Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage

Highlights

• Postpartum Hemorrhage (PPH) is a major cause of maternal morbidity and mortality.

• 6,708 cesarean deliveries and 13,641 vaginal births analyzed.

• Point-of-care viscoelastic testing (PCVT) was utilized in patients with PPH.

• The PCVT produced substantial improvement in both patient outcomes and cost of care.

Introduction

Postpartum hemorrhage (PPH)—defined as an estimated blood loss > 500 mL following vaginal delivery and > 1000 mL following cesarean [1], [2]—is the leading cause of maternal mortality worldwide accounting for 27% of all maternal deaths, [3], [4] and is the foremost cause of direct obstetric death in developed countries [5], [6]. It is also a major cause of maternal morbidity and intensive care unit (ICU) admissions [7], [8]. The incidence of PPH is increasing [9], [10]. This is especially true of severe PPH, defined as an estimated blood loss in excess of 1500 mL [11], [12]. Standardized hospital protocols have been developed in an effort to optimize the management of PPH and reduce peripartum morbidity and mortality [13], [14]. These protocols generally follow the principles of empiric resuscitation, sometimes referred to as ‘damage control resuscitation’ [15]. Such protocols, developed initially in trauma medicine, deemphasizes crystalloid infusion in favor of early transfusion of high volumes of fresh frozen plasma (FFP), packed red blood cells (PRBC), and platelets without adjusting blood product transfusions to the results of coagulation tests [16], [17], [18]. The objective of these standardized protocols is to minimize dilutional and consumptive coagulopathy and avoid delay in blood product replacement in the setting of ongoing blood loss [19], [20]. However, empiric resuscitation is not universally accepted [21].

It has been suggested that blood product resuscitation should be individualized and adjusted according to the results of point-of-care viscoelastic testing (PCVT). This approach has been shown to decrease morbidity and mortality among cardiac, [22], [23] liver transplant, [24] and trauma patients [25], [26] experiencing severe bleeding. In Europe, PCVT has been used also for the management of obstetric hemorrhage with good success [27], [28]. To improve the care of patients with severe PPH, a standardized massive transfusion protocol based on empiric resuscitation principles was implemented on Labor & Delivery at Yale-New Haven Hospital in New Haven, CT in January 2011. Two years later, this was replaced by an individualized PCVT-guided transfusion management approach. The primary objective of this study was to compare clinical outcomes (specifically volume of transfused blood product, rate of volume overload, and rate of ICU admission) and hospital costs for patients with severe PPH managed with and without the PCVT-guided transfusion protocol in an historical cohort. We hypothesized that utilization of bedside thromboelastometry can improve clinical outcomes and decrease the cost of care by supporting accurate and clinically effective decisions in transfusion management in patients with severe PPH.