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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

1Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands, 2Center for Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands, 3Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands, 4Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands, 5Department of Obstetrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands, 6Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands, 7Department of Obstetrics, Birth Center Wilhelmina Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, Netherlands, 8Athena Institute, Faculty of Science, VU University Medical Center, Amsterdam, Netherlands, 9National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom

Abstract Number: OC 62.2

Meeting: ISTH 2021 Congress

Theme: Women Health » Pregnancy and Pregnancy Complications

Background: 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.

Aims: To evaluate whether early assessment of hyperfibrinolysis by ROTEM® during postpartum hemorrhage could predict progression to severe postpartum hemorrhage.

Methods: During a prospective cohort study in the Netherlands among women with postpartum hemorrhage (total blood loss ≥1000mL within 24 hours after childbirth) ROTEM® measurements were performed following 800 to 1500mL of blood loss. Hyperfibrinolysis was defined as an enzymatic fibrinolysis index (ROTEM® EXTEM maximum clot lysis (ML)) – ROTEM® APTEM ML) above 15%. Severe postpartum hemorrhage was defined as a composite endpoint of 1) total blood loss >2000mL, 2) transfusion of ≥4 packed cells, and/or 3) need for an invasive intervention. The predictive value of hyperfibrinolysis for progression to severe postpartum hemorrhage was assessed by an area under the receiver operating curve (AUC) and positive and negative predictive values.

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 >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 1500mL 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.

To cite this abstract in AMA style:

Tahitu M, Ramler P, Gillissen A, Caram-Deelder C, Henriquez DD, de Maat MP, J Duvekot J, Eikenboom J, Bloemenkamp KW, van den Akker T, G van der Bom J. 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 [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/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/. Accessed December 6, 2023.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/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/