Goal-directed correction of disseminated intravascular coagulation in severe antepartum hemorrhage using ROTEM
Abstract Number: T1C-1
Abstract Type: Case Report/Case Series
We present the case of a 29 year female G4P1 20 weeks pregnant presenting with life-threatening hemorrhage requiring emergent cesarean hysterectomy and massive resuscitation guided by point-of-care ROTEM. On the day prior to surgery, the patient was admitted to the wards with a low volume, painless vaginal bleed and observed. On hospital day 2, the patient went into hypovolemic shock after a second bleed of 2 liters and was rushed to the operating room.
Intraoperatively, the patient was aggressively transfused and lost an additional 7 liters of blood. The first intra-operative ROTEM revealed prolonged clotting time (Image A) requiring fresh frozen plasma. The second ROTEM demonstrated decreased alpha angle and maximum clot firmness (Image B) requiring cryoprecipitate and platelets. A third ROTEM demonstrated normal clotting time and alpha angle and improved maximum clot firmness (Image C). At the conclusion of the procedure, the patient had received PRBCx9, FFPx8, Plts x2, Cryo x4, and 1gram transexamic acid. The patient was transferred to the MICU intubated, sedated, and off all vasopressors. She was extubated on postoperative day 1 and discharged home on postoperative day 5.
Obstetric hemorrhage is a leading cause of maternal morbidity and mortality and often requires an anesthesiologist-directed resuscitation and correction of associated coagulopathy. Disseminated intravascular coagulation (DIC) is a severe complication associated with the inherent hypercoagulability of pregnancy in addition to pregnancy complications such as placental abruption, amniotic fluid embolism, and dead fetus syndrome.1 Both the supraphysiologic activation of the coagulation cascade and the depletion of clotting agents by blood loss likely contribute to its presentation. Driven by the prevalence of DIC in trauma surgery resuscitations, the use of point-of-care ROTEM has caught on in obstetrics, mostly in managing post-partum hemorrhage (PPH) and predicting which cases will progress to severe PPH.2,3 However, little evidence is available in the literature for its use in antepartum hemorrhage.
Our case study demonstrates goal-directed correction of coagulopathy in severe antepartum hemorrhage using ROTEM. Given the prevalence and danger of DIC resulting from obstetric complications and the value it provided in our resuscitation, we recommend the use of point-of-care ROTEM be expanded to the treatment of antepartum DIC.
1. Butwick AJ, Goodnough LT. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anesthesiol. 2015 June; 28(3):275-84.
2.Collins PW, Lilley G, Bruynseels D, et al. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood. 2014; 124:1727-1736.
3.Huissoud C, Carrabin N, Audibert F, et al. Bedside assessment of fibrinogen level in postpartum haemorrhage by thromboelastometry. BJOG. 2009; 116:1097-1102.