Does a patient with minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage, with low fibrinogen (hypofibrinogenemia) but normal partial thromboplastin time (PTT), prothrombin time (PT), platelet count, and hemoglobin, require fibrinogen infusion?

From the Guidelines

This patient likely requires fibrinogen replacement to prevent further bleeding complications, despite currently minimal bleeding, as the low fibrinogen level is a significant concern in the setting of recent hemorrhage from miscarriage. The patient's fibrinogen level is below the normal range, and hypofibrinogenemia alone can cause or worsen bleeding, even with normal PT, PTT, and platelet count 1. According to the most recent European guideline on management of major bleeding and coagulopathy following trauma, early fibrinogen administration is of key importance, ideally guided by a fibrinogen concentration < 1.5 g/L or viscoelastic evidence of a functional fibrinogen deficiency 1.

Key Considerations

• The normal plasma fibrinogen concentration ranges from 2 to 4 g L−1, and without supplementation, fibrinogen is the first coagulation factor to fall to critically low levels during major hemorrhage 1
• A decrease in fibrinogen concentration is a predictor of the severity of the hemorrhage in trauma patients and with postpartum hemorrhage 1
• Fibrinogen replacement should aim to achieve a fibrinogen level above 150-200 mg/dL to support adequate clot formation
• Cryoprecipitate or fibrinogen concentrate can be used for fibrinogen replacement, with the goal of raising fibrinogen levels to a safe range

Recommended Treatment

• Cryoprecipitate is the preferred treatment in this acute setting, with a typical adult dose of 10 units which should raise fibrinogen by approximately 70-100 mg/dL
• Alternatively, fibrinogen concentrate (RiaSTAP) could be given at 70 mg/kg
• After administration, fibrinogen levels should be rechecked to ensure adequate replacement, and the patient should be monitored for any increase in bleeding
• Additional doses may be needed if bleeding continues or fibrinogen levels remain low, as guided by viscoelastic testing and standard laboratory coagulation parameters 1

From the FDA Drug Label

For adults: 4g Administer additional doses of 4 g in adults, 50 mg/kg body weight in adolescents 12 years of age and above, and 70 mg/kg body weight in children <12 years of age as needed to bleeding patients when plasma fibrinogen level is ≤200 mg/dL

The patient has minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage, with low fibrinogen (hypofibrinogenemia) but normal partial thromboplastin time (PTT), prothrombin time (PT), platelet count, and hemoglobin. Given that the patient's bleeding is minimal and the fibrinogen level is not explicitly stated to be ≤200 mg/dL, it is unclear if a fibrinogen infusion is required. However, considering the patient's condition and the fact that the drug label recommends administering additional doses when the plasma fibrinogen level is ≤200 mg/dL, a conservative clinical decision would be to monitor the patient's fibrinogen level and bleeding closely. If the bleeding worsens or the fibrinogen level is confirmed to be ≤200 mg/dL, then a fibrinogen infusion may be considered. It is essential to individualize the treatment based on the patient's clinical condition, laboratory values, and the extent of bleeding. 2

From the Research

Fibrinogen Infusion in Patients with Hypofibrinogenemia

• Patients with hypofibrinogenemia are at a significantly greater risk of major hemorrhage and death 3
• The rapid replacement of fibrinogen early on in hypofibrinogenemia may significantly improve outcomes for patients 3
• Fibrinogen concentrate substitution therapy has been shown to improve laboratory and clinical outcomes in patients with massive hemorrhage and low plasma fibrinogen concentrations 4

Indications for Fibrinogen Infusion

• Low fibrinogen levels have been found to be risk factors for exaggerated bleeding, transfusion needs, and adverse outcome 5
• Treatment with exogenous fibrinogen in critically bleeding patients with low fibrinogen levels has been shown to decrease transfusion needs 5
• Algorithm-based individualized goal-directed use of fibrinogen resulted in highly significant reduction in transfusion needs, adverse outcomes, and mortality 5

Clinical Application of Fibrinogen Concentrate

• Fibrinogen concentrate has been used to supplement fibrinogen during massive hemorrhage 6
• Clinical application of fibrinogen concentrate in bleeding patients is included within a multimodal therapeutic concept 6
• High levels of fibrinogen are necessary in order to reach therapeutic goals, and higher plasma fibrinogen might be associated with higher rates of survival 6

Patient with Minimal Bleeding after D&C

• Although the patient has minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage, the patient's low fibrinogen level (hypofibrinogenemia) may still pose a risk for major hemorrhage and death 3
• The patient's normal partial thromboplastin time (PTT), prothrombin time (PT), platelet count, and hemoglobin do not necessarily preclude the need for fibrinogen infusion, as fibrinogen is a critical component of coagulation 4, 5
• Fibrinogen infusion may be considered to rapidly replace fibrinogen and improve outcomes, although the decision to administer fibrinogen infusion should be made on a case-by-case basis, taking into account the patient's individual clinical situation and laboratory results 3, 4, 5