Changes of Coagulation and Fibrinolytic Status Detected by Thromboelastography (TEG6s®) in Pregnancy, Labor, Early Postpartum, Postpartum Hemorrhage and Heparin Treatment for Perinatal Venous Thrombosis
Abstract
:1. Introduction
2. Materials and Methods
2.1. Collection of Patients
2.2. Thromboelastography Assay
2.3. Statistical Analysis
3. Results
3.1. Patient Enrollment
3.2. Comparison of Thromboelastographic Parameters in Different Groups
3.3. Correlation between Thromboelastographic Parameters and APTT Ratio in the Patients with Heparin Therapy
4. Discussion
4.1. Main Findings and Importance
4.2. Comparison of TEG6s® and TEG5000®
4.3. Usefulness of TEG6s® for PPH
4.4. Usefulness of TEG6s® for Monitoring the Effect of Heparin
4.5. Study Limitations and Strength
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
NP n = 13 | 9–13 GW n = 14 | 27–30 GW n = 14 | 35–38 GW n = 14 | Labor n = 8 | 15 min n = 14 | 30 min n = 11 | 60 min n = 14 | 120 min n = 14 | PPH n = 15 | p | |
---|---|---|---|---|---|---|---|---|---|---|---|
CRT | |||||||||||
TEG-ACT | 97.3 (87.9–116) | 87.9 (69.2–125.3) | 78.5 (69.2–116) | 78.5 (49.2–87.9) | 83.2 (69.2–97.3) | 69.2 (69.2–97.3) | 78.5 (69.2–97.3) | 73.9 (69.2–97.3) | 73.9 (69.2–97.3) | 87.9 (69.2–209.5) | <0.001 |
R (min) | 0.5 (0.4–0.7) | 0.4 (0.2–0.8) | 0.3 (0.2–0.7) | 0.3 (0.2–4.7) | 0.4 (0.2–0.5) | 0.2 (0.2–0.5) | 0.3 (0.2–0.5) | 0.3 (0.2–0.5) | 0.3 (0.2–0.5) | 0.4 (0.2–1.7) | <0.001 |
K (min) | 1.5 (1.0–1.9) | 1.3 (0.8–1.6) | 0.9 (0.8–1.3) | 0.9 (0.8–6.4) | 1.0 (0.8–1.3) | 0.9 (0.8–1.3) | 0.9 (0.8–2.3) | 1.0 (0.8–2.6) | 1.0 (0.8–1.3) | 1.4 (1.0–3.6) | <0.001 |
Angle (degree) | 71.7 (69.3–76.9) | 74.7 (73.0–80.6) | 77.6 (75.4–80.0) | 77.8 (45.8–79.6) | 77.6 (75.3–80.0) | 77.7 (75.5–79.6) | 77.8 (76.2–79.2) | 77.4 (72.9–79.6) | 77.5 (73.8–78.5) | 74.1 (56.1–78.1) | <0.001 |
A10 | 55.5 (50.7–64.5) | 60.2 (47.2–69.3) | 61.9 (58.4–67.9) | 63.1 (23.4–68.9) | 63.8 (57.7–66.9) | 64.0 (59.3–68.9) | 64.4 (44.0–67.6) | 60.9 (36.3–67.2) | 60.7 (43.3–65.6) | 57.4 (32.9–65.1) | <0.001 |
MA (mm) | 61.1 (57.5–67.5) | 64.1 (54.3–70.2) | 65.9 (63.6–68.4) | 66.3 (30.6–70.3) | 67.2 (63.0–68.9) | 67.5 (64.3–70.4) | 67.0 (55.9–69.3) | 66.3 (48.8–69.3) | 65.7 (53.4–68.3) | 63.1 (44.2–67.3) | <0.001 |
LY30 (%) | 1.8 (0.3–6.3) | 1.7 (0.1–3.5) | 0.4 (0–2.2) | 0 (0–0.9) | 0.2 (0–3.2) | 0.05 (0–3.2) | 0 (0–0.7) | 0 (0–2.7) | 0 (0–2.9) | 0 (0–1.9) | <0.001 |
CKH | |||||||||||
R (min) | 5.4 (4.7–6.8) | 5.6 (3.4–6.5) | 5.2 (4.3–7.0) | 5.2 (3.8–7.4) | 4.7 (2.5–6.2) | 3.6 (2.2–5.8) | 3.7 (2.7–4.2) | 3.3 (1.5–4.5) | 3.2 (1.2–3.7) | 4.2 (2.0–5.2) | <0.001 |
K (min) | 1.1 (0.9–1.6) | 1.1 (0.9–1.5) | 0.9 (0.8–1.3) | 1.1 (0.9–6.0) | 1.0 (0.8–1.3) | 0.9 (0.8–1.0) | 0.9 (0.8–1.5) | 0.9 (0.8–2.7) | 0.9 (0.8–1.4) | 1.1 (0.8–2.8) | <0.001 |
