Transfusion and coagulation management in major obstetric hemorrhage

Multidisciplinary team training in postpartum hemorrhage: impact on the use of blood products

Objective

Compare the number of puerperal women submitted to blood transfusion before and after the implementation of a care protocol for postpartum hemorrhage (PPH) with multidisciplinary team training.

Methods

Cross-sectional study in a university hospital, analyzing births from 2015 to 2019, compared the use of blood products before and after the adoption of a PPH protocol with multidisciplinary training.

Results

Between 2015 and 2019, there were 17,731 births, with 299 (1.7%) postpartum women receiving blood products and 278 postpartum women were considered for this analysis, 128 (0.7%) at Time 1 and 150 (0.8%) at Time 2. After the multiprofessional team training (T2), there was a difference in the complete use of the PPH protocol (use of oxytocin, misoprostol and tranexamic acid) (T1 = 5.1% x T2 = 49.5%, p≤0.0001). An individual categorized analysis revealed that, in the T2 period, there was lower use of blood component units per patient compared to T1 (Mann-Whitney, p=0.006). It should be noted that at T1 and T2, 54% and 24% respectively received two units of blood products. It is important to highlight that after the multidisciplinary team training for the PPH protocol, the goal of zero maternal death due to hemorrhage was reached.

Conclusion

The adoption of a specific protocol for PPH, combined with the training of a multidisciplinary team, had an impact on the ability to identify women at high risk of hemorrhage, resulting in a decrease in the use of blood components.

Physiologic changes of pregnancy and considerations for screening and diagnosis of sepsis

Obstetric sepsis is a significant cause of morbidity and mortality in pregnant people worldwide. Initial evaluation and timely intervention are crucial to improving outcomes for birthing persons and their newborns. While many of the therapies and interventions for peripartum sepsis are consistent with the general population, there are considerations unique to pregnancy. Stabilization of the septic pregnant or immediately postpartum patient requires an understanding of the physiologic changes of pregnancy, hemodynamic changes during labor, and infections specific to pregnancy. We will review the interaction between pregnant physiology and sepsis pathophysiology, and how this can guide screening and diagnosis.

How do I implement pathogen reduced Cryoprecipitated fibrinogen complex in a tertiary Hospital's blood Bank

BACKGROUND

Kaiser-Permanente Los Angeles Medical Center (LAMC) is a 560 licensed bed facility that provides regional cardiovascular services, including 1200 open heart surgeries annually. In 2021, LAMC explored alternative therapies to offset the impact of pandemic-driven cryo AHF shortages, and implemented Pathogen Reduced Cryoprecipitated Fibrinogen Complex (also known as INTERCEPT Fibrinogen Complex or IFC). IFC is approved to treat and control bleeding associated with fibrinogen deficiency. Unlike cryo AHF, IFC has 5-day post-thaw shelf life with potential operational and clinical benefits. The implementation steps and the operational advantages to the LAMC Blood Bank are described.

STUDY DESIGN AND METHODS

Eighteen months post-implementation, the institution reviewed their product implementation experience and compared IFC with cryo AHF with a retrospective review of transfusion service and cardiac post-op data.

RESULTS

IFC significantly decreased product wastage rates and order-to-issue time. It did not significantly impact post-op product utilization or hospital length of stay (LOS) in cardiac surgery patients when compared with cryo AHF.

DISCUSSION

Implementation of IFC provides improved product supply stability, shorter turnaround times, and reduced wastage.

Antepartum hemorrhage due to placenta previa with autologous transfusion: A case report

INTRODUCTION AND IMPORTANCE

Bleeding during pregnancy or during childbirth can cause significant morbidity and mortality for the mother and baby, this can be overcome by performing a caesarean section (C-section) and blood transfusions. Although blood transfusions can save lives, there is a risk such as transfusion reactions, transmission of infection, and anaphylaxis. Giving autologous blood transfusion can reduce the risk of these events. This case report aims to investigate the advantages of autologous blood transfusion in managing the patient's hemodynamic status compared to homologous blood transfusion.

CASE PRESENTATION

A 21-year-old female (G2P1A0) with antepartum hemorrhage (APH) due to placenta previa underwent emergency C-section with intrauterine device installation and hysterectomy. The patient received an autologous transfusion to improving the hematocrits and hemoglobin within 30 min. Autologous transfusion provided routine postoperative hemodynamics, electrolytes, and blood stability. However, it could not completely replace homologous transfusion.

CLINICAL DISCUSSION

Autologous transfusion reduces transfusion response, infection risk, and immunosuppression. Consequently, it reduces the need for allogenic blood supplies and enables safer transfusion for people with rare blood types and various auto-antibodies.

CONCLUSION

Autologous transfusions may provide better outcomes in C-section surgery for APH patients due to placenta previa. Thus, we recommend the use of autologous over homologous transfusion. Further research is required to compare them to a large population.

Viscoelastic Testing in an Obstetric Population at High Risk of Hemorrhage

INTRODUCTION

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic test used in trauma for goal-directed transfusion. However, there are limited data on baseline ROTEM parameters in the U.S. obstetric population. Obtaining baseline parameters is a first step in implementing a goal-directed massive transfusion protocol in obstetric hemorrhage.

