Assessing and Managing Bleeding Disorders During …Assessing and Managing Bleeding Disorders During Pregnancy: Faculty Selections October 20, 2010 Michael J. Paidas, MD Introduction

TABLE OF CONTENTS

Introduction

Clinical Manifestations and

Management

Plasma Fibrinogen to

Reduce Postoperative

Bleeding

Measuring Global

Hemostasis

References and Related

Reading

Assessing and Managing Bleeding Disorders During Pregnancy: Faculty Selections October 20, 2010

Michael J. Paidas, MD Introduction

The presence of bleeding disorders presents unique clinical

challenges during pregnancy and childbirth. Complications

may include increased risk of miscarriage, placental

abruption, postpartum hemorrhage (PPH), and bleeding

complications for the fetus.

Recently, several publications have called attention to the

clinical challenges of managing patients with rare bleeding

disorders during pregnancy, as well as advances in point-of-

care testing. A synopsis of these articles is provided below,

along with commentary on their clinical relevance.

Bleeding Disorders During Pregnancy: Clinical Manifestations and Management

Primary Author: R. Kadir

Co-authors: C. Chi and P. Bolton-Maggs

Article: Pregnancy and rare bleeding disorders

Reference: Haemophilia. 2009;15:990-1005. Click here to read the abstract of this article.

Synopsis

Limited data exist on the management of pregnancy in women with rare inherited bleeding

disorders. These include deficiencies of fibrinogen, factor V, factor VII, factor X, factor XI, and factor

XIII, along with combined deficiencies of factors V and VIII and deficiency of the vitamin K-

dependent factors, II, VII, IX, and X. Although these disorders account for only 3% to 5% of all

inherited coagulation disorders, they are associated with high morbidity, including miscarriage,

perinatal death, and PPH. Clinical manifestations vary, and treatment must be individualized based

on the patient's presentation, history, and factor deficiency. Obstetric risk factors and causes of

PPH should not be overlooked in women with rare bleeding disorders ( Table 1). A careful,

multidisciplinary approach involving an obstetrician, hematologist, and anesthesiologist is

paramount to minimize the potential for complications among such patients.

Key Facts

l The management of women with rare bleeding disorders may be complicated by a variable

bleeding tendency

l Congenital bleeding disorders have been associated with recurrent miscarriages, placental

abruption, PPH, and other complications

l The 3 principles for reducing the risk of PPH are prophylactic treatment to normalize

hemostatic status, measures to avoid uterine atony, and delivery with minimal genital

trauma

Key Recommendations

l A close and ongoing collaboration between obstetricians and hematologists is essential for

the management of pregnancy in women with bleeding disorders

l Relevant coagulation factor levels should be routinely checked at initial visit, at 28 and 34

weeks of gestation, and prior to any invasive procedure

l A detailed written management plan for labor and delivery should be formulated during the

third trimester and provided to the mother and all caregivers

l In cases involving hemorrhage, following initial assessment and restoration of circulatory

volume, local causes should be excluded and replacement of the deficient clotting factor

with concomitant monitoring of factor levels should be initiated in consultation with the

hemophilia treatment center or the institution's hematologists

l Available therapeutic options for rare bleeding disorders are limited (Table 2) and may require

clinicians to balance the risks of bleeding against the risk of thrombosis

Risks in Selecting Treatment for Pregnant Women With Rare Bleeding Disorders

It is critical for clinicians to consider the natural history of the bleeding disorder in question,

including the inheritance pattern, as the fetal and neonatal concerns might influence the

antepartum, intrapartum, peripartum, and early postnatal management. In addition, clinicians need

to consider the thrombotic risks that can occur from a variety of factors, such as the nature of the

bleeding disorder on occasion, the consequences of medications employed to treat the bleeding

disorder, and pregnancy itself.

