From the Guidelines
Your patient with acute postpartum hemorrhage and early signs of DIC requires immediate intervention to prevent further complications, and I strongly recommend administering 4 grams of fibrinogen concentrate (or 10 units of cryoprecipitate if concentrate is unavailable) and 4 units of fresh frozen plasma to correct coagulation factor deficiencies, as well as continuing aggressive resuscitation with packed red blood cells and adding tranexamic acid 1 gram IV over 10 minutes if not already given, as supported by the AAGBI guidelines 1 and the updated WHO recommendation on intravenous tranexamic acid for the treatment of post-partum haemorrhage 1. The patient's fibrinogen level of 192, although not severely low, indicates a need for replacement in the context of ongoing bleeding, as fibrinogen replacement with cryoprecipitate or fibrinogen concentrate should be considered in these circumstances, if there is bleeding 1. Additionally, the patient's PT and INR are mildly elevated, suggesting some degree of coagulopathy, and the use of fresh frozen plasma is indicated for replacement of coagulation factors during major hemorrhage, particularly in obstetrics, and in patients who are actively bleeding and whose INR is > 1.5 (or POC equivalent) 1. The use of tranexamic acid is also supported by the updated WHO recommendation, which strongly recommends early use of intravenous tranexamic acid (within 3 hours of birth), in addition to standard care for women with clinically diagnosed post-partum haemorrhage following vaginal birth or caesarean section 1. Key considerations in the management of this patient include:
- Aggressive resuscitation with packed red blood cells, aiming for a 1:1:1 ratio of RBCs, plasma, and platelets if bleeding persists
- Administration of uterotonics, such as oxytocin, methylergonovine, or carboprost, to treat uterine atony
- Manual removal or curettage of retained placental tissue
- Surgical repair of lacerations
- Continuous monitoring of vital signs, urine output, and serial coagulation studies to guide further management.
From the Research
Patient's Current Condition
The patient is experiencing disseminated intravascular coagulation (DIC) due to acute postpartum hemorrhage. The current laboratory results are:
- Fibrinogen: 192
- Prothrombin Time (PT): 15.9
- International Normalized Ratio (INR): 1.26
- Partial Thromboplastin Time (PTT): 35 The patient has received 1 unit of blood and albumin.
Fibrinogen Replacement Therapy
According to 2, fibrinogen plays a critical role in achieving and maintaining hemostasis, and its level should be maintained above 1.5 g/L. The patient's current fibrinogen level is 192, which is below the recommended threshold.
- Fibrinogen supplementation can be achieved using plasma or cryoprecipitate, but fibrinogen concentrate is a promising alternative with a good safety profile and rapid administration 2.
- A systematic review of early fibrinogen replacement therapy in postpartum hemorrhage found insufficient evidence to support its use in reducing allogeneic blood transfusion or improving outcomes 3.
Choice of Fibrinogen Replacement
- A study comparing cryoprecipitate and fibrinogen concentrate found that cryoprecipitate may be a superior source of fibrinogen in controlling bleeding in trauma coagulopathy 4.
- However, a retrospective cohort analysis found that fibrinogen supplementation using fibrinogen concentrate was associated with improved outcomes and reduced transfusion requirements compared to cryoprecipitate in traumatic hemorrhagic patients 5.