OBJECTIVE

Our study aimed to establish pre- and postdelivery baseline parameters in a high-risk obstetric population and determine their association with postpartum hemorrhage (PPH).

STUDY DESIGN

Prospective observational study of patients ≥34 weeks' gestation, at high risk of PPH, admitted for delivery. INTEM, EXTEM, FIBTEM, and APTEM assays were performed at the time of admission to labor and delivery and then 2 hours after delivery. Primary outcome was pre- and postdelivery ROTEM parameters among women without PPH. A sample size of 60 women was needed for >90% power to detect at least 50% correlation between pre- and postdelivery assuming a loss of 10% of participants to follow-up.

RESULTS

Of 60 women in the study, 10 (17%) had PPH. Baseline characteristics were not different between those with or without PPH. Pre- and postdelivery ROTEM parameters were not significantly different except for APTEM. None of the patients who had PPH, compared with 4 (10%) of those who did not, had shortened clotting time and higher maximum clot firmness in postdelivery APTEM compared with EXTEM, a pattern suggestive of hyperfibrinolysis (p = 0.4).

CONCLUSION

In this study, we describe baseline ROTEM parameters in women at high risk of PPH. The majority of patients did not have a ROTEM pattern that is suggestive of hyperfibrinolysis, for which tranexamic acid is thought to be beneficial. Based on our findings, previously established obstetric transfusion thresholds for goal-directed massive transfusion protocols are likely valid for the majority of the obstetric population regardless of the presence of comorbidities or pregnancy complications.

KEY POINTS

· ROTEM parameters do not vary significantly before and after delivery.. · Most patients did not have a hyperfibrinolysis pattern, for which tranexamic acid is thought to be beneficial.. · Previous goal-directed obstetric transfusion thresholds are likely valid in most populations..

Analyzing and modeling massive transfusion strategies and the role of fibrinogen-How much is the patient actually receiving?

BACKGROUND

Hemorrhage is a leading cause of preventable death in trauma, cardiac surgery, liver transplant, and childbirth. While emphasis on protocolization and ratio of blood product transfusion improves ability to treat hemorrhage rapidly, tools to facilitate understanding of the overall content of a specific transfusion strategy are lacking. Medical modeling can provide insights into where deficits in treatment could arise and key areas for clinical study. By using a transfusion model to gain insight into the aggregate content of massive transfusion protocols (MTPs), clinicians can optimize protocols and create opportunities for future studies of precision transfusion medicine in hemorrhage treatment.

METHODS

The transfusion model describes the individual round and aggregate content provided by four rounds of MTP, illustrating that the total content of blood elements and coagulation factor changes over time, independent of the patient's condition. The configurable model calculates the aggregate hematocrit, platelet concentration, percent volume plasma, total grams and concentration of citrate, percent volume anticoagulant and additive solution, and concentration of clotting factors: fibrinogen, factor XIII, factor VIII, and von Willebrand factor, provided by the MTP strategy.

RESULTS

Transfusion strategies based on a 1:1:1 or whole blood foundation provide between 13.7 and 17.2 L of blood products over four rounds. Content of strategies varies widely across all measurements based on base strategy and addition of concentrated sources of fibrinogen and other key clotting factors.

DISCUSSION

Differences observed between modeled transfusion strategies provide key insights into potential opportunities to provide patients with precision transfusion strategy.

Risk factors of massive blood transfusion (MTP) in cesarean hysterectomy for placenta accreta spectrum

BACKGROUND

Placenta Accreta Spectrum (PAS) represents a particularly morbid condition for which blood transfusion is the leading cause. Delivery by cesarean hysterectomy is recommended for the management of PAS. Massive Transfusion Protocols (MTP) in obstetrics vary in definition and implementation. Given the significant blood loss during PAS cesarean hysterectomy, this is particularly important for surgeons and blood banks. Our objective was to identify risk factors for MTP in patients with antenatally suspected PAS.

METHODS

We performed a case-control study over a 11-year period from 2012 to 2022 at our center for Placenta Accreta Spectrum. MTP was defined by two methods, >4 units or > 10 units of red blood cells/whole blood transfused over 24 h. Antenatal, operative and post-operative outcomes were obtained from electronic medical records of these cases.

RESULTS

During the study time frame, 142 cases were managed by our PAS team and met all criteria. 85 % (120/142) of patients were transfused at least 1 unit of blood, 64 patients (45 %) received 0-3 units of blood, 50 patients (35 %) received 4-9 units of blood and 28 patients (19.7 %) were transfused > 10 units of blood. Pre-delivery vaginal bleeding, preterm labor and delivery < 34 weeks were independently significant in transfused patients. ROC analysis revealed an area under the curve (AUC) of 0.79 (p < 0.0001) in patients transfused > 10 units, showing predictive capability for this subgroup.

DISCUSSION

We here report pre-operative risk factors for MTP in patients undergoing cesarean hysterectomy for PAS. This allows for both resource utilization and patient counseling for this morbid maternal condition.

Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines

OBJECTIVE

To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.

DESIGN

Comparative study.

