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Utility of Thromboelastography in Post-Partum Hemorrhage
Abstract Number: S-67
Abstract Type: Case Report/Case Series
A 40-year old G3P0 woman was brought to the operating room for emergency hysterectomy under general anesthesia. The patient had an uneventful cesarean section (C/S) 30 minutes earlier under epidural anesthesia for failure to progress. Extensive vaginal bleeding was noted in the PACU after the C/S, for which she received five units of packed red blood cells (PRBCs) and one unit of fresh frozen plasma (FFP). The patient's history was significant for hereditary antithrombin deficiency type 1 (ATD1); one who has a quantitative deficit of antithrombin, and received enoxaparin, an antithrombin amplifying drug, 48 hours before her admission. Individuals with ATD1 need sufficient anticoagulation and DVT prophylaxis with blood thinners. This is especially true in pregnancy when patients are at higher risk for thromboembolic events. Consequently, with anticoagulation comes the possibility of intra-operative bleeding.
During the exploration, lower uterine segment bleeding was noted; subsequently, the obstetrician proceeded with a hysterectomy. An additional three units of PRBCs, one unit of platelets, and two units of FFP were given. With the ongoing bleeding, a blood sample was sent for thromboelastography that showed poor clot firmness due to factor deficiency, hypofibrinogemia, and fibrinolysis. While cryoprecipitate was ordered and thawed, aminocaproic acid was infused and an additional one unit of FFP was given. Repeat thromboelastography results post-FFP and aminocaproic acid (5 grams infused) showed improved clot formation. No further blood products were given. She had a full recovery.
Postpartum hemorrhage is a major cause of maternal morbidity and mortality. A goal-directed transfusion is shown to improve the outcome and minimize the risk of unnecessary blood product transfusion. Thromboelastography is a point of care tool, which could be helpful in achieving these goals when it is used, along with continuous clinical evaluation.
C. Solomon, R. E. Collins, P. W. Collins: Haemostatic monitoring during postpartum haemorrhage and implications for management. BJA 2012; 109(6):851-63.
Huissoud C, Carrabin N, Audibert F, Levrat A, Massignon D, Berland M, Rudigoz RC: Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG 2009; 116(8):1097-102.
A.J. Butwick, Postpartum hemorrhage and low fibrinogen levels: the past, present and future. Editorial, IJOA 2013; 22(2): 87-88