Impact of implementing a thromboelastometry-guided transfusion strategy on fibrinogen supplementation and transfusion in women with postpartum hemorrhage.

STUDY

OBJECTIVE

Coagulopathy is a key determinant of maternal prognosis in case of postpartum hemorrhage. We sought to assess the impact of implementing a thromboelastometry-based coagulopathy management protocol on fibrinogen concentrate use and transfusion strategies.

DESIGN

Retrospective study.

SETTING

Tertiary care obstetric unit, university hospital, Lyon, France.

PATIENTS: Adult women with postpartum hemorrhage (≥500 mL blood loss within 24 h postpartum) at a gestational age ≥ 22 weeks.

INTERVENTIONS: Three distinct periods were analyzed: Period 1 (2016-2018, no viscoelastic test available), Period 2 (2019-2020, thromboelastometry available in our maternity unit) and Period 3 (2021-2023, implementation of a thromboelastometry-based coagulopathy management protocol).

MEASUREMENTS: The primary endpoint was the proportion of patients receiving fibrinogen concentrate in each period. Secondary endpoints were the proportions of patients transfused with blood products within the first 24 h in each period. Adjusted odds ratios (aOR) for each outcome were estimated using bidirectional stepwise regression in a final model that included 12 preselected confounders.

MAIN

RESULTS

A total of 3899 patients were analyzed. Period 3 and Period 2 were independently associated with significantly lower odds of fibrinogen concentrate administration compared to Period 1. The aOR was 0.19 (95 %CI: 0.14 to 0.28) for Period 3 and 0.70 (95 %CI: 0.50 to 0.98) for Period 2. Period 3 was also independently associated with significantly lower odds of transfusion of red blood cells (aOR = 0.25 [95 %CI: 0.19 to 0.33]), fresh frozen plasma (aOR = 0.17 [95 %CI: 0.09 to 0.33]) and platelet concentrates (aOR = 0.23 [95 %CI: 0.08 to 0.62]) compared to Period 1. The frequency of massive postpartum hemorrhage (≥2500 mL) did not change significantly across the three periods.

CONCLUSIONS

Implementing a thromboelastometry-guided protocol was associated with significantly reduced use of fibrinogen concentrate, red blood cells, fresh frozen plasma, and platelet concentrates, without increasing the risk of progression to massive hemorrhage. Further assessments of maternal outcomes and cost-effectiveness are required.