Angle (degree) | 74.8 (69.8–77.0) | 75.2 (72.9–77.6) | 76.3 (72.4–78.4) | 75.9 (49.9–78.0) | 77.2 (72.8–79.5) | 77.5 (75.3–79.8) | 77.4 (72.9–79.0) | 77.1 (72.2–80.1) | 77.1 (74.8–77.9) | 75.2 (62.3–78.4) | <0.001 |
MA (mm) | 61.9 (56.7–65.8) | 62.7 (55.0–68.9) | 66.4 (61.8–67.9) | 66.4 (29.4–70.1) | 65.9 (62.3–68.5) | 66.5 (62.4–69.7) | 66.4 (58.2–69.1) | 66.2 (45.9–69.6) | 65.8 (58.5–69.0) | 64.1 (46.9–67.9) | <0.001 |
CFF | |||||||||||
A10 | 18.6 (16.7–25.3) | 20.3 (14.4–37.4) | 25.3 (20.1–34.4) | 26.4 (22.0–32.9) | 23.6 (20.3–28.9) | 24.6 (20.4–30.3) | 25.1 (20.1–29.1) | 24.7 (16.4–30.3) | 25.4 (19.1–29.3) | 19.3 (2.9–23.9) | <0.001 |
MA (mm) | 19.2 (17.4–27.7) | 20.2 (15.6–39.5) | 25.7 (20.4–37.1) | 27.3 (21.1–35.2) | 24.6 (20.3–31.1) | 26.4 (20.5–34.5) | 26.2 (20.2–32.1) | 25.6 (16.4–33.4) | 26.6 (19.1–32.4) | 19.5 (2.9–24.6) | <0.001 |
References
- Hartert, H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsverfahren. Klin. Wochenschrift. 1948, 26, 577–583. [Google Scholar] [CrossRef] [PubMed]
- Luddington, R.J. Thrombelastography/thromboelastometry. Clin. Lab. Haematol. 2005, 27, 81–90. [Google Scholar] [CrossRef] [PubMed]
- Neal, M.D.; Moore, E.E.; Walsh, M.; Thomas, S.; Callcut, R.A.; Kornblith, L.Z.; Schreiber, M.; Ekeh, A.P.; Singer, A.J.; Lottenberg, L. A comparison between the TEG 6s and TEG 5000 analyzers to assess coagulation in trauma patients. J. Trauma Acute Care Surg. 2020, 88, 279–285. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bolliger, D.; Seeberger, M.D.; Tanaka, K.A. Principles and Practice of Thromboelastography in Clinical Coagulation Management and Transfusion Practice. Transfus. Med. Rev. 2012, 26, 1–13. [Google Scholar] [CrossRef] [PubMed]
- Liew-Spilger, A.E.; Sorg, N.R.; Brenner, T.J.; Langford, J.H.; Berquist, M.; Mark, N.M.; Moore, S.H.; Mark, J.; Baumgartner, S.; Abernathy, M.P. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J. Clin. Med. 2021, 10, 3946. [Google Scholar] [CrossRef] [PubMed]
- Kang, Y.G.; Martin, D.J.; Marquez, J.; Lewis, J.H.; Bontempo, F.A.; Shaw, B.W.; Starzl, T.E.; Winter, P.M. Intraoperative Changes in Blood Coagulation and Thrombelastographic Monitoring in Liver Transplantation. Anesth. Analg. 1985, 64, 888–896. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Spiess, B.D.; Tuman, K.J.; McCarthy, R.J.; DeLaria, G.A.; Schillo, R.; Ivankovich, A.D. Thromboelastography as an indicator of post-cardiopulmonary bypass coagulopathies. J. Clin. Monit. 1987, 3, 25–30. [Google Scholar] [CrossRef]
- Kaufmann, C.R.; Dwyer, K.M.; Crews, J.D.; Dols, S.J.; Trask, A.L. Usefulness of thrombelastography in assessment of trauma patient coagulation. J. Trauma Acute Care Surg. 1997, 42, 716–720. [Google Scholar] [CrossRef]
