A woman undergoes emergency peripartum hysterectomy for placenta percreta. Intraoperatively, massive hemorrhage occurs requiring 12 units packed RBCs, 10 units FFP, and 2 pools of platelets. She develops a worsening coagulopathy with fibrinogen 0.8 g/L and aPTT >100 sec. The intervention with the strongest Level 1 evidence to correct this acute hypofibrinogenemia is:

• A Fresh frozen plasma 4 units to provide all coagulation factors including fibrinogen
• B Cryoprecipitate 10 units providing concentrated fibrinogen ~150 mg per unit
• C Fibrinogen concentrate (RiaSTAP/Haemocomplettan) 2–4 g IV to rapidly raise fibrinogen by ~1 g/L per gram given ✓
• D Recombinant FVIIa 90 mcg/kg to activate fibrin clot formation independent of fibrinogen level

Explanation

Fibrinogen concentrate provides highly concentrated fibrinogen (1 g/vial) in a small volume, can be given rapidly, is pathogen-inactivated, and dose-predictably raises plasma fibrinogen — approximately 0.6–1.0 g/L per gram administered (by weight-based dosing). In obstetric massive hemorrhage, fibrinogen is the first coagulation factor to fall critically, and fibrinogen concentrate is preferred over cryoprecipitate when available because it is standardized, requires no thawing, and has superior pharmacokinetics. Cryoprecipitate (B) remains the standard where concentrate is unavailable. FFP (A) contains ~2 mg/mL fibrinogen and is volume-inefficient for isolated hypofibrinogenemia. rFVIIa (D) does not bypass the need for adequate fibrinogen substrate.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.