SETTING

High-resource countries.

POPULATION

Women with PPH.

METHODS

Systematic comparison of guidance on PPH from eight high-income countries.

MAIN OUTCOME MEASURES

Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour.

CONCLUSIONS

Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines.

RESULTS

Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Red Blood Cell Transfusion after Postpartum Hemorrhage: Clinical Variables Associated with Lack of Postpartum Hemorrhage Etiology Identification

Postpartum hemorrhage (PPH) remains a significant obstetric emergency worldwide and a leading cause of maternal death. However, it is commonly underreported, which can represent a major concern for maternal morbidity and mortality. This retrospective case series study analyzed patients with red blood cell transfusion (RBCt) in the postpartum period over a four-year interval at a specific center. A total of 18,674 patients delivered between January 2018 and December 2021. Patients with postpartum RBCt were classified into two groups: those with identified PPH (i-PPH) and those without (non-i-PPH). Clinical variables, delivery details, blood loss data, and treatment information were collected. Statistical analysis involved a comparison of variables between the i-PPH and non-i-PPH groups. Univariate and multivariate analyses were performed, aiming to identify significant associations between the clinical variables and a lack of PPH identification. The incidence of RBCt was 1.26% (236 cases). Patients receiving RBCt had higher rates of cesarean delivery, twin pregnancy, labor induction, and previous cesarean section. Among patients with postpartum RBCt, 34.3% lacked an identified PPH. The rarity of postpartum RBCt contrasts with the increasing rates of PPH, highlighting the importance of diagnosing PPH and postpartum anemia. A strategy of systematic quantification of blood loss during delivery could help detect PPH and anemia before adverse consequences occur.

Blood component therapy in patients having massive obstetric hemorrhage in a tertiary care center in Puducherry

INTRODUCTION

A proper transfusion protocol must be followed for every patient with massive obstetric hemorrhage (MOH), as each patient may need a different pattern of transfusion support. In this background, it is prudent to understand the current prevalent practices and devise preparatory strategies for managing blood requirements during such scenarios. This study helps us know the pattern and type of blood components given to patients with MOHs.

METHODOLOGY

This prospective cross-sectional study was conducted on patients with a MOH admitted to a single center at a tertiary care teaching hospital in Puducherry between January 2020 and October 2021. During the hospital stay, patient parameters such as diagnosis, obstetric history, blood loss, transfusion of blood products, transfusion reaction, blood group, length of hospital stay, laboratory parameters, and patient vitals and comorbidities were recorded in a predesigned pro forma and tabulated into Excel sheet and analyzed using SPSS software version 19.0.

RESULTS

Fifty-four patients with MOH were included in our study. The median blood loss was 2.15 L, with a range of 2 L. The mean difference between the baseline and posthemorrhage hemoglobin is 1.7 g/dl. No correlation was observed between the number of packed red blood cell (PRBC) transfused and baseline hemoglobin or between random donor platelets (RDP) transfusion and baseline platelet count. The median number of hospital stays was 10 days, ranging from 7 to 14.5 days. Eleven (20.38%) patients had a hysterectomy done to control bleeding. The remaining 43 patients were managed successfully by other measures such as medical management, compressive surgical suturing, and arterial ligation. Forty-eight (88.9%) patients survived, and 6 (11.1%) patients expired.

CONCLUSION

The percentage of RDP and cryoprecipitate transfused to the patients was less than PRBC and fresh frozen plasma (FFP). The FFP-to-PRBC ratio was 2. Regular transfusion audits must be conducted to assess the flaws and improve current strategies.

Anesthesia Considerations for Placenta Accreta Spectrum

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..

Patient Blood Management in Pregnancy

BACKGROUND

Patient blood management (PBM) is a multidisciplinary and patient-centered treatment approach, comprising the detection and treatment of anemia, the minimization of blood loss, and the rational use of allogeneic transfusions. Pregnancy, delivery, and the puerperium are associated with increased rates of iron deficiency and anemia, which correlates with worse maternal and fetal outcomes and places pregnant women at increased risk of obstetric hemorrhage.

SUMMARY

Early screening for iron deficiency before the onset of anemia, as well as the use of oral and intravenous iron to treat iron deficiency anemia, has been shown to be beneficial. Anemia in pregnancy and the puerperium should be treated according to a staged regimen, administering either iron alone or in combination with an off-label use of human recombinant erythropoietin in selected patients. This regimen should be tailored to the needs of each individual patient. Postpartum hemorrhage (PPH) accounts for up to one-third of maternal deaths in both developing and developed countries. Bleeding complications should be anticipated and blood loss reduced by interdisciplinary preventive measures and individually tailored care. It is recommended that facilities have a PPH algorithm, primarily focusing on prevention through use of uterotonics, but also incorporating early diagnosis of the cause of bleeding, optimization of hemostatic conditions, timely administration of tranexamic acid, and integration of point-of-care tests to support the guided substitution of coagulation factors, alongside standard laboratory tests. Additionally, cell salvage has proven beneficial and should be considered for various indications in obstetrics including hematologic disturbances, as well as various forms of placental disorders.

