What is the recommended dose and administration of Fresh Frozen Plasma (FFP) in cases of postpartum hemorrhage with suspected or confirmed coagulopathy?

FFP Administration in Postpartum Hemorrhage with Coagulopathy

In cases of postpartum hemorrhage with suspected or confirmed coagulopathy, Fresh Frozen Plasma (FFP) should be administered at a dose of 10-15 ml/kg when there is evidence of coagulopathy, ideally guided by coagulation tests or after 4 units of RBC transfusion if test results are unavailable. 1

Assessment and Initial Management

• Postpartum hemorrhage (PPH) is defined as:

  • 500 ml blood loss after vaginal delivery

  • 1000 ml blood loss after cesarean delivery

• Initial coagulation assessment:

  • Draw blood for full blood count, coagulation studies, and fibrinogen levels
  • Use point-of-care (POC) testing when available for rapid results
  • Monitor fibrinogen levels closely (normal pregnancy levels: 4-6 g/L)

FFP Administration Protocol

When to Administer FFP:

1. With confirmed coagulopathy:

   • PT >1.5 times normal or INR >2.0
   • aPTT >2 times normal 1
   • Fibrinogen <2 g/L with ongoing bleeding 1

2. Without coagulation test results:

   • Withhold FFP until 4 units of RBC have been given
   • After 4 units of RBC, if bleeding continues and no test results are available, administer 4 units of FFP
   • Maintain 1:1 ratio of RBC:FFP until coagulation results are available 1

Dosing:

• Standard dose: 10-15 ml/kg to achieve minimum 30% of plasma factor concentration 1
• This typically requires 4 units of FFP for an average-sized adult

Special Considerations:

• Severe early consumptive coagulopathy (associated with placental abruption, amniotic fluid embolism, severe pre-eclampsia) may require FFP administration before RBC transfusion 1
• ABO compatibility is important - use group AB FFP if blood group is unknown 2

Monitoring and Additional Management

• Continue monitoring coagulation parameters throughout resuscitation
• Hypofibrinogenemia (fibrinogen <3 g/L, especially <2 g/L) predicts progression to major obstetric hemorrhage 1
• Consider fibrinogen replacement with cryoprecipitate (5-10 ml/kg) or fibrinogen concentrate when fibrinogen is low 1
• Tranexamic acid (1g) should be administered early in severe PPH 1

Evidence-Based Rationale

Recent evidence suggests that a higher FFP:RBC ratio (approaching 1:1) may be beneficial in severe PPH, potentially reducing the need for advanced interventional procedures 3. This mirrors trauma resuscitation protocols where balanced transfusion strategies have improved outcomes.

Common Pitfalls to Avoid

1. Delayed recognition of coagulopathy: Early POC testing is preferred over laboratory testing which may be too slow during obstetric hemorrhage 1

2. Overuse of FFP: Protocolled use without testing can lead to unnecessary FFP transfusion in many cases 1

3. Underestimating fibrinogen importance: Normal pregnancy fibrinogen levels are higher (4-6 g/L) than non-pregnant values, so a "normal" non-pregnant level may actually represent significant depletion 1

4. Using FFP inappropriately: FFP is not indicated solely for volume replacement or albumin concentration augmentation 1

By following this evidence-based approach to FFP administration in postpartum hemorrhage with coagulopathy, you can optimize maternal outcomes while avoiding unnecessary blood product use.