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Transfusion Ratios for Postpartum Hemorrhage: It’s Time to Consider All Fibrinogen-Containing Products
Abstract Number: F4A-2
Abstract Type: Original Research
Transfusion strategies for postpartum hemorrhage (PPH) emphasize fibrinogen (FIB) replacement, based on the observation that serum FIB <200 mg/dL strongly predicts severe PPH (1). A 1:1 ratio of packed red blood cells (PRBC) to fresh frozen plasma (FFP) has been proposed as a resuscitation target in severe PPH (2), but this might result in under repletion of fibrinogen.
Here we propose a new ratio that may be a more appropriate guide in transfusion management: the ratio of PRBC:FIB equivalents (PRBC:FIBe). 1 FIB equivalent equals 800mg fibrinogen, the amount of fibrinogen in 1 unit of FFP. We report the ratios of blood products transfused for severe PPH at a tertiary center comparing PRBC:FFP to PRBC:FIBe ratios. Our hypothesis was that PRBC:FIBe would differ from PRBC:FFP, particularly in cases often associated with coagulopathy e.g. placental abruption.
Cases of severe PPH (defined as >4u PRBCs transfused postpartum) at our center from Jan 2012- Dec 2016 were reviewed. Patients with no FIB replacement were excluded. PPH etiology, nadir serum FIB levels and transfusions were analyzed. FIB components were converted into FIBe (1 dose of cryoprecipitate has 1500mg; FIB concentrate has 1000mg). Data was analyzed with a one-sided Wilcoxon rank-sum test and significance level of 0.05.
For the 65 patients with severe PPH and FIB replacement, the median adjusted PRBC:FIBe (1.0) was significantly less than PRBC:FFP (1.6) (p<0.0001). 37 patients (56.9%) received additional FIB, with a lower PRBC:FIBe than PRBC:FFP. Most patients with abruption, uterine rupture or coagulopathy had a PRBC:FIBe less than PRBC:FFP. Patients with PRBC:FibE less than PRBC:FFP had more total products transfused (-0.55; p<0.0001) and a lower nadir fibrinogen (0.4; p=0.001). Frequency of the comparative ratios by PPH etiology is shown in Table 1.
We have yet to define optimal PPH transfusion ratios; mechanisms to interpret outcomes are needed. We have demonstrated that more than half of patients transfused for severe PPH at our center received FIB supplementation beyond FFP. Reporting outcomes based on PRBC:FFP ratios overlook non-FFP FIB equivalents and may underemphasize the importance of FIB replacement, as in our cases of placental abruption, rupture and coagulopathy. Reporting PRBC:FIBe ratios in PPH may be a preferred metric as it accounts for all FIB-rich products.
1. Charbit B. J Thromb Haemost 2007
2. Shaylor R. Anesth Analg 2017