<![CDATA[Major obstetric hemorrhage remains a critical cause of maternal morbidity and mortality, requiring rapid yet precise transfusion management to prevent coagulopathy and adverse outcomes. We report a case series of seven obstetric patients with major perioperative hemorrhage managed using rotational thromboelastometry (ROTEM) guided transfusion at a tertiary referral center. The patients, predominantly with placenta accreta spectrum disorders, placenta previa, uterine atony, and one case of idiopathic thrombocytopenic purpura, experienced a wide range of estimated blood loss from 200 to 4500 mL. ROTEM assessment using EXTEM and FIBTEM parameters was performed during active bleeding to identify specific coagulation abnormalities and guide transfusion decisions. All patients received packed red cell transfusion, while fibrinogen replacement, fresh frozen plasma, platelet concentrates, and tranexamic acid were administered selectively based on viscoelastic findings rather than estimated blood loss alone. Four patients received tranexamic acid due to evidence of impaired clot stability, whereas others with preserved clot firmness were managed without empiric plasma or antifibrinolytic therapy despite significant hemorrhage. One patient with minimal bleeding required platelet transfusion after ROTEM detected qualitative platelet dysfunction. All patients achieved hemodynamic stabilization without major transfusion-related complications or need for reoperation. This case series highlights the clinical value of ROTEM in enabling goal-directed, individualized transfusion strategies in obstetric hemorrhage, emphasizing that viscoelastic-guided management may optimize hemostasis while limiting unnecessary blood product exposure.]]>
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