Article Data

  • Views 89
  • Dowloads 20

Mini-Reviews

Open Access Special Issue

Blood management in post-partum haemorrhage, including point of care coagulation tests

  • Martha Belete1,†
  • Edmund Gerrans1,†
  • Madhavi Keskar1

1Somerset Foundation Trust, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, UK

DOI: 10.22514/sv.2021.030

Online publish date: 09 February 2021

*Corresponding Author(s): Madhavi Keskar E-mail: madhavi.keskar@somersetft.nhs.uk

† These authors contributed equally.

Abstract

Postpartum haemorrhage (PPH) is the leading global cause of maternal mortality, and an important cause of morbidity and mortality in the UK. Management of PPH requires a patient centred team approach to ensure effective management. Early recognition is crucial, hence quantitative measurement of blood loss should be started as soon as bleeding is identified and continue throughout an evolving haemorrhage. Pregnancy is associated with haematological changes resulting in a pro-coagulant state. Blood management in PPH has moved away from the use of shock packs and fixed transfusion ratios. Most women are not initially coagulopathic and coagulopathy is uncommon in mild to moderate PPH, Practice has therefore moved towards goal directed transfusion of blood products informed by haematological investigations alongside clinical assessment. Fibrinogen tends to be the first coagulation factor to fall and Clauss fibrinogen is an important predictor of PPH severity. Transfusion of fibrinogen rich blood products such as cryoprecipitate and fibrinogen complex are more effective at rapidly increasing fibrinogen levels compared to FFP. Point of care (POC) coagulation tests such as rotational thromboelastometry (ROTEM) and thromboeslastography (TEG) allow rapid bedside assessment compared to traditional laboratory tests. Surrogate markers of fibrinogen from POC tests can be used to both predict severity of PPH and inform blood transfusion. There is growing evidence that POC coagulation tests can be used to safely guide blood management in PPH, with its use associated with lower transfusion rates and possibly improved clinical outcomes. Further multi-centre studies are required to clarify debate surrounding their use. In this review we discuss blood management in PPH, with a focus on recent evidence regarding assessment of coagulopathy and the use of blood products.


Keywords

Postpartum haemorrhage (PPH); Blood management; Coagulopathy; Fibrinogen; Transfusion; Point of care (POC) tests; ROTEM; TEG


Cite and Share

Martha Belete,Edmund Gerrans,Madhavi Keskar. Blood management in post-partum haemorrhage, including point of care coagulation tests. Signa Vitae. 2021.doi:10.22514/sv.2021.030.

References

[1] Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology. 2016; 124: e106-e149.

[2] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J, et al. Global causes of maternal death: a who systematic analysis. The Lancet Global Health. 2014; 2: e323-e333.

[3] Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology. 2017; 130: e168-e186.

[4] Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, et al. (Eds.) Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. MBRRACE-UK. 2019.

[5] Royal College of Obstetricians and Gynaecologists. Blood transfusion in obstetrics (Green-top Guideline No. 47). 2015.

[6] Klein AA, Arnold P, Bingham RM, Brohi K, Clark R, Collis R, et al. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia. 2016; 71: 829-842.

[7] Mallaiah S, Barclay P, Harrod I, Chevannes C, Bhalla A. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015; 70: 166-175.

[8] Hunt BJ, Allard S, Keeling D, Norfolk D, Stanworth SJ, Pendry K. A practical guideline for the haematological management of major haemorrhage. British Journal of Haematology. 2015; 170: 788-803.

[9] Muñoz M, Stensballe J, Ducloy-Bouthors AS, Bonnet MP, De Robertis E, Fornet I, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion. 2019; 17: 112-136.

[10] Wong C. Analgesia and anaesthesia for labor and delivery. Gynecology and Obstetrics. 2004; 3.

[11] Katz D, Beilin Y. Disorders of coagulation in pregnancy. British Journal of Anaesthesia. 2015; 115: ii75-ii88.

[12] McNamara H, Mallaiah S. Managing coagulopathy following PPH. Best Practice & Research Clinical Obstetrics & Gynaecology. 2019; 61: 106-120.

[13] Collins PW, Bell SF, de Lloyd L, Collis RE. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the cardiff experience. International Journal of Obstetric Anesthesia. 2019; 39: 175-175.

[14] Pieters M, Wolberg AS. Fibrinogen and fibrin: an illustrated review. Research and Practice in Thrombosis and Haemostasis. 2019; 3: 161-172.

[15] Collis RE, Collins PW. Haemostatic management of obstetric haemor-rhage. Anaesthesia. 2015; 70: 78-e28.

[16] Thachil J, Toh C. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Reviews. 2009; 23: 167-176.

[17] Othman M, Falcón B, Kadir R. Global Hemostasis in pregnancy: are we using thromboelastography to its full potential? Seminars in Thrombosis and Hemostasis. 2010; 36: 738-746.

