2026 SOAP Annual Meeting

Title: Fibrinogen Replacement in Postpartum Hemorrhage due to Uterine Atony
Authors: Christine A. Daly MD, MS, Leziga T. Obiyo MD, MPH; University of Chicago

[Slide 1]

Background
•Postpartum hemorrhage (PPH) remains a significant cause of maternal mortality in the U.S¹
•2000-2019: ↑ rate of PPH, ↑ pregnancies with >1 risk factors for PPH
•Fibrinogen levels fall faster than other clotting factors during episodes of acute bleeding
•Levels <200 mg/dL are associated with an increased risk of progression to severe PPH²•Empiric treatment of PPH with fibrinogen concentrate:
•Prevents further decrease in plasma fibrinogen levels³ •≠ improved outcomes^3,4•However, laboratory-guided replacement of fibrinogen is recommended for plasma levels < 200mg/dL⁵

[Slide 2]

Case Report

•37 year-old G4P3003, vaginal birth after cesarean (VBAC)

•Course complicated by: uterine atony → PPH

•See figure 1 for full timeline

•Repeat hemorrhage labs due to persistent bleeding

•Postpartum plasma fibrinogen: 273mg/dL → 160 mg/dL

↳Tx: 1,000mg fibrinogen concentrate
•Fibrinogen > 200mg/dL, however, bleeding persisted with 1.45L total quantitative blood loss (QBL)

•Hgb 6.6 → 1 unit of red blood cells (RBC)

[Slide 3]

Discussion

•Laboratory-guided replacement of fibrinogen in PPH:

•Not associated with ↓ need for at least one blood transfusion⁶

•Associated with ↓ rates of massive hemorrhage (> 2,500ml) and large volume transfusion (> 4 units RBC or > 8 units of any blood products)⁶
•Benefits of fibrinogen replacement in PPH may vary by etiology of PPH

•Hyperfibrinolysis likely not the primary mechanism underlying PPH in case of uterine atony²

•More effective in consumption-driven etiologies (e.g. placental abruption, amniotic fluid embolism/DIC)? Further research is needed

Conclusion: Given the increase in pregnant patients at risk for PPH in the U.S., laboratory-guided fibrinogen concentrate administration should be considered as it may reduce massive blood loss and mass transfusion rates. However, it may not prevent the need for at least one RBC transfusion. Therefore, the benefits of fibrinogen concentrate administration should be carefully weighed against possible risks including thromboembolic events, anaphylaxis/hypersensitivity reactions, and increased cost of treatment.⁷

[References]

1.Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum hemorrhage trends and outcomes in the united states, 2000-2019. Obstet Gynecol. 2023;141(1):152-161.

2.Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266-273

3.Ducloy-Bouthors AS, Mercier FJ, Grouin JM, et al. Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial. BJOG. 2021;128(11):1814-1823. doi:10.1111/1471-0528.16699

4.Zaidi A, Kohli R, Daru J, et al. Early use of fibrinogen replacement therapy in postpartum hemorrhage-a systematic review. Transfus Med Rev. 2020;34(2):101-107.

5.Muñoz M, Stensballe J, Ducloy-Bouthors AS, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus. 2019;17(2):112-136.

6.de Lloyd LJ, Bell SF, Roberts T, et al. Early viscoelastometric guided fibrinogen replacement combined with escalation of clinical care reduces progression in postpartum haemorrhage: a comparison of outcomes from two prospective observational studies. Int J Obstet Anesth. 2024;59:104209.

7.Kaur J, Patel P, Jain A. Fibrinogen. In: StatPearls. StatPearls Publishing; 2026. http://www.ncbi.nlm.nih.gov/books/NBK537184/

2026 SOAP Annual Meeting

Fibrinogen Replacement in Postpartum Hemorrhage due to Uterine Atony

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