Antepartum risk factors and outcomes of massive transfusion for elective cesarean section: a nationwide retrospective cohort study

BACKGROUND

Postpartum hemorrhage is one of the leading causes of maternal mortality and morbidity. The etiology of postpartum hemorrhage exhibits variations in relation to the mode of birth; consequently, risk factors for massive transfusion in elective cesarean section might diverge from those encountered in vaginal birth or emergency cesarean section. The main purpose of this study was to investigate antepartum risk factors of massive transfusion for elective cesarean section.

METHODS

We conducted a retrospective cohort study based on data from a nationwide system that collected inpatient medical records from tertiary hospitals in mainland China. We included women who had undergone elective cesarean section from January 2013 to August 2018. Primary outcome was massive transfusion defined as transfusion of more than eight units of red blood cells on the day of childbirth. Candidate risk factors were identified by the 10th revision of International Classification of Diseases Codes of admission diagnoses. The relationship between each factor and massive transfusion was assessed using multivariable logistic regression.

RESULTS

A total of 294,695 women were included and 572 of them received massive transfusion (incidence: 194 per 100,000 elective cesarean sections). Maternal age [adjusted odds ratio (aOR) 1.22; 95% confidence interval (CI) 1.10-1.48], anemia (aOR 1.66; 95% CI 1.34-2.05), thrombocytopenia (aOR 3.54; 95% CI 2.39-5.05), coagulopathy (aOR 25.92; 95% CI 8.59-69.50), hypoalbuminemia (aOR 2.97; 95% CI 1.86-4.53), hepatic dysfunction (aOR 1.65; 95% CI 1.04-2.47), uterine scar (aOR 1.39; 95% CI 1.15-1.67), multiple pregnancy (aOR 2.84; 95% CI 1.74-4.38), polyhydramnios (aOR 2.52; 95% CI 1.19-4.68) and placenta previa (aOR 25.03; 95% CI 21.04-29.77) were associated with massive blood transfusion for elective cesarean section. Among the women receiving massive blood transfusion, 7 (1.2%) died during hospitalization, 126 (22.0%) needed hysterectomy, 25 (4.4%) uterine packing and 57 (10.0%) uterine artery ligation.

CONCLUSIONS

Ten risk factors of massive transfusion were identified in women undergoing elective cesarean section. Our findings may facilitate blood products preparation and provide opportunities for applying prophylactic strategies prior to cesarean section for women at high risk of massive transfusion.

Does Omega-3 supplementation increase profuse postpartum hemorrhage? A hospital-based register study

INTRODUCTION

Although Omega-3 is thought to have anticoagulative properties, the potential untoward effects of Omega-3 during pregnancy have not been investigated. No previous studies have been made to specifically assess its effect on postpartum hemorrhage (PPH). Our aim was to determine if an association exists between Omega-3 intake during pregnancy and profuse PPH or massive PPH.

MATERIAL AND METHODS

Data on all deliveries that occurred at Karolinska University Hospital during the years 2007-2011 (n = 41 139) was collected from the medical record of Obstetrix, maternal health and delivery chart system. Women with reported Omega-3 use in early pregnancy were considered exposed and all other as unexposed. Bivariate and adjusted multivariate analysis was performed on main outcomes.

RESULTS

Omega-3 use was associated with 25% increased odds of PPH (adjusted odds ratio (aOR) 1.25, 95% confidence interval [CI] (1.06-1.47)) and a more than doubled odds of massive PPH (aOR 2.36, 95% CI 1.26-4.44). In addition, there was a minor increase in the amount of blood loss. Although few, women on low-dose discontinued terminated at 36th week showed no significant association to blood loss measurements.

CONCLUSIONS

Our observational findings showed 25% higher odds of PPH and two times higher odds of massive PPH in women who reported using Omega-3 in early pregnancy. Our findings give some support to advocate discontinued use of Omega-3 in late pregnancy.

Association of intra-operative red blood cell transfusion on the systemic immune index and recovery in patients undergoing cesarean section: a large propensity score-matched study

BACKGROUND

Post-partum hemorrhage (PPH) is a leading cause of maternal death worldwide. However, the effect of blood transfusion in patients undergoing cesarean section remains unclear.

MATERIALS AND METHODS

The analysis was based on the retrospective evaluation of the pre- and post-operative data for 1231 patients who underwent a cesarean section at our hospital between January 2016 and June 2020. Patients were classified into the blood transfusion group (BT) and the no blood transfusion group (NBT) based on their intra-operative blood transfusion status.