Case Report

This patient, first described by Funai and colleagues (1997), was a 31-year-old woman, gravida 5,

para 0040, who manifested both a bleeding disorder and a thrombophilia. The patient had a medical

history of deep vein thrombosis and pulmonary embolism while on oral contraceptives, and was

ultimately diagnosed with a protein S deficiency and low titers of anticardiolipin antibodies. She

experienced recurrent pregnancy loss with normal karyotypes, despite receiving heparin

anticoagulation with each conception. Of interest, her fibrinogen levels were consistent, at 70

mg/dL. The patient's father was noted to have a fibrinogen level of 125 mg/dL. After a subsequent

pregnancy, the patient was treated with fresh frozen plasma (FFP) transfusions, 1 to 2 U every 2

weeks, in addition to heparin, low-dose aspirin, and progesterone supplementation. Her fibrinogen

level was maintained at greater than 150 mg/dL during this time. At 38 weeks' gestation, heparin

was discontinued and induction of labor followed. Due to fetal heart rate tracing concerns, the

patient delivered via cesarean section. She went on to have an uncomplicated postoperative course.

Of note, the newborn's fibrinogen level was 66 mg/dL.

Plasma Fibrinogen to Reduce Postoperative Bleeding

Primary Author: N. Rahe-Meyer

Co-authors: M. Pichlmaier, A. Haverich, C. Solomon, M. Winterhalter, S. Piepenbrock, and K. A.

Tanaka

Article: Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen

level: a pilot study

Reference: Br J Anaesth. 2009;102:785-792. Click here to read the abstract of this article.

Synopsis

The traditional management of bleeding diathesis after complex surgery involves the administration

of FFP and platelet concentrates. In this pilot study, a 2-step blood products transfusion algorithm

( Figure 1) was developed using retrospective data from 42 elective cardiac surgery patients to

compare the hemostatic effects of conventional transfusion management and FIBTEM

(thromboelastometry test)-guided fibrinogen concentrate.

Select Study Facts

l Investigators examined whether postoperative hemostasis could be improved by increasing

plasma fibrinogen concentrations

l 42 elective patients (group A) were transfused with 2 U of platelet concentrate after

cardiopulmonary bypass, followed by 4 U of FFP if bleeding persisted

l Assignment to 2 prospective groups (neither randomized nor blinded)

¡ Group B (n=5): treated according to algorithm

¡ Group C (n=10): received fibrinogen concentrate prior to algorithm-based therapy

l Fibrinogen concentrate administration was guided by the bedside assay, FIBTEM (clot

strength in the presence of platelet inhibition), with an empirical target maximum clot

firmness (MCF) of 22 mm and an arbitrary limit for the maximal dose set at 6 g fibrinogen

concentrate

Select Study Results

l A mean of 5.7 g fibrinogen concentrate decreased blood loss to below the transfusion trigger

in all group C patients

l Prior to hemostatic therapy, coagulation disturbances seen in laboratory tests were

comparable between the conventional therapy groups and prospective fibrinogen therapy

group

¡ Prolonged PT, decreased platelet counts, and decreased fibrinogen levels were

detected in each group compared with baseline

l The administration of fibrinogen concentrate restored fibrinogen plasma to baseline levels

without affecting PT and platelet count

l Hemostatic therapy with fibrinogen concentrate targeting a high plasma fibrinogen level in

cardiac surgery patients resulted in a reduction in transfusion of allogeneic blood products

and drainage volume compared with a historical control group that received conventional

hemostatic therapy

l A longer follow-up study with a large number of patients is necessary to confirm the safety

and efficacy of fibrinogen concentrate for hemostatic efficacy

Study Evaluation Summary

Study findings from Rahe-Meyer and colleagues suggest that fibrinogen replacement will decrease

the amount of allogeneic blood product transfusion and improve surgical drainage in patients

undergoing cardiac surgery. The FIBTEM (thromboelastometry) is a useful bedside test to guide

fibrinogen concentrate administration. Since PPH is characterized by decreases in fibrinogen

concentration, the FIBTEM represents an intriguing approach to the monitoring of patients with

PPH due to uterine atony. This bedside test can monitor response to therapy, especially fibrinogen

concentrate.

Measuring Global Hemostasis

Primary Author: S.C. Nair

Co-authors: Y. Dargaud, M. Chitlur, A. Srivastava

Article: Tests of global haemostasis and their applications in bleeding disorders

Reference: Haemophilia. 2010;16(suppl 5):85-92. Click here to read the abstract of this article.

Synopsis

Hemostasis and bleeding disorders have traditionally been assessed by plasma clotting times,

including the prothrombin (PT), activated partial thromboplastin (APTT), and thrombin time.

