The Role of Thromboelastography during the Management of Postpartum Hemorrhage: Background, Evidence, and Practical Application

Abstract

Postpartum hemorrhage (PPH) is a common cause of significant maternal morbidity and mortality that can be associated with coagulopathy, especially hypofibrinogenemia. There is interest in point-of-care viscoelastic hemostatic assays (POC-VHA) in PPH because prompt knowledge of coagulation status can aid diagnosis, identify cases of severe coagulopathy, and allow ongoing monitoring during rapid bleeding. The incidence of coagulopathy in most cases of PPH is low because of the procoagulant state of pregnancy, including raised fibrinogen levels of around 4 to 6 g/L. A Clauss fibrinogen of >2 g/L or POC-VHA equivalent has been found to be adequate for hemostasis during PPH. POC-VHA has been used successfully to diagnose hypofibrinogenemia (Clauss fibrinogen of ≤2 g/L) and guide fibrinogen treatment which has reduced bleed size and complications of massive transfusion. There are uncertainties about the use of POC-VHA to direct fresh frozen plasma and platelet administration during PPH. Several POC-VHA algorithms have been used successfully incorporated in the management of many thousands of PPHs and clinicians report that they are easy to use, interpret, and aid decision making. Due to the relative cost of POC-VHA and lack of definitive data on improving outcomes, these devices have not been universally adopted during PPH.

Peripartum Haemorrhage: Haemostatic Aspects of the Updated Peripartum Haemorrhage Guideline of the German-Speaking Countries

“…One of the few therapeutic options with international consensus might be the threshold for fibrinogen replacement of <2 g/L [41, 67, 68]. For a prior non-anaemic woman at term, this is rarely the case with a BL of 1,000 mL (2.4% [63]) but almost always, if bleeding volume is >4,000 mL [66, 67]. Of note, some obstetric bleeding aetiologies like placental abruption or amniotic fluid embolism may initially induce a hyperfibrinolytic state with early coagulopathy and low fibrinogen.…”

Review of Thromboelastography (TEG): Medical and Surgical Applications

“…56 TEG use in postpartum hemorrhage (PPH) is an emerging area of interest with some parallels to non-traumatic hemorrgage. 57 Patients receiving point-of-care viseoelastic testing in the setting of postpartum hemorrhage have shown fewer transfusions of platelets, FFP, and red blood cells along with lower incidence of postoperative ICU admissions and cesarean hysterectomy. 58 Other retrospective cohort studies have shown that in PPH, TEG provides rapid detection of hypofibrinogenemia and thrombocytopenia to allow rapid identification of clotting disorders.…”

Reply to Bareille et al. Are Viscoelastometric Assays of Old Generation Ready for Disposal? Comment on “Volod et al. Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J. Clin. Med. 2022, 11, 860”

“…In summary, we are very grateful for the commentary that Bareille et al have given on our manuscript and we point out that for the special edition of the JCM devoted to VHAs our “primer” paper by Volod et al was of central importance because of its purpose of providing an introduction for experts and nonexperts to viscoelastic testing in the clinical and research settings. We believe that Bareille et al’s characterization of our enthusiasm as excessive contradicts the extraordinary experience and growth of these devices not just during the pandemic but also recently in the care of severe trauma patients and in patients with post-partum hemorrhage, (PPH), extracorporeal mechanical oxygenation (ECMO) as well as in surgical and medical critical care medicine [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ].…”