RESULTS

After propensity score matching, 322 patients were included in both groups and between-group differences in length of hospital stay (LOS), perioperative systemic inflammation indicators, and post-operative complications were evaluated. The LOS was longer in the BT (median, 6.6 days) than the NBT (median, 4.2 days) group (P = 0.026). The post-operative complication rate was higher for the BT than NBT group, as follows: vomiting, 3.2% vs. 4.9%, P = 0.032; fever, 5.41% vs. 2.24%, P = 0.032; wound complications, 15.44% vs. 10.45%, P = 0.028; and intestinal obstructions, 5.88% vs. 2.75%, P = 0.034. Systemic inflammation indicators increased significantly, from the pre-operative baseline, for both groups at post-operative day (POD) 1 and POD3. On multivariate analysis, intra-operative blood transfusion was associated with a longer LOS (hazard ratio, 1.52; 95% confidence interval, 1.07-2.25).

CONCLUSION

Intraoperative blood transfusion for cesarean section was associated with increased levels of systemic inflammation indicators, higher post-operative complication rates, and prolonged hospital stay.

Predicting postpartum hemorrhage in women undergoing planned cesarean section: A multicenter retrospective cohort study in Japan

Given Japan's unique social background, it is critical to understand the current risk factors for postpartum hemorrhage (PPH) to effectively manage the condition, especially among specific groups. Therefore, this study aimed to identify the current risk factors for PPH during planned cesarean section (CS) in Japan. This multicenter retrospective cohort study was conducted in two tertiary maternal-fetal medicine units in Fukushima, Japan and included 1,069 women who underwent planned CS between January 1, 2013, and December 31, 2022. Risk factors for PPH (of > 1000 g and > 1500 g) were assessed using multivariate logistic regression analysis, considering variables such as maternal age, parity, assisted reproductive technology (ART) pregnancy, pre-pregnancy body mass index (BMI), uterine myoma, placenta previa, gestational age at delivery, birth weight categories, and hypertensive disorders of pregnancy (HDP). Multivariate linear regression analyses were conducted to predict estimated blood loss during planned CS. ART pregnancy, a pre-pregnancy BMI of 25.0-29.9 kg/m2, and uterine myoma increased PPH risk at various levels. Maternal smoking increased the risk of >1500 g PPH (adjusted odds ratio: 3.09, 95% confidence interval [CI]: 1.16-8.20). Multivariate linear analysis showed that advanced maternal age (B: 83 g; 95% CI: 27-139 g), ART pregnancy (B: 239 g; 95% CI: 121-357 g), pre-pregnancy BMI of 25.0-29.9 kg/m2 (B: 74 g; 95% CI: 22-167 g), uterine myoma (B: 151 g; 95% CI: 47-256 g), smoking (B: 107 g; 95% CI: 13-200 g), and birth weight > 3,500 g (B: 203 g; 95% CI: 67-338 g) were associated with blood loss during planned CS. Considering a patient's clinical characteristic may help predict bleeding in planned CSs and help improve patient safety.

Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage - A single-center retrospective cohort study

INTRODUCTION

Red blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved.

OBJECTIVE

To determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries.

STUDY DESIGN

Monocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL).

RESULTS

Over the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion". After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27-9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69-24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80-9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57-15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05-12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions.

CONCLUSIONS

In a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.

Dose-dependent increase in risk of bleeding and bleeding complications in relation to SSRI use at delivery

INTRODUCTION

Depression during pregnancy is a severe state that increases the risk of suicide, as well as adverse newborn outcomes. Selective serotonin re-uptake inhibitors (SSRIs) are effective for the treatment of depression, but increase the risk of bleeding complications at delivery. Knowledge on the dose dependency of this association is lacking.

METHODS

A hospital-based cohort study of all women who gave birth at Karolinska University Hospital in Stockholm over the 5-year period from 2007 to 2011, with or without SSRI use, was undertaken. In total, 334 women who delivered vaginally and were exposed to SSRIs at delivery were identified. All other women who delivered vaginally formed the control group (n = 31,929). The electronic maternal health records of the 334 SSRI users were scrutinized, and the women were categorized into two groups: moderate (n = 246) or high (n = 88) SSRI dose at delivery. The main outcome was bleeding complications at delivery in relation to SSRI dose.