Although these times rely upon the thrombin-dependent conversion of fibrinogen to fibrin, they note

only the beginning of this process and do not take into account its speed or extent. A more

complete assessment with heightened sensitivity may be obtained by utilizing tests that measure

global hemostasis, such as the thrombin generation tests/assay (TGT/TGA), activated partial

thromboplastin time (APTT) wave-form analysis, and thromboelastography (TEG). Global

hemostasis tests have the potential to revolutionize our understanding of hemostasis and related

disorders. Research is ongoing to standardize methodology, applications, and clinical correlations

with the measured hemostatic parameters.

“There is a potential for significant paradigm shift in the

assessment of haemostasis from the conventional plasma

recalcification times, such as prothrombin time (PT) and

activated partial thromboplastin time (APTT), which

correspond to artificially created compartments of

haemostasis to tests that assess the entire process in a more

physiological and holistic manner.”

Thrombin Generation Tests/Assay

Thrombin is both the final product and the key enzyme of the coagulation system. The rationale

behind measurement of thrombin generation is that it has the capacity to reflect the overall

coagulating capacity of an individual while considering all influential hemostatic parameters. A

standard TGT measures the overall potential of plasma to form thrombin, while a second assay is

available that gauges the amounts of thrombin that are formed in vivo. This includes D-dimers,

which indicate that fibrin has been formed; F1 + 2, which indicate that prothrombin has been split;

and thrombin-antithrombin complex, which indicates the presence of active thrombin. All of these

are markers of ongoing coagulation activation.

APTT Waveform Analysis

Activated partial thromboplastin time analysis measures the time it takes for a fibrin clot to form.

Many of the most advanced automated coagulometers, particularly those that have been enabled

with a photo-optical mode of detection, evaluate the entire process of the rate of fibrin formation not

only in seconds, but over an extended period of time as well. With this method, the change in the

optical output of the incident light of photo-optical coagulation parameters during the formation of a

fibrin clot is recorded as a clot curve. The clot curve can be displayed on the coagulometer monitor

and provides information regarding the velocity and amount of fibrin formation, which is reflected in

the height and shape of the curve. A novel method developed by Nair and colleagues, the APTT

Clot Curve Analysis (CCA) for use with the ACL 10 0000, assesses thrombin generation and fibrin

clot formation based on an analysis of photo-optical data and light scatter.

Thromboelastography

Thromboelastography was first developed in 1948 by Dr. Hellmut Harter. Advances in technology

over the years have improved its reliability and increased its usage and TEG is now gaining

increasing attention for its potential to assess hemostatic parameters in a number of clinical

settings. Thromboelastography allows for the assessment of the cumulative effects of plasma

factors and platelets, leucocytes, and red cells on coagulation. Additionally, clot formation from

initialization to formation and stability are measured by TEG. Currently, two instruments are

available: the TEG® Hemostasis Analyzer and the ROTEM®. Minor mechanical differences between

the two devices exist and results are not comparable between instruments. Initially, TEG was used

to minimize transfusion requirements in patients undergoing complicated surgical procedures, but

its use has now expanded to include bleeding and thrombotic disorders in a number of settings,

including obstetrics.

Primary Author: A. Chen

Co-authors: J. Teruya

Article: Global hemostasis testing thromboelastography: old technology, new applications

Reference: Clin Lab Med. 2009;391-407. Click here to read the abstract of this article.

Synopsis

Thromboelastography has been in use for more than 60 years for the assessment of primary and

secondary hemostasis. In recent decades, its utility in settings requiring rapid assessment of

global hemostatic function during complex surgical procedures, such as liver transplants and

cardiac bypass, has been well established. In addition, technical improvements including

computerized equipment, real-time view from remote computers, and automatic calculation of all

TEG parameters, have greatly improved its reliability. Its primary use has been to manage

transfusion therapy during surgery; recently, however, its value in nonurgent patient care has

garnered increasing attention.

TEG permits rapid, point-of-care calculation of many hemostatic parameters ( Figure 2). These

include:

l Reaction time (R): the time in minutes until levels of fibrin clot formation can be detected.

