By PPH Foundation
Postpartum haemorrhage is often framed as a problem of uterine atony or delayed access to care, but emerging evidence shows that hidden coagulation disorders, both inherited and acquired, play a far more significant role than commonly reported. Recent research demonstrates that failure of blood clotting mechanisms during and after childbirth can rapidly escalate bleeding severity, turning otherwise manageable cases into life-threatening emergencies.
A 2023 cohort study published in the Journal of Thrombosis and Haemostasis shows that acute obstetric coagulopathy during postpartum haemorrhage is driven by hyperfibrinolysis and dysfibrinogenemia, meaning the body breaks down clots too quickly or fails to form stable fibrin clots. This process has been identified as a key driver of severe and rapidly escalating postpartum haemorrhage cases in high-risk obstetric populations.
Importantly, pregnancy itself creates a delicate balance in the coagulation system. While it is a naturally hypercoagulable state designed to prevent bleeding during delivery, this balance can quickly collapse in complications such as placental abruption, sepsis, pre-eclampsia, or massive haemorrhage, leading to disseminated intravascular coagulation, a life-threatening condition where clotting factors are consumed faster than they can be replaced.
Recent reviews also show that coagulopathy is not a secondary event but often develops early in severe postpartum haemorrhage. A 2024 clinical review on obstetric haemorrhage highlights that coagulation failure is present in a significant proportion of severe cases and contributes directly to poor outcomes when not rapidly identified and treated.
Further evidence from large-scale obstetric studies confirms that coagulopathy is one of the key drivers of maternal mortality in postpartum haemorrhage, alongside uterine atony and trauma. Importantly, up to one in five severe PPH cases show measurable coagulation abnormalities at presentation, underscoring the need for early point-of-care testing and rapid transfusion protocols.
According to Prof Moses Obimbo, Project Lead at the PPH Foundation, “Postpartum haemorrhage is not only a problem of bleeding, it is a problem of failed clotting. Strengthening early detection of coagulation disorders is critical in preventing rapid deterioration and maternal deaths.”
Evidence-based approaches increasingly emphasize point-of-care coagulation testing, fibrinogen replacement therapy, and structured massive transfusion protocols as essential interventions in managing obstetric coagulopathy. A 2023 systematic review further shows that early guided correction of fibrinogen levels significantly reduces progression to severe haemorrhage and improves survival outcomes in obstetric emergencies.
As global maternal health strategies evolve, there is growing recognition that addressing coagulation disorders must sit at the centre of postpartum haemorrhage prevention and response frameworks, not as a secondary consideration but as a core determinant of survival.
Ultimately, understanding the hidden role of coagulation failure shifts the narrative from reactive bleeding control to early physiological prevention of collapse, offering a clearer path toward reducing preventable maternal deaths.
Sources
de Lloyd L, Jenkins PV, Bell SF et al., Acute obstetric coagulopathy during postpartum haemorrhage is caused by hyperfibrinolysis and dysfibrinogenemia, Journal of Thrombosis and Haemostasis, 2023, 21, 4, 862–879.
Gill N et al., Navigating coagulopathy in obstetric hemorrhage, Obstetric Anaesthesia and Critical Care Review, 2024.
Wormer KC et al., Postpartum hemorrhage, StatPearls Publishing, 2024 update, NCBI Bookshelf.
Collins PW et al., Acute obstetric coagulopathy and hyperfibrinolysis in severe PPH, Blood Advances commentary, 2025.
Erez O et al., Disseminated intravascular coagulation in pregnancy, Obstetric thrombosis review, 2022.
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