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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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Stanciakova L, Dobrotova M, Holly P, Zolkova J, Vadelova L, Skornova I, Ivankova J, Bolek T, Samos M, Grendar M, Danko J, Kubisz P, Stasko J. How Can Rotational Thromboelastometry as a Point-of-Care Method Be Useful for the Management of Secondary Thromboprophylaxis in High-Risk Pregnant Patients? Diagnostics (Basel) 2021; 11:diagnostics11050828. [PMID: 34063712 PMCID: PMC8147835 DOI: 10.3390/diagnostics11050828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/16/2022] Open
Abstract
Thromboprophylaxis with low-molecular-weight heparin (LMWH) for patients with a history of venous thromboembolism (VTE) is suggested. Rotational thromboelastometry (ROTEM®) represents an innovative point-of-care method enabling the complex and quick evaluation of hemostasis. However, there are only episodic cases of its use for hemostasis assessment and guidance of LMWH in pregnancy. Therefore, we provide the results of unique prospective and longitudinal monitoring of hemostasis in high-risk pregnant women, which we used for the individualized optimalization of secondary thromboprophylaxis. According to the shortening of clot formation time (CFT) in EXTEM (p = 0.0007 from the 26th gestational week vs. controls) and INTEM (p = 0.002 from the 35th gestational week), increase in alpha angle (AA) in EXTEM, INTEM, and HEPTEM, and the persistence of increase in maximum clot firmness (MCF) in EXTEM, INTEM, and HEPTEM (p < 0.001 from the 26th and 35th gestational week vs. controls for EXTEM and INTEM, p = 0.0012 from the 26th gestational week in HEPTEM), LMWH dose was modified. Even after the postpartum period, AA in EXTEM was steeper than in controls (p = 0.0007), indicating that hemostasis is not fully normalized after 6–8 weeks following delivery. Therefore, ROTEM may be a useful tool for the individual evaluation of the termination of anticoagulant thromboprophylaxis.
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Affiliation(s)
- Lucia Stanciakova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
- Correspondence: ; Tel.: +42-143-420-3696
| | - Miroslava Dobrotova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Pavol Holly
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Jana Zolkova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Lubica Vadelova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
- Center of Immunology in Martin, 03601 Martin, Slovakia
| | - Ingrid Skornova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Jela Ivankova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Tomas Bolek
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (T.B.); (M.S.)
| | - Matej Samos
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (T.B.); (M.S.)
| | - Marian Grendar
- Biomedical center Martin, Laboratory of Bioinformatics and Biostatistics, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia;
- Laboratory of Theoretical Methods, Institute of Measurement Science, Slovak Academy of Sciences, 84104 Karlova Ves, Slovakia
| | - Jan Danko
- Department of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia;
| | - Peter Kubisz
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
| | - Jan Stasko
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital, 03659 Martin, Slovakia; (M.D.); (P.H.); (J.Z.); (L.V.); (I.S.); (J.I.); (P.K.); (J.S.)
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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: 56] [Impact Index Per Article: 14.0] [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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Wheeler AP, Hemingway C, Gailani D. The clinical management of factor XI deficiency in pregnant women. Expert Rev Hematol 2020; 13:719-729. [PMID: 32437625 DOI: 10.1080/17474086.2020.1772745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Factor XI (FXI) deficiency is associated with highly variable bleeding, including excessive gynecologic and obstetrical bleeding. Since approximately 20% of FXI-deficient women will experience pregnancy-related bleeding, careful planning and knowledge of appropriate hemostatic management is pivotal for their care. AREAS COVERED In this manuscript, authors present our current understanding of the role of FXI in hemostasis, the nature of the bleeding phenotype caused by its deficiency, and the impact of deficiency on obstetrical care. The authors searched PubMed with the terms, 'factor XI', 'factor XI deficiency', 'women', 'pregnancy', and 'obstetrics' to identify literature on these topics. Expectations of pregnancy-related complications in women with FXI deficiency, including antepartum, abortion-related, and postpartum bleeding, as well as bleeding associated with regional anesthesia are discussed. Recommendations for the care of these women are considered, including guidance for management of prophylactic care and acute bleeding. EXPERT COMMENTARY FXI deficiency results in a bleeding diathesis in some, but not all, patients, making treatment decisions and clinical management challenging. Currently available laboratory assays are not particularly useful for distinguishing patients with FXI deficiency who are prone to bleeding from those who are not. There is a need for alternative testing strategies to address this limitation.
