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Katz D, Farber M, Getrajdman C, Hamburger J, Reale S, Butwick A. The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care. Am J Obstet Gynecol 2024; 230:S1089-S1106. [PMID: 38462250 DOI: 10.1016/j.ajog.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 03/12/2024]
Abstract
Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.
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Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Michaela Farber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chloe Getrajdman
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Hamburger
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sharon Reale
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Othman M, Pradhan A. Laboratory Testing of Hemostasis in Pregnancy: A Brief Overview. Methods Mol Biol 2023; 2663:111-125. [PMID: 37204707 DOI: 10.1007/978-1-0716-3175-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Normal pregnancy is associated with significant physiological changes in the coagulation and fibrinolytic systems with an inclination toward a hypercoagulable state. This includes an increase in plasma levels of most clotting factors, a decrease in endogenous anticoagulants, and inhibition of fibrinolysis. Although these changes are critical in maintaining placental function and reducing postpartum hemorrhage, they may contribute to an increased risk of thromboembolism, particularly toward the end of pregnancy and during puerperium. Hemostasis parameters and the non-pregnant population reference ranges cannot be used in the assessment of bleeding or thrombotic complication risk during pregnancy, and pregnancy-specific information and reference ranges are not always available to support the interpretation of laboratory tests. This review aims to summarize the use of relevant hemostasis tests to promote evidence-based interpretation of laboratory test results as well as discuss challenges associated with testing during pregnancy.
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Affiliation(s)
- Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada.
- Department of Clinical Pathology, School of Medicine, Mansoura University, Mansoura, Egypt.
| | - Anushka Pradhan
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020; 18:1813-1838. [PMID: 32356929 DOI: 10.1111/jth.14882] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.
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Affiliation(s)
| | - Terrence Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Chen W, Hu A, Chen Q, Zhang Y, Yu X, Huang Y. A comparative study of fibrinogen measurement using TEG® functional fibrinogen and Clauss in adolescents undergoing scoliosis surgery. Int J Lab Hematol 2020; 42:380-386. [PMID: 32222095 DOI: 10.1111/ijlh.13192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/29/2020] [Accepted: 03/09/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Thromboelastography (TEG®) functional fibrinogen (FF) test is a point-of-care test for fibrinogen measurement and is preferred for its rapid turnaround time. This study was designed to compare TEG® functional fibrinogen level (FLEV) with classic Clauss fibrinogen in patients undergoing scoliosis surgery and to evaluate the concordance between the two methods. METHODS Patients in this study were part of a larger study evaluating the effect of fibrinogen concentrate (FC) supplementation on perioperative blood loss in scoliosis surgery. Paired samples for TEG® FF and Clauss fibrinogen assays were taken from 40 patients at three different timepoints perioperatively. The agreement between FLEV and Clauss was assessed, and the possibility of using FLEV measurements to predict Clauss fibrinogen was explored. RESULTS One hundred and seventeen paired samples from 39 patients were finally analyzed. Pearson correlation test confirmed positive linear correlations between FLEV and Clauss at all three timepoints (r = .70, .67, and .66 at baseline, before FC administration, and after FC administration, respectively; P < .001 for all) and together for all measures (r = .76, P < .001), while Bland-Altman plots showed FLEV significantly overestimated Clauss constantly. Optimum diagnostic values of FLEV at 4.27 and 3.77 g/L were generated to predict normal fibrinogen as Clauss ≥ 3.0 g/L (AUROC 0.941, 95% CI: 0.891-0.991) and critical intraoperative hypofibrinogenemia as Clauss ≤ 2.0g/L (AUROC 0.894, 95% CI: 0.838-0.950), respectively. CONCLUSIONS In adolescents undergoing scoliosis surgery, FLEV correlated linearly with Clauss fibrinogen. Though FLEV overestimates Clauss constantly, FLEV values are able to predict hypofibrinogenemia and normal fibrinogen with both AUROC > 0.85.
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Affiliation(s)
- Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Ai Hu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Qian Chen
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, China
| | - Xuerong Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Spasiano A, Matellon C, Orso D, Brussa A, Cafagna M, Marangone A, Dogareschi T, Bove T, Giacomello R, Fontana D, Vetrugno L, Della Rocca G. Functional fibrinogen (FLEV-TEG) versus the Clauss method in an obstetric population: a comparative study. BMC Anesthesiol 2019; 19:90. [PMID: 31153366 PMCID: PMC6545203 DOI: 10.1186/s12871-019-0769-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Hemostasis is the dynamic equilibrium between coagulation and fibrinolysis. During pregnancy, the balance shifts toward a hypercoagulative state; however placental abruption and abnormal placentations may lead to rapidly evolving coagulopathy characterized by the increased activation of procoagulant pathways. These processes can result in hypofibrinogenemia, with fibrinogen levels dropping to 2 g/L or less and an associated increased risk of post-partum hemorrhage. The aim of the present study was to evaluate the concordance between two methods of functional fibrinogen measurement: the Thromboelastography (TEG) method (also known as FLEV) vs. the Clauss method. Three patient groups were considered: healthy volunteers; non-pathological pregnant patients; and pregnant patients who went on to develop postpartum hemorrhage. METHODS A prospective observational study. Inclusion criteria were: healthy volunteer women of childbearing age, non-pathological pregnant women at term, and pregnant hemorrhagic patients subjected to elective or urgent caesarean section (CS), with blood loss exceeding 1000 mL. Exclusion criteria were age < 18 years, a history of coagulopathy, and treatment with contraceptives, anticoagulants, or antiplatelet agents. RESULTS Bland-Altman plots showed a significant overestimation with the FLEV method in all three patient groups: bias was - 133.36 mg/dL for healthy volunteers (95% IC: - 257.84; - 8.88. Critical difference: 124.48); - 56.30 mg/dL for healthy pregnant patients (95% IC: - 225.53; 112.93. Critical difference: 169.23); and - 159.05 mg/dL for hemorrhagic pregnant patients (95% IC: - 333.24; 15.148. Critical difference: 174.19). Regression analyses detected a linear correlation between FLEV and Clauss for healthy volunteers, healthy pregnant patients, and hemorrhagic pregnant patients (R2 0.27, p value = 0.002; R2 0.31, p value = 0.001; R2 0.35, p value = 0.001, respectively). ANOVA revealed a statistically significant difference in fibrinogen concentration between all three patients groups when assayed using the Clauss method (p value < 0.001 for all the comparisons), but no statistically significant difference between the two patients groups of pregnant women when using the FLEV method. CONCLUSIONS The FLEV method does not provide a valid alternative to the Clauss method due to the problem of fibrinogen overestimation, and for this reason it should not be recommended for the evaluation of patients with an increased risk of hypofibrinogenemia.
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Affiliation(s)
- Alessandra Spasiano
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Carola Matellon
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Daniele Orso
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Alessandro Brussa
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Maria Cafagna
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Anna Marangone
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Teresa Dogareschi
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Roberta Giacomello
- Department of Laboratory Medicine, ASUIUD Hospital of Udine, Udine, Italy
| | - Desrè Fontana
- Postgraduate School of Clinical Pathology and Biochemistry, University of Padua, Padua, Italy
| | - Luigi Vetrugno
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
| | - Giorgio Della Rocca
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy
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