No abstract

Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are pointof-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.

IntroductionDespite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies.MethodsWe screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale.ResultsWe screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection—as compared with uninfected pregnant women—were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias.ConclusionsThis analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.

ObjectiveThere has been an appreciable rise in postpartum hemorrhage requiring blood transfusions in the United States. Our objective is to better define patients at greatest risk for peripartum transfusion at the time of cesarean in order to identify cases for early intervention and monitoring.MethodsOur study is a secondary analysis of a retrospective cohort study. Cases of intraoperative and immediate postpartum blood transfusion among women undergoing cesarean delivery were identified. Multivariable logistic regression models were used to identify antepartum and intrapartum risk factors that were independently associated with blood transfusion. A risk calculator was then developed to predict the need for transfusion.ResultsOf 56,967 women, 1488 (2.6%) required any blood transfusion. The strongest risk factors for peripartum blood transfusion included anemia (odds ratio [OR] 3.7, 95% CI 3.3–4.3), abruption on presentation (OR 3.3, CI 2.6–4.1), general anesthesia (OR 5.2, CI 4.4–6.1) and abnormal placentation (OR 92.0, CI 57.4–147.6). An antepartum (model 1) and combined antepartum plus intrapartum risk model (model 2) were developed (model 1 AUC = 0.77, model 2 AUC = 0.83) and internally validated.ConclusionsAmong women who required cesarean delivery, we were able to identify risk factors which predispose women to peripartum blood transfusion and developed a prediction model with good discrimination.

Magnetic resonance imaging is an important tool in prenatal diagnosis of ICH, especially when US describes nonspecific intracranial abnormalities. GMH occurs more frequently and later in pregnancy than non-GMH. © 2017 John Wiley & Sons, Ltd.