When is Fresh Frozen Plasma (FFP) transfusion indicated in a patient with eclampsia?

FFP Transfusion in Eclampsia

FFP transfusion in eclampsia patients is indicated only when there is active bleeding with documented coagulopathy (PT/APTT >1.5 times normal) or severe early consumptive coagulopathy associated with complications like abruption or amniotic fluid embolus. 1

Primary Indications for FFP in Eclampsia

Severe Early Consumptive Coagulopathy

• Severe early consumptive coagulopathy is specifically associated with abruption, amniotic fluid embolus, and severe bleeding with pre-eclampsia, requiring early use of FFP before RBC transfusion may be needed. 1
• This represents a distinct clinical scenario where coagulopathy develops rapidly and precedes significant blood loss. 1

Active Hemorrhage with Coagulopathy

• FFP should be withheld until 4 units of RBC have been given in postpartum hemorrhage unless coagulation tests confirm early coagulopathy. 1
• If no coagulation results are available and bleeding is ongoing after 4 units of RBC, then 4 units of FFP should be infused and a 1:1 ratio of RBC-FFP transfusion maintained until haemostatic test results are known. 1
• Point-of-care (POC) testing is strongly recommended in obstetric hemorrhage settings, as laboratory testing is often too slow during active bleeding. 1

Critical Laboratory Thresholds

Coagulation Parameters

• FFP is indicated when PT or APTT >1.5 times normal control with active bleeding. 1
• The standard dose is 10-15 ml/kg body weight, approximately 2-4 units (500-1000 ml) for a 70 kg adult. 2

Fibrinogen Monitoring

• Hypofibrinogenemia below normal pregnancy levels (normal 4-6 g/L) predicts ongoing postpartum hemorrhage risk. 1
• Laboratory Clauss fibrinogen <3 g/L, and especially <2 g/L with ongoing bleeding, is associated with progression to major obstetric bleeding. 1
• Fibrinogen replacement with cryoprecipitate or fibrinogen concentrate should be prioritized over FFP for hypofibrinogenemia, as FFP is inefficient for isolated fibrinogen replacement. 1

Important Clinical Distinctions

When FFP is NOT Indicated

• Postpartum hemorrhage associated with atony or trauma is unlikely to be associated with haemostatic impairment unless diagnosis is delayed. 1
• Protocolled use of blood products leads to overtransfusion of FFP in the majority of cases without early coagulopathy. 1
• FFP should not be used prophylactically to correct abnormal coagulation tests in non-bleeding patients. 2

Alternative Therapies

• Tranexamic acid reduces total blood loss and should be given if postpartum hemorrhage is severe (>500 ml after vaginal delivery, >1000 ml after cesarean), at an initial dose of 1 g. 1
• For isolated hypofibrinogenemia, cryoprecipitate or fibrinogen concentrate is more effective than FFP. 1, 2

Practical Administration Guidelines

Dosing Strategy

• Initial dose: 10-15 ml/kg body weight (approximately 700-1050 ml or 3-4 units for a 70 kg patient). 2
• FFP should be infused as rapidly as clinically tolerated in acute bleeding situations. 2
• FFP must be ABO compatible with the recipient. 2

Monitoring Requirements

• Blood should be taken for full blood count, clotting studies, group and screen, and venous blood gas for rapid Hb measurement and lactate (>2 mmol/L indicates shock). 1
• Coagulation parameters should be rechecked after transfusion to determine need for additional doses. 2
• Monitor for transfusion complications including TRALI, circulatory overload, and allergic reactions. 2

Special Considerations for Persistent HELLP Syndrome

• In cases of persistent postpartum HELLP syndrome with ongoing thrombocytopenia and microangiopathic disease beyond 72 hours, plasma exchange with fresh frozen plasma may be considered as rescue therapy. 3, 4, 5, 6
• This represents an atypical presentation requiring specialized intervention beyond standard FFP transfusion protocols. 6

Critical Pitfalls to Avoid

• Do not delay recognition of bleeding—systematically weigh blood-soaked pads immediately after delivery, as estimating blood loss is notoriously difficult. 1
• Do not use FFP for volume expansion or as a plasma volume expander. 2
• Platelet transfusions are rarely required in obstetric hemorrhage and should only be given once the platelet count is known. 1