This provides a general reflection of coagulation factor levels

l Angle (A): the size in degrees of the angle formed by the tangent line to TEG tracing

measure at the reaction time. The angle reveals fibrinogen activity

l Maximum amplitude (MA): the width in millimeters of the widest gap in TEG tracing. This

measurement indicates the greatest strength of the final hemostatic plug and evaluates the

combination of platelet count and fibrinogen activity

The ability of TEG to provide rapid, point-of-care assessment of coagulation parameters with or

without an FXII activator is a significant advantage. It is ideal for use in urgent settings where

patients require blood component therapy. TEG is also gaining increasing use in central clinical

laboratories for the assessment of hyperfibrinolysis, factor XIII (FXIII) deficiency, and

hypercoagulable states. TEG platelet mapping can also monitor platelet function during antiplatelet

therapy. TEG is also ideal for the assessment of hemostatic function in newborns because of the

small specimen volume that is required. Despite the fact that the PT and PTT are prolonged in

newborns, the reported normal range of reaction time in newborns is much shorter than in adults

and older children ( Figure 3).

TEG may be useful for the early diagnosis and management of neonatal sepsis and to monitor the

anticoagulant effect in neonates treated with extracorporeal membrane oxygenation (ECMO), in

which bleeding complications are common due to the prematurity of the coagulation system

together with the use of unfractionated heparin.

Other novel settings where the use of TEG can be valuable include:

l Factor VIII deficiency: TEG is faster and has a higher sensitivity than the standard 5 M urea

solubility test or 1% monochloroacetic acid ( Figure 4). TEG may also be used to monitor

the effect of FXIII replacement therapy

l Hyperfibrinolysis: TEG may be a good substitute test where other tests are not available

l Glanzmann's thrombasthenia: TEG may be used when platelet dysfunction is suspected

and to monitor the effects of recombinant activated factor VII (FVII) or platelet transfusion

l Hypofibrinogenemia and dysfibrinogenemia: TEG may be able to distinguish

hypofibrinogenemia from dysfibrinogenemia

l Hypercoagulable states: Some data indicate TEG may reveal information relevant to

thrombotic risk; more study is needed

l Disseminated intravascular coagulation: TEG may be used to monitor the effect of fibrin

fragments on general hemostasis and on the inhibition of thrombin and platelets for

appropriate management

l von Willebrand disease: TEG may be useful for monitoring the effect of replacement therapy

in cases involving severe FVIII deficiency

l Monitoring recombinant activated FVII: Because TEG tracing demonstrates speed of clot

formation and clot strength, it is considered a good test for predicting the efficacy and risk of

thrombotic complications with rFVIIa therapy

l Monitoring antiplatelet therapy: The advent of TEG platelet mapping enables TEG to be used

for monitoring antiplatelet therapy in patients using aspirin, dipyridamole, or clopidogrel

Primary Author: C. Huissoud

Co-authors: N. Carrabin, F. Audibert, A. Levrat, D. Massignon, M. Berland, and R.C. Rudigoz

Article: Bedside assessment of fibrinogen level in postpartum haemorrhage by thromboelastometry

Reference: BJOG. 2009;116:1097-1102. Click here to read the abstract of this article.

Synopsis

It has been established that early diagnosis and management of PPH is associated with improved

maternal outcomes. In most cases, PPH develops as a result of uterine atony, with the subsequent

presentation of coagulation disorders. PPH can also occur secondary to surgical bleeding, placenta

previa, placenta accreta, abruptio placentae, uterine rupture, amniotic fluid embolism, or vaginal

tearing. When bleeding occurs, a decrease in fibrinogen levels is the first indication of impairment

among the coagulation biomarkers.

“When bleeding occurs, a decrease in fibrinogen levels is the

first indication of impairment among the coagulation

biomarkers.”

A rotation thromboelastometry system, ROTEM®, can be used in the laboratory or at patient

bedside for the diagnosis of coagulation disorders in hemorrhaging patients. Huissoud and

colleagues recently demonstrated that the ROTEM system can be used to detect hypercoagulation

related to pregnancy. Moreover, the investigators demonstrated that ROTEM provides a fast,

reliable assessment of coagulation during normal pregnancy parameters. In this paper, they

analyzed the use of ROTEM to detect early decrease in fibrinogen levels in obstetric patients with

PPH.

