Obstetrics and GynecologyObstetrics and GynecologyАкушерство и гинекология0300-90922412-5679Bionika Media63207210.18565/aig.2024.90ReviewsОбзорыReview ArticleThe role of integral methods for assessing the hemostatic system in the diagnosis and transfusion tactics in postpartum hemorrhageРоль интегральных методов оценки системы гемостаза в диагностике и трансфузиологической тактике при послеродовом кровотеченииDikovAlexey V.ДиковАлексей Вадимович
Russian Federation

anesthesiologist-resuscitator at the Institute of Anesthesiology-Resuscitation and Transfusiology

врач анестезиолог-реаниматолог института анестезиологии-реаниматологии и трансфузиологии

dikov.08@gmail.comBeznoshchenkoOlga S.БезнощенкоОльга Сергеевна
Russian Federation

Ph.D. (Med), Doctor at the Clinical Laboratory Diagnostics, Institute of Anesthesiology-Resuscitation and Transfusiology

врач клинической лабораторной диагностики института анестезиологии-реаниматологии и трансфузиологии

pyregov@mail.ruYusupovaAmina I.ЮсуповаАмина Идирисовна
Russian Federation

resident of the Institute of Anesthesiology-Resuscitation and Transfusiology

ординатор института анестезиологии-реаниматологии и трансфузиологии

yusupov8991@yandex.ruPyregovAleksey V.ПыреговАлексей Викторович
Russian Federation

Dr. Med. Sci., Professor, Deputy Chief Physician for Anesthesiology and Resuscitation; Chief Non-staff Specialist of the Ministry of Health of the Moscow Region for Anesthesiology and Resuscitation in Obstetrics and Gynecology

д.м.н., профессор, заместитель главного врача по анестезиологии и реанимации; ГВС МЗ МО по анестезиологии-реаниматологии в акушерстве-гинекологии

pyregov@mail.ruAcademician V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Ministry of Health of RussiaФГБУ «Национальный медицинский исследовательский центр акушерства, гинекологии и перинатологии имени академика В.И. Кулакова» Министерства здравоохранения Российской ФедерацииMoscow Regional Perinatal CenterГБУЗ МО «Московский областной перинатальный центр»17042024416231605202416052024Copyright ©; 2024, Bionika MediaCopyright ©; 2024, ООО «Бионика Медиа»2024Bionika MediaООО «Бионика Медиа»https://journals.eco-vector.com/0300-9092/article/view/632072

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in the world. Timely detection of hemostatic disorders is crucial for the prevention of massive PPH. Numerous data confirm the high clinical significance of the point of care (POC) testing in PPH. Rapid assessment of the state of the hemostatic system using thromboelastography (TEG) and thromboelastometry (TEM) makes it possible to identify the cause of coagulopathy; transfusion tactics in PPH can be justified using algorithms based on parameters of TEG and TEM. The use of integral methods (TEG, TEM) in patients with postpartum hemorrhage led to improved outcomes, including intra- and postoperative complications, reduced mortality, and improved patients’ safety. The introduction of the TEG and TEM methods into routine practice requires appropriate technical equipment and an interdisciplinary approach.

Conclusion: The study presents the summary and analysis of information on the role of integral methods (TEG, TEM) for the diagnosis of hemostatic disorders in patients with PPH. There is a description of the POC algorithm which is relevant from the clinical point of view for finding the causes of massive hemorrhage and targeted therapy.

Послеродовое кровотечение (ПРК) является ведущей причиной материнской смертности в мире. Своевременное выявление нарушений системы гемостаза имеет решающее значение для предотвращения массивного ПРК. Многочисленные данные подтверждают высокую клиническую значимость для POINT OF CARE (POC – по месту оказания помощи) при ПРК. Экспресс-оценка состояния системы гемостаза с помощью тромбоэластографии (ТЭГ) и тромбоэластометрии (ТЭМ) позволяет выявить причину коагулопатии, а использование алгоритмов на основании параметров (ТЭГ и ТЭМ) – обосновать трансфузиологическую тактику при ПРК. Применение интегральных методов (ТЭГ, ТЭМ) у пациенток с послеродовым кровотечением привело к улучшению исходов, включая интра- и послеоперационные осложнения, снижению смертности и в конечном счете – к повышению безопасности пациентов. Внедрение в рутинную практику ТЭГ и ТЭМ требует соответствующей технической оснащенности и междисциплинарного подхода.

