Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry

Abstract

Objectives To establish whether reagent-supported thrombelastometry with the rotation thrombelastometry system (ROTEM Ò ) point-of-care device correlated with fibrinogen level in postpartum haemorrhages.Design Prospective observational study.Population and setting Ninety-one women at the third trimester of pregnancy: 37 with postpartum haemorrhage (study group) and 54 without abnormal bleeding (control group).Methods Standard laboratory test results were compared with those obtained at bedside from the ROTEM with the FIBTEM Ò test (54 tests in the control group and 51 in the study group). Results Median fibrinogen level was significantly lower in the haemorrhage group than in the control group (3.4 and 5.1 g/l, respectively, P < 0.0001). Median CT was higher in the haemorrhage group than in the control group (P = 0.05). CA 5 , CA 15 and MCF were significantly lower in the haemorrhage group than in controls (P < 0.0001) and strongly correlated with fibrinogen levels in both groups (r = 0.84-0.87, P < 0.0001). A cut-off value of CA 5 at 5 mm and CA 15 at 6 mm presented an excellent sensitivity (100% for both parameters) and a good specificity (respectively 85 and 88%) to detect fibrinogen levels <1.5 g/l in postpartum haemorrhage.Conclusions The early parameters obtained from the FIBTEM test correlated well with fibrinogen levels. ROTEM might be helpful in guiding fibrinogen transfusion during postpartum haemorrhage.

Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage

“…We also found a robust correlation between FibTEM MCF and A5 [7], which was confirmed in subsequent studies [20,21]. There is also a strong reported correlation between FibTEM A5 measurements and fibrinogen levels [22][23][24][25][26][27][28].…”

“…, a conventional level at which fibrinogen replacement therapy has been widely recommended [28,30,31]. Our algorithm allowed us to reassess the response to its administration promptly, and administer more fibrinogen rapidly if the FibTEM value still indicated abnormality.…”

How I treat postpartum hemorrhage

“…Our patient had profound hypofibrinogenemia, now recognized as an important early coagulation abnormality associated with MOH. [24][25][26] Fibrinogen is consumed in widespread clot development and enhanced fibrinolytic factors accelerate breakdown of fibrin and fibrinogen. The resulting degradation products interfere with platelet activation and fibrin creation and hyperfibrinolysis occurs, whereby fibrinolytic activity is greater than fibrin formation, leading to severely diminished clot strength.…”

“…In particular, the technique to quantify fibrinogen has been refined, enabling early detection of hypofibrinogenemia and suitable replacement. 24 As with all tests, it is important that validated reference ranges for pregnancy are used when interpreting results. [37][38][39] Our pregnancy ranges are derived from a local study of 100 low-risk pregnancies.…”

Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study

“…The maximum clot firmness (MCF) measures clot strength and correlates moderately with laboratory fibrinogen during PPH. 20 The amplitude after 5 minutes (A5) is related to the MCF but is available sooner. No data are available on whether Fibtem has a similar utility for predicting progression of PPH as Clauss fibrinogen.…”