[18] Collins P, Abdul-Kadir R, Thachil J. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. Journal of Thrombosis and Haemostasis. 2016; 14: 205-210.

[19] Sloan N, Durocher J, Aldrich T, Blum J, Winikoff B. What measured blood loss tells us about postpartum bleeding: a systematic review. BJOG: an International Journal of Obstetrics & Gynaecology. 2010; 117: 788- 800.

[20] Quantitative Blood Loss in Obstetric Hemorrhage: ACOG COMMIT-TEE OPINION, Number 794. Obstetrics & Gynecology. 2019; 134: e150-e156.

[21] Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA. The accuracy of blood loss estimation after simulated vaginal delivery. Anesthesia & Analgesia. 2007; 105: 1736-1740.

[22] Hancock A, Weeks AD, Tina LD. Assessing blood loss in clinical practice. Best Practice & Research Clinical Obstetrics & Gynaecology. 2019; 61: 28-40.

[23] Rath W. Postpartum haemorrhage-update on problems of definitions and diagnosis. Acta obstetricia et gynecologica Scandinavica. 2011; 90: 421-428.

[24] Henriquez D, Bloemenkamp K, Van der Bom J. Management of postpartum haemorrhage: how to improve maternal outcomes. Journal of thrombosis and haemostasis. 2018; 16: 1523-1534.

[25] Allard S, Green L, Hunt BJ. How we manage the haematological aspects of major obstetric haemorrhage. British Journal of Haematology. 2013; 164: 177-188.

[26] de Lloyd L, Bovington R, Kaye A, Collis RE, Rayment R, Sanders J, et al. Standard haemostatic tests following major obstetric haemorrhage. International Journal of Obstetric Anesthesia. 2011; 20: 135-141.

[27] Collins PW, Lilley G, Bruynseels D, Laurent DB, Cannings-John R, Precious E, et al. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood. 2014; 124: 1727-1736.

[28] Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. Journal of Thrombosis and Haemostasis. 2007; 5: 266-273.

[29] Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. British Journal of Anaesthesia. 2012; 108: 984-989.

[30] Srivastava A, Kelleher A. Point-of-care coagulation testing. Continuing Education in Anaesthesia Critical Care & Pain. 2013; 13: 12-16.

[31] 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. Journal of Thrombosis and Haemostasis. 2020; 18: 1813-1838.

[32] Hum J, Amador D, Shatzel JJ, Naugler WE, Ahn J, Zaman A, et al. Thromboelastography better reflects hemostatic abnormalities in cirrhotics compared with the international normalized ratio. Journal of Clinical Gastroenterology. 2020; 54: 741-746.

[33] Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, et al. The use of viscoelastic haemostatic assays in the management of major bleeding. British Journal of Haematology. 2018; 182: 789-806.

[34] de Lange NM, van Rheenen-Flach LE, Lancé MD, Mooyman L, Woiski M, van Pampus EC, et al. Peri-partum reference ranges for ROTEM® thromboelastometry. British Journal of Anaesthesia. 2014; 112: 852-859.

[35] Drife J. Point‐of‐care coagulation testing in obstetrics: more evidence, please? BJOG: An International Journal of Obstetrics & Gynaecology. 2020; 127: 828-828.

[36] Armstrong S, Fernando R, Ashpole K, Simons R, Columb M. Assessment of coagulation in the obstetric population using ROTEM® thromboelas-tometry. International Journal of Obstetric Anesthesia. 2011; 20: 293-298.

[37] de Vries JJ, Veen CSB, Snoek CJM, Kruip MJHA, de Maat MPM. FIBTEM clot firmness parameters correlate well with the fibrinogen concentration measured by the Clauss assay in patients and healthy subjects. Scandinavian Journal of Clinical and Laboratory Investigation. 2020; 80: 600-605.

[38] Huissoud C, Carrabin N, Audibert F, Levrat A, Massignon D, Berland M, et al. Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG: An International Journal of Obstetrics & Gynaecology. 2009; 116: 1097-1102.

[39] Collins PW, Cannings-John R, Bruynseels D, Mallaiah S, Dick J, Elton C, et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. British Journal of Anaesthesia. 2017; 119: 411-421.

[40] McNamara H, Kenyon C, Smith R, Mallaiah S, Barclay P. Four years’ experience of a ROTEM guided algorithm for treatment of coagulopathy in obstetric haemorrhage. Anaesthesia. 2019; 74: 984-991.

[41] Toffaletti JG, Buckner KA. Use of earlier-reported rotational thromboe-lastometry parameters to evaluate clotting status, fibrinogen, and platelet activities in postpartum hemorrhage compared to surgery and intensive care patients. Anesthesia & Analgesia. 2019; 128: 414-423.

[42] Karlsson O, Jeppsson A, Hellgren M. Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both?International Journal of Obstetric Anesthesia. 2014; 23: 10-17.

[43] Katz D, Hamburger J, Batt D, Zahn J, Beilin Y. Point-of-care fibrinogen testing in pregnancy. Anesthesia & Analgesia. 2019; 129: e86-e88.