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Affiliation(s)
- Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University , Nashville, TN, USA
| | - Celeste Hemingway
- Department of Obstetrics and Gynecology, Vanderbilt University , Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University , Nashville, TN, USA
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Gerber GF, Klute KA, Chapin J, Bussel J, DeSancho MT. Peri- and Postpartum Management of Patients With Factor XI Deficiency. Clin Appl Thromb Hemost 2020; 25:1076029619880262. [PMID: 31595781 PMCID: PMC6900674 DOI: 10.1177/1076029619880262] [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: 11/16/2022] Open
Abstract
Factor XI (FXI) deficiency is an uncommon autosomal disorder with variable bleeding phenotype, making peripartum management challenging. We describe our experience in pregnant women with FXI deficiency and identify strategies to minimize the use of hemostatic agents and increase utilization of neuraxial anesthesia. Electronic records of 28 pregnant women with FXI deficiency seen by a hematology service in an academic medical center from January 2006 to August 2018 were reviewed. Data on bleeding, obstetric history, peripartum management, and FXI activity were collected. Partial FXI deficiency was defined as >20 IU/dL and severe <20 IU/dL. Median FXI activity was 42 IU/dL (range <1-73 IU/dL), and median activated partial thromboplastin time was 32.2 seconds (range: 27.8-75 seconds). There were 64 pregnancies: 53 (83%) live births and 11 (17%) pregnancy losses. Postpartum hemorrhage occurred in 9 (17%) pregnancies. Antifibrinolytic agents and fresh frozen plasma were used only in women with severe deficiency (42% with bleeding and 17% with no bleeding phenotype, respectively). Neuraxial anesthesia was successfully administered in 32 (59%) deliveries. Most women with FXI deficiency have uncomplicated pregnancies and deliveries with minimal hemostatic support. Neuraxial anesthesia can be safely administered in most women.
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Affiliation(s)
- Gloria F Gerber
- Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Kelsey A Klute
- Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
| | - John Chapin
- Clinical Development, CRISPR Therapeutics, Cambridge, MA, USA
| | - James Bussel
- Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
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Shander A, Friedman T, Palleschi G, Shore-Lesserson L. The Evolving Dilemma of Factor XI in Pregnancy: Suggestions for Management. Anesth Analg 2019; 126:2032-2037. [PMID: 29381511 DOI: 10.1213/ane.0000000000002836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
A case of a patient with severe factor XI (FXI) deficiency who presented for her seventh labor and delivery is presented. The nature of FXI deficiency, its prevalence, and issues related to genetic screening are discussed. Published literature on the topic is reviewed, including criteria that were developed to assess bleeding, laboratory tools used to estimate bleeding risk, and available treatments. Within the context of this challenging clinical dilemma, specific recommendations are provided for the antepartum, intrapartum, and postpartum stages of pregnancy. These include recommendations that take into account both FXI levels and history of any abnormal bleeding. While there are effective treatments available, it is important to consider that institutional multidisciplinary protocols are needed to manage this complex disorder. More work is needed to define the best management protocols.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care Medicine, Pain Management, and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey.,TeamHealth Research Institute, TeamHealth, Englewood, New Jersey
| | - Tamara Friedman
- TeamHealth Research Institute, TeamHealth, Englewood, New Jersey
| | - Greg Palleschi
- Department of Anesthesiology, Northshore University Hospital at Northwell Health, Manhasset, New York
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Northshore University Hospital at Northwell Health, Manhasset, New York
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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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Hans GA, Besser MW. The place of viscoelastic testing in clinical practice. Br J Haematol 2016; 173:37-48. [DOI: 10.1111/bjh.13930] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Gregory A. Hans
- Department of Anaesthesia and Intensive Care Medicine; CHU of Liege; Liege Belgium
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