Impact of fibrinogen and prothrombin complex concentrate on clotting time in a model of obstetric hemorrhage.

STUDY OBJECTIVE: Determine the impact of varying doses of fibrinogen concentrate and 4-factor prothrombin complex concentrate on clotting time as measured by thromboelastometry in an in-vitro model of dilutional coagulopathy. DESIGN: In-Vitro Study. SETTING: Tertiary academic center. PATIENTS: 31 healthy term singleton gestation patients. INTERVENTIONS: Blood was analyzed and diluted 95% with crystalloid. Washed red blood cells were added to simulate red blood cell transfusion. Two levels of fibrinogen repletion were then added to samples to simulate fibrinogen repletion in massive transfusion. Finally, 4-factor prothrombin complex concentrate (10 U/kg, 15 U /kg, or 25 U/kg) adjusted for body weight and estimated blood volume was added. MEASUREMENTS: Samples were analyzed by thromboelastometry, and the main outcome was a FIBTEM clotting time > 80s. MAIN RESULTS: FIBTEM clotting times were prolonged after dilution. After repletion with fibrinogen and prothrombin complex concentrates 7/31 (22.5%) of samples had a prolonged FIBTEM clotting time (> 80s) in the 50% fibrinogen repletion arm and 0 (0%) had a prolonged clotting time in the 100% fibrinogen repletion arm. FIBTEM clotting times approached their baseline levels at each dose of prothrombin complex concentrate. Median clotting time in the 100% fibrinogen repletion arm was under 80s prior to the administration of prothrombin complex concentrate. CONCLUSIONS: Commonly cited doses for prothrombin complex concentrates in hemorrhage might be too high for the obstetric patient. After fibrinogen correction alone, several samples required no further correction, highlighting the importance of frequent testing at the point of care. Limitations of this study include the in vitro study design and ability to directly apply findings to patient care. Further studies are needed to elucidate the ideal dose of prothrombin complex concentrate for obstetric hemorrhage. TWEETABLE ABSTRACT: Fibrinogen concentrate and low dose 4-factor PCC corrected coagulopathy in in-vitro obstetric hemorrhage.

Are Women with a History of Low PAPP-A at Risk for Adverse Perinatal Outcomes in a Subsequent Pregnancy?

OBJECTIVE: To determine if patients with a history of low pregnancy-associated plasma protein A (PAPP-A) in an initial pregnancy are at higher risk for adverse obstetric outcomes in a subsequent pregnancy. STUDY DESIGN: This was a retrospective cohort study in patients who underwent first trimester screening for PAPP-A in two consecutive pregnancies. Two groups were examined: patients who had low PAPP-A in the first pregnancy followed by normal PAPP-A in the second pregnancy and patients who had recurrent low PAPP-A. Maternal and neonatal outcomes were compared between the groups, with the primary outcome being intrauterine growth restriction (IUGR) or preeclampsia. RESULTS: A total of 124 patients were included, representing 248 pregnancies. Ninety-two (74.2%) patients had normal PAPP-A in the second pregnancy, and 32 (12.9%) patients had recurrent low PAPP-A. Patients with recurrent low PAPP-A had a higher rate of IUGR or preeclampsia compared with patients with normal PAPP-A in the second pregnancy but this was not significantly different (12.5 vs. 10.9%, p = 0.51). There were no significant differences for all other outcomes. CONCLUSION: Among patients with a history of low PAPP-A, patients with normal PAPP-A in the subsequent pregnancy have a similar risk of adverse neonatal outcomes compared with patients with recurrent low PAPP-A.

Maternal clinical disease characteristics and maternal and neonatal outcomes in twin and singleton pregnancies with severe preeclampsia.

OBJECTIVE: Based on anecdotal observations, there is concern that severe preeclampsia leads to greater morbidity and mortality for mothers and neonates of twin pregnancies than for mothers and neonates of singleton pregnancies. Because few studies have been done, this study compared maternal disease characteristics and maternal/neonatal clinical outcomes of twin and singleton pregnancies complicated by severe preeclampsia. STUDY DESIGN: An historical cohort study of patients hospitalized at the Mount Sinai Hospital in New York City, NY, USA, from 2006 to 2010, compared 63 twin and 339 singleton pregnancies complicated by severe preeclampsia via chart review. Women were analyzed in two groups: hospitalized ≤34 weeks gestational age (GA) and hospitalized >34 weeks GA. Univariable analysis (using Chi-square test, Fisher's Exact test, Student's t-test, or Wilcoxon Rank-Sum test, as appropriate) then multivariable analysis (using multivariable linear regression or multivariable logistic regression, as appropriate) compared maternal disease characteristics and maternal/neonatal clinical outcomes in twin and singleton pregnancies. RESULTS: Women with twins were older [mean age 34.9 years (standard deviation (SD) 7.9 years) vs. 29.4 years (SD 7.4 years), P-value<.001] and women with singletons had a higher prevalence of chronic hypertension (21% vs. 8%, P=.02) and higher prevalence of history of preeclampsia (13% vs. 2%, P=.006). Women with twins were admitted for severe preeclampsia at an earlier gestational age (GA) [median twin 34.9 weeks GA (interquartile range, IQR, 32.7, 36.1) vs. median singleton 37.1 weeks GA (IQR 35.0, 38.9), P<.001]. Among women presenting ≤34 weeks GA (27 twins; 108 singletons), women with singletons had a higher mean systolic blood pressure (BP) (181.1 vs. 163.5, P<.001), higher mean diastolic BP (108.4 vs. 100.1, P=.002), and higher prevalence of headache (56% vs. 30%, P=.02). Among women presenting >34 weeks GA (36 twins; 231 singletons), women with singletons had a higher prevalence of headache (54% vs. 28%, P=.004). CONCLUSION: Mothers and neonates of twin pregnancies complicated by severe preeclampsia do not appear to have greater morbidity and mortality compared to mothers and neonates of singleton pregnancies complicated by severe preeclampsia.