The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: a prospective observational study

Bell, Sarah; Roberts, T.C.D.; Pereira, J. Freyer Martins; Lloyd, L. de; Amir, Z.; James, Donna; Jenkins, Patrick; Collis, Rachel; Collins, Peter William

doi:10.1016/j.ijoa.2021.103238

Cited by 30 publications

(22 citation statements)

References 20 publications

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“…In uterine atony, at an estimated blood loss around 1,000 mL, only 2.2% of cases had first fibrinogen levels of ≤2 g/L and/or Fibtem A5 <12 mm, and between 1,500 and 2,500 mL PPH, the rate increased only slightly to 2.5%. 40 52 53 When bleeding was not controlled with obstetric intervention with bleeds of ≥2,500 mL, the rate of fibrinogen of <2 g/L and/or Fibtem <12 mm was 14%, which was lower than the average of 17% in the whole cohort. 49…”

Section: Incidence Of Coagulation Abnormalities In Pphmentioning

confidence: 95%

“…Studies in pregnancy and PPH describe similar but only moderate correlation ( r = 0.6–0.7) between ROTEM-Fibtem A5 (Fibtem amplitude at 5 minutes) or TEG-CFF MA and Clauss fibrinogen, with differences between older and more recent devices. 36 52 71 72 Use of both the CFF MA (TEG6S) and Fibtem A5 (ROTEM Sigma) to predict Claus fibrinogen <2 g/L is very similar in the clinical setting. Using a value of 17 mm for CFF amplitude (at 10 minutes) and 11 mm for Fibtem A5 to predict Clauss fibrinogen <2 g/L, the sensitivity is 0.74 to 0.76, specificity 0.97 to 0.96, a PPV of 0.57 to 0.54, and a negative predictive value (NPV) of 0.99 to 0.98.…”

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

“…In this study, if platelet transfusion had been guided by Pltem <17 mm, 12 women would have received a platelet transfusion with only three having an actual platelet number <75 × 10 9 /L. 52 The use of TEG has also been explored in three studies. 28 72 77 Kaolin MA and/or α angle was reported to have good utility for detecting platelet count <80 × 10 9 /L and/or fibrinogen ≤2 g/L in 98 women with PPH, although data for platelet count alone were not presented.…”

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

“…49 53 Early FFP to treat significant hypofibrinogenemia is also unlikely to be helpful because of its low fibrinogen content of around 2 g/L and the very large amounts of fibrinogen sometimes required to correct PPH-related hypofibrinogenemia, sometimes up to 16 g. 58 65 78 79 There are no studies that have been specifically designed to test possible thresholds for clot initiation time in the ROTEM or TEG and neither the Extem CT nor the Kaolin R time appears to be useful in identifying abnormalities in PT/aPTT or directing FFP transfusion. 52 77 The Kaolin K parameter may be useful if the PT/aPTT is >1.5× the upper reference range value, but this requires further evaluation. 77 In addition, a simple binary cut is complicated to investigate as a significant prolongation of women with abnormal clot initiation times can normalize when fibrinogen is replaced first.…”

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

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

Collis

Bell

2022

Semin Thromb Hemost

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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.

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Section: Incidence Of Coagulation Abnormalities In Pphmentioning

confidence: 95%

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

Section: Poc-vha Pph Algorithmsmentioning

confidence: 99%

See 2 more Smart Citations

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

Collis

Bell

2022

Semin Thromb Hemost

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“…Both TEG and FIBTEM amplitude at 5 min (A5) can reliably detect fibrinogen levels ≤2 g l −1 and thus provide very fast and useful information about coagulation impairment. 48 , 49 However, VET is more expensive than SLTs and not available in all hospitals.…”

Section: Assessment Of Postpartum Haemorrhage-associated Coagulopathymentioning

confidence: 99%

Haemostatic support in postpartum haemorrhage

Hofer

Bláha

Collins

et al. 2022

European Journal of Anaesthesiology

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Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.

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