Gruneberg Daniel, Braun Paula, Schöchl Herbert, Nachtigall-Schmitt Tereza, von der Forst Maik, Tourelle Kevin, Dietrich Maximilian, Wallwiener Markus, Wallwiener Stephanie, Weigand Markus A, Fluhr Herbert, Spratte Julia, Hofer Stefan, Schmitt Felix Carl Fabian
Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany.
Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with Allgemeine Unfallversicherungsanstalt, Vienna, Austria.
Front Med (Lausanne). 2023 Sep 8;10:1208103. doi: 10.3389/fmed.2023.1208103. eCollection 2023.
Postpartum hemorrhage (PPH) is still the leading cause of maternal morbidity and mortality worldwide. While impaired fibrin polymerization plays a crucial role in the development and progress of PPH, recent approaches using viscoelastic measurements have failed to sensitively detect early changes in fibrinolysis in PPH. This study aimed to evaluate whether women experiencing PPH show alterations in POC-VET fibrinolytic potential during childbirth and whether fibrinolytic potential offers benefits in the prediction and treatment of PPH.
Blood samples were collected at three different timepoints: T0 = hospital admission (19 h ± 18 h prepartum), T1 = 30-60 min after placental separation, and T2 = first day postpartum (19 h ± 6 h postpartum). In addition to standard laboratory tests, whole-blood impedance aggregometry (Multiplate) and viscoelastic testing (VET) were performed using the ClotPro system, which included the TPA-test lysis time, to assess the POC-VET fibrinolytic potential, and selected coagulation factors were measured. The results were correlated with blood loss and clinical outcome markers. Severe PPH was defined as a hemoglobin drop > 4g/dl and/or the occurrence of shock or the need for red blood cell transfusion.
Blood samples of 217 parturient women were analyzed between June 2020 and December 2020 at Heidelberg University Women's Hospital, and 206 measurements were eligible for the final analysis. Women experiencing severe PPH showed increased fibrinolytic potential already at the time of hospital admission. When compared to non-PPH, the difference persisted 30-60 min after placental separation. A higher fibrinolytic potential was accompanied by a greater drop in fibrinogen and higher d-dimer values after placental separation. While 70% of women experiencing severe PPH showed fibrinolytic potential, 54% of those without PPH showed increased fibrinolytic potential as well.
We were able to show that antepartal and peripartal fibrinolytic potential was elevated in women experiencing severe PPH. However, several women showed high fibrinolytic potential but lacked clinical signs of PPH. The findings indicate that high fibrinolytic potential is a risk factor for the development of coagulopathy, but further conditions are required to cause PPH.
产后出血（PPH）仍是全球孕产妇发病和死亡的主要原因。虽然纤维蛋白聚合受损在PPH的发生和发展中起关键作用，但最近使用粘弹性测量的方法未能灵敏地检测到PPH中纤溶的早期变化。本研究旨在评估经历PPH的女性在分娩期间即时检测粘弹性血栓弹力图（POC-VET）纤溶潜力是否有改变，以及纤溶潜力在PPH的预测和治疗中是否有益。
在三个不同时间点采集血样：T0 = 入院时（产前19小时±18小时），T1 = 胎盘剥离后30 - 60分钟，T2 = 产后第一天（产后19小时±6小时）。除了标准实验室检查外，使用ClotPro系统进行全血阻抗凝集试验（Multiplate）和粘弹性检测（VET），包括组织型纤溶酶原激活剂（TPA）试验溶解时间，以评估POC-VET纤溶潜力，并检测选定的凝血因子。结果与失血量和临床结局指标相关。严重PPH定义为血红蛋白下降>4g/dl和/或发生休克或需要输注红细胞。
2020年6月至2020年12月期间，在海德堡大学妇女医院对217名产妇的血样进行了分析，206次测量符合最终分析要求。经历严重PPH的女性在入院时纤溶潜力就已增加。与无PPH的女性相比,胎盘剥离后30 - 60分钟差异仍然存在。纤溶潜力较高伴随着胎盘剥离后纤维蛋白原下降幅度更大和D-二聚体值更高。虽然70%经历严重PPH的女性显示有纤溶潜力，但54%无PPH的女性也显示纤溶潜力增加。
我们能够证明，经历严重PPH的女性产前和产时纤溶潜力升高。然而，一些女性纤溶潜力高，但缺乏PPH的临床体征。研究结果表明，高纤溶潜力是凝血病发生的一个危险因素，但还需要其他条件才会导致PPH。