- Schöchl, H.; Schlimp, C.J. Trauma Bleeding Management: The Concept of Goal-Directed Primary Care. Anesth. Analg. 2014, 119, 1064–1073. [Google Scholar] [CrossRef]
- Macafee, B.; Campbell, J.P.; Ashpole, K.; Cox, M.; Matthey, F.; Acton, L.; Yentis, S.M. Reference ranges for thromboelastography (TEG(®)) and traditional coagulation tests in term parturients undergoing caesarean section under spinal anaesthesia. Anaesthesia 2012, 67, 741–747. [Google Scholar] [CrossRef]
- Kramer, M.S.; Berg, C.; Abenhaim, H.; Dahhou, M.; Rouleau, J.; Mehrabadi, A.; Joseph, K.S. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am. J. Obstet. Gynecol. 2013, 209, e1–e449. [Google Scholar] [CrossRef]
- 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, 1523–1534. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Backe, S.K.; Lyons, G.R. High-dose tinzaparin in pregnancy and the need for urgent delivery. Br. J. Anaesth. 2002, 89, 331–334. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Middleton, P.; Shepherd, E.; Gomersall, J.C. Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period. Cochrane Database Syst. Rev. 2021, 29, 3. [Google Scholar]
- Clark, S.L.; Hankins, G.D.V.; Dudley, D.A.; Dildy, G.A.; Porter, T.F. Amniotic fluid embolism: Analysis of the national registry. Am. J. Obstet. Gynecol. 1995, 172, 1158–1169. [Google Scholar] [CrossRef]
- Morgan, M. Amniotic fluid embolism. Anaesthesia 1979, 34, 20–32. [Google Scholar] [CrossRef]
- Fudaba, M.; Tachibana, D.; Misugi, T.; Nakano, A.; Koyama, M. Excessive fibrinolysis detected with thromboelastography in a case of amniotic fluid embolism: Fibrinolysis may precede coagulopathy. J. Thromb. Thrombolysis 2021, 51, 818–820. [Google Scholar] [CrossRef]
- Lloyd-Donald, P.; Churilov, L.; Zia, F.; Bellomo, R.; Hart, G. Assessment of agreement and interchangeability between the TEG5000 and TEG6S thromboelastography haemostasis analysers: A prospective validation study. BMC Anesthesiol. 2019, 19, 45. [Google Scholar] [CrossRef]
- Shreeve, N.E.; Barry, J.A.; Deutsch, L.R.; Gomez, K.; Kadir, R.A. Changes in thromboelastography parameters in pregnancy, labor, and the immediate postpartum period. Int. J. Gynecol. Obstet. 2016, 134, 290–293. [Google Scholar] [CrossRef]
- Sharma, S.K.; Philip, J.; Wiley, J. Thromboelastographic Changes in Healthy Parturients and Postpartum Women. Anesth. Analg. 1997, 85, 94–98. [Google Scholar]
- Kruithof, E.K.O.; Tran-Thang, C.; Gudinchet, A.; Hauert, J.; Nicoloso, G.; Genton, C.; Welti, H.; Bachmann, F. Fibrinolysis in pregnancy: A study of plasminogen activator inhibitors. Blood 1987, 69, 460–466. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bonnar, J.; McNicol, G.P.; Douglas, A.S. Coagulation and Fibrinolytic Mechanisms During and After Normal Childbirth. Br. Med. J. 1970, 2, 200–203. [Google Scholar] [CrossRef] [PubMed]
