Does a patient with minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage, with low fibrinogen (hypofibrinogenemia) level, require fibrinogen infusion?

From the Guidelines

The patient with minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage and low fibrinogen level likely requires fibrinogen infusion to prevent further bleeding and support adequate clot formation. The patient's condition, although currently presenting with minimal bleeding, is at risk due to the low fibrinogen level, which is a critical component for clot formation. According to the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, fibrinogen supplementation is recommended in cases of hypofibrinogenemia. Key points to consider in the management of this patient include:

• The use of fibrinogen concentrate or cryoprecipitate for fibrinogen supplementation, with an initial dose of 3-4 g, as suggested by the guideline 1.
• The importance of monitoring fibrinogen levels and adjusting the dose based on viscoelastic monitoring and/or laboratory assessment of fibrinogen levels, as indicated in the guideline 1.
• The goal of raising the fibrinogen level above 150-200 mg/dL to support adequate clot formation and prevent further bleeding.
• The potential for fibrinogen levels to drop rapidly in obstetric hemorrhage due to consumption and dilution, highlighting the need for prompt intervention.
• The essential role of fibrinogen in clot formation, as it converts to fibrin and provides the structural framework for clots, underscoring the importance of its replacement in cases of hypofibrinogenemia.

From the FDA Drug Label

For adults: 4g Administer additional doses of 4 g in adults, ... as needed to bleeding patients when plasma fibrinogen level is ≤200 mg/dL

The patient requires fibrinogen infusion if the plasma fibrinogen level is ≤200 mg/dL. Since the patient has low fibrinogen (hypofibrinogenemia) level, and is experiencing minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage, fibrinogen infusion may be necessary. However, the exact fibrinogen level is not provided, and the decision to administer fibrinogen infusion should be based on the patient's individual clinical condition and laboratory values, such as plasma fibrinogen level 2.

From the Research

Fibrinogen Infusion in Patients with Hypofibrinogenemia

• Fibrinogen concentrate substitution therapy has been shown to improve laboratory and clinical outcomes in patients with massive hemorrhage and low plasma fibrinogen concentrations 3.
• The use of fibrinogen concentrate in massive hemorrhage has been associated with a reduction in blood loss and a decrease in the requirements for red blood cells, fresh frozen plasma, and platelets 3, 4.
• Fibrinogen plays a critical role in achieving and maintaining hemostasis, and current guidelines recommend maintaining the plasma fibrinogen level above 1.5 g/L 5.
• Fibrinogen concentrate provides a promising alternative to allogeneic blood products, allowing for a standardized dose of fibrinogen to be rapidly administered in a small volume, with a good safety profile and viral inactivation as standard 5, 6.

Clinical Application of Fibrinogen Concentrate

• Fibrinogen concentrate has been successfully used as hemostatic therapy in a range of clinical settings, including cardiovascular surgery, postpartum hemorrhage, and trauma 5, 6.
• The administration of fibrinogen concentrate has been associated with a reduction or even total avoidance of allogeneic blood product transfusion 5, 6.
• Fibrinogen concentrate may be an effective addition to conventional treatments for obstetric hemorrhage associated with hypofibrinogenemia, allowing for rapid restoration of fibrinogen levels with a small volume infusion and minimal preparation time 7.

Considerations for Patients with Minimal Bleeding

• While the studies suggest that fibrinogen concentrate can be effective in treating patients with hypofibrinogenemia, the decision to administer fibrinogen infusion in a patient with minimal bleeding after suction dilation and curettage (D&C) for hemorrhage due to miscarriage should be based on individual patient needs and laboratory results 3, 4, 5, 6, 7.