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Am J Perinatol
DOI: 10.1055/a-1974-5055
Original Article

Thromboelastography versus Standard Coagulation Assays in Patients with Postpartum Hemorrhage

Allison D. Perelman
1   Department of Obstetrics & Gynecology, New York University Langone Health, New York, New York
,
Meghana Limaye 
2   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York
,
Jennifer Blakemore
1   Department of Obstetrics & Gynecology, New York University Langone Health, New York, New York
,
Iffath A. Hoskins
2   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York
› Author Affiliations Funding There was no funding or personal assistance for this study.
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Abstract

Objective Thromboelastography (TEG), a point-of-care test that measures blood's dynamic viscoelastic properties, is routinely used to guide resuscitation in surgical specialties with high hemorrhage risk. Patients with ongoing postpartum hemorrhage (PPH) often develop coagulopathy and hypofibrinogenemia. Timely assessment of fibrinogen is crucial because cryoprecipitate for repletion requires thawing time prior to administration. TEG may provide rapid assessment of coagulopathy in ongoing hemorrhage but this has not been thoroughly studied. Our objective was to determine if TEG accurately reflects coagulopathy in ongoing PPH when compared with standard assays.

Study Design This was a retrospective cohort study of people with ongoing PPH (quantified blood loss >1,000 mL), from January 1, 2016, to December 31, 2019. TEG variables and standard coagulation parameters were compared in patients who had both assays drawn simultaneously. As a secondary analysis, patients who had TEG were compared with those who did not. The Mann–Whitney, Fisher's exact, Kruskal–Wallis, Spearman's rho, and logistic regression tests were used for analysis. Significance was set at p < 0.05.

Results A total of 680 patients were included, 69 of whom had TEG and coagulation parameters drawn simultaneously and were included in the primary analysis. The remainder were included in the secondary analysis. TEG variables and coagulation assays correlated significantly—prolonged R with increased PTT (rho 0.25, p = 0.04), prolonged K and decreased α angle with decreased fibrinogen (rho −0.61, p < 0.001; rho 0.24, p < 0.001), and decreased maximum amplitude with decreased platelets (rho 0.62, p < 0.001). Those who had thromboelastographic assays had higher blood loss and need for interventions to manage hemorrhage than those who did not.

Conclusion TEG correlated significantly with standard laboratory assays in ongoing PPH, including for patients with hypofibrinogenemia. Given the point-of-care nature and rapid turnaround time, TEG should be considered for timely hemorrhage evaluation and directed resuscitation of coagulopathy.

Key Points

  • TEG significantly correlates with standard laboratory measures of coagulopathy in postpartum hemorrhage, including in patients with hybofibrinogemia (fibrinogen <200).

  • TEG is routinely used in nonobstetric hemorrhage, and should be considered in PPH.

  • Due to the point-of-care nature, TEG may allow for rapid guided resuscitation, including fibrinogen.

Keywords

postpartum hemorrhage - thromboelastography - coagulopathy - fibrinogen - massive transfusion


Publication History

Received: 08 April 2022

Accepted: 01 November 2022

Accepted Manuscript online:
08 November 2022

Article published online:
29 December 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol 2017; 130 (04) e168-e186
    Google Scholar
  • 2 Creanga AA, Berg CJ, Ko JY. et al. Maternal mortality and morbidity in the United States: where are we now?. J Womens Health (Larchmt) 2014; 23 (01) 3-9
    CrossrefPubMedGoogle Scholar
  • 3 Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2 (06) e323-e333
    CrossrefPubMedGoogle Scholar
  • 4 Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120 (05) 1029-1036
    CrossrefPubMedGoogle Scholar
  • 5 Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994-2006. Am J Obstet Gynecol 2010; 202 (04) 353.e1-353.e6
    Google Scholar
  • 6 Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews 2019; 20 (10) e561-e574
    CrossrefPubMedGoogle Scholar
  • 7 Grottke O, Mallaiah S, Karkouti K, Saner F, Haas T. Fibrinogen Supplementation and Its Indications. Semin Thromb Hemost 2020; 46 (01) 38-49
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Luddington RJ. Thrombelastography/thromboelastometry. Clin Lab Haematol 2005; 27 (02) 81-90
    CrossrefPubMedGoogle Scholar
  • 9 Shaydakov ME, Sigmon DF, Blebea J. Thromboelastography. StatPearls. Treasure Island, FL: StatPearls Publishing; 2021
    Google Scholar
  • 10 Mohamed M, Majeske K, Sachwani GR, Kennedy K, Salib M, McCann M. The impact of early thromboelastography directed therapy in trauma resuscitation. Scand J Trauma Resusc Emerg Med 2017; 25 (01) 99
    CrossrefPubMedGoogle Scholar
  • 11 Karlsson O, Sporrong T, Hillarp A, Jeppsson A, Hellgren M. Prospective longitudinal study of thromboelastography and standard hemostatic laboratory tests in healthy women during normal pregnancy. Anesth Analg 2012; 115 (04) 890-898
    Google Scholar
  • 12 Spasiano A, Matellon C, Orso D. et al. Functional fibrinogen (FLEV-TEG) versus the Clauss method in an obstetric population: a comparative study. BMC Anesthesiol 2019; 19 (01) 90
    CrossrefPubMedGoogle Scholar
  • 13 Yang J, Yang H, Tang A. et al. Trimester-specific reference intervals for kaolin-activated thromboelastography (TEG®) in healthy Chinese pregnant women. Thromb Res 2019; 184: 81-85
    CrossrefPubMedGoogle Scholar
  • 14 Solomon C, Collis RE, Collins PW. Haemostatic monitoring during postpartum haemorrhage and implications for management. Br J Anaesth 2012; 109 (06) 851-863
    CrossrefPubMedGoogle Scholar
  • 15 Ekelund K, Hanke G, Stensballe J, Wikkelsøe A, Albrechtsen CK, Afshari A. Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery. Acta Obstet Gynecol Scand 2015; 94 (07) 680-692
    CrossrefPubMedGoogle Scholar
  • 16 Karlsson O, Jeppsson A, Hellgren M. Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both?. Int J Obstet Anesth 2014; 23 (01) 10-17
    Google Scholar
  • 17 Nelson DB, Ogunkua O, Cunningham FG. Point-of-Care Viscoelastic Tests in the Management of Obstetric Hemorrhage. Obstet Gynecol 2022; 139 (03) 463-472
    CrossrefPubMedGoogle Scholar
  • 18 Kaur J, Jain A. Fibrinogen. StatPearls. Treasure Island, FL: StatPearls Publishing; 2022
    Google Scholar
  • 19 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 2012; 40 (06) 1007-1015
    CrossrefPubMedGoogle Scholar
  • 20 Gonzalez E, Moore EE, Moore HB. et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2016; 263 (06) 1051-1059
    CrossrefPubMedGoogle Scholar