KEY MESSAGE

This article reviews PBM in pregnancy, delivery, and the puerperium. The concept comprises early screening and treatment of anemia and iron deficiency, a transfusion and coagulation algorithm during delivery, as well as cell salvage.

Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management

Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.

Beyond uterine atony: characterizing postpartum hemorrhage coagulopathy

BACKGROUND

Postpartum hemorrhage is a leading cause of morbidity and mortality worldwide, yet the associated early coagulopathy is not well defined.

OBJECTIVE

We hypothesized that women who develop postpartum hemorrhage have a distinct derangement of thrombin generation and coagulation factors compared with postpartum women without postpartum hemorrhage.

STUDY DESIGN

This prospective study of pregnant patients with postpartum hemorrhage was completed at a single urban hospital. Blood was drawn on postpartum hemorrhage diagnosis and 2 and 4 hours later. Assays of patients with postpartum hemorrhage included thrombelastography, whole blood thrombin generation, coagulation factor activity, tissue factor levels and activity, and tissue factor pathway inhibitor levels, which were compared with that of patients without postpartum hemorrhage.

RESULTS

A total of 81 patients were included in this study. Of those patients, 66 had postpartum hemorrhage, and 15 served as controls. Compared with patients without PPH, patients with postpartum hemorrhage had lower fibrinogen levels (469.0 mg/dL vs 411.0 mg/dL; P=.02), increased tissue plasminogen activator resistance (fibrinolysis 30 minutes after maximal clot strength: 8.7% vs 4.2%; P=.02), decreased peak thrombin concentration (150.2 nM vs 40.7 nM; P=.01), and decreased maximal rate of thrombin generation (60.1 nM/minute vs 2.8 nM/minute; P=.02). Furthermore, compared with patients without postpartum hemorrhage, patients with postpartum hemorrhage had decreased tissue factor levels (444.3 pg/mL vs 267.1 pg/mL; P=.02) and increased tissue factor pathway inhibitor levels (0.6 U/mL vs 0.8 U/mL; P=.04), with decreased tissue factor pathway inhibitor ratios (624 vs 299; P=.01).

CONCLUSION

PPH is not only an issue of uterine tone and mechanical bleeding but also a distinct coagulopathy that is characterized by decreased fibrinogen level, clot breakdown resistance, and markedly low thrombin generation. This pathology seemed to be driven by low tissue factor and high tissue factor pathway inhibitor levels.

Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trial

BACKGROUND

Postpartum haemorrhage causes significant mortality among parturients. Early transfusion of blood products based on clinical judgement and conventional coagulation testing has been adapted to the treatment of postpartum haemorrhage, but rotational thromboelastometry (ROTEM) may provide clinicians means for a goal-directed therapy to control coagulation. We conducted a parallel design, randomised, controlled trial comparing these two approaches. We hypothesised that a ROTEM-guided protocol would decrease the need for red blood cell transfusion.

METHODS

We randomised 60 parturients with postpartum haemorrhage of more than 1500 ml to receive either ROTEM-guided or conventional treatment, with 54 patients included in the final analysis. The primary outcome was consumption of blood products, and secondarily we assessed for possible side-effects of managing blood loss such as thromboembolic complications, infections, and transfusion reactions.

RESULTS

The median (25th-75th percentile) number of RBC units transfused was 2 (1-4) in the ROTEM group and 3 (2-4) in the control group (P=0.399). The median number of OctaplasLG® units given was 0 in both groups (0-0 and 0-2) (P=0.030). The median total estimated blood loss was 2500 ml (2100-3000) in the ROTEM group and 3000 ml (2200-3100) in the control group (P=0.033). No differences were observed in secondary outcomes.

CONCLUSIONS

ROTEM-guided treatment of postpartum haemorrhage could have a plasma-sparing effect but possibly only a small reduction in total blood loss.

CLINICAL TRIAL REGISTRATION

NCT02461251.

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Latest advances in postpartum hemorrhage management

Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. Anesthesiologists rely on clinical and diagnostic information for initiating and evaluating medical management. Therefore, we review modalities for measuring blood loss after delivery, which includes visual, volumetric, gravimetric, and colorimetric approaches. Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.

Clinical Results of a Massive Blood Transfusion Protocol for Postpartum Hemorrhage in a University Hospital in Japan: A Retrospective Study

