Fibrinogen for the management of critical obstetric hemorrhage

Abstract

The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.

Hemostasis for Massive Hemorrhage during Cesarean Section

“…Once hemorrhage has occurred, it is important not only to determine red blood cell (RBC) count, hemoglobin level, hematocrit value, and biochemical parameters but also to measure plasma fibrinogen levels over time by using a simple rapid fibrinogen measuring instrument as point-of-care testing in order to perform early diagnosis and treatment of coagulopathy [5,10]. In cases of massive hemorrhage, it may be difficult to assess the accurate amount of bleeding.…”

“…Administration of FFP is necessary for achieving the elevation and maintenance of blood pressure and colloid osmotic pressure. It should be noted that if the patient experiences shock, RBC transfusion alone cannot increase blood pressure; FFP and RBC should be administered at a ratio of 1:1 in the same manner as in cases of trauma [3,5,10]. In cases of consumption coagulopathy, such as in placenta abruption or amniotic fluid embolism, and coagulopathy following massive hemorrhage, the blood fibrinogen level is often <100 mg/dL.…”

“…Without this treatment, hemorrhage may persist, and the hemorrhagic tendency may continue for days [11]. The mainstay coagulopathy management is elimination of coagulopathy within 6 h. For this purpose, rapid transfusion of FFP should be performed to obtain a blood fibrinogen level of ≥150-200 mg/dL, and a prothrombin time of ≥70% should be targeted [3,5,10,11]. After these treatments, the FFP/RBC ratio of the total transfusion volume may exceed 2.0 in some cases.…”

“…In patients with hypofibrinogenemia, the blood fibrinogen level could be more promptly, more efficiently elevated by administration of 3 g of fibrinogen concentrates (3 g of fibrinogen concentrate is almost equivalent to fibrinogen in 12 units of FFP) or three bags of cryoprecipitate (one bag of cryoprecipitate is derived from approximately 480 ml of FFP) [10][11][12][13]. If the patient develops coagulopathy, any other coagulation factors than fibrinogen will also decrease.…”

“…The current revised edition of this guideline [5] recommends a new concept of obstetrical transfusion therapy, treatment of coagulopathy, and hemostatic techniques such as compression sutures, intrauterine balloon tamponade, administration of uterotonics and tranexamic acid [3,[5][6][7][8][9]. If coagulopathy is present, the fibrinogen level becomes extremely low, and reversal of hemorrhagic tendency can be achieved only by administration of cryoprecipitate or fibrinogen concentrate or transfusion of fresh-frozen plasma (FFP) [3,5,10]. In addition, simulation training for obstetrical emergency care has been conducted widely to promote good team medical care in emergency settings [1].…”