Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities

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.

Ultrasound Image Quality Comparison Between a Handheld Ultrasound Transducer and Mid-Range Ultrasound Machine

Objectives: Not all labor and delivery floors are equipped with ultrasound machines which can serve the needs of both obstetricians and anesthesiologists. This cross-sectional, blinded, randomized observational study compares the image resolution (RES), detail (DET), and quality (IQ) acquired by a handheld ultrasound, the Butterfly iQ, and a mid-range mobile device, the Sonosite M-turbo US (SU), to evaluate their use as a shared resource. Methods: Seventy-four pairs of ultrasound images were obtained for different imaging purposes: 29 for spine (Sp), 15 for transversus abdominis plane (TAP) and 30 for diagnostic obstetrics (OB) purposes. Each location was scanned by both the handheld and mid-range machine, resulting in 148 images. The images were graded by three blinded experienced sonographers on a 10-point Likert scale. Results: The mean difference for Sp imaging favored the handheld device (RES: -0.6 [(95% CI -1.1, -0.1), p = 0.017], DET: -0.8 [(95% CI -1.2, -0.3), p = 0.001] and IQ: -0.9 [95% CI-1.3, -0.4, p = 0.001]). For the TAP images, there was no statistical difference in RES or IQ, but DET was favored in the handheld device (-0.8 [(95% CI-1.2, -0.5), p < 0.001]). For OB images, the SU was favored over the handheld device with RES, DET and IQ with mean differences of 1.7 [(95% CI 1.2, 2.1), p < 0.001], 1.6 [(95% CI 1.2, 2.0], p < 0.001] and 1.1 [(95% CI 0.7, 1.5]), p < 0.001), respectively. Conclusions: Where resources are limited, a handheld ultrasound may be considered as a potential low-cost alternative to a more expensive ultrasound machine for point of care ultrasonography, better suited to anesthetic vs. diagnostic obstetrical indications.

Prevalence of aberrant blood pressure readings across two automated intraoperative blood pressure monitoring systems among patients undergoing caesarean delivery

OBJECTIVES

Aberrant automated blood pressure (BP) readings during caesarean delivery may lead to disruptions in monitoring. The present study compared the frequency of aberrant BP readings across two types of commercially available BP monitoring systems in use during caesarean delivery.

METHODS

This was a retrospective observational study using two comparable patient cohorts that resulted from simultaneous introduction of two types of monitors into a single obstetric surgical center in which similar patients were treated for the same surgical procedure by the same set of clinicians during the same year. Our primary hypothesis was that aberrant readings were significantly associated with the type of monitor being used for BP measurement, controlling for a variety of relevant covariates as specified in the analytic plan.

RESULTS

A total of 1418 cesarean delivery patients met inclusion criteria. Gaps of at least 6 min in machine-captured BP readings occurred in 159 (21.1%) of cases done in the operating room using a Datex-Ohmeda monitor vs. 183 (27.5%) of cases in the operating rooms using Phillips monitors (P = 0.005). In multivariable logistic regression analysis, the relative odds of the occurrence of monitoring gaps was 35% higher in rooms with the Phillips BP monitors as compared to the Datex-Ohmeda monitor while controlling for pre-specified covariates (odds ratio = 1.35, 95% confidence interval = 1.04-1.74, P = 0.02).

CONCLUSION

The present analysis suggests that aberrant BP readings for parturients undergoing caesarean delivery are significantly different between the two types of automated BP monitoring systems used in the operating rooms at our institution.

Anesthesia for Obstetric Disasters

Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.

Anesthesia for Obstetric Disasters

Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.

SARS-CoV-2 infection of the placenta

BACKGROUNDThe effects of the novel coronavirus disease 2019 (COVID-19) in pregnancy remain relatively unknown. We present a case of second trimester pregnancy with symptomatic COVID-19 complicated by severe preeclampsia and placental abruption.METHODSWe analyzed the placenta for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through molecular and immunohistochemical assays and by and electron microscopy and measured the maternal antibody response in the blood to this infection.RESULTSSARS-CoV-2 localized predominantly to syncytiotrophoblast cells at the materno-fetal interface of the placenta. Histological examination of the placenta revealed a dense macrophage infiltrate, but no evidence for the vasculopathy typically associated with preeclampsia.CONCLUSIONThis case demonstrates SARS-CoV-2 invasion of the placenta, highlighting the potential for severe morbidity among pregnant women with COVID-19.FUNDINGBeatrice Kleinberg Neuwirth Fund and Fast Grant Emergent Ventures funding from the Mercatus Center at George Mason University. The funding bodies did not have roles in the design of the study or data collection, analysis, and interpretation and played no role in writing the manuscript.