BACKGROUND
Postpartum hemorrhage is a leading cause of morbidity and mortality worldwide, yet
the associated early coagulopathy is not well defined.
OBJECTIVE
We hypothesized that women who develop postpartum hemorrhage have a distinct derangement
of thrombin generation and coagulation factors compared with postpartum women without
postpartum hemorrhage.
STUDY DESIGN
This prospective study of pregnant patients with postpartum hemorrhage was completed
at a single urban hospital. Blood was drawn on postpartum hemorrhage diagnosis and
2 and 4 hours later. Assays of patients with postpartum hemorrhage included thrombelastography,
whole blood thrombin generation, coagulation factor activity, tissue factor levels
and activity, and tissue factor pathway inhibitor levels, which were compared with
that of patients without postpartum hemorrhage.
RESULTS
A total of 81 patients were included in this study. Of those patients, 66 had postpartum
hemorrhage, and 15 served as controls. Compared with patients without PPH, patients
with postpartum hemorrhage had lower fibrinogen levels (469.0 mg/dL vs 411.0 mg/dL;
P=.02), increased tissue plasminogen activator resistance (fibrinolysis 30 minutes
after maximal clot strength: 8.7% vs 4.2%; P=.02), decreased peak thrombin concentration (150.2 nM vs 40.7 nM; P=.01), and decreased maximal rate of thrombin generation (60.1 nM/minute vs 2.8 nM/minute;
P=.02). Furthermore, compared with patients without postpartum hemorrhage, patients
with postpartum hemorrhage had decreased tissue factor levels (444.3 pg/mL vs 267.1
pg/mL; P=.02) and increased tissue factor pathway inhibitor levels (0.6 U/mL vs 0.8 U/mL;
P=.04), with decreased tissue factor pathway inhibitor ratios (624 vs 299; P=.01).
CONCLUSION
PPH is not only an issue of uterine tone and mechanical bleeding but also a distinct
coagulopathy that is characterized by decreased fibrinogen level, clot breakdown resistance,
and markedly low thrombin generation. This pathology seemed to be driven by low tissue
factor and high tissue factor pathway inhibitor levels.
Keywords
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Article info
Publication history
Published online: November 30, 2022
Accepted:
November 28,
2022
Received in revised form:
November 16,
2022
Received:
September 13,
2022
Footnotes
Research reported in this publication was supported by grants T32 GM008315 and P50 GM049222 from the National Institute of General Medical Sciences, National Institutes of Health (NIH), and a grant from the Foundation for Patients and Girls with Bleeding Disorders. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or other sponsors of the project. This research was also supported with materials from Haemonetics Corporation (Braintree, MA) and Diagnostica Stago (Asnières-sur-Seine, France). The funding sources were not involved in the study design; collection, analysis, and interpretation of data; writing of the report; or decision to submit the article for publication.
The authors report no conflict of interest.
Study data were presented as a poster at the American College of Surgeons Clinical Congress meeting held virtually on October 3, 2020.
Cite this article as: Coleman JR, Fabbri S, Anderson M, et al. Beyond uterine atony: characterizing postpartum hemorrhage coagulopathy. Am J Obstet Gynecol MFM 2022;XX:x.ex–x.ex.
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© 2022 Published by Elsevier Inc.
