Matsunaga Shigetaka, Takai Yasushi, Seki Hiroyuki
Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan.
J Obstet Gynaecol Res. 2019 Jan;45(1):13-21. doi: 10.1111/jog.13788. Epub 2018 Aug 28.
In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome.
We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point-of-care testing.
The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5 . Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload.
The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.
在导致极度低纤维蛋白原血症的严重产科出血病例中，纤维蛋白原是指示危急严重程度的标志物，以止血复苏为中心的早期纤维蛋白原补充是稳定灾难性状况的关键治疗方法。在本综述中，我们研究了纤维蛋白原水平对止血的影响以及我们可以采取哪些措施来有效治疗低纤维蛋白原血症并改善患者预后。
我们回顾了大量与严重产科出血中低纤维蛋白原血症相关的文章。特别是，我们对纤维蛋白原止血的目标值和纤维蛋白原浓缩物的有效性进行了系统综述。我们还回顾了关于纤维蛋白原水平早期正常化方法的文章，如氨甲环酸、大量输血方案和即时检验。
根据大量输血需求计算出的纤维蛋白原目标值为200mg/dL或A5为10mm。尽管纤维蛋白原浓缩物对正常范围内的纤维蛋白原水平作用不佳，但当给予严重低纤维蛋白原血症的严重产科出血患者时，它能迅速提高血液纤维蛋白原水平。因此，可以减少新鲜冰冻血浆的输注量，并减少因容量超负荷导致的肺水肿发生率。
纤维蛋白原浓缩物最有效的患者群体是严重低纤维蛋白原血症患者。需要根据证据进行进一步研究。严重产科出血输血算法的核心是接近止血的目标值，通过即时检验确保准确及时地掌握严重程度，引入大量输血方案并使用氨甲环酸。