Select Study Facts

l Investigators sought to evaluate the ability of the ROTEM to quickly detect decrease in

fibrinogen levels in patients experiencing PPH

l Prospective, observational study involving 91 women and 105 tests

¡ 37 with PPH (study group, 51 tests)

¡ 54 without abnormal bleeding (control group, 54 tests)

¡ Test was repeated in cases of persistent bleeding

l Table 3 depicts standard laboratory test results compared with the results of tests taken at

bedside from the ROTEM with the FIBTEM test (54 tests in the control group and 51 in the

PPH group)

l Main outcome measures included analysis of correlation between fibrinogen levels and

FIBTEM test results (clotting time, clot amplitude, and maximal amplitude)


l As shown in Table 3, median fibrinogen level was significantly lower in the PPH group than in

the control group (3.4 and 5.1 g/L, respectively, P<.0001)

l Median clotting time (CT) was higher in the PPH group than in the control group (P=.05)

l Clot amplitude at 5 and 15 minutes was significantly lower in the PPH group than in the

control group and strongly correlated with fibrinogen levels in both groups (r=.84-.87,

P<.0001)

l Lower clot amplitudes in cases of PPH, in association with lower fibrinogen values,

translated into substantial differences observed in real time on FIBTEM TEMograms ( Figure

5)

l These findings suggest that the use of ROTEM in PPH could allow early and objective

screening of coagulation disorders as well as rapid identification of patients at high risk for

negative outcomes

l Further evaluation of real-time coagulability monitoring in PPH is recommended

Decreases in fibrinogen represent the earliest coagulation changes associated with PPH. Huissoud

and colleagues have demonstrated in this elegant study that the thromboelastometry system

ROTEM, with FIBTEM, detects hypofibrinogenemia and provides a real-time assessment of the

evolving coagulation changes associated with PPH. The ROTEM therefore enables the physician to

monitor response, literally at the patient's bedside, to specific therapies such as fibrinogen

replacement. This type of coagulation assessment, coupled with targeted therapies aimed at

reversing the hemostatic derangements, represents a rational approach to the contemporary

management of PPH. Confirmatory studies are required to determine if this strategy should be

adopted as the norm in managing patients with PPH, particularly those with uterine atony.

To learn about acquired factor

VIII inhibitors as a precipitating

cause of postpartum

hemorrhage, click here.

To listen to a podcast featuring

blood management expert

Aryeh Shander, MD, discuss

the correlation between

fibrinogen levels and surgical

hemostasis, click here.

References

Acharya SS, DiMichele DM. Rare inherited disorders of fibrinogen. Haemophilia. 2008;14:1151-

1158.

Berntorp E. Inherited bleeding disorders in women. Eur J Haematol. 2010;84:369.

Castaman G, Tosetto A, Rodeghiero F. Pregnancy and delivery in women with von Willebrand's

disease and different von Willebrand factor mutations. Haematologica. 2010;95:963-969.

Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the

severity of postpartum hemorrhage. J Thromb Haemost. 2007;5:266-273.

Chen A, Teruya J. Global hemostasis testing thromboelastography: old technology, new

applications. Clin Lab Med. 2009;29:391-407.

Danés AF, Cuenca LG, Bueno SR, et al. Efficacy and tolerability of human fibrinogen concentrate

administration to patients with acquired fibrinogen deficiency and active or in high-risk severe

bleeding. Vox Sang. 2008;94:221-226.

DiMichele D, Mannucci P. Treatment of congenital bleeding disorders: future trends in

management. Thromb Res. 2009;124(suppl 2):S1.

Dunkley SM, Russell SJ, Rowell JA, et al, for the Australian Haemophilia Centre Directors'

Organisation. A consensus statement on the management of pregnancy and delivery in women

who are carriers of or have bleeding disorders. Med J Aust. 2009;191:460-463.

Funai EF, Klein SA, Luckwood CJ. Successful pregnancy outcome in a patient with both

congenital hypofibrinogenemia and protein S deficiency. Obstet Gynecol. 1997;89(5 pt 2):858.

