Patient Blood Management for Massive Obstetric Hemorrhage

Summary

Obstetric Hemorrhage continues to be the first cause of maternal morbidity and mortality around the world especially in middle to low income countriesThe blood components are high value resources; however, its use has been shown to be a risk factor of known complications. The aim of the study is to compare two algorithms of coagulation management in massive obstetric hemorrhage Methods A randomized prospective trial single center two arms study in patients with severe obstetric hemorrhage (PPH \> 1000) 2 different transfusion protocols one guided by thromboelastometry and hemostatic drugs (protrombine complex concentrate and fibrinogen concentrate) and the second guided by standard coagulation test and hemocomponents. Sample is calculated to known variance, Analyses are intention-to-treat without imputation, with outcomes will be performed between groups using mixed-effects two level regression models. For binary outcomes, a logistic model will be used and results presented as adjusted odds ratios (ORs) alongside 95% confidence intervals (CIs). Count data will be analysed using Poisson multilevel or negative binomial models.

Primary Outcome Parameter:

Compare between the two protocols:

Number of allogeneic blood products transfused intra-op, within 24h after screening and in-hospital (RBC, Platelets and FFP; separate and overall)

Secondary Outcome Parameter:

Analysis of mortality, lenth of stay admission to the ICU, hysterectomy surgical reintervencion, Transfuse associated circulatory overload, Transfusion associated Acute lung injury, health associated infection will be measured as secondary outcome.

Conditions

• Post Partum Hemorrhage
• Fibrinogenolysis; Hemorrhage
• Fibrinogen; Deficiency, Acquired
• Massive Hemorrhage
• Transfusion Related Complication

Interventions

DIAGNOSTIC_TEST

Thromboelastometry

devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated

DIAGNOSTIC_TEST

Standard Coagulation Test

coagulation tests, such as the prothrombin time (PT), activated partial thromboplastin time (aPTT), and thrombin time (TT), to assess blood clotting function in patients. Clauss Fibrinogen.

DRUG

Fibrinogen Concentrate Human

To treat acquired fribinogen deficiency investigators will treat with the following doses FIBTEM A5 = 9-11 MM a 2 G FIBRINOGEN CONC. (25 MG/KG); FIBTEM A5 = 4-8 MM a 4 G FIBRINOGEN CONC. (50 MG/KG); FIBTEM A5 \< 4 MM a 6 G FIBRINOGEN CONC. (75 MG/KG)

DRUG

Prothrombin Complex Concentrates

to treat acquired factor deficiency investigators will treat as follows PROTROMBIN COMPLEX CONCENTRATE EXTEM CT \> 80 SEC AND FIBTEM A5 ≥ 8 MM 4F-PCC 20 IU/KG (F II, VII, IX and X) GOAL: EXTEM CT ≤ 80 SEC

OTHER

Platelets

PLATELETS EXTEM A5 \< 40 MM AND FIBTEM A5 ≥ 12 MM EXTEM A5 \< 40 MM → 1 PLATELET POOL OR APHERESIS; EXTEM A5 \< 30 MM → 2 PLATELET POOL OR APHERESIS GOAL: EXTEM A5: 40-50 MM or PLATELET COUNT \< 100/µL PLT \< 100/µL → 1 PLATELET POOL OR APHERESIS; PLT \> 50/µL → 2 PLATELET POOL OR APHERESIS GOAL: PLT COUNT \> 100/µL

OTHER

Red Blood Cells

Transfuce Red Blood Cells if Hemoglobine levels \< 7 G/DL; 1 unit of FFP for every unit of RBC Transfused GOAL: Hb \> 7.5 G/DL

OTHER

Fresh Frozen Plasma

FRESH FROZEN PLASMA TP AND/OR TTP PATHOLOGICAL INR, 2.0-4.0 → FFP 20 ML/KG GOAL: TP AND TTP NORMAL AND INR \< 2.0

OTHER

cryoprecipitates

FIBRINOGEN (CLAUSS) \< 250 MG/DL FIB 200-250 MG/DL → CRYOS, PACK OF 10 (25 MG/KG); FIB 100-200 MG/DL → CRYOS, PACK OF 20 (50 MG/KG); FIB \< 100 MG/DL → CRYOS, PACK OF 30 (75 MG/KG) GOAL: FIB \> 250 MG/DL

Sponsors & Collaborators

• Grupo Mexicano para el Estudio de la Medicina Intensiva

  collaborator OTHER

• Angel Augusto Perez Calatayud

  lead OTHER

Principal Investigators

• Angel Augusto Perez Calatayud, M.D. · Head Obstetric ICU

Study Design

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Max Age

45 Years

Sex

FEMALE

Healthy Volunteers

No

Timeline & Regulatory

Start

2018-11-01

Primary Completion

2020-11-30

Completion

2020-12-30

Countries

• Mexico

Study Locations