Experiences with the Treatment of Coagulopathy in Obstetrics – ROTEM-Guided Algorithm
An observational study from a hospital in Liverpool, UK, was published in the journal Anaesthesia, where they implemented a bleeding management algorithm for obstetric procedures based on rotational thromboelastometry (ROTEM) testing. After 4 years of using this algorithm, it was found that selective administration of fibrinogen concentrates based on ROTEM results led to better clinical outcomes in the treatment of coagulopathy.
Coagulopathy in Obstetrics
Despite advancements in obstetrics, bleeding remains a significant cause of morbidity and mortality among parturients. During pregnancy, the concentration of most coagulation factors, including fibrinogen, increases, enabling the overcoming of most cases of postpartum hemorrhage without the need for clotting agents.
Low fibrinogen concentration in blood plasma, which can be part of certain complications arising during childbirth, is associated with an increased risk of severe postpartum hemorrhage. The benefit of the ROTEM method for early diagnosis of bleeding associated with significant coagulopathy is well described. The authors of the study began using the ROTEM technique for bedside testing (bedside) of patients in April 2011.
New Postpartum Hemorrhage Management Algorithm
The standard procedure for severe postpartum bleeding was the administration of a so-called shock package – 4 units of fresh frozen plasma (FFP), 4 units of red blood cells (RBC), and 1 dose of platelets. If necessary, cryoprecipitate, which contains a higher concentration of fibrinogen, could be administered.
The introduction of the ROTEM technique into practice led to a change in the standard procedure, and the „shock package“ was replaced by targeted therapy using blood coagulation components that were deficient according to the ROTEM results. The FibTEM test, which detects fibrinogen function disorders, proved to be one of the key tests. Since then, patients with a FibTEM A5 value < 7 mm, or in the range of 7–12 mm with a high risk of bleeding, have been given a fibrinogen-containing preparation.
Retrospective Analysis
To assess the effectiveness of the used algorithm, a retrospective analysis was conducted on a cohort of patients with severe postpartum hemorrhage (blood loss ≥ 1500 ml with ongoing bleeding and/or clinical shock symptoms) and coagulopathy (FibTEM A5 ≤ 12 mm), treated from 1. 4. 2011 to 31. 3. 2012, i.e., at a time when ROTEM testing was already used, but patients still received the standard „shock package“. The following parameters were evaluated: the number of transfusions of blood products, total blood loss, incidence rate of transfusion-associated circulatory overload (TACO), ICU hospitalization, the need for hysterectomy, and mortality.
The same data were also evaluated for a cohort of patients meeting the same entry criteria, treated between 1. 7. 2012 and 31. 7. 2016, whose treatment was guided by the ROTEM-based algorithm.
Results
During the analyzed 4-year period, there were 32,647 deliveries at the Liverpool Women’s Hospital, during which 893 women (2.7%) had estimated blood loss ≥ 1500 ml. Of these, 203 women had a measured FibTEM A5 value ≤ 12 mm, and 110 patients were given fibrinogen concentrate.
Compared to the control group (n = 52), the group treated according to the so-called ROTEM algorithm showed a significant reduction in the number of blood units administered (average 3 vs. 6; p < 0.0001) and the total volume (0.8 vs. 1.7 l; p = 0.0007) of administered blood products. There was also a reduction in TACO incidences (0 vs. 7.7%; p = 0.002).
When analyzing subgroups, it was shown that parturients with placental abruption exhibited more severe coagulopathy, and their treatment required the administration of higher doses of fibrinogen concentrate than bleeding from other causes.
Conclusion
The analysis of ROTEM results demonstrated that not all women with severe postpartum hemorrhage develop coagulopathy. This cannot be predicted solely based on blood loss, and the administration of blood products to all women without distinction is not justified.
If coagulopathy occurs, which is better grasped using the ROTEM method, the causes seem to be multifactorial. Bedside testing of the patient allows early identification of the degree of coagulation system disruption and can facilitate individualized treatment of this complication.
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Source: McNamara H., Kenyon C., Smith R. et al. Four years' experience of a ROTEM®-guided algorithm for treatment of coagulopathy in obstetric haemorrhage. Anaesthesia 2019; 74 (8): 984–991, doi: 10.1111/anae.14628.
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