RESULTS

A dose-dependent increase in the rate of postpartum haemorrhage (≥1000 ml) was found, affecting 8.4 %, 14.6 % and 23.9 % (p ≤ 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. In addition, a dose-dependent increase in the rate of postpartum anaemia was found, affecting 7.0 %, 9.3 % and 15.9 % (p = 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. Mean blood loss of 406 ml, 483 ml and 482 ml (p ≤ 0.001) was found in the control group, the moderate-dose group and the high-dose group, respectively. Women exposed to SSRIs delivered earlier, but did not have higher prevalence of pre-eclampsia compared with the control group.

CONCLUSIONS

The dose-dependent relationship between SSRIs and bleeding complications may be clinically useful in the management of this vulnerable group of women.

Red Blood Cell Storage with Xenon: Safe or Disruption?

Xenon, an inert gas commonly used in medicine, has been considered as a potential option for prolonged preservation of donor packed red blood cells (pRBCs) under hypoxic conditions. This study aimed to investigate how xenon affects erythrocyte parameters under prolonged storage. In vitro model experiments were performed using two methods to create hypoxic conditions. In the first method, xenon was introduced into bags of pRBCs which were then stored for 42 days, while in the second method, xenon was added to samples in glass tubes. The results of our experiment showed that the presence of xenon resulted in notable alterations in erythrocyte morphology, similar to those observed under standard storage conditions. For pRBC bags, hemolysis during storage with xenon exceeded the acceptable limit by a factor of six, whereas the closed-glass-tube experiment showed minimal hemolysis in samples exposed to xenon. Notably, the production of deoxyhemoglobin was specific to xenon exposure in both cell suspension and hemolysate. However, this study did not provide evidence for the purported protective properties of xenon.

The association between maternal vitamin D deficiency and postpartum hemorrhage and uterine atony

INTRODUCTION

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide. There are several known risk factors for postpartum hemorrhage related to pregnancy and delivery, but less evidence of predisposing factors. Recent research has shown that vitamin D deficiency may increase the risk of cesarean section due to dystocia, based on its effect on striated muscle as well as possible effect on the myometrium. Whether vitamin D deficiency increases the risk for postpartum hemorrhage and especially atonic hemorrhage is unknown.

MATERIAL AND METHODS

This was a retrospective translational study. The study population included 1367 women in Sweden and the main exposure was the serum concentration of 25-hydroxylated vitamin D at time of delivery. The LIASON® 25 OH vitamin D total assay method was used for analyzing 25-hydroxylated vitamin D. Vitamin D insufficiency was defined as serum concentration <50 nmol/L and vitamin D deficiency as serum concentrations <25 nmol/L. Primary outcomes were postpartum hemorrhage and severe postpartum hemorrhage defined as bleeding ≥500 mL and ≥ 1000 mL, respectively 2 h after delivery. Secondary outcome was atonic postpartum hemorrhage. Crude and adjusted odds ratios were calculated with 95% confidence intervals using univariable and multivariable logistic regression. Three different adjustment methods were used, adjusting for maternal, obstetrical and neonatal confounders.

RESULTS

Postpartum hemorrhage and severe postpartum hemorrhage afflicted 31.3% and 6.4% of the women, respectively. Rate of atonic postpartum hemorrhage was 21% in the whole population. Rate of vitamin D insufficiency and deficiency was 57%. Vitamin D insufficiency or deficiency was neither found to be associated with postpartum hemorrhage, nor with atonic postpartum hemorrhage.

CONCLUSIONS

In this study, the vitamin D status of women at the time of delivery was not a predictor of postpartum hemorrhage overall or atonic postpartum hemorrhage.

Medical abortion in the second trimester - an update

The safety and efficacy of medical abortion in the second trimester is provider independent and may therefore offer advantages over surgical second trimester abortion in certain settings. Due to bleeding risk, medical abortions in the second trimester are still mostly performed in a clinic or hospital setting. The most effective regimen for abortion includes pretreatment with oral mifepristone and following doses of misoprostol. An alternative is misoprostol only which should only be used when mifepristone is not available. The optimal dosing of prostaglandin to achieve the highest efficacy with the lowest proportion of complications remains to be established. Complications are rare and serious adverse events uncommon but may include uterine rupture especially in women with a previous cesarean delivery or uterine surgery. Women having second trimester medical abortion are a diverse group with different indications for the abortion. All women should be offered pain relief and respectful care. Staff involved in second trimester medical abortion often find their work challenging. At the same time, staff indicate pride and a conviction of contributing to the 'greater good' for women and society. Staff involved in second trimester abortion should be offered guidance and support through the employer. Post abortion contraception should be offered to all women having second trimester medical abortions, including those who have the abortion due to fetal malformation. All methods of contraception can be started immediately after a second trimester medical abortion except for cycle based methods and diaphragms.