Заключение: Обобщена и проанализирована информация о роли интегральных методов (ТЭГ, ТЭМ) для диагностики нарушений гемостаза у пациенток с ПРК. Приведен актуальный в настоящий момент с клинической точки зрения POC алгоритм поиска причин массивного кровотечения и целенаправленной терапии.

postpartum hemorrhageintegral methodsthromboelastometrythromboelastographytargeted therapyпослеродовое кровотечениеинтегральные методытромбоэластометриятромбоэластографияцеленаправленная терапияRigouzzo A., Louvet N., Favier R., Ore M.V., Piana F., Girault L. et al. Assessment of coagulation by thromboelastography during ongoing postpartum hemorrhage: a retrospective cohort analysis. Anesth. Analg. 2020; 130(2): 416-25. https://dx.doi.org/10.1213/ANE.0000000000004422.Gonzalez-Brown V., Schneider P. Prevention of postpartum hemorrhage. Semin. Fetal. Neonatal. Med. 2020; 25(5): 101129. https://dx.doi.org/10.1016/ j.siny.2020.101129.Федорова Т.А., Шмаков Р.Г., Рогачевский О.В., Пырегов А.В., Стрельникова Е.В., Виницкий А.А., Королев А.Ю. Инфузионно-трансфузионное обеспечение при операции кесарева сечения у беременных с врастанием плаценты. Акушерство и гинекология. 2017; 12: 38-44. [Fedorova T.A., Shmakov R.G., Rogachevsky O.V., Pyregov A.V., Strelnikova E.V., Vinitsky A.A., Korolev A.Yu. Infusion-transfusion therapy during cesarean section in pregnant women with placenta increta. Obstetrics and Gynecology. 2017; (12): 38-44. (in Russian)]. https://dx.doi.org/10.18565/aig.2017.12.38-44.Henriquez D.D.C.A., Bloemenkamp K.W.M., van der Bom J.G. Management of postpartum hemorrhage: how to improve maternal outcomes? J. Thromb. Haemost. 2018; 16(8): 1523-34. https://dx.doi.org/10.1111/jth.14200.Muñoz M., Stensballe J., Ducloy-Bouthors A.S., Bonnet M.P., De Robertis E., Fornet I. et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus. 2019; 17(2): 112-36. https://dx.doi.org/10.2450/2019.0245-18.Михеева А.А., Ярыгина Т.А., Шмаков Р.Г., Низяева Н.В., Амирасланов Э.Ю., Карапетян Т.Э., Рогачевский О.В., Пырегов А.В. Особенности течения беременности и хирургической тактики при врастании плаценты у пациенток с аномалиями развития органов репродуктивной системы. Акушерство и гинекология. 2022; 9: 146-54. [Mikheeva A.A., Yarygina T.A., Shmakov R.G., Nizyaeva N.V., Amiraslanov E.Yu., Karapetyan T.E., Rogachevskiy O.V., Pyregov A.V. The characteristics of the course of pregnancy and surgical management in placenta increta in patients with reproductive tract malformations. Obstetrics and Gynecology. 2022; (9): 146-54 (in Russian)] https://dx.doi.org/10.18565/aig.2022.9.146-154.Amgalan A., Allen T., Othman M., Ahmadzia H.K. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J. Thromb. Haemost. 2020; 18(8): 1813-38. https://dx.doi.org/10.1111/jth.14882. PMID: 32356929.Gillissen A., Van Den Akker T., Caram-Deelder C., Henriquez D.D.C.A., Bloemenkamp K.W.M., De Maat M.P.M. et al. Coagulation parameters during the course of severe postpartum hemorrhage: A nationwide retrospective cohort study. Blood Adv. 2018; 2(19): 2433-42. https://dx.doi.org/10.1182/bloodadvances.2018022632.Roubinian N. TACO and TRALI: biology, risk factors, and prevention strategies. Hematology Am. Soc. Hematol. Educ. Program. 2018; 2018(1): 585-94. https://dx.doi.org/10.1182/asheducation-2018.1.585.Kohlhepp L.M., Hollerich G., Vo L., Hofmann-Kiefer K., Rehm M., Louwen F. et al. Physiologische Veränderungen in der Schwangerschaft [Physiological changes during pregnancy]. Anaesthesist. 2018; 67(5): 383-96. (in German). https://dx.doi.org/10.1007/s00101-018-0437-2.Karlsson O., Jeppsson A., Hellgren M. Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both? Int. J. Obstet. Anesth. 2014; 23(1): 10-7. https://dx.doi.org/10.1016/j.ijoa.2013.07.003.Распопин Ю.С., Потылицина В.В., Грицан А.И., Ковалев А.В., Ольховский И.А. Референсные интервалы параметров ротационной тромбоэластометрии у беременных и родильниц: одноцентровое рандомизированное исследование. Тромбоз, гемостаз и реология. 2020; 3: 47-54. [Raspopin Y.S., Potylitsina V.V., Gritsan A.I., Kovalev A.V., Olkhovskiy I.A. Reference ranges of rotational thromboelastometry parameters in pregnant women and puerperas: a single-center randomized trial. Thrombosis, Hemostasis and Reology. 2020; (3): 47-54. https://dx.doi.org/10.25555/ THR.2020.3.0928.Hellgren M. Hemostasis during normal pregnancy and puerperium. Semin. Thromb. Hemost. 2003; 29(2): 125-30. https://dx.doi.org/10.1055/s-2003-38897.Роненсон А.М., Шифман Е.М., Куликов А.В., Распопин Ю.С. Референсные показатели ротационной тромбоэластометрии у беременных и рожениц: систематический обзор и метаанализ. Анестезиология и реаниматология. 2021; (3): 28-40. [Ronenson A.M., Shifman E.M., Kulikov A.V., Raspopin Yu.S. Reference values of rotational thromboelastometry in pregnancy and parturition: a systematic review and meta-analysis. Russian Journal of Anesthesiology and Reanimatology. 2021; (3): 28-40. (in Russian)]. https://dx.doi.org/10.17116/anaesthesiology202103128.Lee J., Wyssusek K.H., Kimble R.M.N., Way M., van Zundert A.A., Cohen J. et al. Baseline parameters for rotational thromboelastometry (ROTEM®) in healthy pregnant Australian women: a comparison of labouring and non-labouring women at term. Int. J. Obstet. Anesth. 2020; 41: 7-13. https://dx.doi.org/10.1016/j.ijoa.2019.10.003.Brooks M., Legendre G., Brun S., Bouet P.E., Mendes L.P., Merlot B., Sentilhes L. Use of a visual aid in addition to a collector bag to evaluate postpartum blood loss: a prospective simulation study. Sci. Rep. 2017; 7: 46333. https://dx.doi.org/ 10.1038/srep46333.Collins P.W., Lilley G., Bruynseels D., Laurent D.B., Cannings-John R., Precious E. et al. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood. 2014; 124(11): 1727-36. https://dx.doi.org/10.1182/blood-2014-04-567891.Федорова Т.А., Шмаков Р.Г., Рогачевский О.В., Пырегов А.В., Виницкий А.А., Королев А.Ю., Иванец Т.Ю., Пирогова М.М. Менеджмент крови пациентки в акушерской практике при врастании плаценты. Медицинский совет. 2019; 7: 134-41. [Fedorova T.A., Shmakov R.G., Rogachevsky O.V., Pyregov A.V., Vinitsky A.A., Korolev A.Yu., Ivanets T.U., Pirogova M.M. Patient’s blood management in obstetric practice with placenta accreta. Medical Council. 2019; (7): 134-41. (in Russian)]. https://dx.doi.org/10.21518/ 2079-701X-2019-7-134-141.Доброхотова Ю.Э., Джохадзе Л.С. Применение транексамовой кислоты для профилактики кровотечения в раннем послеродовом периоде. РМЖ. Мать и дитя. 2019; 2(1): 34-8. [Dobrokhotova Yu.E., Djokhadze L.S. Tranexamic acid to prevent early postpartum hemorrhages. Russian Journal of Woman and Child Health. 2019; 2(1): 34-8. (in Russian)]. https://dx.doi.org/10.32364/2618-8430-2019-2-1-34-38.Hartmann J., Walsh M., Grisoli A., Thomas A.V., Shariff F., McCauley R. et al. Diagnosis and treatment of trauma-induced coagulopathy by viscoelastography. Semin. Thromb. Hemost. 2020; 46(2): 134-46. https://dx.doi.org/10.1055/s-0040-1702171.Butwick A., Lyell D., Goodnough L. How do I manage severe postpartum hemorrhage? Transfusion. 