Fibrinogen concentrate use during major obstetric haemorrhage

Bell and colleagues described a series of six cases in which fibrinogen concentrate was used in combination with blood products to treat postpartum obstetric haemorrhage [1]. Other studies have also demonstrated a reduction in blood loss when using this blood product [2, 3]. Hypofibrinogenaemia is common in obstetric haemorrhage, especially if there is a consumptive coagulopathy [4] and we would like to report a case where fibrinogen concentrate was sufficient to arrest major antenatal vaginal bleeding after diagnosis of abruption and fetal death, before other blood products were available. A 38-year-old multiparous woman was admitted at 34 + 2 weeks of gestation with a five-hour history of severe abdominal pain and no fetal movements. A transabdominal ultrasound scan revealed an intrauterine death, secondary to placental abruption, with a large retroplacental clot. On admission she had no vaginal bleeding, but was tachycardic with a pulse rate of 116 beats.min−1 and a blood pressure of 108/70 mmHg. We administered a bolus of 500 ml of colloid solution and commenced Hartmann’s solution at 125 ml.h−1, and sent blood for cross-matching. Initial blood results (taken at the time of admission, but available two hours later) showed haemoglobin (Hb) 8.1 g.dl−1, platelets 258 × 109.l−1, fibrinogen 1.9 g.l−1, activated partial thromboplastin time (APPT) 27 s and prothrombin time (PT) 14.5 s. As the blood results became available, she had a sudden vaginal blood loss of 750 ml followed by continuous bleeding of 200–300 ml every 15 min; her blood pressure was 89/56 and heart rate 114 beats.min−1. She looked pale and peripherally shut down. We took a further full blood count and coagulation test, but based on the clinical deterioration, the previous low fibrinogen of 1.9, the history of abruption and the likelihood of fulminating disseminated intravascular coagulopathy (DIC), a consultant haematologist advised that 4 g fibrinogen concentrate should immediately be given with four units of fresh-frozen plasma. We administered the fibrinogen concentrate (CSL Behring, King of Prussia, PA, USA) within 15 min, with two units of blood, and within 10 min her vaginal bleeding stopped. We then administered the fresh frozen plasma and a further two units of blood. Her clinical picture improved over the next 30 min; she had artificial rupture of membranes and labour was induced with an oxytocin infusion at 0.06 units.h−1. The blood results taken before and after the blood products showed Hb 6.8 g.dl−1, platelets 241 × 109.l−1, fibrinogen 0.9 g.dl−1, APPT 34.6 s and PT 15.8, and Hb 6.1 g.dl−1, platelets 111 × 109.l−1, fibrinogen 1.5 g.dl−1, APPT 36.5 s and PT 15.7 s, respectively. We gave her further three units of blood and four of fresh frozen plasma, on the basis of a third set of blood results. There was no further bleeding, her clinical condition stabilised and she had a spontaneous vaginal delivery of a dead fetus with a 2000-ml blood clot three and-a-half hours later. At delivery, she was normotensive, her heart rate had settled to 90 beats.min−1, she was passing over 100 ml.h−1 of urine and she was peripherally well perfused. Following delivery, she received no further blood products although her platelets fell to 57 × 109.l−1 and she had three 500-mg doses of tranexamic acid on the advice of the haematologist. We believe that this is the first report of major antenatal obstetric haemorrhage associated with DIC arrested by fibrinogen concentrate alone, which allowed induction of labour and subsequent vaginal delivery. Fibrinogen concentrate was available more quickly than other clotting products as it is rapidly solubilised from an ampoule in 50 ml water and given as a bolus. To raise the plasma fibrinogen concentration by 1 g.l−1 in a 70-kg person, 1000 ml fresh frozen plasma (6 standard UK units), or 260 ml cryoprecipitate (10 standard UK units) will be required [5]. Administration of adequate doses of fresh frozen plasma or cryoprecipitate to treat hypofibrinogenaemia during obstetric haemorrhage will therefore take a substantial amount of time, even with an efficient blood bank and portering system. This case also highlights the importance of monitoring the fibrinogen levels in obstetric haemorrhage and treating hypofibrinogenaemia early and aggressively as the APTT, PT and platelet count were unreliable during the initial presentation. No external funding and no competing interests declared. Published with the written consent of the patient.