Massive obstetric haemorrhage with DIC — FFICM MCQ

Correct answer: E — Replace fibrinogen early with cryoprecipitate or fibrinogen concentrate according to protocol

Option E, replace fibrinogen early with cryoprecipitate or fibrinogen concentrate according to protocol, is correct. This patient has a fibrinogen of 0.9 g/L, well below the 2 g/L threshold associated with progressive haemorrhage, and RCOG guidance states that a plasma fibrinogen level greater than 2 g/l should be maintained during ongoing PPH, with cryoprecipitate used for fibrinogen replacement. Fibrinogen falls fastest of all coagulation factors in obstetric haemorrhage and is the earliest predictor of progression to severe PPH, so it must be targeted specifically rather than relying on generic ratio-based transfusion. Given ongoing bleeding, hypothermia and acidosis (the lethal triad), empirical correction of fibrinogen alongside the massive transfusion protocol, rather than waiting for further deterioration, is the guideline-directed step that most directly addresses the discriminating abnormality in this stem. Why the other options are wrong: C. Give red cells until haemoglobin is normal: red cells alone do not correct coagulopathy and, given without adequate plasma and fibrinogen replacement, worsens dilutional coagulopathy and does not address the critically low fibrinogen driving continued bleeding. A. Avoid tranexamic acid in obstetric bleeding: tranexamic acid should be considered in PPH management and reduces death from haemorrhage; withholding it is not supported by current guidance. B. Wait for laboratory tests before blood products: clinical picture should drive transfusion decisions and time should not be spent unnecessarily awaiting laboratory results in life-threatening haemorrhage. D. Treat coagulopathy after hysterectomy: coagulopathy must be corrected concurrently with source control, not deferred until after surgery, since uncorrected coagulopathy increases surgical bleeding and mortality risk. Key point: In PPH, fibrinogen falls earlier and faster than other clotting factors, so a level below 2 g/L mandates prompt correction with cryoprecipitate or fibrinogen concentrate as part of the massive transfusion protocol, rather than relying on red cells or delaying for further tests.

Reference: RCOG Green-top Guideline No. 52, Prevention and Management of Postpartum Haemorrhage (2016, reaffirmed), Section 5: A plasma fibrinogen level greater than 2 g/l should be maintained during ongoing PPH; cryoprecipitate (or fibrinogen concentrate) should be used for fibrinogen replacement. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/prevention-and-management-of-postpartum-haemorrhage-green-top-guideline-no-52/