The Utilization of Viscoelastic Testing to Guide Blood Component Therapy and Adjunctive Hemostatic Therapy for Postpartum Hemorrhage: A Narrative Review

Baumgartner S,Mccauley R,Thomas Av,Patel S,Zackariya S,Walsh M,Vande Lune Sa,Grisoli A,Hake D,Zackariya N,Sualeh A,Shariff F

doi:10.18314/cogo.v2i1.1837

Abstract

This narrative review discusses the history of the pathophysiologic principles and utilization of point-of-care (POC) viscoelastic tests (VETs) in the definition and treatment of postpartum hemorrhage (PPH). This paper addresses the epidemiology of PPH, describes the hemostatic changes that occur in pregnancy and in PPH, and demonstrates the utilization of viscoelastic testing in the identification and treatment of patients with PPH. Additionally, a description of rotational thromboelastometry (ROTEM) and thromboelastography (TEG), the two most commonly used VETs, is detailed in this paper. VETs have only recently been used to guide blood component therapy (BCT) in trauma in the last decade. The recent increased utilization of VETs to guide BCT in PPH is following a similar trend with a delay of ten years. In a similar fashion to the trauma literature, which expanded greatly within this last decade, the literature concerning the use of VETs in PPH has also increased in the last few years. However, because of differing pathophysiologies associated with the coagulopathy of PPH verses traumatic-induced coagulopathy (TIC), utilization of VETs has been more refined and focused on the VETs’ capacity to determine low fibrinogen and to guide the utilization of blood components and prohemostatic agents. The identification and treatment of PPH depends on clinical parameters, conventional coagulation tests (CCTs) including Clauss fibrinogen, and VETs. Successful treatment of PPH will no doubt include utilization of all three strategies with an increasing utilization of VETs in the future.

Highlights

Epidemiology, definition, and utilization of Viscoelastic Test (VET) in postpartum hemorrhage (PPH)Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide [1,2,3], and the incidence has increased in many countries despite improvements in obstetric protocols to prevent and treat severe hemorrhage [4,5,6,7]
A review of the literature concerning the use of rotational thromboelastometry (ROTEM)/TEG in the treatment and early detection of PPH found that studies have shown that the use of VET-guided administration of fibrinogen concentrate to treat PPH-related complications has reduced overall blood product usage and is useful in the early detection and treatment of PPHrelated complications by guiding the administration of appropriate blood products
The literature has established a clear link between low fibrinogen and development of PPH; the lack of sensitivity and prolonged turnaround time of Conventional Coagulation Test (CCT) make it difficult to guide blood component therapy (BCT) in patients with low fibrinogen that are at risk of developing PPH [12,28,29]

Summary

Introduction

Epidemiology, definition, and utilization of VETs in PPHPostpartum hemorrhage (PPH) is the leading cause of maternal death worldwide [1,2,3], and the incidence has increased in many countries despite improvements in obstetric protocols to prevent and treat severe hemorrhage [4,5,6,7]. The viscoelastic tests (VETs) thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been used to guide blood component therapy (BCT) and prohemostatic agents in PPH [9,10]. Even though the first paper describing the utilization of VETs to diagnose and treat PPH was published more than 30 years ago, ROTEM and TEG have only recently been studied with increasing numbers in the diagnosis and treatment of PPH [8,9,24,38,43].

Results

Conclusion