Transfusion and coagulation management in major obstetric hemorrhage

Abstract

Purpose of review: Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage.

Recent findings: Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels.

Summary: A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.

Figure 1

Massive transfusion protocol; modified from Burtelow et al.[29] ABG = arterial blood gas; CBC= complete blood count; DIC = disseminated intravascular coagulation; FFP = fresh frozen plasma; INR = international normalized ratio; MT = massive transfusion protocol; PLT = platelets; PT = prothrombin time; PTT = activated partial thromboplastin time; RBC = red blood cells; rFVIIa = recombinant factor VIIa.

Figure 2

ROTEM coagulation profiles in health parturients and in parturients with obstetric coagulopathy due to severe postpartum hemorrhage.[62] Schematic representations of healthy (A) and coagulopathic (B) ROTEM coagulation profiles for EXTEM and FIBTEM tests. Tissue factor is used in EXTEM assays for assessment of the extrinsic pathway. A platelet inhibitor, cytochalasin, is added to the blood sample for the FIBTEM assay to differentiate between platelet dysfunction and the alterations in fibrin polymerization. CT = Clotting time; A5/A10/A15/A20 = Clot amplitude at 5, 10, 15 and 20 min after clotting time has passed; MCF = maximum clot firmness. Source = Title = Haemostatic monitoring during postpartum haemorrhage and implications for management Reference = C. Solomon et al.; Brit J Anesth 2012; 109: 851–63

Figure 3

TEG profiles from a healthy parturient who experienced normal bleeding postpartum and a parturient who experienced major obstetric hemorrhage.[67] Two thromboelastographic profiles represent: (A) TEG profile in a woman with normal bleeding postpartum with an estimated blood loss 250 mL, TEG-R 4.9 min, TEG-MA 81.4 mm, platelets 239 × 10⁹/L, fibrinogen 6.0 g/L and antithrombin 0.98 kIU/L; and (B) TEG profile in a woman with major obstetric hemorrhage with an estimated blood loss 2500 mL, TEG-R 6.6 min, TEG-MA 48.9 mm, platelets 55 × 10⁹/L, fibrinogen 1.7 g/L, antithrombin 0.37 kIU/L. Source = Title: Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both? Reference: Karlsson O et al.; Int J Obstet Anesth 2014; 23: 10–17.