In a postpartum patient with massive hemorrhage, an O-negative crossmatch-incompatible transfusion must be initiated urgently. After giving 6 units PRBC, 4 units FFP, and 1 unit of apheresis platelets, the patient still has uncontrolled ooze from wound edges. Which coagulation derangement is MOST likely responsible for this ongoing microvascular bleeding?
- A Fibrinogen depletion (consumptive hypofibrinogenemia) ✓
- B Factor VII deficiency from dilutional coagulopathy
- C Heparin-like effect from stored blood
- D Thrombocytopenia from dilution
Explanation
Hypofibrinogenemia (fibrinogen < 200 mg/dL) is the most critical and earliest coagulation abnormality in obstetric hemorrhage and is specifically predictive of severe PPH. Fibrinogen is consumed rapidly by the placental fibrinolytic environment, and each unit of PRBC transfused progressively dilutes it. The FIBTEM on ROTEM (clot amplitude <12 mm at 5 minutes) can rapidly identify this. Cryoprecipitate (rich in fibrinogen, factor VIII, vWF) or fibrinogen concentrate should be administered. While platelets and FFP replace other factors, fibrinogen is the rate-limiting hemostatic substrate in massive obstetric hemorrhage.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.