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Is antiphospholipid syndrome a contraindication to the use of rotational thromboelastometry (ROTEM) guided therapy during cesarean section?
Abstract Number: T1C-5
Abstract Type: Case Report/Case Series
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thrombotic events in patients with antiphospholipid antibodies. The rate of preeclampsia in APS patients is estimated to be 20-50% (1), whereas the incidence of preeclampsia in pregnancy overall is 2-8% (2). HELLP syndrome, a variant of severe preeclampsia, has also been associated with APS (3).
We present the case of a patient with HELLP syndrome who was diagnosed with coexisting APS postpartum. On initial presentation, the etiology of the prolonged aPTT was unclear. The patient’s coagulation status was evaluated with rotational thromboelastometry (ROTEM) prior to urgent cesarean delivery. ROTEM was significant for a prolonged clotting time (CT) on EXTEM and INTEM (see figure 1). She received one unit of Octaplas during cesarean delivery. On post-operative day one, mixing study results became available. The prolonged aPTT did not correct on mixing and the patient was found to have positive ANA and IgG and IgM anticardiolipin antibodies. She was diagnosed with probable APS.
We review case reports that have shown variable effects of antiphospholipid antibodies on viscoelastic testing parameters such as ROTEM and thromoboelastography (TEG). Just as antiphospholipid antibodies cause prolongation of aPTT, they can also cause false prolongation CT on ROTEM. ROTEM relies on a phospholipid dependent reagent similarly to aPTT, whereas TEG does not. The presence of antiphospholipid antibodies may be a contraindication to using ROTEM to guide transfusion therapy.
1. Clark EAS, Silver RM, Branch DW. Do antiphospholipid antibodies cause preeclampsia and HELLP syndrome? Curr Rheumatol Rep. 2007;9(3):219-225. doi:10.1007/s11926-007-0035-9.
2. Appenzeller S, Souza FHC, Wagner Silva de Souza A, Shoenfeld Y, de Carvalho JF. HELLP syndrome and its relationship with antiphospholipid syndrome and antiphospholipid antibodies. Semin Arthritis Rheum. 2011;41(3):517-523. doi:10.1016/j.semarthrit.2011.05.007.
3. Haram K, Trovik J, Sandset PM, Hordnes K. Severe syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP) in the 18th week of pregnancy associated with the antiphospholipid-antibody syndrome. Acta Obstetricia et Gynecologica Scandinavica. 2003;82(7):679-680. doi:10.1080/j.1600-0412.2003.00181.x.