14/2016] [Accepted: 06/20/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Kerry L. O'Brien
- Beth Israel Deaconess Medical Center and Harvard Medical SchoolBoston Massachusetts
| | - Lynne Uhl
- Beth Israel Deaconess Medical Center and Harvard Medical SchoolBoston Massachusetts
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Gehrie EA, Baine I, Booth GS. Pathology Consultation on Viscoelastic Studies of Coagulopathic Obstetrical Patients. Am J Clin Pathol 2016; 146:149-55. [PMID: 27124951 DOI: 10.1093/ajcp/aqw044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES In obstetrics, the decision to transfuse blood components has historically been driven by traditional laboratory testing in combination with direct observation of bleeding. The adjunctive use of viscoelastic testing, including thromboelastometry and thromboelastography, has gained increasing acceptance in the clinical domain. METHODS We performed a review of the published medical literature by searching the PUBMED database for keywords "viscoelastic" and "obstetric," as well as "viscoelastic" and "postpartum hemorrhage." Additionally, case reports and expert opinion publications that referenced viscoelastic studies in obstetrical patients were evaluated. RESULTS There is very little high-quality evidence currently published in the medical literature to support the notion that viscoelastic testing obviates the need for traditional coagulation testing or improves mortality resulting from major obstetrical hemorrhage. CONCLUSIONS Additional research is needed to further focus the optimum role of viscoelastic tests in major obstetrical hemorrhage.
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Affiliation(s)
- Eric A Gehrie
- From the Department of Laboratory Medicine, Yale University, New Haven, CT;
| | - Ian Baine
- From the Department of Laboratory Medicine, Yale University, New Haven, CT
| | - Garrett S Booth
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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Massive obstetric hemorrhage: Current approach to management. Med Intensiva 2016; 40:298-310. [PMID: 27184441 DOI: 10.1016/j.medin.2016.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 01/25/2023]
Abstract
Massive obstetric hemorrhage is a major cause of maternal mortality and morbidity worldwide. It is defined (among others) as the loss of>2,500ml of blood, and is associated to a need for admission to critical care and/or hysterectomy. The relative hemodilution and high cardiac output found in normal pregnancy allows substantial bleeding before a drop in hemoglobin and/or hematocrit can be identified. Some comorbidities associated with pregnancy can contribute to the occurrence of catastrophic bleeding with consumption coagulopathy, which makes the situation even worse. Optimization, preparation, rational use of resources and protocolization of actions are often useful to improve outcomes in patients with postpartum hemorrhage. Using massive obstetric hemorrhage protocols is useful for facilitating rapid transfusion if needed, and can also be cost-effective. If hypofibrinogenemia during the bleeding episode is identified, early fibrinogen administration can be very useful. Other coagulation factors in addition to fibrinogen may be necessary during postpartum hemorrhage replacement measures in order to effectively correct coagulopathy. A hysterectomy is recommended if the medical and surgical measures prove ineffective.
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