Thromboelastography in the management of the obstetric patient

[Thromboelastography in the management of the obstetric patient]

Osvaldo Reyes1

1. Coordinador de investigaciones – Maternidad del Hospital Santo Tomás; Miembro del Sistema Nacional de Investigadores de Panamá.

Published: 2022-12-06

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Abstract

La mortalidad materna varía mucho a nivel mundial, siendo más alta en países en vías de desarrollo o en áreas rurales. Las medidas tomadas a nivel local y global que estén dirigidas a reducir esta brecha y la mortalidad materna como tal son de un valor incalculable, pero a pesar de contar con la tecnología y los medicamentos requeridos, su uso no se traduce en una reducción evidente en término de muertes. Una de las condiciones con mayor prevalencia es la hemorragia postparto, la cual ocupa el primer lugar en muchos países y se cita como una de las tres primeras causes a nivel mundial.

Hay muchas guías relacionadas con el manejo de la hemorragia postparto, pero en la mayoría se deja por fuera o se menciona poco la utilidad de una herramienta disponible y relativamente económica, como lo es la tromboelastografía. En este artículo discutiremos la misma, sus fortalezas y debilidades, así como el papel que puede tener la misma en el manejo de la paciente que se presenta con esta condición.


Abstract

Maternal mortality varies greatly worldwide, being higher in developing countries or in rural areas. Measures taken at the local and global level to reduce this gap and maternal mortality as such are invaluable, but despite the availability of the required technology and drugs, their use does not translate into a clear reduction in terms of deaths. One of the most prevalent conditions is postpartum hemorrhage, which ranks first in many countries and is cited as one of the top three causes worldwide.

There are many guidelines related to the management of postpartum hemorrhage, but most of them leave out or make little mention of the usefulness of an available and relatively inexpensive tool, thromboelastography. In this article we will discuss it, its strengths and weaknesses, as well as the role it can play in the management of the patient presenting with this condition.

References

[1] Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2019.

[2] Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022.

[3] Abedzadeh-Kalahroudi M. Prevention of Postpartum Hemorrhage: Our Options. Nurs Midwifery Stud. 2015 Sep;4(3):e29641. doi: 10.17795/nmsjournal29641. Epub 2015 Sep 23. PMID: 26576446; PMCID: PMC4644608.

[4] Bailey, R. , Foley, M. , Hall, N. , Fleischer, A. , D’Alton, M. , Dildy, G. , Belfort, M. , Hankins, G. and Clark, S. (2016) The Active Management of Postpartum Uterine Atony—A Checklist Based Approach. Open Journal of Obstetrics and Gynecology, 6, 646-653. doi: 10.4236/ojog.2016.611081.

[5] Hancock A, Weeks AD, Lavender DT. Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth. 2015 Sep 28;15:230. doi: 10.1186/s12884-015-0653-6. PMID: 26415952; PMCID: PMC4587838.

[6] Thurn L, Wikman A, Westgren M, Lindqvist PG. Incidence and risk factors of transfusion reactions in postpartum blood transfusions. Blood Adv. 2019 Aug 13;3(15):2298-2306. doi: 10.1182/bloodadvances.2019000074. PMID: 31366586; PMCID: PMC6693016.

[7] Hellgren M. Hemostasis during normal pregnancy and puerperium. Semin Thromb Hemost. 2003 Apr;29(2):125-30. doi: 10.1055/s-2003-38897. PMID: 12709915.

[8] Mackman N. Role of tissue factor in hemostasis, thrombosis, and vascular development. Arterioscler Thromb Vasc Biol. 2004 Jun;24(6):1015-22. doi: 10.1161/01.ATV.0000130465.23430.74. Epub 2004 Apr 29. PMID: 15117736.

[9] de Lloyd L, Bovington R, Kaye A, et al. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth. 2011;20:135–41.

[10] Armstrong S, Fernando R, Ashpole K, Simons R, Columb M. Assessment of coagulation in the obstetric population using ROTEM® thromboelastometry. Int J Obstet Anesth. 2011;20:293–8.

[11] Theresa Nguyen Kinard, Alana Christie, Philip E. Greilich, Ravindra Sarode; Comparison Of Thromboelastography (TEG) With Rotational Thromboelastrometry (ROTEM) In Surgical Patients. Blood 2013; 122 (21): 3659.

[12] Taylor JR, Cotton BA. Coagulation Issues and the Trauma Patient. Current Surgical Therapy, 1251-1259

[13] P Whiting, M Al, M Westwood, et al. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess, 19 (2015), pp. 1-228

[14] Walsh M, Fritz S, Hake D, Son M, Greve S, Jbara M, Chitta S, Fritz B, Miller A, Bader MK, McCollester J, Binz S, Liew-Spilger A, Thomas S, Crepinsek A, Shariff F, Ploplis V, Castellino FJ. Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy. Curr Drug Targets. 2016;17(8):954-70.

[15] Hellgren M. Hemostasis during normal pregnancy and puerperium. Semin Thromb Hemost. 2003 Apr;29(2):125-30.

[16] PL Steer, HB. Krantz. Thromboelastography and Sonoclot analysis in the healthy parturient. J Clin Anesth, 5 (1993), pp. 419-424

[17] SK Sharma, J Philip, J. Wiley. Thromboelastographic changes in healthy parturients and postpartum women. Anesth Analg, 85 (1997), pp. 94-98

[18] G Fan, M Yuan, H Niu, Y Lu, H Yang, X. Liang. The significance of thromboelastogram in predicting postpartum hemorrhage and guiding blood transfusion. Clin Lab (2022), p. 68

[19] PW Collins, R Cannings-John, D Bruynseels, et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth, 119 (2017), pp. 411-421

[20] C D Roberts, T., De Lloyd, L., Bell, S., Cohen, L., James, D., Ridgway, A., Jenkins, V.,

[21] Field, V., Collis, R., Collins, P., Utility of viscoelastography with TEG6s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study, International Journal of Obstetric Anesthesia (2021), doi: https://doi.org/10.1016/j.ijoa.2021.103192

[22] Charbit B, Mandelbro 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.

[23] D Snegovskikh, D Souza, Z Walton, et al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. J Clin Anesth, 44 (2018), pp. 50-56

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