Critical Obstetrical Hemorrhage

  • Shigetaka MatsunagaEmail author
  • Satoru Takeda


Currently, critical obstetrical hemorrhage is reported to be the number one cause of maternal deaths in Japan. The Japanese Clinical Practice Guide for Critical Obstetrical Hemorrhage was revised in 2017. According to these guidelines, the role of treatment strategies in tertiary medical facilities is important, but the role of the criteria used by clinics for determining the timing of transport is also important. Thus, the aim of these guidelines is to further reduce the maternal death rate in Japan. With this revision, the guideline newly emphasizes the measurement of fibrinogen level and the importance of supplementation. Fibrinogen is an essential protein for hemostasis. It is the first coagulation factor below the critical level for hemostasis. Therefore, treating hypofibrinogenemia at an early stage of coagulopathy due to massive obstetric hemorrhage is the most important strategy. Additionally, administration of sufficient coagulation factor from an early stage, particularly fibrinogen supplementation, is essential to prevent worsening of coagulopathy. The use of fibrinogen concentrate is discussed as an efficient way to supplement fibrinogen.


Fibrinogen concentrate Obstetrical hemorrhage Disseminated intravascular coagulation Shock Coagulopathy 


  1. 1.
    Takeda S, Makino S, Takeda J, Kanayama N, Kubo T, Nakai A, et al. Japanese clinical practice guide for critical obstetrical hemorrhage (2017 revision). J Obstet Gynaecol Res. 2017;43(10):1517–21. Scholar
  2. 2.
    Japan Association of Obstetricians and Gynecologist, Maternal Death Exploratory Committee. Recommendations for maternal safety 2016. 2017. Accessed 10 Oct 2017.
  3. 3.
    Kanayama N, Inori J, Ishibashi-Ueda H, Takeuchi M, Nakayama M, Kimura S, et al. Maternal death analysis from the Japanese autopsy registry for recent 16 years: significance of amniotic fluid embolism. J Obstet Gynaecol Res. 2011;37(1):58–63. Scholar
  4. 4.
    Aitkenhead AR, Rowbotham DJ, Smith G, editors. Textbook of anaesthesia. 4th ed. Edinburgh: Churchill Livingstone; 2001.Google Scholar
  5. 5.
    Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006;113(8):919–24. Scholar
  6. 6.
    Rath WH. Postpartum hemorrhage—update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand. 2011;90(5):421–8. Scholar
  7. 7.
    Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, et al. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG. 2015;122(2):268–75. Scholar
  8. 8.
    El Ayadi AM, Nathan HL, Seed PT, Butrick EA, Hezelgrave NL, Shennan AH, et al. Vital sign prediction of adverse maternal outcomes in women with hypovolemic shock: the role of shock index. PLoS One. 2016;11(2):e0148729. Scholar
  9. 9.
    Era S, Matsunaga S, Matsumura H, Murayama Y, Takai Y, Seki H. Usefulness of shock indicators for determining the need for blood transfusion after massive obstetrical hemorrhage. J Obstet Gynaecol Res. 2014;41(1):39–43. Scholar
  10. 10.
    Le Bas A, Chandraharan E, Addei A, Arulkumaran S. Use of the “obstetric shock index” as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage. Int J Gynaecol Obstet. 2014;124(3):253–5. Scholar
  11. 11.
    Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, et al. Study protocol. TRAAP—TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. BMC Pregnancy Childbirth. 2015;15:135. Scholar
  12. 12.
    Ker K, Roberts I, Shakur H, Coats TJ. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2015;5:CD004896. Scholar
  13. 13.
    WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105–16. Scholar
  14. 14.
    Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007;62(8):540–7. Scholar
  15. 15.
    Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG. 2009;116(6):748–57. Scholar
  16. 16.
    Wang L, Matsunaga S, Mikami Y, Takai Y, Terui K, Seki H. Pre-delivery fibrinogen predicts adverse maternal or neonatal outcomes in patients with placental abruption. J Obstet Gynaecol Res. 2016;42(7):796–802. Scholar
  17. 17.
    Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266–73. Scholar
  18. 18.
    Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108(6):984–9. Scholar
  19. 19.
    Kobayashi T. Obstetrical disseminated intravascular coagulation score. J Obstet Gynaecol Res. 2014;40(6):1500–6. Scholar
  20. 20.