- Karlsson, O.; Jeppsson, A.; Hellgren, M. Major obstetric haemorrhage: Monitoring with thromboelastography, laboratory analyses or both? Int. J. Obstet. Anesth. 2014, 23, 10–17. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- McNamara, H.; Kenyon, C.; Smith, R.; Mallaiah, S.; Barclay, P. Four years’ experience of a ROTEM-guided algorithm for treatment of coagulopathy in obstetric haemorrhage. Anaesthesia 2019, 74, 984–991. [Google Scholar] [CrossRef] [PubMed]
- Bell, S.F.; Collis, R.E.; Collins, P.W. Comparison of haematological indices and transfusion management in severe and massive postpartum haemorrhage: Analysis of a two-year national prospective observational study. Int. J. Obstet. Anesth. 2022, 50, 103547. [Google Scholar] [CrossRef]
- Gillissen, A.; van den Akker, T.; Caram-Deelder, C.; Henriquez, D.D.C.A.; Bloemenkamp, K.W.M.; Eikenboom, J.; van der Bom, J.G.; de Maat, M.P.M. Comparison of thromboelastometry by ROTEM® Delta and ROTEM® Sigma in women with postpartum haemorrhage. Scand. J. Clin. Lab. Investig. 2019, 79, 32–38. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hurwich, M.; Zimmer, D.; Guerra, E.; Evans, E.; Shire, T.; Abernathy, M.; Shreve, J.T.; Kolettis, G.R.; McCurdy, M.T.; Castellino, F.J.; et al. A Case of Successful Thromboelastographic Guided Resuscitation after Postpartum Hemorrhage and Cardiac Arrest. J. Extra-Corpor. Technol. 2016, 48, 194–197. [Google Scholar]
- Walsh, M.; Thomas, S.G.; Howard, J.C.; Evans, E.; Guyer, K.; Medvecz, A.; Swearingen, A.; Navari, R.M.; Ploplis, V.; Castellino, F.J. Blood Component Therapy in Trauma Guided with the Utilization of the Perfusionist and Thromboelastography. J. Extra-Corpor. Technol. 2011, 43, 162–167. [Google Scholar]
- Shore-Lesserson, L.; Manspeizer, H.E.; DePerio, M.; Francis, S.; Vela-Cantos, F.; Ergin, M.A. Thromboelastography-Guided Transfusion Algorithm Reduces Transfusions in Complex Cardiac Surgery. Anesth. Analg. 1999, 88, 312–319. [Google Scholar] [CrossRef]
- Aubron, C.; DePuydt, J.; Belon, F.; Bailey, M.; Schmidt, M.; Sheldrake, J.; Murphy, D.; Scheinkestel, C.; Cooper, D.J.; Capellier, G.; et al. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann. Intensive Care 2016, 6, 97. [Google Scholar] [CrossRef] [Green Version]
- Combes, A.; Brodie, D.; Chen, Y.; Fan, E.; Henriques, J.P.S.; Hodgson, C.; Lepper, P.M.; Leprince, P.; Maekawa, K.; Muller, T.; et al. The ICM research agenda on extracorporeal life support. Intensive Care Med. 2017, 43, 1306–1318. [Google Scholar] [CrossRef] [PubMed]