2020; 60(5): 897-907. https://dx.doi.org/10.1111/trf.15794.Stettler G.R., Moore E.E., Nunns G.R., Chandler J., Peltz E., Silliman C.C. et al. Rotational thromboelastometry thresholds for patients at risk for massive transfusion. J. Surg. Res. 2018; 228: 154-9. https://dx.doi.org/10.1016/ j.jss.2018.03.027.Liew-Spilger A.E., Sorg N.R., Brenner T.J., Langford J.H., Berquist M., Mark N.M. et al. Viscoelastic hemostatic assays for postpartum hemorrhage. J. Clin. Med. 2021; 10(17): 3946. https://dx.doi.org/10.3390/ jcm10173946.de Lloyd L., Bovington R., Kaye A., Collis R.E., Rayment R., Sanders J. et al. Standard haemostatic tests following major obstetric haemorrhage. Int. J. Obstet. Anesth. 2011; 20(2): 135-41. https://dx.doi.org/10.1016/j.ijoa.2010.12.002.Collins P.W., Bell S.F., de Lloyd L., Collis R.E. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int. J. Obstet. Anesth. 2019; 37: 106-17. https://dx.doi.org/10.1016/j.ijoa.2018.08.008.Leyra F., Jofre C., Peña N., Olmos E., Del Campo J.M., Aranzubia M., Moreno I. Prediction of platelet counts with ROTEM-sigma in cardiac surgery. Minerva Anestesiol. 2022; 88(7-8): 573-9. https://dx.doi.org/10.23736/ S0375-9393.22.15912-2.Rossetto A., Vulliamy P., Green L., Davenport R. Platelet transfusion better preserves ROTEM clot strength and thrombin generation: a case-control study. Abstract Number: PB1227. ISTH 2022 Congress. Available at: https://abstracts.isth.org/abstract/platelet-transfusion-better-preserves-rotem-clot-strength-and-thrombin-generation-a-case-control-study/ (accessed April 13, 2024).Riojas C.M., Ekaney M.L., Ross S.W., Cunningham K.W., Furay E.J., Brown C.V.R. et al. Platelet dysfunction after traumatic brain injury: a review. J. Neurotrauma. 2021; 38(7): 819-29. https://dx.doi.org/10.1089/neu.2020.7301.de Vries J.J., Veen C.S.B., Snoek C.J.M., Kruip M.J.H.A., de Maat M.P.M. FIBTEM clot firmness parameters correlate well with the fibrinogen concentration measured by the Clauss assay in patients and healthy subjects. Scand. J. Clin. Lab. Invest. 2020; 80(7): 600-5. https://dx.doi.org/10.1080/ 00365513.2020.1818283.Toffaletti J.G., Buckner K.A. Use of earlier-reported rotational thromboelastometry parameters to evaluate clotting status, fibrinogen, and platelet activities in postpartum hemorrhage compared to surgery and intensive care patients. Anesth. Analg. 2019; 128(3): 414-23. https://dx.doi.org/10.1213/ANE.0000000000003499.WHO. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. Geneva, Switzerland: World Health Organization; 2017: 3-27.Dowd N.P., Karski J.M., Cheng D.C., Carroll J.A., Lin Y., James R.L., Butterworth J. Pharmacokinetics of tranexamic acid during cardiopulmonary bypass. Anesthesiology. 2002; 97(2): 390-9. https://dx.doi.org/10.1097/ 00000542-200208000-00016.Королев А.Ю., Федорова Т.А., Пырегов А.В., Рогачевский О.В., Шмаков Р.Г., Безнощенко О.С. Трансфузиологическое обеспечение абдоминального родоразрешения у беременных высокого риска развития кровотечения при контроле гемостаза. Медицинский совет. 2020; (13): 29-38. [Korolev A.Y., Fedorova T.A., Pyregov A.V., Rogachevskiy O.V., Shmakov R.G., Beznoshchenko O.S. Transfusion management of abdominal delivery in pregnant women at high risk of bleeding of hemostasis control. Medical Council. 2020; (13): 29-38. (in Russian)]. https://dx.doi.org/10.21518/ 2079-701X-2020-13-29-38.Cortet M., Deneux-Tharaux C., Dupont C., Colin C., Rudigoz R.C., Bouvier-Colle M.H., Huissoud C. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br. J. Anaesth. 