Does a patient with hypofibrinogenemia (fibrinogen level of 98) and normal coagulation studies, including partial thromboplastin time (PTT), prothrombin time (PT), platelet count, and hemoglobin, following suction dilation and curettage (D&C) for hemorrhage due to miscarriage, require fibrinogen infusion?

From the Guidelines

A patient with hypofibrinogenemia (fibrinogen level of 98 mg/dL) following suction dilation and curettage (D&C) for hemorrhage due to miscarriage should receive fibrinogen replacement, as the current level is below the threshold for adequate clot formation. According to the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, treatment with fibrinogen concentrate or cryoprecipitate is recommended if major bleeding is accompanied by hypofibrinogenemia (viscoelastic signs of a functional fibrinogen deficit or a plasma Clauss fibrinogen level ≤ 1.5 g/L).

Key Considerations

• The patient's fibrinogen level of 98 mg/dL is below the normal range and indicates a need for supplementation to support adequate clot formation.
• Normal PTT, PT, platelets, and hemoglobin do not negate the need for fibrinogen replacement, as low fibrinogen significantly impairs clot formation and stability, increasing bleeding risk.
• The recommended initial fibrinogen supplementation is 3–4 g, which can be achieved with fibrinogen concentrate or cryoprecipitate, with repeat doses guided by viscoelastic monitoring (VEM) and laboratory assessment of fibrinogen levels 1.

Treatment Approach

• For fibrinogen concentrate, an initial dose of 3–4 g can be administered intravenously.
• The goal of fibrinogen replacement is to increase the fibrinogen level above 150-200 mg/dL to support adequate clot formation.
• After administration, fibrinogen levels should be rechecked in 1-2 hours to assess response and determine if additional doses are needed.

Rationale

• Fibrinogen is often the first coagulation factor to reach critically low levels during hemorrhage, and replacement is essential for hemostasis even when other coagulation parameters appear normal.
• Prompt correction of hypofibrinogenemia is particularly important in obstetric hemorrhage, where fibrinolysis may be accelerated, highlighting the need for timely intervention to prevent further complications.

From the FDA Drug Label

For adults: ... Administer additional doses of 4 g in adults, ... as needed to bleeding patients when plasma fibrinogen level is ≤200 mg/dL The recommended target plasma fibrinogen level is 100 mg/dL for minor bleeding and 150 mg/dL for major bleeding

The patient has a fibrinogen level of 98 mg/dL, which is below the recommended target level for minor bleeding (100 mg/dL) and major bleeding (150 mg/dL). Fibrinogen infusion is required for this patient, as the plasma fibrinogen level is below the target level, especially considering the patient has experienced hemorrhage due to miscarriage, which can be classified as major bleeding 2.

From the Research

Fibrinogen Infusion in Hypofibrinogenemia

• The patient's fibrinogen level is 98, which is below the normal range of 200-400 mg/dL 3.
• The patient has normal coagulation studies, including partial thromboplastin time (PTT), prothrombin time (PT), platelet count, and hemoglobin, following suction dilation and curettage (D&C) for hemorrhage due to miscarriage.
• Fibrinogen supplementation is essential for clot formation, and in severe bleeding, fibrinogen reaches a critically low plasma concentration earlier than other coagulation factors 4.
• The critical minimum concentration of fibrinogen to maintain hemostasis is debated, but many patients with coagulopathic bleeding require fibrinogen supplementation 4.

Treatment Options for Fibrinogen Supplementation

• Fibrinogen concentrate may be preferable to fresh frozen plasma or cryoprecipitate for fibrinogen supplementation [(4,5)].
• Fibrinogen concentrate therapy has been shown to improve laboratory and clinical outcomes in patients with massive haemorrhage 6.
• However, a systematic review and meta-analysis found that fibrinogen concentrate treatment may result in a slight increase in in-hospital mortality and increased use of fresh-frozen plasma transfusion 7.

Decision for Fibrinogen Infusion

• The decision to administer fibrinogen infusion should be based on the patient's individual needs and clinical situation [(4,5)].
• The use of fibrinogen as part of coagulation factor concentrate-based therapy guided by point-of-care viscoelastic coagulation monitoring may be beneficial 4.
• However, more evidence is needed to support the use of fibrinogen infusion in patients with hypofibrinogenemia and normal coagulation studies [(4,7)].