reports describe nonpregnant Normal coagulation trauma victims, but some obser vational studies address obstetrical hemorrhage (Green, 2016; 60 60 Pacheco, 2016). More data with 40 40 use of these protocols is needed. 20 20 rotational thromboelastometry (ROTEM) are point-of-care tests 10 20 30 40 50 min 10 20 30 40 50 min that assess coagulation in whole A EXTEM B FIBTEM blood during massive transfu
FIGURE 41-32 TEG/ROTEM based viscoelastic assays of coagulation profiles in a pregnant sions. These tests work by ana woman. A. EXTEM clot profile: CT = clotting time; A5-20 = clot amplified at 5, 10, 15,o20 min;
MCF = maximum clot firmness. B. FIBTEM clot profile showing excellent fibrin-based clot qualbreakdown in a whole blood samity. (Reproduced with permission from Solomon C, Collis RE, Collins PW: Haemostatic monitorple from a given patient. Testing ing during postpartum haemorrhage and implications for management, Br J Anaesth. 201o2 produces a proile of coagulation Dec;1o09(6):851-863.) dynamics, and displayed values indicate the speed and quality of clot formation (Fig. 41-32). hese assays provide information regarding time to clot formation, clot strength, and fibrinolysis. Currently, they guide blood product replacement in trauma, liver transplant, and cardiac surgery patients. Studies of TEG and ROTEM techniques in pregnant women have conirmed the hypercoagulable state of pregnancy and provide reference ranges for use in this population (Butwick, 2015; de Lange, 2014; Solomon, 2012).
Although these point-of-care tests appear promising, they also have several limitations. For example, they cannot be used to detect disorders of primary hemostasis (Solomon, 2012). Additionally, these tests cannot diagnose coagulopathies stemming from platelet dysfunction or anti platelet drugs. A major drawback is the risk of misinterpretation when tests are used by inadequately trained personnel. Further study is necessary before these tests are widely applied for treatment of obstetrical hemorrhage.
Several agents can be used to control persistent surgical oozing. These were recently reviewed by Miller and colleagues (2015). Other than for cesarean hysterectomy, these are seldom used in obstetrical hemorrhage.
Preoperative patient phlebotomy and autologous blood storage for transfusion has been disappointing. Exceptions are women with a rare blood type or with unusual antibodies. Most have concluded that autologous transfusions are not cost efective (Etchason, 1995; Pacheco, 2011, 2013).
Intraoperative blood salvage with reinfusion is considered to be a safe intervention in obstetrical patients. As discussed in Chapter 30 (p. 569), this practice may be helpful for women declining transfusion. Prior concern centered on amnionic fluid contamination and embolism (Dhariwal, 2014; Goucher, 2015; Pacheco, 2011). A recent randomized trial involving 3028 women compared routine cell salvage use against routine care, in which salvage was employed only for bleeding indications. he rate of nonautologous donor blood transfusion was reduced in the cell salvage group-2.5 versus 3.5 percent, but this was not a signiicant diference (han, 2017). Similar to prior reports, no cases of amnionic luid embolism were reported.