Arellano RA, Galván MMA, Guerrero NL, Ruiz BMD

Language: Spanish
References: 14
Page: 152-157
PDF size: 1293.73 Kb.

ABSTRACT

Hypertensive disorders of pregnancy remain a leading cause of maternal morbidity and mortality worldwide. Among them, HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) represents a severe variant of preeclampsia with the potential for fulminant progression. Evolution toward eclampsia and neurological complications, such as intracerebral hemorrhage, may result in catastrophic outcomes, including brain death. In this context, coagulation abnormalities are of particular importance, as HELLP syndrome is associated with platelet consumption, endothelial dysfunction, early-stage disseminated intravascular coagulation (DIC), and critical hypofibrinogenemia. Conventional coagulation tests provide a static, limited, and often delayed assessment of the real hemostatic status. In contrast, viscoelastic testing, such as rotational thromboelastometry (ROTEM®), offers a dynamic and comprehensive evaluation of clot formation, mechanical stability, and fibrinolysis, allowing distinction between cellular and plasma component defects. We present the case of a previously healthy 27-year-old primigravida who developed postpartum eclampsia complicated by class I HELLP syndrome and massive cerebral hemorrhage, with confirmed diagnosis of brain death. Given the presence of severe coagulopathy, serial ROTEM assessments were performed, demonstrating global hypocoagulability and critical hypofibrinogenemia. Targeted therapy with fibrinogen concentrate and platelets was administered, resulting in progressive ROTEM profile correction without active hemorrhagic events. This case highlights the relevance of viscoelastic monitoring in critical care obstetrics to guide individualized and timely transfusion decisions in scenarios of extreme clinical severity.

REFERENCES

1. Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M,Mark NM, et al. Viscoelastic hemostatic assays for postpartumhemorrhage. J Clin Med. 2021;10(17):3946.

2. Jokinen S, Kuitunen A , Uotila J, Yli-Hankala A .Thromboelastometry-guided treatment algorithm in postpartumhaemorrhage: a randomised, controlled pilot trial. Br J Anaesth.2023;130(2):165-174.

3. Carrillo-Esper R, de la Torre-León T, Nava-López JA, Posada-NavaA, Pérez-Calatayud ÁA, de la Torre-León MA, et al. Consensomultidisciplinario para el manejo de la hemorragia obstétrica en elperioperatorio. Rev Mex Anest. 2018;41(3):155-182.

4. Sunoqrot M, Keivan M, Ahmadzia HK. Definition, managementstrategies, and risk assessment of obstetric hemorrhage: anarrative review. Ann Blood. 2025;10:4.

5. National Blood Authority (NBA). Patient blood managementguideline for adults with critical bleeding [Internet]. 2nd ed.Canberra: National Blood Authority; 2023. 104 p. Available in:https://www.blood.gov.au/

6. Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematicreview of viscoelastic testing (TEG/ROTEM) in obstetrics andrecommendations from the women’s SSC of the ISTH. J ThrombHaemost. 2020;18(8):1813-1838.

7. Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, BaudD, et al. Patient blood management (PBM) in pregnancy andchildbirth: literature review and expert opinion. Arch GynecolObstet. 2020;301(2):627-641.

8. Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, BaudD, et al. Patient blood management (PBM) in pregnancy andchildbirth: literature review and expert opinion. Arch GynecolObstet. 2020;301(2):627-641.

9. Bell SF, Roberts TCD, Freyer Martins Pereira J, De Lloyd L, AmirZ, James D, et al. The sensitivity and specificity of rotationalthromboelastometry (ROTEM) to detect coagulopathy duringmoderate and severe postpartum haemorrhage: a prospectiveobservational study. Int J Obstet Anesth. 2022;49:103238.

10. Bell SF, de Lloyd L, Preston N, Collins PW. Managing thecoagulopathy of postpartum hemorrhage: an evolving rolefor viscoelastic hemostatic assays. J Thromb Haemost.2023;21(8):2064-2077.

11. Katz D, Farber M, Getrajdman C, Hamburger J, Reale S, ButwickA. The role of viscoelastic hemostatic assays for postpartumhemorrhage management and bedside intrapartum care. Am JObstet Gynecol. 2024;230(3S):S1089-S1106.

12. Khanna P, Sinha C, Singh AK, Kumar A, Sarkar S. Therole of point of care thromboelastography (TEG) andthromboelastometry (ROTEM) in management of Primarypostpartum haemorrhage: A meta-analysis and systematicreview. Saudi J Anaesth. 2023;17(1):23-32.

13. Calderon JA, Ebeid AM, Lee SM, Ahmadzia HK. Correlation ofpredelivery Rotational Thromboelastometry readings with the riskof postpartum hemorrhage during delivery: The ROTEM Study. JNeonatal Perinatal Med. 2025;18(1):18-24.

14. Gill N, Butwick A, Bell SF. Navigating coagulopathy in obstetrichemorrhage: The role of point-of-care testing. Best Pract ResClin Anaesthesiol. 2024;38(3):233-245.