2012; 108(6): 984-9. https://dx.doi.org/10.1093/bja/ aes096.McDonnell N.J., Browning R. How to replace fibrinogen in postpartum haemorrhage situations? (Hint: Don't use FFP!). Int. J. Obstet. Anesth. 2018; 33: 4-7. https://dx.doi.org/10.1016/j.ijoa.2017.08.008.Pacheco L.D., Saade G.R., Hankins G.D.V. Medical management of postpartum hemorrhage: An update. Semin. Perinatol. 2019; 43(1): 22-6. https://dx.doi.org/10.1053/j.semperi.2018.11.005.Seto S., Itakura A., Okagaki R., Suzuki M., Ishihara O. An algorithm for the management of coagulopathy from postpartum hemorrhage, using fibrinogen concentrate as first-line therapy. Int. J. Obstet. Anesth. 2017; 32: 11-6. https://dx.doi.org/10.1016/j.ijoa.2017.03.005.Gootjes D.V., Kuipers I., Thomassen B.J.W., Verheul R.J., de Vries S., Mingelen W. et al. ROTEM reference ranges in a pregnant population from different nationalities/ethnic backgrounds. Int. J. Lab. Hematol. 2019; 41(5): e99-e103. https://dx.doi.org/10.1111/ijlh.12996.Fuchs F., Benhamou D. Césarienne et post-partum. Recommandations pour la pratique clinique [Post-partum management after cesarean delivery. Guidelines for clinical practice]. J. Gynecol. Obstet. Biol. Reprod. (Paris). 2015; 44(10): 1111-7. (in French). https://dx.doi.org/10.1016/ j.jgyn.2015.09.020.Kozek-Langenecker S.A., Ahmed A.B., Afshari A., Albaladejo P., Aldecoa C., Barauskas G. et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur. J. Anaesthesiol. 2017; 34(6): 332-95. https://dx.doi.org/10.1097/ EJA.0000000000000630.Российская ассоциация трансфузиологов. Координационный совет служб крови гоcударств-участников СНГ. [Rossiiskaya assotsiatsiya transfuziologov. Koordinatsionnyi sovet sluzhb krovi gosudarstv-uchastnikov SNG. (in Russian)]. Available at: https://www.transfusion.ru/ (дата обращения 08.04.2024).Görlinger K., Pérez-Ferrer A., Dirkmann D., Saner F., Maegele M., Calatayud Á.A.P. et al. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J. Anesthesiol. 2019; 72(4): 297-322. https://dx.doi.org/10.4097/kja.19169.WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389(10084): 2105-16. https://dx.doi.org/10.1016/S0140-6736(17)30638-4.de Lange N.M., van Rheenen-Flach L.E., Lancé M.D., Mooyman L., Woiski M., van Pampus E.C. et al. Peri-partum reference ranges for ROTEM(R) thromboelastometry. Br. J. Anaesth. 2014; 112(5): 852-9. https://dx.doi.org/10.1093/bja/aet480.Peng H.T., Nascimento B., Beckett A. Thromboelastography and thromboelastometry in assessment of fibrinogen deficiency and prediction for transfusion requirement: a descriptive review. Biomed. Res. Int. 2018; 2018: 7020539. https://dx.doi.org/10.1155/2018/7020539.Bell S.F., Collis R.E., Pallmann P., Bailey C., James K., John M. et al. Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study. BMC Pregnancy Childbirth. 2021; 21(1): 377. https://dx.doi.org/10.1186/ s12884-021-03853-y.Wikkelsø A., Wetterslev J., Møller A.M., Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst. Rev. 2016; 2016(8): CD007871. https://dx.doi.org/10.1002/ 14651858.CD007871.pub3.Snegovskikh D., Souza D., Walton Z., Dai F., Rachler R., Garay A. et al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. J. Clin. Anesth. 2018; 44: 50-6. https://dx.doi.org/10.1016/j.jclinane.2017.10.003.McNamara H., Mallaiah S. Managing coagulopathy following PPH. Best Pract. Res. Clin. Obstet. Gynaecol. 2019; 61: 106-20. https://dx.doi.org/10.1016/ j.bpobgyn.2019.04.002.Министерство здравоохранения Российской Федерации. Клинические рекомендации «Послеродовое кровотечение». 2021. [Ministry of Health of the Russian Federation. Clinical guidelines "Postpartum bleeding." 2021. (in Russian)].