Massive obstetric haemorrhage: transfusion, ROTEM-guided replacement and DIC

She has lost 2600 mL, she has had four uterotonics and a balloon, and the field is now oozing from everywhere you have touched. Somebody hands you a coagulation result from 40 minutes ago. That is the moment this topic exists for — when the problem stops being the uterus and becomes the clot.^[14][12]

The uterotonic ladder, the 4 T's, balloon tamponade and the surgical ladder live in the primary postpartum haemorrhage topic. This topic is the transfusion, coagulopathy and protocol science that sits underneath them.^[1]

Overview and definition

There is no single definition, and examiners know it. Give the family of thresholds, then say which one you would use to act. ^[1][2]

• Volume: loss of 2500 mL or more; or one whole blood volume in 24 hours; or 50% of blood volume within 3 hours.^[1][2]
• Transfusion: 4 or more units of red cells (many obstetric protocols use 5 or more, which is the threshold the Welsh national cohort applied alongside a 2500 mL loss).^[14][1]
• Rate: ongoing loss of about 150 mL/min, which is where the laboratory can no longer keep pace with you.^[2][1]
• Physiology: any bleeding with hypovolaemic compromise, regardless of the measured number.^[2][1]

Classify the coagulopathy, not just the volume. Four mechanisms, and they demand different products: ^[20][7]

• Dilutional — crystalloid and red cells without factor replacement.
• Consumptive (DIC) — tissue factor exposure driving thrombin generation and fibrinogen consumption.
• Hyperfibrinolytic — excess plasmin activity; the target of tranexamic acid.
• Pre-existing — inherited bleeding disorder, anticoagulant effect, liver disease.^[20][3]

References24ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
2. [2]Robinson D, Basso M, Chan WS, et al. Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock J Obstet Gynaecol Can, 2022.PMID 36567097
3. [3]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.PMID 28456509
4. [4]Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients Lancet, 2018.PMID 29126600
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9. [9]Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial Br J Anaesth, 2015.PMID 25586727
10. [10]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.PMID 33713384
11. [11]Mallaiah S, Barclay P, Harrod I, et al. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage Anaesthesia, 2015.PMID 25289791
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19. [19]Iba T, Levy JH, Maier CL, et al. Updated definition and scoring of disseminated intravascular coagulation in 2025: communication from the ISTH SSC Subcommittee on Disseminated Intravascular Coagulation J Thromb Haemost, 2025.PMID 40216223
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