904 PART IX Obstetric Complications
TABLE 38-6 Karakteristik Komponen Darah
Komponen Dosis Volume per dosis
Packed red 1 unit 250-325 mL
blood cells
Fresh frozen Factor replacement: 200 mL
plasma 10-15 mL/kg
Platelets 4-6 units of pooled 200-250 mL
whole blood–derived
platelets or one unit
of apheresis platelets
Cryoprecipitate 10 pooled units 100 mL
aPTT, activated partial thromboplastin time; INR, international normalized ratio; PT, prothrombin time.
Modified from Sanford K, Roseff S. A surgeon’s guide to blood banking and transfusion medicine. In: Spiess BD, Spence RK, Shander A,
editors. Perioperative Transfusion Medicine, 2nd edition. Philadelphia, Lippincott Williams and Wilkins, 2006: 179-98.
than two times normal.221 FFP should not be used to treat
hypovolemia or as a protein supplement. One unit of FFP
per 20 kg of body weight (or 10 to 15 mL/kg body
weight) is an appropriate initial dose.221 The prophylactic
use of FFP is not effective for decreasing blood loss in
patients at risk for massive blood loss.222
Cryoprecipitate is prepared from thawed FFP and
contains fibrinogen, factor VIII, von Willebrand factor,
fibronectin, and factor XIII. In the setting of postpartum
hemorrhage, cryoprecipitate is used to replace fibrino-
gen, which is rapidly consumed during obstetric hemor-
rhage. Normal pregnancy is a hypercoagulable state,258,259
and coagulation activity peaks at the time of parturi-
tion260,261 because of an increase in circulating tissue
factor concentration and enhancement of the tissue
factor–dependent coagulation pathway.262 It is postulated
that tissue factor and other procoagulant substances are
released from the placental implantation site at the time
of placental separation, augmenting thrombin formation
and serving an important hemostatic function after deliv-
ery.48 In the setting of continued bleeding from the pla-
cental bed, these thromboplastic substances may continue
to enter the circulation and, in severe cases, may lead to
a consumptive coagulopathy and DIC.48
The consumption of fibrinogen appears to play a
central role in the pathophysiology of peripartum hemor-
rhage.263 Charbit et al.188 prospectively identified 128
patients who had postpartum hemorrhage and classified
the hemorrhage as severe (decrease in hemoglobin con-
centration of ≥ 4 g/dL, transfusion of ≥ 4 units PRBCs,
or invasive hemostatic intervention required) or nonse-
vere.188 At the time postpartum hemorrhage was diag-
nosed, patients who subsequently developed severe
hemorrhage had lower fibrinogen, prothrombin, factor
V, and antithrombin levels compared with patients
without severe hemorrhage. These early differences were
most marked for fibrinogen. A fibrinogen concentration
less than 200 mg/dL at the time hemorrhage was diag-
nosed had a 100% positive predictive value for severe
hemorrhage; a fibrinogen concentration greater than
Umur Simpan Kondisi Penyimpanan Respon yang diharapkan
21-42 hari 1° C to 6° C meningkatkan
konsentrasi
hemoglobin 1g/dl
Frozen: 1 th Frozen: ≤ −18° C Correction of PT,
dicairkan: 24 jam dicairkan1° C sampai aPTT, INR by
10° C replacement of
coagulation factors
5 hari Increase in platelet
20° C to 24° C with count of 30,000-
continuous and 60,000/mm3
gentle agitation
Frozen: 1 hari Increase in levels of
dicairkan/ fibrinogen, von
pooled: 4 h 10° C ≤ −18°
Frozen: C Willebrand factor,
Thawed: 1° C to factor VIII, factor XIII
400 mg/dL had a 79% negative predictive value for
severe hemorrhage. The coagulation changes were con-
sistent with a consumptive coagulopathy because they
were accompanied by increases in thrombin-antithrombin
complexes and d-dimer levels, both markers of excessive
coagulation. Furthermore, because the fall in fibrinogen
concentration was twice the fall in hemoglobin concen-
tration, it was believed that dilution did not account for
the difference in fibrinogen levels between the two
groups. Other investigators have confirmed that decreases
in fibrinogen correlate better than other hemostatic mea-
sures with the severity of hemorrhage.264,265
The alarmingly rapid consumption of coagulation
factors, especially fibrinogen, during obstetric hemor-
rhage has prompted experts to recommend early
monitoring for, and aggressive treatment of, hypofibrino-
genemia with rapid central laboratory or point-of-care
testing.266-268 During active hemorrhage, clinicians should
attempt to maintain the fibrinogen concentration higher
than 150 to 200 mg/dL.268 Each dose of cryoprecipitate
supplied by most blood banks contains 5 to 10 single-
donor units of cryoprecipitate, and each unit of cryopre-
cipitate contains approximately twice the fibrinogen of 1
unit of FFP. Therefore, the most efficient method to
replace fibrinogen during obstetric hemorrhage may be
to administer cryoprecipitate.269 In a multicenter pro-
spective cohort study of trauma victims (n = 1175),
administration of cryoprecipitate compared with large
doses of FFP was associated with a decreased risk for
multiorgan failure.270 In a small case series of obstetric
hemorrhage associated with hypofibrinogenemia, fibrin-
ogen concentrate was used to restore fibrinogen levels.271
This product is currently approved for the treatment of
acute bleeding in individuals with congenital hypofibrin-
ogenemia. Further study is required to clarify its role in
the treatment of the acquired hypofibrinogenemia associ-
ated with obstetric hemorrhage.263,270
Thrombocytopenia may develop after massive trans-
fusion secondary to dilution or in association with obstet-
ric comorbidities such as HELLP syndrome. Platelet