Background and objectives: Massive postpartum hemorrhage (PPH) is the most common cause of maternal death worldwide. A massive transfusion protocol (MTP) may be used to provide significant benefits in the management of PPH; however, only a limited number of hospitals use MTP protocol to manage massive obstetric hemorrhages, especially in Japan. This study aimed to assess the clinical outcomes in patients in whom MTP was activated in our hospital. Materials and Methods: We retrospectively reviewed the etiology of PPH, transfusion outcomes, and laboratory findings among the patients treated with MTP after delivery in our hospital. Results: MTP was applied in 24 cases (0.7% of deliveries). Among them, MTP was activated within 2 h of delivery in 15 patients (62.5%). The median estimated blood loss was 5017 mL. Additional procedures to control bleeding were performed in 19 cases, including transarterial embolization (18 cases, 75%) and hysterectomy (1 case, 4.2%). The mean number of units of red blood cells, fresh frozen plasma, and platelets were 17.9, 20.2, and 20.4 units, respectively. The correlation coefficients of any two items among red blood cells, fresh frozen plasma, platelets, blood loss, and obstetrical disseminated intravascular coagulation score ranged from 0.757 to 0.892, indicating high levels of correlation coefficients. Although prothrombin time and activated partial thromboplastin time levels were significantly higher in the <150 mg/dL fibrinogen group than in the ≥150 mg/dL fibrinogen group at the onset of PPH, the amount of blood loss and blood transfusion were comparable between the two groups. Conclusions: Our MTP provides early access to blood products for patients experiencing severe PPH and could contribute to improving maternal outcomes after resuscitation in our hospital. Our study suggests the implementation of a hospital-specific MTP protocol to improve the supply and utilization of blood products to physicians managing major obstetric hemorrhage.

Anesthetic management for Placenta Accreta

Дослідження виконані у 82 вагітних і породіль при кесаревому розтині з приводу передлежання плаценти з вростанням на 37–38 тижні. Органозберігаюча операція була виконана за такою методикою: лапаротомія за Джоель Кохен, донний кесарів розтин з залишенням плаценти, перев’язка трьох пар магістральних маткових судин і внутрішніх клубових артерій з обох сторін (поетапна деваскуляризація матки) з подальшим видаленням стінки матки (метропластика) при вростанні плаценти. Операції виконані в умовах спінальної анестезії (Сан) 0,5 % гіпербаричним розчином бупівакаїну. Інфузійна програма будувалася відповідно до рекомендацій з обмежувальної інфузії. Преінфузію проводили збалансованим кристалоїдом Реосорбілакт (10–15 мл/кг) з подальшим введенням на етапах операції збалансованого кристалоїду і компонентів крові за необхідності. Оцінювали гемодинаміку, КОР та електроліти крові. Оцінку крововтрати проводили гравіметричним способом. Дослідження показали, що Сан і Реосорбілакт у програмі малооб’ємної інфузійної терапії зберігають доставку кисню на фізіологічному рівні, стабілізують гемодинамічний профіль і КОР. При вростанні плаценти використання сучасних технологій в анестезіології реаніматології та акушерстві, з мультидисциплінарним підходом, дозволяють реалізувати органозберігаючу тактику у цієї категорії жінок

How Can Rotational Thromboelastometry as a Point-of-Care Method Be Useful for the Management of Secondary Thromboprophylaxis in High-Risk Pregnant Patients?

Thromboprophylaxis with low-molecular-weight heparin (LMWH) for patients with a history of venous thromboembolism (VTE) is suggested. Rotational thromboelastometry (ROTEM^®) represents an innovative point-of-care method enabling the complex and quick evaluation of hemostasis. However, there are only episodic cases of its use for hemostasis assessment and guidance of LMWH in pregnancy. Therefore, we provide the results of unique prospective and longitudinal monitoring of hemostasis in high-risk pregnant women, which we used for the individualized optimalization of secondary thromboprophylaxis. According to the shortening of clot formation time (CFT) in EXTEM (p = 0.0007 from the 26th gestational week vs. controls) and INTEM (p = 0.002 from the 35th gestational week), increase in alpha angle (AA) in EXTEM, INTEM, and HEPTEM, and the persistence of increase in maximum clot firmness (MCF) in EXTEM, INTEM, and HEPTEM (p < 0.001 from the 26th and 35th gestational week vs. controls for EXTEM and INTEM, p = 0.0012 from the 26th gestational week in HEPTEM), LMWH dose was modified. Even after the postpartum period, AA in EXTEM was steeper than in controls (p = 0.0007), indicating that hemostasis is not fully normalized after 6–8 weeks following delivery. Therefore, ROTEM may be a useful tool for the individual evaluation of the termination of anticoagulant thromboprophylaxis.

Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report

Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.

When does obstetric coagulopathy occur and how do I manage it?

Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy 'in or out', decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.

RBC Inventory-Management System Based on XGBoost Model

It is difficult to predict RBC consumption accurately. This paper aims to use big data to establish a XGBoost Model to understand the trend of RBC accurately, and forecast the demand in time. XGBoost, which implements machine learning algorithms under the Gradient Boosting framework can provide a parallel tree boosting. The daily RBC usage and inventory (May 2014-September 2017) were investigated, and rules for RBC usage were analysed. All data were divided into training sets and testing sets. A XGBoost Model was established to predict the future RBC demand for durations ranging from a day to a week. In addition, the alert range was added to the predicted value to ensure RBC demand of emergency patients and surgical accidents. The gap between RBC usage and inventory was fluctuant, and had no obvious rule. The maximum residual inventory of a certain blood group was up to 700 units one day, while the minimum was nearly 0 units. Upon comparing MAE (mean absolute error):A:10.69, B:11.19, O:10.93, and AB:5.91, respectively, the XGBoost Model was found to have a predictive advantage over other state-of-the-art approaches. It showed the model could fit the trend of daily RBC usage. An alert range could manage the demand of emergency patients or surgical accidents. The model had been built to predict RBC demand, and the alert range of RBC inventory is designed to increase the safety of inventory management.