    Matsunaga S, Seki H, Ono Y, Matsumura H, Murayama Y, Takai Y, et al. A retrospective analysis of transfusion management for obstetrical hemorrhage in a Japanese obstetric center. ISRN Obstet Gynecol. 2012;2012:854064. Scholar
  21. 21.
    Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, et al. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol. 2016;172(4):616–24. Scholar
  22. 22.
    Gutierrez MC, Goodnough LT, Druzin M, Butwick AJ. Postpartum hemorrhage treated with a massive transfusion protocol at a tertiary obstetric center: a retrospective study. Int J Obstet Anesth. 2012;21(3):230–5. Scholar
  23. 23.
    Tanaka H, Katsuragi S, Osato K, Hasegawa J, Nakata M, Murakoshi T, et al. Efficacy of transfusion with fresh-frozen plasma:red blood cell concentrate ratio of 1 or more for amniotic fluid embolism with coagulopathy: a case-control study. Transfusion. 2016;56(12):3042–6. Scholar
  24. 24.
    Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13. Scholar
  25. 25.
    Ickx BE. Fluid and blood transfusion management in obstetrics. Eur J Anaesthesiol. 2010;27(12):1031–5. Scholar
  26. 26.
    Cerneca F, Ricci G, Simeone R, Malisano M, Alberico S, Guaschino S. Coagulation and fibrinolysis changes in normal pregnancy. Increased levels of procoagulants and reduced levels of inhibitors during pregnancy induce a hypercoagulable state, combined with a reactive fibrinolysis. Eur J Obstet Gynecol Reprod Biol. 1997;73(1):31–6.CrossRefGoogle Scholar
  27. 27.
    Sher G. Pathogenesis and management of uterine inertia complicating abruptio placentae with consumption coagulopathy. Am J Obstet Gynecol. 1977;129(2):164–70.CrossRefGoogle Scholar
  28. 28.
    Santoso JT, Saunders BA, Grosshart K. Massive blood loss and transfusion in obstetrics and gynecology. Obstet Gynecol Surv. 2005;60(12):827–37. Scholar
  29. 29.
    Krikun G, Lockwood CJ, Wu XX, Zhou XD, Guller S, Calandri C, et al. The expression of the placental anticoagulant protein, annexin V, by villous trophoblasts: immunolocalization and in vitro regulation. Placenta. 1994;15(6):601–12.CrossRefGoogle Scholar
  30. 30.
    Basu HK. Fibrinolysis and abruptio placentae. J Obstet Gynaecol Br Commonw. 1969;76(6):481–96.CrossRefGoogle Scholar
  31. 31.
    Lurie S, Feinstein M, Mamet Y. Disseminated intravascular coagulopathy in pregnancy: thorough comprehension of etiology and management reduces obstetricians' stress. Arch Gynecol Obstet. 2000;263(3):126–30.CrossRefGoogle Scholar
  32. 32.
    Karlsson O, Jeppsson A, Thornemo M, Lafrenz H, Radstrom M, Hellgren M. Fibrinogen plasma concentration before delivery is not associated with postpartum haemorrhage: a prospective observational study. Br J Anaesth. 2015;115(1):99–104. Scholar
  33. 33.
    Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg. 1995;81(2):360–5.PubMedGoogle Scholar
  34. 34.
    Simon L, Santi TM, Sacquin P, Hamza J. Pre-anaesthetic assessment of coagulation abnormalities in obstetric patients: usefulness, timing and clinical implications. Br J Anaesth. 1997;78(6):678–83.CrossRefGoogle Scholar
  35. 35.
    Hunt BJ, Allard S, Keeling D, Norfolk D, Stanworth SJ, Pendry K, et al. A practical guideline for the haematological management of major haemorrhage. Br J Haematol. 2015;170(6):788–803. Scholar
  36. 36.
    Stinger HK, Spinella PC, Perkins JG, Grathwohl KW, Salinas J, Martini WZ, et al. The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma. 2008;64(2 Suppl):S79–85; discussion S85. Scholar
  37. 37.
    Matsunaga S, Takai Y, Nakamura E, Era S, Ono Y, Yamamoto K, et al. The clinical efficacy of fibrinogen concentrate in massive obstetric haemorrhage with hypofibrinogenaemia. Sci Rep. 2017;7:46749. Scholar
  38. 38.
    Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. Scholar
  39. 39.
    J-MELS Editorial Committee of Maternal Emergency Life-Saving Advanced Guidebook. J-MELS advanced course guidebook of maternal emergency life-saving. 1st ed. Tokyo: Herusu Shuppan; 2017.Google Scholar
  40. 40.
    Solomon C, Groner A, Ye J, Pendrak I. Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data. Thromb Haemost. 2014;113(3):759–71. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Center for Maternal, Fetal, and Neonatal Medicine, Saitama Medical CenterSaitama Medical UniversityKawagoeJapan
  2. 2.Department of Obstetrics and Gynecology, Faculty of MedicineJuntendo UniversityBunkyo-kuJapan

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