Case of the Month #45 Major Obstetric Haemorrhage - Part 2

Published 16/11/2023

How do POC coagulation results translate to clinical practice?

Actions based on TEG results- 

  • CK – Prolonged R time suggests a deficiency in clotting factors. If R time > 9 minutes, give 15ml/kg of FFP or 2 pools of cryoprecipitate.  

  • CFF - Reduced MA suggests fibrinogen deficiency. If CFF MA < 16mm give 3g of fibrinogen concentrate. 
    (An MA of 16mm correlates with fibrinogen concentration of 2g/L, an MA of 22mm correlates with fibrinogen concentration of 3 g/L). 

  • CRT (and CK) – Reduced MA (in the presence of a normal CFF MA) suggests a platelet deficiency. If CRT MA < 52mm give 1 unit of platelets. If CK MA < 50mm give 1 unit of platelets. 

Actions based on ROTEM results - 

  • FIBTEM A5 < 11 mm (or fibrinogen < 2 g/L) - give fibrinogen concentrate (A5 7-11 mm give 4 g, A5 < 7 give 6 g).  

  • EXTEM CT > 75 sec (or prolonged APTT/ PT) - give FFP (booking weight < 50 kg give 3 units, booking weight > 50 kg given 4 units) 

Notes on coagulation and clotting products 

  • Coagulopathy during MOH may be dilutional, consumptive, or due to DIC. 

  • Haemorrhage secondary to amniotic fluid embolus, uterine rupture or placental abruption may be associated with early onset DIC. FFP/ fibrinogen concentrate should be considered early for these conditions. 

  • FFP contains all clotting factors whereas cryoprecipitate contains high levels of factor VIII, fibrinogen and von Willebrand factor.  

  • Pregnancy is a prothrombotic state with higher baseline fibrinogen levels of 4-6 g/L (2-4 g/L in non-pregnant patients). This acts as a physiological buffer for haemorrhage. 

  • Fibrinogen levels decrease more rapidly during haemorrhage than other coagulation factors (often a predictor of progression to MOH). 

  • Fibrinogen <3 g/L, particularly < 2g/L is associated with poor outcomes. 

  • Fibrinogen < 2gL occurs in 1-2/1000 deliveries. 

  • Fibrinogen > 2 g/L is adequate for haemostasis during obstetric bleeding. 

  • Fibrinogen concentrate or cryoprecipitate can be used as the source of fibrinogen, depending on availability. 

  • There is evidence suggesting fibrinogen replacement using Fibrinogen Concentrate can reduce the need for FFP and cryoprecipitate. 

  • FFP and cryoprecipitate need to be thawed in the transfusion laboratory prior to use. This can take up to 40 minutes, therefore close and pre-emptive communication with the lab is essential. 

  • Cryoprecipitate- one pool contains 5 single units. 1-2 pools are recommended for an average adult. 

  • FFP- dose is 12-15 ml/kg, on average 4 units for an adult. Should be administered based on POC/ lab haemostatic tests, or after 4 units of RBCs have been administered if haemostatic tests are unavailable. 

  • 1 Adult Dose (AD) of platelets should be administered in the first instance if platelet count < 75 x 109/L and/ or bleeding in ongoing. Platelets may need to be obtained from the local NHS blood and transplant (NHSBT) site which can take > 1 hour for delivery by blue light from ordering.