Authors: Zheng A et al.
Journal of Clinical Anesthesia, 2025
Summary
This retrospective study examined whether implementing a thromboelastometry-guided coagulopathy management protocol altered fibrinogen supplementation and blood product transfusion practices in women with postpartum hemorrhage (PPH). Given that coagulopathy is a major driver of maternal morbidity in PPH, the authors focused on whether point-of-care viscoelastic testing could support more targeted, physiologically informed transfusion decisions.
The analysis included 3,899 adult women with postpartum hemorrhage (≥500 mL blood loss within 24 hours of delivery) at a tertiary-care obstetric center in Lyon, France. Outcomes were compared across three sequential time periods:
• Period 1 (2016–2018): no viscoelastic testing available
• Period 2 (2019–2020): thromboelastometry available but no formal protocol
• Period 3 (2021–2023): thromboelastometry-guided coagulopathy management protocol implemented
The primary outcome was the proportion of patients receiving fibrinogen concentrate. Secondary outcomes included transfusion of red blood cells, fresh frozen plasma, and platelets within the first 24 hours after delivery. Multivariable regression models adjusted for 12 preselected confounders were used to estimate adjusted odds ratios.
Implementation of thromboelastometry—particularly when paired with a structured, protocolized approach—was associated with substantial reductions in fibrinogen use and blood product transfusion. Compared with Period 1, the odds of fibrinogen concentrate administration fell markedly in Period 3 (aOR 0.19) and more modestly in Period 2 (aOR 0.70). Similarly, Period 3 was associated with significantly lower odds of red blood cell, plasma, and platelet transfusion. Importantly, these reductions were not accompanied by an increase in severe hemorrhage, as rates of massive PPH (≥2500 mL blood loss) were unchanged across all three periods.
These findings suggest that thromboelastometry-guided, goal-directed coagulation management enables clinicians to better discriminate which patients truly require fibrinogen supplementation and transfusion, reducing unnecessary exposure to blood products without compromising hemorrhage control.
Key Points
• Coagulopathy-focused management is central to maternal outcomes in postpartum hemorrhage
• Thromboelastometry supports more precise, goal-directed transfusion decisions
• Protocolized viscoelastic-guided care was associated with large reductions in fibrinogen and blood product use
• Reductions in transfusion did not increase the risk of massive postpartum hemorrhage
• These findings support broader adoption of thromboelastometry-driven PPH protocols, pending cost-effectiveness and outcome studies
Thank you to the Journal of Clinical Anesthesia for allowing us to summarize and discuss this important contribution to evidence-based management of postpartum hemorrhage.