Managing coagulopathy following PPH

The prothrombotic state during pregnancy protects against coagulopathy. Fibrinogen is of key importance with concentrations of 4-6 g/l in parturients preventing the majority of women with postpartum haemorrhage developing hypofibrinogenaemia. However, plasma levels below 2 g/l are strongly predictive of bleed progression and should be maintained above this. Laboratory tests of coagulation have a low sensitivity in major haemorrhage, and results are not quickly available. Viscoelastometry provides rapid results, and the FIBTEM A5 test correlates with fibrinogen levels in PPH. Fibrinogen concentrate or cryoprecipitate is more suitable for fibrinogen replacement in pregnancy than fresh frozen plasma. Formulaic blood product administration results in unnecessary treatment for the majority. Reduced morbidity with viscoelastometry-guided blood product administration has been demonstrated with observational studies but not with randomised controlled trials. Further studies are needed to assess the optimal treatment threshold and outcome benefits from targeted fibrinogen replacement.