- Panigada, M.; Iapichino, G.E.; Brioni, M.; Panarello, G.; Protti, A.; Grasselli, G.; Occhipinti, G.; Novembrino, C.; Consonni, D.; Arcadipane, A.; et al. Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: A safety and feasibility pilot study. Ann. Intensive Care 2018, 8, 7. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Shinoda, T.; Arakura, H.; Katakura, M.; Shirota, T.; Nakagawa, S. Usefulness of thrombelastography for dosage monitoring of low molecular weight heparin and unfractionated heparin during hemodialysis. Artif. Organs 1990, 14, 413–415. [Google Scholar] [CrossRef]
- Kuiper, G.J.; Kleinegris, M.C.; van Oerle, R.; Spronk, H.M.; Lancé, M.D.; ten Cate, H.; Henskens, Y.M. Validation of a modified thromboelastometry approach to detect changes in fibrinolytic activity. Thromb. J. 2016, 14, 1. [Google Scholar] [CrossRef] [PubMed]
- Panigada, M.; Zacchetti, L.; L’Acqua, C.; Cressoni, M.; Anzoletti, M.; Bader, R.; Protti, A.; Consonni, D.; D’Angelo, A.; Gattinoni, L. Assessment of Fibrinolysis in Sepsis Patients with Urokinase Modified Thromboelastography. PLoS ONE 2015, 10, e0136463. [Google Scholar]
- Neki, R.; Fujita, T.; Kokame, K.; Nakanishi, I.; Waguri, M.; Imayoshi, Y.; Suehara, N.; Suehara, T.; Miyata, T. Genetic analysis of patients with deep vein thrombosis during pregnancy and postpartum. Int. J. Hematol. 2011, 94, 150–155. [Google Scholar] [CrossRef]
- Kupferminc, M.J.; Eldor, A.; Steinman, N.; Bar-Am, A.; Jaffa, A.; Fait, G.; Lessing, J.B. Increased Frequency of Genetic Thrombophilia in Women with Complications of Pregnancy. N. Engl. J. Med. 1999, 340, 9–13. [Google Scholar] [CrossRef]
- Andrea, G.; Eberhard, S.R.; Wilhelm, B.M.; Sabine, S.; Georg, B.H.; Michael, P.; Wilhelm, S.; Bernd, Z.R. Prothrombin and Factor V Mutations in Women with a History of Thrombosis during Pregnancy and the Puerperium. N. Engl. J. Med. 2000, 342, 374–380. [Google Scholar]
NP n = 13 | 9–13 GW n = 13 | 27–30 GW n = 14 | 35–38 GW n = 14 | Delivery n = 14 | PPH n = 15 | DVT/PE n = 11 | p | |
---|---|---|---|---|---|---|---|---|
Age (years) | 30.0 (27–39) | 33.0 (29–42) | 31.0 (25–42) | 33.0 (28–39) | 32.0 (26–41) | 36.0 (26–44) | 30.0 (27–42) | 0.382 |
Pre-pregnancy BMI (kg/m2) | 20.0 (18.5–22.0) | 20.1 (15.9–32.9) | 21.4 (15.8–33.6) | 21.1 (17.1–32.5) | 20.9 (16.7–26.0) | 22.2 (19.2–26.2) | 22.0 (18.0–31.6) | 0.689 |
Nulliparity, n (%) | 54 | 54 | 50 | 21 | 64 | 40 | 36 | 0.213 |
EBL at TEG sampling (mL) | 295 (75–478) | 2520 (2000–3885) | ||||||
EBL total (mL) | 295 (75–478) | 2985 (2000–6000) |
NP n = 13 | 9–13 GW n = 14 | 27–30 GW n = 14 | 35–38 GW n = 14 | Labor n = 8 | 15 min n = 14 | 30 min n = 11 | 60 min n = 14 | 120 min n = 14 | PPH n = 15 | p | |
