Pregnancy and post-partum
Fibrinogen and post-partum
haemorrhage
Because hypofibrinogenemia is a major and early part of post-partum
haemorrhage-associated coagulopathy, fibrinogen supplementation appears
to be one of the most promising targets for this haemostatic intervention
Anne-Sophie Ducloy-Bouthors
Anne-Sophie Baptiste
Pole anesthésie-réanimation, maternité
Jeanne de Flandre, academic hospital,
avenue Oscar Lambret, Lille, France
Cyril Huissoud
Pole Obstétrique et Gynécologie Hôpital Croix
Rousse Hospices Civils 103 Grande Rue de la
Croix-Rousse, Lyon, France
Post-partum haemorrhage (PPH) is the
leading cause of maternal mortality and
morbidity in Europe and worldwide. 1,2
PPH following vaginal delivery is due to
uterine atony, retained placental products
and placental abnormal implantation,
genital-tract trauma and systemic medical
disorders. A large proportion of women
who develop PPH do not have previous
identifiable risk factors; so all women
must be considered at risk. Antenatal
screening is important to detect high risk
parturients using the 4T rule: Tone,
Tissue, Trauma, and Thrombin. 3 Acquired
coagulopathy (hypofibrinogenemia and
hyperfibrinolysis) appears early in the
course of PPH, worsening its prognosis by
increasing the bleeding volume. 4,5 The
diagnosis and treatment of the acquired
coagulopathy is a part of the PPH
management protocol in parallel with
uterotonics, obstetrical procedures and
transfusion. 3
Hypofibrinogenemia is a risk
marker of PPH severity
Fibrinogen is a central substrate for clot
formation. It is the main thrombin
substrate leading, through fibrin
monomers and their polymerisation, to
fibrin clot formation. Fibrinogen is also
the target of plasmin in excess.
Fibrinogenolysis has been identified as a
major component in PPH, trauma, and
massive haemorrhage-induced
coagulopathy. 6–8 Charbit et al
demonstrated, in 128 women with PPH
requiring prostaglandin administration,
that plasma fibrinogen concentration at
enrolment was the sole independent
predictive factor for poor outcome. 4
A plasma fibrinogen level under a 2g/l
threshold showed a predictive value for
progression toward severe bleeding of
100% (CI 95% 79–100). This level was
higher than the ‘historical’ threshold of
<1g/l, which indicated in the general
population the need to initiate
replacement therapy, or the 1.5g/dl
threshold identified by Grottke et al in an
experimental animal setting. 9 This higher
threshold could be explained by a higher
than normal plasma fibrinogen level
during pregnancy and the post-partum
period. 10 An analysis by Cortet et al of 738
women with PPH clearly confirmed the
importance of fibrinogen levels. 11 The
mean plasma fibrinogen concentration at
diagnosis was 4.2g/l (SD= 1.2g/l) among
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