Exploring trends of severe postpartum haemorrhage: a hospital-based study

BACKGROUND

Over the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH.

METHODS

We estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends.

RESULTS

Among 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period.

CONCLUSION

We found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.

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

Postpartum hemorrhage (PPH) is a common cause of significant maternal morbidity and mortality that can be associated with coagulopathy, especially hypofibrinogenemia. There is interest in point-of-care viscoelastic hemostatic assays (POC-VHA) in PPH because prompt knowledge of coagulation status can aid diagnosis, identify cases of severe coagulopathy, and allow ongoing monitoring during rapid bleeding. The incidence of coagulopathy in most cases of PPH is low because of the procoagulant state of pregnancy, including raised fibrinogen levels of around 4 to 6 g/L. A Clauss fibrinogen of >2 g/L or POC-VHA equivalent has been found to be adequate for hemostasis during PPH. POC-VHA has been used successfully to diagnose hypofibrinogenemia (Clauss fibrinogen of ≤2 g/L) and guide fibrinogen treatment which has reduced bleed size and complications of massive transfusion. There are uncertainties about the use of POC-VHA to direct fresh frozen plasma and platelet administration during PPH. Several POC-VHA algorithms have been used successfully incorporated in the management of many thousands of PPHs and clinicians report that they are easy to use, interpret, and aid decision making. Due to the relative cost of POC-VHA and lack of definitive data on improving outcomes, these devices have not been universally adopted during PPH.

Mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour: A retrospective cohort study of nulliparous women

OBJECTIVE

To investigate the mode of delivery and birth outcomes in relation to the duration of the passive second stage of labour in nulliparous women.

METHODS AND FINDINGS

A retrospective cohort study of all nulliparous women (n = 1131) at two delivery units in Sweden. Maternal and obstetric data were obtained from electronic medical records during 2019. The passive second stage was defined as the complete dilation of the cervix until the start of the active second stage. The duration of the passive second stage was categorized into three groups: 0 to 119 min (0 to <2 h), 120-239 min (2- <4h) and ≥240 min (≥4h). Differences between the groups were examined using t-test and Chi2-tests and regression analyses were used to analyse adjusted odds ratio with 95% confidence intervals. The primary outcome was mode of delivery in relation to the duration of the passive second stage and the secondary outcomes covered a series of adverse maternal and neonatal birth outcomes. The rates of instrumental and caesarean deliveries increased as the duration of the passive second stage increased. A ≥4-hour duration of the passive second stage was associated with a nine-times increased risk of caesarean section, and a four-times risk of instrumental delivery compared to a duration of <2 hours in the adjusted analyses. No differences were found in the maternal birth outcomes. The risk of a 5-minute Apgar score <7 was increased in the 2-<4h group. A longer passive second stage was not associated with an increased risk of negative birth experience.

CONCLUSIONS

Our study demonstrates an increased risk of operative delivery for a longer duration (>2h) of the passive second stage in nulliparous women, although most of the women gave birth by spontaneous vaginal delivery even after ≥4 hours. There was no evidence of an increased risk of adverse maternal outcomes in a longer duration of the passive second stage but there were indications of increased adverse neonatal outcomes. Assessment of fetal well-being is important when the duration of the passive phase is prolonged.

Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate red blood cell use during delivery in patients with placenta accreta spectrum.

DATA SOURCES

We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies.

METHODS OF STUDY SELECTION

Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype.

TABULATION, INTEGRATION, AND RESULTS

Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes.

CONCLUSION

Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021240993.

Predictive accuracy of the shock index for severe postpartum hemorrhage in high-income countries: A systematic review and meta-analysis

AIM

The shock index has been suggested as a screening tool for predicting postpartum hemorrhage (PPH); however, there is little comprehensive evidence regarding its predictive accuracy. This systematic review and meta-analysis aim to investigate the predictive accuracy of the shock index for severe PPH in high-income countries.

