Massive Blood Transfusion During Hospitalization for Delivery in New York State, 1998–2007

Abstract

OBJECTIVE To define the frequency, risk factors, and outcomes of massive transfusion in obstetrics. METHODS The State Inpatient Dataset for New York (1998–2007) was used to identify all delivery hospitalizations for hospitals that reported at least one delivery-related transfusion per year. Multivariable logistic regression analysis was performed to examine the relationship between maternal age, race, and relevant clinical variables and the risk of massive blood transfusion defined as 10 or more units of blood recorded. RESULTS Massive blood transfusion complicated 6 of every 10,000 deliveries with cases observed even in the smallest facilities. Risk factors with the strongest independent associations with massive blood transfusion included abnormal placentation (1.6/10,000 deliveries, adjusted odds ratio [OR] 18.5, 95% confidence interval [CI] 14.7–23.3), placental abruption (1.0/10,000, adjusted OR 14.6, 95% CI 11.2–19.0), severe preeclampsia (0.8/10,000, adjusted OR 10.4, 95% CI 7.7–14.2), and intrauterine fetal demise (0.7/10,000, adjusted OR 5.5, 95% CI 3.9–7.8). The most common etiologies of massive blood transfusion were abnormal placentation (26.6% of cases), uterine atony (21.2%), placental abruption (16.7%), and postpartum hemorrhage associated with coagulopathy (15.0%). A disproportionate number of women who received a massive blood transfusion experienced severe morbidity including renal failure, acute respiratory distress syndrome, sepsis, and in-hospital death. CONCLUSION Massive blood transfusion was infrequent, regardless of facility size. In the presence of known risk for receipt of massive blood transfusion, women should be informed of this possibility, should deliver in a well-resourced facility if possible, and should receive appropriate blood product preparation and venous access in advance of delivery.

Revisit of risk factors for major obstetric hemorrhage: insights from a large medical center

“…In the current report, the primary etiologies for major obstetric hemorrhage were obstetric trauma, abnormal placentation, and uterine atony, while others reported leading causes for severe postpartum hemorrhage to be abnormal placentation, uterine atony, and placental abruption [5]. Nevertheless, comparison of this series to others is difficult because of different definitions of major obstetric hemorrhage and varying inclusion criteria.…”

“…Using these criteria, the incidence of major obstetric hemorrhage event in the current study is within the range reported for developed countries: the Scottish confidential audit of severe maternal morbidity noted a rate of 5.9/1000 births during 2011 [22] and the Canadian incidence of PPH requiring hysterectomy or transfusion was 1.04/1000 births between 1998 and 2000 [23]. A population level analysis in New York State calculated the expected incidence of C10 RBC units transfusion in facilities with delivery volume [4000 births annually as 0.8/1000 deliveries [5].…”

“…This may be an outcome of medically indicated/induced preterm delivery rather than an outcome of major obstetric hemorrhage; higher numbers of previous Arch Gynecol Obstet cesarean sections, abnormal placentation, and/or a hypertensive disorder probably mandated an indication for preterm delivery and all were more common among women in the major obstetric hemorrhage group. Hysterectomy, whether emergent or planned, was performed in 36.9 % of women with major obstetric hemorrhage, as noted in a previous publication [5]; emergent hysterectomy was performed in 26.2 % of major obstetric hemorrhage women [39]. We suggest that the strict definition of massive hemorrhage, the greater emergency of the cases, and the high percentage of abnormal/invasive placentation in this group of patients are among the underlying causes for the relatively high hysterectomy rate in our study.…”

“…As much as 30 %, and in some countries more than 50 % of maternal mortality, is due to hemorrhage, primarily in the postpartum period [2][3][4]. The challenge of identifying and reducing risk factors for major obstetric hemorrhage is also relevant in developed countries where these events are increasingly seen [5][6][7], especially because of complications of overinvasive placentation and postpartum hemorrhage (PPH) [8][9][10][11][12].Real-time assessment and/or quantification of blood loss perinatally is notoriously difficult to assess leading to underestimation of the amount of maternal blood loss [13]; therefore, for this analysis it was decided to circumscribe the study population to women with no co-morbidities (e.g., pre-existing maternal anemia) posing potentially catastrophic outcomes and to specify transfusion of C5 packed red blood cells (pRBC) units at birth.Our purpose was to identify the incidence of major obstetric hemorrhage and revisit clinical and peripartum obstetric risk factors, both modifiable and non-modifiable, for major obstetric hemorrhage, and assess related neonatal outcome. …”

“…As much as 30 %, and in some countries more than 50 % of maternal mortality, is due to hemorrhage, primarily in the postpartum period [2][3][4]. The challenge of identifying and reducing risk factors for major obstetric hemorrhage is also relevant in developed countries where these events are increasingly seen [5][6][7], especially because of complications of overinvasive placentation and postpartum hemorrhage (PPH) [8][9][10][11][12].…”