Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

Abstract

Summary Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world‐wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi‐national cohort study of MOH defined as bleeding at ≥20 weeks’ gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4 h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2 g/l) occurred in 52% of cases in the first 24 h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7–7·2), placenta praevia (OR 7·2, 95% CI: 2·0–26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0–11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.

Outcomes in emergency versus elective cases of placenta accreta spectrum disorder managed by caesarean-hysterectomy within a dedicated multidisciplinary care team: retrospective cohort study.

“…(Nicolaides, 2018). Median Apgar scores at 5 minutes were also lower in the emergency delivery group compared to the elective delivery group (Apgar 5-minutes, median IQR 9 [0] versus 8 [5][6][7][8][9], p<0.001), though no differences in mean arterial or venous cord pH values, or base excess were found. Perinatal death rates, including termination of pregnancy, were higher in the emergency delivery group compared to the elective delivery group (20% versus 3%, p=0.001).…”

“…Comparison of outcomes following emergency versus elective caesarean-hysterectomy by a dedicated and specialized multidisciplinary PAS team has demonstrated significantly poorer outcomes with emergency surgery 8 . In this context, emergency surgery is an independent risk factor for massive blood loss and blood product transfusion requirements 9 . Data comparing maternal and perinatal outcomes between emergency and elective delivery in patients with PAS disorders is presently lacking in Canada.…”

Emergencies in obstetric anaesthesia: a narrative review

“…Levels tend to fall below 4 g.l ‐1 after 2 l blood loss and below 2 g.l ‐1 after 4 l loss [38]. Hypofibrinogenaemia can develop well before prolongation of the activated partial thromboplastin time/prothrombin time and thrombocytopenia, particularly after placental abruption [52–55]. Despite this, trials of empiric fibrinogen concentrate administration without laboratory testing in PPH > 1500 ml have been disappointing (Table 3) [56–58].…”

The Role of Thromboelastography during the Management of Postpartum Hemorrhage: Background, Evidence, and Practical Application

“…33 Four PPH studies defining massive PPH as requiring RBC transfusion ≥4 units reported an incidence of lowest fibrinogen levels of <2 g/L in >24% of cases. 14 47 48 49 A reduction in platelet count and prolongation of aPTT/PT were also reported, although only a minority reached treatment levels (platelets <75 × 10 9 /L in 5% and PT/aPTT >1.5× reference range in 3%). 49 In a very severe cohort requiring ≥8 units RBC transfusion, >60% developed plasma fibrinogen <2 g/L at some time during the bleed.…”