[44] Spasiano A, Matellon C, Orso D, Brussa A, Cafagna M, Marangone A, et al. Functional fibrinogen (FLEV-TEG) versus the Clauss method in an obstetric population: a comparative study. BMC Anesthesiology. 2019; 19: 90.

[45] Richmond A, Mitra A, Mousa T, Singhal T, Dhillon J. Clinical application of TEG (thromboelastograph) in obstetric patients. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2012; 97: A90.

[46] Hill JS, Devenie G, Powell M. Point-of-care testing of coagulation and fibrinolytic status during postpartum haemorrhage: developing a Thrombelastography®-guided transfusion algorithm. Anaesthesia and Intensive Care. 2012; 40: 1007-1015.

[47] Schenk B, Görlinger K, Treml B, Tauber H, Fries D, Niederwanger C, et al. A comparison of the new ROTEM® sigma with its predecessor, the ROTEMdelta. Anaesthesia. 2018; 74: 348-356.

[48] Neal MD, Moore EE, Walsh M, Thomas S, Callcut RA, Kornblith LZ, et al. A comparison between the TEG 6s and TEG 5000 analyzers to assess coagulation in trauma patients. Journal of Trauma and Acute Care Surgery. 2020; 88: 279-285.

[49] Lloyd-Donald P, Churilov L, Zia F, Bellomo R, Hart G, McCall P, et al. Assessment of agreement and interchangeability between the TEG5000 and TEG6S thromboelastography haemostasis analysers: a prospective validation study. BMC Anesthesiology. 2019; 19: 45.

[50] Duffield C, Davies R, Barclay P. Advances in thromboelastograph technology. Anaesthesia. 2018; 73: 398-399.

[51] 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. Journal of Thrombosis and Haemostasis. 2019; 17: 1184-1189.

[52] Kitchen DP, Jennings I, Kitchen S, Walker I. Letter in response to article “Systematic review of viscoelastic testing (TEG/Rotem) in obstetrics and recommendations from the women’s SSC of the ISTH” Journal of Thrombosis and Haemostasis. 2020; 18: 2418-2420.

[53] Solomon C, Collis RE, Collins PW. Haemostatic monitoring during postpartum haemorrhage and implications for management. British Journal of Anaesthesia. 2012; 109: 851-863.

[54] National Institute for Health and Care Excellence (NICE). Detecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems) (DG13). 2014.

[55] OBS Cymru Quality and Safety Sub Group of Maternity Network Wales. All wales guideline: prevention and management of postpartum haemorrhage. 2017. Available at: http://www.wisdom.wales.nhs. uk/sitesplus/documents/1183/All%20Wales%20Prevention%20of%20Postpartum%20Haemorrhage%20%281.4%29_2018.pdf.

[56] Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. European Journal of Anaesthesiology. 2017; 34: 332-395.

[57] Khan KS, Moore PAS, Wilson MJ, Hooper R, Allard S, Wrench I, et al. Cell salvage and donor blood transfusion during cesarean section: a pragmatic, multicentre randomised controlled trial (SALVO). PLoS Medicine. 2017; 14: e1002471.

[58] Klein AA, Bailey CR, Charlton AJ, Evans E, Guckian-Fisher M, McCrossan R, et al. Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018. Anaesthesia. 2018; 73: 1141-1150.

[59] Wikkelsø AJ, Edwards HM, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. British Journal of Anaesthesia. 2015; 114: 623-633.

[60] WOMAN Trial Collaborators. Effect of early tranexamic acid admin-istration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017; 389: 2105-2116.

[61] Vogel JP, Oladapo OT, Dowswell T, Gülmezoglu AM. Updated who recommendation on intravenous tranexamic acid for the treatment of post-partum haemorrhage. The Lancet Global Health. 2018; 6: e18-e19.

[62] Sultan AA, West J, Grainge MJ, Riley RD, Tata LJ, Stephansson O, Fleming KM, Nelson-Piercy C, Ludvigsson JF. Development and validation of risk prediction model for venous thromboembolism in postpartum women: multinational cohort study. British Medical Journal. 2016; 355: i6253.

[63] Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboem-bolism. Journal of Thrombosis and Thrombolysis. 2016; 41: 92-128.

[64] Liu S, Rouleau J, Joseph KS, Sauve R, Liston RM, Young D, et al. Epidemiology of pregnancy-associated venous thromboembolism: a population-based study in Canada. Journal of Obstetrics and Gynaecology Canada. 2009; 31: 611-620.

[65] Thurn L, Wikman A, Lindqvist PG. Postpartum blood transfusion and hemorrhage as independent risk factors for venous thromboembolism. Thrombosis Research. 2018; 165: 54-60.

[66] Royal College of Obstetricians and Gynaecologists. Thrombosis and embolism during pregnancy and the puerperium, reducing the risk (Green-top Guideline No. 37a). 2015.



Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time

Conferences

    Top