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Oh no, no fibrinogen: use of ROTEM to guide management of postpartum hemorrhage after vaginal delivery
Abstract Number: FCD-208
Abstract Type: Case Report Case Series
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Strategies to prevent PPH are well studied. But, the use of systematic processes to manage PPH when it occurs is also needed to decrease maternal morbidity and mortality. We present a case of PPH where ROTEM – as part of an institutional PPH algorithm – was used to successfully guide transfusion management in a patient with disseminated intravascular coagulopathy (DIC) after vaginal delivery.
Case Report: The patient is a 40 year-old G5P4 who presented to Labor and Delivery with painful contractions. Approximately 9 hours after admission, the patient delivered a male neonate with APGARS 8,9. Immediately after delivery, lower uterine segment atony and heavy vaginal bleeding were noted. In addition to the usual oxytocin infusion, the patient received methylergonovine 200 mcg IM, while placement of an intrauterine balloon was attempted. Given ongoing bleeding, additional uterotonics were given, as well as tranexamic acid 1 gram. Early on, ROTEM revealed DIC (Figure 1). Based on the results of the ROTEM, transfusion of cryoprecipitate, in addition to red blood cells, was initiated. Despite seemingly adequate uterine tone, however, bleeding continued. The patient was brought to the interventional radiology suite, where she underwent successful embolization of her bilateral uterine arteries and continued resuscitation with the use of consecutive ROTEM evaluations to guide transfusion management. Laboratory values – resulted significantly after the initial ROTEM specimen – revealed an undetectable fibrinogen level. The rest of her hospital course was uneventful, and she was transferred to home on post-partum day #5.
Discussion: To best manage PPH, it is important to understand the mechanism whereby coagulopathy develops. Low fibrinogen levels, in particular, are associated with severe PPH. Algorithms to manage PPH and use of ROTEM can lead to early identification of hypofibrinogenemia. Importantly, ROTEM also allows for targeted correction of coagulopathy, as opposed to an empiric transfusion strategy, which may result in the need for fewer blood products during PPH.
Butwick and Goodnough. Transfusion and coagulation management in obstetric hemorrhage. 2016.
Ducloy-Bouthers et al. Postpartum hemorrhage related early increase in D-dimers is inhibited by tranexamic acid: hemostasis parameters of a randomized controlled open label trial. 2016.