---|---|---|---|---|---|---|---|---|---|---|---|
R (min) | 5.7 (4.7–6.7) | 5.3 (4.2–6.2) | 5.2 (4.2–6.4) | 5.4 (4.1–7.3) | 5.6 (2.6–6.8) | 3.55 (2.3–5.7) | 3.9 (2.8–4.4) | 3.3 (1.7–4.3) | 3.05 (1.2–4.7) | 3.8 (2.0–7.2) | <0.001 |
K (min) | 1.3 (0.9–1.5) | 1.1 (0.9–1.4) | 0.9 (0.8–1.2) | 1.0 (0.8–1.2) | 0.9 (0.8–1.2) | 0.85 (0.7–1) | 0.9 (0.8–1.3) | 0.9 (0.8–3.4) | 0.9 (0.8–1.3) | 1.1 (0.9–2.8) | <0.001 |
Angle (degree) | 74.2 (70.4–76.8) | 75.2 (70.8–77.5) | 76.65 (73.9–79.1) | 76.1 (50.6–79.1) | 76.0 (73.7–79) | 77.85 (75.7–80.1) | 77.7 (74.7–79.2) | 77.45 (71.2–79.2) | 77.05 (74.3–79.1) | 75.2 (63.7–78.0) | <0.001 |
MA (mm) | 60.7 (57.2–64.9) | 62.7 (55.7–68.4) | 66.8 (62.2–69.6) | 66.35 (63.2–69.7) | 66.1 (61.4–68.7) | 67.15 (63.8–71.7) | 66.1 (60.6–69.2) | 66.55 (42.6–69.3) | 65.9 (56.8–68.7) | 64.7 (46.9–68.1) | <0.001 |
LY30 (%) | 2.3 (0.3–5.7) | 2.3 (0.8–3.7) | 1.0 (0–3.1) | 0.55 (0–2.4) | 1.0 (0–3.2) | 0.2 (0–1.2) | 0.2 (0–1.2) | 0.15 (0–3.7) | 0 (0–3.6) | 0.1 (0–1.9) | <0.001 |
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Suemitsu, C.; Fudaba, M.; Kitada, K.; Kurihara, Y.; Tahara, M.; Hamuro, A.; Misugi, T.; Nakano, A.; Koyama, M.; Tachibana, D. Changes of Coagulation and Fibrinolytic Status Detected by Thromboelastography (TEG6s®) in Pregnancy, Labor, Early Postpartum, Postpartum Hemorrhage and Heparin Treatment for Perinatal Venous Thrombosis. Healthcare 2022, 10, 2060. https://doi.org/10.3390/healthcare10102060
Suemitsu C, Fudaba M, Kitada K, Kurihara Y, Tahara M, Hamuro A, Misugi T, Nakano A, Koyama M, Tachibana D. Changes of Coagulation and Fibrinolytic Status Detected by Thromboelastography (TEG6s®) in Pregnancy, Labor, Early Postpartum, Postpartum Hemorrhage and Heparin Treatment for Perinatal Venous Thrombosis. Healthcare. 2022; 10(10):2060. https://doi.org/10.3390/healthcare10102060
Chicago/Turabian StyleSuemitsu, Chiharu, Megumi Fudaba, Kohei Kitada, Yasushi Kurihara, Mie Tahara, Akihiro Hamuro, Takuya Misugi, Akemi Nakano, Masayasu Koyama, and Daisuke Tachibana. 2022. "Changes of Coagulation and Fibrinolytic Status Detected by Thromboelastography (TEG6s®) in Pregnancy, Labor, Early Postpartum, Postpartum Hemorrhage and Heparin Treatment for Perinatal Venous Thrombosis" Healthcare 10, no. 10: 2060. https://doi.org/10.3390/healthcare10102060
APA StyleSuemitsu, C., Fudaba, M., Kitada, K., Kurihara, Y., Tahara, M., Hamuro, A., Misugi, T., Nakano, A., Koyama, M., & Tachibana, D. (2022). Changes of Coagulation and Fibrinolytic Status Detected by Thromboelastography (TEG6s®) in Pregnancy, Labor, Early Postpartum, Postpartum Hemorrhage and Heparin Treatment for Perinatal Venous Thrombosis. Healthcare, 10(10), 2060. https://doi.org/10.3390/healthcare10102060