Blood management in post-partum haemorrhage, including point of care coagulation tests

Abstract

Postpartum haemorrhage (PPH) is the leading global cause of maternal mortality, and an important cause of morbidity and mortality in the UK. Management of PPH requires a patient centred team approach to ensure effective management. Early recognition is crucial, hence quantitative measurement of blood loss should be started as soon as bleeding is identified and continue throughout an evolving haemorrhage. Pregnancy is associated with haematological changes resulting in a pro-coagulant state. Blood management in PPH has moved away from the use of shock packs and fixed transfusion ratios. Most women are not initially coagulopathic and coagulopathy is uncommon in mild to moderate PPH, Practice has therefore moved towards goal directed transfusion of blood products informed by haematological investigations alongside clinical assessment. Fibrinogen tends to be the first coagulation factor to fall and Clauss fibrinogen is an important predictor of PPH severity. Transfusion of fibrinogen rich blood products such as cryoprecipitate and fibrinogen complex are more effective at rapidly increasing fibrinogen levels compared to FFP. Point of care (POC) coagulation tests such as rotational thromboelastometry (ROTEM) and thromboeslastography (TEG) allow rapid bedside assessment compared to traditional laboratory tests. Surrogate markers of fibrinogen from POC tests can be used to both predict severity of PPH and inform blood transfusion. There is growing evidence that POC coagulation tests can be used to safely guide blood management in PPH, with its use associated with lower transfusion rates and possibly improved clinical outcomes. Further multi-centre studies are required to clarify debate surrounding their use. In this review we discuss blood management in PPH, with a focus on recent evidence regarding assessment of coagulopathy and the use of blood products.