Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

Alyson E Liew-Spilger, Nikki R Sorg, Toby J Brenner, Jack H Langford, Margaret Berquist, Natalie M Mark, Spencer H Moore, Julie Mark, Sara Baumgartner, Mary P Abernathy, Alyson E Liew-Spilger, Nikki R Sorg, Toby J Brenner, Jack H Langford, Margaret Berquist, Natalie M Mark, Spencer H Moore, Julie Mark, Sara Baumgartner, Mary P Abernathy

Abstract

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

Keywords: amniotic fluid embolism; blood coagulation; blood component transfusion; disseminated intravascular coagulation; obstetrics; postpartum hemorrhage; pregnancy; rotational thromboelastometry; thromboelastography; von Willebrand factor.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Depictions of normal or physiologic TEG (top) and ROTEM (bottom) tracings. TEG and ROTEM use equivalent but independently labelled parameters. Reaction time (R) and clot time (CT) refer to the time required for the transducer to be displaced 2 mm, correlating with the parameters of the PT/aPTT tests. Clot formation/kinetics (k) and clot formation time (CFT) are measures of initial clot strength and clot formation kinetics, referring to the time required for the transducer to be displaced 20 mm after it reached the 2 mm mark. α-angle is the angle formed between the horizontal axis and the sloped line formed between 0 and 20 mm of amplitude and is used in both TEG and ROTEM technologies. CFT/k and α-angle are broadly correlated with fibrinogen levels. Clot amplitude at 5/10 min (A5/A10) are measurements of the amplitude at 5-min intervals after the CT. Maximum amplitude (MA) and maximum clot firmness (MCF) refer to the maximum displacement acquired and are measures of maximum clot strength. They correlate with maximum clot retraction as a reflection of the crosslinking of fibrin with platelets. TEG and ROTEM analyzers also use differing parameters to describe fibrinolysis. Lysis at 30 min (LY30) shows the percent decrease in amplitude 30 min after achieving MA. Clot lysis index at 30 min (CLI30) is the residual clot remaining 30 min after CT, measured as a percentage of MCF. Maximum lysis (ML) is a measure of the percent decrease in amplitude at the end of the run. Adapted from [23] with permission from Semin Thromb Hemost., 2020.
Figure 2
Figure 2
35-year-old woman presenting with a cardiac arrest due to an amniotic fluid embolism during delivery. Patient required cardiopulmonary resuscitation and developed immediate disseminated intravascular coagulation, respiratory and renal failure which required ventilation and eventual dialysis. The fetus was successfully delivered by immediate cesarean section and the patient completely recovered. First thromboelastography tracing reveals no clot formation (A). Improvement over 2 (B) and 8 (C) hours were achieved by following thromboelastography-guided massive transfusion and use of HAT. Physiologic thromboelastography tracing is also depicted (C) Adapted from [29] permission from J. Extra Corpor. Technol., 2016.

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