Four years’ experience of a ROTEM((R))-guided algorithm for treatment of coagulopathy in obstetric haemorrhage.

McNamara H, Kenyon C, Smith R, Mallaiah S, Barclay P
Anaesthesia 2019;74:984-991.
NATA Rating :
Review by : B. Froessler
NATA Review

This important study by McNamara et al. reports on four years of observational data from a large UK hospital and tertiary referral unit, following the introduction of a rotational thromboelastometry-guided algorithm for treatment of coagulopathy in major obstetric haemorrhage. This was compared to a matched cohort from the year prior when a “shock pack” was dispatched in a massive bleeding scenario.

Their work demonstrates the magnitude of “real-world” outcome improvements through the implementation of a thromboelastometry-guided algorithm for treatment of coagulopathy in obstetric haemorrhage. In the algorithm group, there was a significant reduction in the number of units (P < 0.0001) and total volume (P = 0.0007) of blood products transfused (in particular fresh frozen plasma), with a reduction in transfusion-associated circulatory overload (P = 0.002).

This study highlights the importance of fibrinogen as a marker/predictor of obstetric haemorrhage and in addition the usefulness and value of fibrinogen concentrate as treatment option. Compared with cryoprecipitate, availability is immediate, dosing is consistent, safety enhanced, and wastage minimised.

The analysis of the thrombelastometry results underpins the “individuality” of the obstetric haemorrhage and the subsequent need for a personalised treatment approach, also outlined in an excellent accompanying editorial by Shah and Collis (Anaesthesia 2019;74: 961-4).

For some time, there has been a lack of support for viscoelastic haemostatic assays (VHA) outside of cardiac surgery. Evidence is now growing that VHA is beneficial in obstetric haemorrhage. Therefore, a recommendation was made in the latest British Society for Haematology Guideline (Curry NS et al. Br J Haematol 2018;182:789-806) and an increasing number of hospitals (like my own) have added this diagnostic tool successfully to their PBM modalities

The work by McNamara et al. will reassure clinicians who already have the ability of VHA and may reflect their own experiences with obstetric haemorrhage. Health care settings without VHA should be encouraged to work towards the implementation of this test in the future.

– Bernd Froessler

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