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Utility of Tranexamic Acid for Postpartum Hemorrhage: Can We Detect Low Fibrinogen or Hyperfibrinolysis using ROTEM?
Abstract Number: T1C-4
Abstract Type: Case Report/Case Series
Tranexamic acid (TXA) has been advocated for all cases of postpartum hemorrhage (PPH) since the recent WOMAN international randomized controlled trial showed a 31% reduction in death from PPH if TXA was administered within 3h after PPH was diagnosed (1). This trial included a disproportionate number patients from low-resource countries, and the external validity of its findings in higher-resource settings has been questioned. Strategies to determine threshold or timing for initiating TXA therapy in high-resource settings are needed. The use of point-of-care testing such as rotational thromboelastometry (ROTEM) to detect a low fibrinogen state or hyperfibrinolysis may be helpful. Here we describe ROTEM characteristics for cases of PPH, including etiology and onset of PPH, ROTEM timing, and coagulation status.
A retrospective analysis of ROTEM testing from March 1, 2017 through January 1, 2018 was performed. ROTEM testing was done for parturients with risk factors for hemorrhage, upon recognition of PPH, or after transfusion for PPH to confirm adequate coagulation. Eligible patients had ROTEM testing and PPH defined as EBL >1,000 mL. Onset time of PPH, timing of ROTEM, and detection of a low fibrinogen state (FIBTEM A10 <14mm) or hyperfibrinolysis (APTEM testing) was evaluated.
Of 45 patients for whom ROTEM testing was performed, 17 fit the eligibility criteria for EBL >1,000 mL. By etiology, 5 of 17 (29%) had placenta accreta, 7 of 17 (41%) had uterine atony, 4 of 17 (24%) had lacerations, and 1 of 17 (6%) had baseline thrombocytopenia. ROTEM demonstrated a low fibrinogen state in only 4 of 17 (24%) cases, all in the context of ongoing transfusion requirement: (1) with placenta accreta and (3) from iatrogenic trauma. Of these 4 cases, APTEM testing was performed in 3 cases and revealed shortening of APTEM CT. A representative case is shown in the figure. For this patient, CT shortened by 16% on APTEM compared to EXTEM. After interval therapy with 1g TXA, EXTEM and APTEM CT equilibrated.
The majority (75%) of PPH cases in this cohort had normal coagulation by ROTEM, irrespective of etiology or timing. However, when low-fibrinogen states were detected, the presence of early hyperfibrinolysis by APTEM testing was apparent. Subtle APTEM changes or low fibrinogen state may be useful indicators for initation of TXA therapy for PPH. Further studies are warranted.
WOMAN Trial Collaborators, Lancet 2017;389:2105-16.