Characteristics of Nontrauma Patients Receiving Prehospital Blood Transfusion with the Same Triggers as Trauma Patients: A Retrospective Observational Cohort Study

Objective: While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers. Methods: We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse. Results: Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56-73] vs 37 [IQR 25-57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84-119] vs 124 [108-133], p < 0.0001), higher pH (median 7.40 [7.27-7.44] vs 7.30 [7.19-7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45-81] vs 72 [58-86], p = 0.0261) than the trauma patients. Conclusions: We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.

Practical approach to transfusion management of post-partum haemorrhage

OBJECTIVES

To describe transfusion management during post-partum haemorrhage (PPH) and the usefulness of standard or point-of-care (POC) laboratory tests for guiding haemostatic management.

BACKGROUND

PPH is the leading cause of maternal mortality and severe maternal morbidity worldwide. Despite the efforts made in recent years, PPH is often burdened by preventable death. Recent data from the active Italian Obstetric Surveillance System (ItOSS) highlighted the following main critical issues: inadequate communication between healthcare professionals, inability to correctly and promptly assess the severity of haemorrhage, delays in diagnosis and treatment, failure to request blood promptly and inappropriate monitoring post-partum.

MATERIALS AND METHODS

Data in the literature have been compared with the rotational thromboelastometry (ROTEM)- and the thromboelastography (TEG)-guided algorithms applied in the authors' departments.

RESULTS

PPH transfusion therapy may have an empirical approach based on the standard use of blood products or a targeted approach based on coagulation monitoring by laboratory or POC tests. Here, the authors describe how they manage PPH in their departments, according to the Italian guidelines, along with the addition of a ROTEM- and a TEG-guided algorithms developed by themselves.

CONCLUSION

Although the proposed algorithms have not been validated by trials or observational studies conducted in our departments, we believe that these indications could be useful for supporting clinical practice. Furthermore, we deem it appropriate to emphasise the importance of a multidisciplinary approach and the need for standardised and shared protocols to support the decisions of healthcare professionals.

Association between ionised calcium and severity of postpartum haemorrhage: a retrospective cohort study

BACKGROUND

Postpartum haemorrhage (PPH) is often complicated by impaired coagulation. We aimed to determine whether the level of ionised calcium (Ca²⁺), an essential coagulation co-factor, at diagnosis of PPH is associated with bleeding severity.

METHODS

This was a retrospective cohort study of women diagnosed with PPH during vaginal delivery between January 2009 and April 2020. Ca²⁺ levels at PPH diagnosis were compared between women who progressed to severe PPH (primary outcome) and those with less severe bleeding. Severe PPH was defined by transfusion of ≥2 blood units, arterial embolisation or emergency surgery, admission to ICU, or death. Associations between other variables (e.g. fibrinogen concentration) and bleeding severity were also assessed.

RESULTS

For 436 patients included in the analysis, hypocalcaemia was more common among patients with severe PPH (51.5% vs 10.6%, P<0.001). In a multivariable logistic regression model, Ca²⁺ and fibrinogen were the only parameters independently associated with PPH severity with odds ratios of 1.14 for each 10 mg dl^-1 decrease in fibrinogen (95% confidence interval [CI], 1.05-1.24; P=0.002) and 1.97 for each 0.1 mmol L^-1 decrease in Ca²⁺ (95% CI, 1.25-3.1; P=0.003). The performance of Ca²⁺ or fibrinogen was not significantly different (area under the curve [AUC]=0.79 [95% CI, 0.75-0.83] vs AUC=0.86 [95% CI, 0.82-0.9]; P=0.09). The addition of Ca²⁺ to fibrinogen improved the model, leading to AUC of 0.9 (95% CI, 0.86-0.93), P=0.03.

CONCLUSIONS

Ca²⁺ level at the time of diagnosis of PPH was associated with risk of severe bleeding. Ca²⁺ monitoring may facilitate identification and treatment of high-risk patients.

Minimally Invasive Hemodynamic Assessment during Obstetric Hysterectomy for Invasive Placentation with Epidural Anesthesia

Background

The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia.

Methods

A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d).

Results

The mean age of the patients was 29.2 ± 3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d = 0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d = -0.36, NS) and cardiac workload requirements (d = -0.29, P=0.034) toward the completion of surgery.

Conclusion

Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.

Fibrinogen Diagnostics in Major Hemorrhage

Fibrinogen is one of the first factors to fall to critically low levels in the blood in many coagulopathic events. Patients with hypofibrinogenemia are at a significantly greater risk of major hemorrhage and death. The rapid replacement of fibrinogen early on in hypofibrinogenemia may significantly improve outcomes for patients. Fibrinogen is present at concentrations between 2 and 4 g/L in the plasma of healthy people. However, hypofibrinogenemia is diagnosed when the fibrinogen level drops below 1.5-2 g/L. This review analyses different types of fibrinogen assays that can be used for diagnosing hypofibrinogenemia. The scientific mechanisms and limitations behind these tests are then presented. Additionally, the current state of clinical major hemorrhage protocols (MHPs) is presented and the structure, function and physiological role of fibrinogen is summarized.