Haas T, Fries D, Velik-Salchner C, Oswald E, Innerhofer P. Fibrinogen in craniosynostosis surgery.

Anesth Analg. 2008;106:725-731.

Huissoud C, Carrabin N, Audibert F, et al. Bedside assessment of fibrinogen level in postpartum

haemorrhage by thrombelastometry. BJOG. 2009;116:1097-1102.

Huissoud C, Carrabin N, Benchaib M, et al. Coagulation assessment by rotation

thromboelastometry in normal pregnancy. Thromb Haemost. 2009;101:755-761.

Kadir R, Chi C, Bolton-Maggs P. Pregnancy and rare bleeding disorders. Haemophilia.

2009;15:990-1005.

Lee CA, Kadir R, Kouides PA. Inherited Bleeding Disorders in Women. London: Blackwell

Publishing Ltd; 2009.

Levy JH, Dutton RP, Hemphill JC 3rd, et al. Multidisciplinary approach to the challenge of

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Martin-Salces M, Jimenez-Yuste V, Alvarez MT, Quintana M, Hernandez-Navarro F. Factor XI

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Nair SC, Dargaud Y, Chitlur M, Srivastava A. Tests of global haemostasis and their applications in

bleeding disorders. Haemophilia. 2010;16(suppl 5):85-92.

Padmanabhan A, Schwartz J, Spitalnik SL. Transfusion therapy in postpartum hemorrhage. Semin

Perinatol. 2009;33:124-127.

Paidas MJ, Ku DH, Langhoff-Roos J, Arkel YS. Inherited thrombophilias and adverse pregnancy

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Rahe-Meyer N, Pichlmaier M, Haverich A, et al. Bleeding management with fibrinogen concentrate

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Sharma SK, Vera RL, Stegall WC, Whitten CW. Management of a postpartum coagulopathy using

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Transfus Med. 2008;18:151-157.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Haemophilia+%3A+the+official+journal+of+the+World+Federation+of+Hemophilia%22%5BJour%5D+AND+15%5Bvolume%5D+AND+990%5Bpage%5D+AND+2009%5Bpdat%5D+AND+kadir%5Bauthor%5D&cmd=detailssearch

http://www.bloodcmecenter.org/dev/activities/eMono_Paidas/print.html#

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.


TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22British+journal+of+anaesthesia%22%5BJour%5D+AND+102%5Bvolume%5D+AND+785%5Bpage%5D+AND+2009%5Bpdat%5D+AND+rahe-meyer%5Bauthor%5D&cmd=detailssearch


TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

http://www.ncbi.nlm.nih.gov/pubmed/20590862

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Clinics+in+laboratory+medicine%22%5BJour%5D+AND+391%5Bpage%5D+AND+2009%5Bpdat%5D+AND+Chen%5Bauthor%5D&cmd=detailssearch


TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.



http://www.ncbi.nlm.nih.gov/pubmed?term=%22BJOG+%3A+an+international+journal+of+obstetrics+and+gynaecology%22%5BJour%5D+AND+116%5Bvolume%5D+AND+1097%5Bpage%5D+AND+2009%5Bpdat%5D+AND+huissoud%5Bauthor%5D&cmd=detailssearch

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.




TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

http://www.bloodcmecenter.org/LearningCenter.aspx

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

http://www.bloodcmecenter.org/LearningCenter.aspx

TABLE OF CONTENTS

Introduction


Management



Bleeding

Measuring Global

Hemostasis


Reading


















Synopsis











Key Facts


bleeding tendency





trauma

Key Recommendations




















Case Report

















Tanaka




Synopsis






Select Study Facts











concentrate






group








hemostatic therapy










concentrate.






Synopsis






































Thromboelastography
















Synopsis










include:














































Synopsis









biomarkers.”







PPH.

Select Study Facts









PPH group)









P<.0001)



5)



negative outcomes













cause of postpartum








References


1158.



















Anesth Analg. 2008;106:725-731.






2009;15:990-1005.







213.




Perinatol. 2009;33:124-127.

















Transfus Med. 2008;18:151-157.

Documents

Assessing and Managing Bleeding Disorders During …Assessing and Managing Bleeding Disorders During Pregnancy: Faculty Selections October 20, 2010 Michael J. Paidas, MD Introduction