Clinical value of early assessment of hyperfibrinolysis by rotational thromboelastometry during postpartum hemorrhage for the prediction of severity of bleeding: A multicenter prospective cohort study in the Netherlands

Marije Tahitu, Paul I. Ramler, Ada Gillissen, Camila Caram-Deelder, Dacia D.C.A. Henriquez, Moniek P.M. de Maat, Johannes J. Duvekot, Jeroen Eikenboom, Kitty W.M. Bloemenkamp, Thomas van den Akker, Johanna G. van der Bom*

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review

Abstract

Introduction: Coagulopathy may be the result of hyperfibrinolysis and could exacerbate bleeding following childbirth. Timely recognition of hyperfibrinolysis during the earliest stages of postpartum hemorrhage could identify women at risk of more severe blood loss who may benefit from targeted anti-fibrinolytic therapy. Rotational thromboelastometry (ROTEM®) is a point-of-care test that could detect hyperfibrinolysis. The aim of this study was to evaluate whether early assessment of hyperfibrinolysis by ROTEM during postpartum hemorrhage could predict progression to severe postpartum hemorrhage. Material and methods: During a prospective cohort study in the Netherlands among women with postpartum hemorrhage (total blood loss at least 1000 ml within 24 h after childbirth) ROTEM measurements were performed following 800–1500 ml of blood loss. Hyperfibrinolysis was defined as an enzymatic fibrinolysis index (ROTEM EXTEM maximum clot lysis [ML] minus the ROTEM APTEM ML) above 15%. Severe postpartum hemorrhage was defined as a composite end point of total blood loss greater than 2000 ml, transfusion of four or more units of packed cells, and/or need for an invasive intervention. The predictive value of hyperfibrinolysis for progression to severe postpartum hemorrhage was assessed by area under the receiver operating curve (AUC) and positive and negative predictive values. Trial registration: ClinicalTrials.gov (NCT02149472). Results: Of 390 women included, 82 (21%) had severe postpartum hemorrhage. Four (1%) women had thromboelastometric evidence of hyperfibrinolysis, of whom two developed severe postpartum hemorrhage. The AUC for enzymatic fibrinolysis index more than 15% for progression to severe postpartum hemorrhage was 0.47 (95% CI 0.40–0.54). Positive and negative predictive values for this index were 50.0% (95% CI 6.8–93.2) and 79.3% (95% CI 74.9–83.2), respectively. Conclusions: Thromboelastometric evidence of hyperfibrinolysis was rare in women with postpartum hemorrhage when assessed between 800 and 1500 ml of blood loss. The clinical predictive value of viscoelastometric point-of-care testing for hyperfibrinolysis for progression to severe postpartum hemorrhage during early postpartum hemorrhage is limited.

Original languageEnglish
Pages (from-to)145-152
Number of pages8
JournalActa Obstetricia et Gynecologica Scandinavica
Volume101
Issue number1
Early online date3 Nov 2021
DOIs
Publication statusPublished - Jan 2022

Bibliographical note

Funding Information:
The TeMpOH-2 study was supported by an internal grant from Sanquin Research (PPOC 13-029). The ROTEM device that was used by the Leiden University Medical Center was provided by Tem International GmbH (Munich, Germany) on the basis of a loan agreement without additional charge for the duration of the study. Reagents used in the ROTEM devices were at the expense of the study without discount. The funding body and Tem International GmbH had no control over the study design, conduct or decision to publish this study. We would like to express our appreciation to research nurses C. Kolster-Bijdevaate, MS Bourgonje-Verhart, CE Bleeker-Taborh, E Roos-van Milligen, RJM Berkhout, E Sucu, EC Willems of Brilman-Tuinhof de Mode, M Stigter-Dekker, NCW van Rijn, and J van Rhee, medical students M van de Sande, RH Wouters, and LS Smits, and clinical midwifes of the participating hospitals for their contributions to the TeMpOH-2 study.

Funding Information:
The TeMpOH‐2 study was supported by an internal grant from Sanquin Research (PPOC 13‐029). The ROTEM device that was used by the Leiden University Medical Center was provided by Tem International GmbH (Munich, Germany) on the basis of a loan agreement without additional charge for the duration of the study. Reagents used in the ROTEM devices were at the expense of the study without discount. The funding body and Tem International GmbH had no control over the study design, conduct or decision to publish this study. ® ® ®

Publisher Copyright:
© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG)

Keywords

  • hyperfibrinolysis
  • postpartum hemorrhage
  • rotational thromboelastometry
  • ROTEM
  • severity of bleeding

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