Successful Perioperative Management with Damage Control Surgery in a Patient with Massive Postpartum Hemorrhage of More Than 20,000 mL

Disseminated intravascular coagulation (DIC) in obstetrics is related to postpartum hemorrhage and has been a leading cause of maternal death. We here report a successful treatment, via damage control surgery (DCS), of a life-threatening massive hemorrhage of more than 20,000 mL due to DIC. A 30-year-old female was admitted to our hospital because of atonic bleeding. Since she was having a uterine rupture, an emergency hysterectomy was performed. Because of the severe DIC (fibrinogen, 65 mg/dL; platelet count, 6.0 × 10⁹/L), oozing persisted after the hysterectomy; thus, intraperitoneal gauze packing was performed as DCS. Afterwards, the coagulopathy was corrected, and the gauze was removed on the second postoperative day (POD 2). The patient was discharged without complications on POD 16. The present case demonstrated that performing DCS and waiting for improvement of the coagulation system can be one of the treatment options for management of patients with severe DIC.

Anesthetic considerations for repeat cesarean section

PURPOSE OF REVIEW

The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section.

RECENT FINDINGS

This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation.

SUMMARY

According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.

Retrospective Evaluation of Anesthetic Management in Cesarean Sections of Pregnant Women with Placental Anomaly

Background

In this study, patients who underwent cesarean section and had placenta previa and placenta accreta were examined and compared in terms of haemorrhagic indicators and perioperative anesthetic management.

Methods

A retrospective study was conducted in a university hospital in Kahramanmaras, Turkey. It included 95 pregnant women who had placental anomaly and underwent cesarean section between December 15, 2014, and February 15, 2016.

Results

The pregnant women were divided into two groups: Group P (previa) (n = 67) and Group A (accreta) (n = 28). The types of anesthesia administered were general anesthesia (GA), which was administered to 50 patients (74.6%) in Group P and 27 patients (96.4%) in Group A, and spinal anesthesia (SA), which was administered to 17 patients (25.4%) in Group P and one patient (3.6%) in Group A.. The mean blood loss was 685.82 ± 262.82 in Group P and 1582.14 ± 790.71 in Group A, and the given amount of crystalloid was higher in Group A with an average of 1628.57 ± 728.19 ml. The use of erythrocyte and fresh frozen plasma solution was higher in Group A than Group P. Eleven patients were intubated and taken to the Intensive Care Unit (ICU) in Group A. Postoperative mechanical ventilation duration was significantly higher in Group A (75.14 ± 43.84 h) (p < 0.001). ICU stay was longer in Group A with 2.80 ± 1.13 days. (p < 0.001).

Conclusion

The intraoperative management and the availability of postoperative ICU conditions are important in placental anomalies cases. The communication between operation team with regard to the development of a standard protocol for these cases will be of great benefit in reducing morbidity and mortality.

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

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.

Case report of amniotic fluid embolism coagulopathy following abortion; use of viscoelastic point-of-care analysis

BACKGROUND

Amniotic fluid embolism (AFE) is a rare, life threatening obstetric complication, often associated with severe coagulopathy. Induced abortions are extremely safe procedures however complications including AFE can occur.

CASE PRESENTATION

A 29-year-old previously healthy woman, gravida 1 para 0, presented for a scheduled second trimester induced abortion via dilation and evacuation at 22-weeks gestation. The case was complicated by a suspected AFE with associated profound coagulopathy. Viscoelastic point-of-care coagulation analysis was used to successfully and swiftly guide management of her coagulopathy.

CONCLUSION

AFE can occur in the setting of induced abortion. This case report suggests viscoelastic point-of-care coagulation analyzers may aid in the management of pregnancy-related coagulopathy by providing faster coagulation assessment than laboratory testing, and facilitating timely, targeted management of coagulopathy.

Rapid, hand-held paper diagnostic for measuring Fibrinogen Concentration in blood

Critical bleeding causes over 2 million deaths a year. Early hypofibrinogenemia is a strong predictor of mortality in critically bleeding patients. The early replenishment of fibrinogen can significantly improve outcomes. However, over replenishment can also be dangerous. Furthermore, there is no rapid, cheap, hand-held diagnostic that can aid critically bleeding patients in fibrinogen replacement therapy. In this study, we have developed a hand-held paper diagnostic that measures plasma fibrinogen concentrations. The diagnostic has the potential to be used as a point of care device both inside and outside of hospital settings. It can vastly reduce the time to treatment for fibrinogen replacement therapy. The diagnostic is a two-step process. First, thrombin and plasma are added onto horizontially-orientated paper strips where the fibrinogen is converted into fibrin, drastically increasing the plasma's hydrophobicity. Second, an aqueous blue dye is pipetted onto the strips and allowed to wick through the fibrin. The distance the blue dye wicks through the strip correlates precisely to the fibrinogen concentration. The diagnostic can provide results within a minute. It can distinguish low fibrinogen concentrations (ie. <2 g/L) from normal fibrinogen concentrations. It shows remarkable reproducibility between healthy individuals. It is unaffected by common blood conditions such as acidosis, blood alcohol, severe hypertriglyceridemia, severe haemolysis and warfarin administration. Finally, it is unaffected by humidity and can withstand cold temperatures.

