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Clinical ReviewValue of TEG in Management of Postpartum Haemorrahge Presented by Xu OuMedical director, APWednesday, September 10, 2014The United Nations has identified a 75% reduction of maternal mortality by 2015 as a millennium development goal.Postpartum hemorrhage (PPH) continues to be a leading cause of maternal mortality globally accounting for 1/3 of maternal deaths in some regions and was estimated to be responsible for around 143,000 deaths each year.Background Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics CorpEvaluation and management of postpartum hemorrhage: consensus from an international expert panelRezan Abdul-Kadir, Claire McLintock, Anne-Sophie Ducloy, et al

Royal Free Hospital, London, UKAuckland City Hospital, Auckland, New ZealandCentre Hospitalier Rgional Universitaire de Lille, Lille, France

TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics CorpPersistent (ongoing) PPH is active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage.Definition Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics Corp

Main CausesSolomon et al. Br J Anaesth. 2012;109(6):851-63# 2013 Haemonetics CorpMain Causes

Solomon et al. Br J Anaesth. 2012;109(6):851-63# 2013 Haemonetics Corp1) uterine atony2) placental problems including retained placenta and abnormal placental implantation3) genital tract trauma4) systemic medical disorders (including inherited and acquired coagulation defects)Uterine atony is the major cause of PPH accounting for up to 80% of cases of primary PPH. A large proportion of women who develop PPH do not have identifiable risk factors, so all women must be considered to be at risk

2013

Coagulation status during pregnancy and the peripartum periodMarked changes in haemostasis are observed during pregnancy. In comparison with the non-pregnant state, procoagulant levels are generally elevated (Fig. 2), but antagonists of coagulation decrease or remain unchanged. This hypercoagulable state may reduce the risk of haemorrhage during delivery and the postpartum period. In contrast, platelet counts typically decrease during pregnancy, although the clinical significance of this is uncertain. Haemostasis can be further influenced by anaemia and preeclampsia. Anaemia (haemoglobin ,11 or 10.5 g/dl in second trimester) affects 20% of pregnant women worldwide and is associated with increased blood loss and likelihood of transfusion during delivery. Similarly, preeclampsia, which occurs in 0.42.8% of births, is associated with haemostatic abnormalities including thrombocytopenia and disseminated intravascular coagulopathy2013Inherited bleeding disorder von Willebrand diseaseCarriers of hemophiliaRare bleeding disorders (congenital hypofibrinogenemiaFV, FVII, FX, FXI & FXII deficiencies)Severe inherited platelet function defects (Glanzmann thrombasthenia, Bernard-Soulier syndrome)Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics Corp2013Commercially available clotting factor

Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics CorpA plan for hemostatic coverage (including the type, dose, and duration of hemostatic agent) for labor and postpartum shouldbe formulated according to evaluation of risk. Current recommendations for postpartum factor replacement suggest treatment duration of at least 3 to 5 days (Grade 3-I29) extended up to 2 weeks or even longer to maintain clotting factors at or above the recommended hemostatic level, especially after cesarean section or in women with other risk factors. Women should be kept under clinical surveillance for up to 4 weeks postpartum. Treatment with hemostatic agents such as antifibrinolytics should continue until the lochia is minimal.2013Mild: such as PLT secretion and activation defects --Tranexamic acid (TXA; 1 g four times daily until lochia is minimal) is generally sufficient (Grade 3-I). Moderate: who are not at risk for fluid retention --DDAVP (1-2 doses) during the immediate postpartum period can be used in addition to TXA. PLT transfusion should be available in case of hemorrhage with recombinant activated FVII (rFVIIa) on standby. Severe: Glanzmann thrombasthenia and Bernard-Soulier syndrome) --TXA with or without rFVIIa is used in cases of uncomplicated vaginal delivery (Grade 3-I)Treatment of PLT function disorders Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics Corp2013Monitoring of coagulopathy of PPH

Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics CorpHowever, episodes of PPH with differing causes may have common pathological progression, with measurement of haemostatic impairment potentially providing important information for diagnosis and therapeutic intervention. Bleeding leads to loss and consumption of coagulation factors, which may be exacerbated by dilutional coagulopathy after volume resuscitation. Coagulationdefects may be compounded by hyperfibrinolysis. Rapid correction of coagulopathies that develop during PPH may be crucial for controlling bleeding and improving outcomes. However, appropriate haemostatic intervention may depend on the availability of tests which allow rapid diagnosis of the cause of bleeding2013Coagulation screens should be performed as soon as persistent (ongoing) PPH is declared to guide subsequent therapy. Standard tests should include PLT count, prothrombin time, activated partial thromboplastin time, and fibrinogen concentration. Where available, POC testing can be performed in addition to standard tests of coagulation. Coagulation status assessment should be repeated every 45 to 60 minutes until the bleeding is controlled and coagulation abnormalities are corrected.Recommendation: coagulation screeningAbdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics Corp

The consensus confirms the value of TEG as a POC test in diagnosis of coagulopathy during treatment of PPHPLT mapping is able to measure the disorder of platelet dysfunction but it wasnt mentioned in the consensus. More education is needed to get awareness of the additional value of TEG testPositioning Abdul-Kadir R, et al. TRANSFUSION 2014;54:1756-1768.# 2013 Haemonetics CorpQuestions# 2013 Haemonetics Corp