Thread by @OBsleepmerchant

Up next: @ValZaph moderates the #OBAnes session on PPH: a focus on coagulation. Dr Karine Doyon and @LorrainechowMD presenting. #CASAM2023

PPH: a focus on coagulation is kicked off by Dr Karine Doyon (a hematologist). Objectives. Canada ranked 39th in world in maternal mortality - not sure if that’s good. We’re doing better than USA. #OBAnes #CASAM2023

Causes of coagulopathy in pregnancy - Dr Doyon won’t be discussing inherited disorders. The focus will be on the acquired hemorrhagic disorders. #OBAnes #CASAM2023

The coagulation pathway (she IS a hematologist 😉) Coagulation cascade describes in vitro/ laboratory coagulation. More modern is the cell based model: initiation, amplification and propagation. Natural inhibitors of coagulation exist. Hemodynamic changes in pregnancy =… twitter.com/i/web/status/1…

Let’s discuss coagulation testing in PPH. When? What? If you have POC testing in Canada you’re lucky. Guidelines. Caveat with laboratory testing - turn around time means lots of bleeding BEFORE you get a result. Changes occur LATE. #OBAnes #CASAM2023

What of POC testing? Knowing what’s normal is key. Note the FIBTEM in normal pregnancy (it’s not pink) - if FIBTEM looks normal in pregnancy, there’s probably trouble! Caveats to POC testing: misses vWD, insensitive to antiplatelet agents #OBAnes #CASAM2023

Pathophysiology of coagulopathy during pregnancy. OB DIC: bleeding > thrombosis. DIC score NOT valid in pregnancy - there is a pregnancy specific score (have to look that up). DIC in pregnancy - severe bleeding. Quite a high mortality worldwide - knock on effects abound. AFE and… twitter.com/i/web/status/1…

Pathophysiology of coagulopathy in massive bleeding. Dilutional. Take home message from Dr Doyon, including what the role of a hematologist may be: improve turn around, assist interpretation, inform about latest products. #OBAnes #CASAM2023

@LorrainechowMD feeling the pressure of a tall podium and short time. Admits to trying to get AI to create the talk - muppet anesthesiologists cool, it’s approach to managing PPH… we’ll have to wait and see. #OBAnes #CASAM2023

Causes of coagulopathy in PPH: 3 broad categories: late dilutional; early hypofibrinogenemia; and generalized systemic coagulation failure. Management of PPH- key steps: find & treat cause; assess coagulopathy; resuscitate massive hemorrhage. #OBAnes #CASAM2023

Starting with TXA @LorrainechowMD reviews the literature… #OBAnes #CASAM2023

… and a few more to generate take home points on TXA. Important to acknowledge the risk of inadvertent administration of TXA neuraxially - high mortality (new case report in latest @CJA_Journal - @DavidGray37 raised the alarm, presenting at #OAA3dc2022 and #OBSIG23SYD #ASM23SYD)… twitter.com/i/web/status/1…

Moving on to fibrinogen literature… #OBAnes #CASAM2023

… and more literature to take home points on fibrinogen. Note special populations! High doses required. #OBAnes #CASAM2023

On transfusion: #OBAnes bleeding is not trauma. Lab based transfusion decisions superior to standard 4:4:1 (1:1:1) trauma transfusion. #CASAM2023

What of POC testing? Not much literature. Take home points. Quicker turnaround but probably unwarranted <1500ml. FIBTEM correlates well with Clauss fibrinogen. #OBAnes #CASAM2023

So what was the AI generated algorithm?… hmmm… simplistic? That just won’t do (@LorrainechowMD asked the question several different ways before surrendering to preparing this lecture herself) #OBAnes #CASAM2023

The @LorrainechowMD PPH with coagulopathy algorithm (my name not hers, she appropriately attributes the shoulders upon which she stands).
Quite a straight forward approach. One of first questions - are there risk factors for DIC? If yes fibrinogen early (2-4g is fine) #OBAnes… twitter.com/i/web/status/1…

2nd half of algorithm is how to transfuse - traditional lab testing vs POC testing. And don’t forget post PPH care. #OBAnes #CASAM2023

An abbreviated but no less enjoyable discussion before the organizers switched off the lights for the evening: @ValZaph moderating for Dr Karine Doyon & @LorrainechowMD #OBAnes #CASAM2023