Prehospital Transfusion of Low-Titer O + Whole Blood for Severe Maternal Hemorrhage: A Case Report

Introduction: Beginning in 2017, multiple stakeholders within the Southwest Texas Regional Advisory Council for Trauma collaborated to incorporate cold-stored low-titer O RhD-positive whole blood (LTO + WB) into all phases of their trauma system, including the prehospital phase of care. Although the program was initially focused on trauma resuscitation, it was expanded to included non-traumatic hemorrhagic shock patients that may benefit from whole blood resuscitation.Case Report: We report the case of a patient with severe maternal hemorrhage secondary to placenta accreta who received a prehospital transfusion of LTO + WB. We believe this to be the first reported case of post-partum hemorrhage resuscitated out of hospital with whole blood.Discussion: This case highlights the potential benefits of a prehospital whole blood program as well as the controversy surrounding a LTO + WB program that includes females of childbearing age.

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.

Trauma in Pregnancy

Although trauma in pregnancy is rare, it is one of the most common causes of morbidity and mortality to pregnant women and fetus. Pathophysiology of trauma is generally time sensitive, and this is still true in pregnant patients, with the additional challenge of rare presentation and balancing the management of two patients concurrently. Successful resuscitation requires understanding the physiologic changes to the woman throughout the course of pregnancy. Ultimately, trauma management is best approached by prioritizing maternal resuscitation.

Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis, and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the prevention and treatment of postpartum haemorrhage as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, and transfusion medicine was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). Members of the task force assessed the quantity, quality and consistency of the published evidence, and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings, and by policy-makers in charge of decision making for the update of clinical practice in health care establishments.

Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review

BACKGROUND

A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team.

METHODS

A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records.

RESULTS

There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively.

CONCLUSIONS

Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.

Clinical pearls part 3: anaesthetic management of abnormally invasive placentation

PURPOSE OF REVIEW

Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature.

RECENT FINDINGS

Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients.

SUMMARY

A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol

BACKGROUND

Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol.

METHODS

The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables.

RESULTS

273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol.

CONCLUSIONS

Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.

Emergency release uncross-matched packed red blood cells for immediate double volume exchange transfusion in neonates with intermediate to advanced acute bilirubin encephalopathy: timely but insufficient?

Given the urgency of double volume exchange transfusion (ExT) in an infant with intermediate to advanced stages of acute bilirubin encephalopathy (ABE), it has been suggested that emergency release uncross-matched packed red blood cells (ER-PRBC) be used. The efficacy of an ExT in removing bilirubin from the brain, however, is a direct function of the mass of albumin exchanged. The very low albumin content of ER-PRBC may fail to be neuroprotective. Predicted changes in total serum bilirubin (TSB), serum albumin, the bilirubin/albumin (B/A) ratio, plasma volume (PV), and bilirubin equilibration from the extravascular space during ER-PRBC ExT are described. ExT using ER-PRBC is efficacious in lowering the TSB. However, this result is falsely reassuring as significant concurrent serum albumin loss, resultant hypoalbuminemia, contraction of PV, limited bilirubin clearance from the extravascular space, and sustained B/A ratio elevations above recommended ExT treatment thresholds suggest that bilirubin neurotoxicity will continue.

Transfusion Rates and the Utility of Type and Screen for Pelvic Organ Prolapse Surgery

OBJECTIVES

Limited data exist directly comparing the likelihood of blood transfusion by route of apical pelvic organ prolapse (POP) surgery. In addition, limited evidence is available regarding the risk of not ordering preoperative type and screen (T&S) in apical POP surgery. The objectives of the study are to (1) provide baseline data regarding the current need for preoperative T&S by comparing perioperative blood transfusion rates between 3 routes of apical POP surgery and (2) determine the rate of a positive preoperative antibody screen in women who underwent apical POP surgery.

METHODS

This was a retrospective cohort study of women who underwent apical POP surgery by 3 different routes: abdominal (abdominal sacrocolpopexy), robotic (robotic sacrocolpopexy), or vaginal (uterosacral or sacrospinous ligament fixation).

RESULTS

Among 610 women who underwent apical POP surgeries between May 2005 and May 2016, 24 women (3.9%) received a perioperative blood transfusion. The rate of transfusion was higher in the abdominal group (11.1%) compared with robotic (0.5%, P < 0.001) and vaginal (0.5%, P < 0.001). In a logistic regression model, abdominal route of POP surgery remained significantly associated with transfusion (odds ratio, 20.7; 95% confidence interval, 2.7-156.6). Among the 572 women who had a preoperative T&S performed, 9 (1.5%) had a positive antibody screen.

CONCLUSIONS

Blood transfusion was significantly more common in abdominal compared with robotic and vaginal apical POP surgeries. The rate of a positive antibody screen was low, suggesting that type O blood is low risk if cross-matched blood is not available. Thus, it may be reasonable to not order a preoperative T&S prior to robotic or vaginal apical POP surgery.