Pathogenetic approach to the treatment of coagulopathic bleeding in obstetrics

Aim: to justify a differentiated approach to the treatment of obstetric coagulopathic bleeding depending on the nature of hemostasis disorders.

Materials and Methods. A prospective cohort study was conducted involving 52 patients with postpartum hemorrhage (PPH) who gave a child birth between 2021 and 2023. Diagnostics and treatment of coagulopathy was carried out according to the algorithm using thromboelastometry (TEM) parameters. Patients were divided into 3 groups depending on blood loss volume: group 1 (n = 19) – blood loss up to 1499 ml; group 2 (n = 14) – blood loss from 1500 to 1999 ml; group 3 (n = 19) – blood loss 2000 ml and more. The following hemostasis parameters were determined: platelet count, prothrombin index, activated partial thromboplastin time (APTT), Claus fibrinogen level, international normalized ratio, and TEM parameters, including clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and maximum clot firmness at 10 minutes (A10) on the EXTEM channels (a test in which recombinant tissue factor is used to activate the extrinsic coagulation pathway), FIBTEM (a test in which platelet activity is suppressed by cytochalasin D, which allows detecting fibrinogen deficiency or qualitative disturbances in fibrin polymerization), and INTEM (a test in which ellagic acid is used as a contact activator of the intrinsic coagulation pathway). Blood samples were collected before administration of blood components and products, tranexamic acid.

Results. Statistically significant differences were found for the fibrinogen level, MCF and A10 parameters on the FIBTEM channel depending on blood loss volume (p < 0.05), indicating a decrease in the quality of fibrin clot upon with increasing blood loss. Highly tight direct relationships were found between the fibrinogen, MCF and A10 values, demonstrating that with a decrease in the fibrinogen level at the time of bleeding by 1.0 g/L, a decrease in MCF by 3.802 mm (the resulting model explains 64.3 % of the observed variance), and A10 by 3.497 mm (the resulting model explains 64.1 % of the observed variance) should be expected. All patients whose blood loss volume reached 2000 ml and more were administered cryoprecipitate, the differences in the parameters were statistically significant between group 3 vs. group 1 and group 2 (p < 0.001). TEM parameters CT and CFT on the INTEM channel also correlated with blood loss volume and had a significant direct correlation between noticeable tightness (according to the Chaddock scale) between APTT and CT (ρ = 0.612; p < 0.001) as well as moderate tightness between APTT and CFT (r_xy = 0.44; p = 0.017). The need for transfusion of fresh frozen plasma (FFP) and prothrombin complex concentrates (PCСs) arose with APTT more than 35 seconds in 77 % of cases (among all patients), with the CT parameter more than 260 seconds – in 63 % of cases and CFT more than 110 sec – in 63 % of cases, respectively; the differences in the indicators are significant while compared with those of patients requiring no introduction of FFP and PPC (p < 0.05). Based on controlled transfusion protocol, in group 1, in 57.9 % of cases it was possible apply no transfusion therapy; the differences in indicators are significant while comparing group 2 and group 3 (p < 0.05).

Conclusion. The use of the TEM method in the diagnostics of hemostasis disorders with PPH allowed for the differential and short-term application of pathogenetically justified therapy with blood components and preparations only in cases where it was required.

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