METHODS

A comprehensive search was conducted on MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science (from inception to June 2021). Studies assessing the predictive performance of the shock index for PPH in high-income countries were included. Two or more reviewers independently extracted the data and assessed the risk of bias and applicability concerns using the modified Quality Assessment of Diagnostic Accuracy Studies 2 tool. PPH requiring higher-level care, such as blood transfusions, were considered as primary analyses. We described the hierarchical summary receiver-operating characteristic curve for data synthesis.

RESULTS

Nine studies were included after the eligibility assessment. All studies were considered to either have a high risk of bias or high applicability concerns. The sensitivity of the four studies that defined severe PPH as PPH requiring blood transfusion ranged from 0.51 to 0.80, whereas their specificity ranged from 0.33 to 0.92.

CONCLUSIONS

This review shows that the predictive performance of the shock index for severe PPH is inconsistent. Therefore, the evidence for using the shock index alone as a screening tool for PPH in high-income countries is insufficient.

STUDY REGISTRATION

This review was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000044230).

Prevalence and Associated Factors for Post-Caesarean Delivery Blood Transfusion in Eastern Sudan: A Cross-Sectional Study

Background

Obstetric haemorrhage is a leading cause of maternal mortality and morbidity worldwide. Caesarean delivery (CD) is associated with significant blood loss, which may require blood transfusions. This study aimed to determine the prevalence and associated factors for post-CD transfusion.

Methods

A cross-sectional study was conducted in Gadarif maternity hospital, eastern Sudan, from March to September 2020. Sociodemographic, obstetric and clinical data, including pre- and postoperative haemoglobin levels, were collected. A multivariate logistic regression analysis was performed.

Results

A total of 539 women were enrolled in the study; the median (interquartile range) age of these women was 28.0 (8.0) years. The overall post-CD transfusion rate was 8.2%. Emergency CD (adjusted odds ratio [AOR]=2.57, 95% confidence interval [CI]=1.25‒5.28) and antepartum haemorrhage (AOR=44.70, 95% CI=11.18‒178.76) were associated with increased risk of post-CD blood transfusion. Preoperative haemoglobin (AOR=0.48, 95% CI=0.36‒0.64) and rural residence (AOR=0.45, 95% CI=0.22‒0.93) were associated with reduced risk for post-CD blood transfusion.

Conclusion

The overall prevalence of post-CD transfusion in this part of Sudan is 8.2%. Women with emergency CD, low preoperative haemoglobin levels and antepartum haemorrhage were at higher risk for post-CD transfusion. Risk identification and correction of antenatal anaemia can reduce the hazard of blood transfusion among CD women.

A risk prediction model of perinatal blood transfusion for patients who underwent cesarean section: a case control study

Background

Severe obstetric hemorrhage is a leading cause of severe maternal morbidity. A perinatal blood transfusion is the key factor in the treatment of severe obstetric hemorrhage. Our aim is to identify patients with a high risk of perinatal blood transfusions before Cesarean Section, which can promote the effectiveness of the treatment of severe obstetric hemorrhage, as well as improve obstetric preparations.

Methods

This study retrospectively analyzed the data of 71 perinatal blood transfusion patients and 170 controls, who were both underwent Cesarean Section from July 2018 to September 2019. These data were included in the training set to build the risk prediction model of needing blood transfusion. Additionally, the data of 148 patients with the same protocol from October 2019 to May 2020 were included in the validation set for model validation. A multivariable logistic regression model was used. A risk prediction nomogram was formulated per the results of the multivariate analysis.

Results

The strongest risk factors for perinatal blood transfusions included preeclampsia (OR = 6.876, 95% CI: 2.226–23.964), abnormal placentation (OR = 5.480, 95% CI: 2.478–12.591), maternal age (OR = 1.087, 95% CI: 1.016–1.166), predelivery hemoglobin (OR = 0.973, 95% CI: 0.948–0.998) and predelivery fibrinogen (OR = 0.479, 95% CI: 0.290–0.759). A risk prediction model of perinatal blood transfusions for cesarean sections was developed (AUC = 0.819; sensitivity: 0.735; specificity: 0.848; critical value: 0.287).

Conclusions

The risk prediction model can identify the perinatal blood transfusions before Cesarean Section. With the nomogram, the model can be further quantified and visualized, and clinical decision-making can subsequently be further simplified and promoted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04696-x.

Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases

Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage.

Risk of postpartum haemorrhage is associated with ethnicity: a cohort study of 981 801 births in England

OBJECTIVE

To determine the association between ethnic group and risk of postpartum haemorrhage in women giving birth.

DESIGN

Cohort study.

SETTING

Maternity units in England.

POPULATION OR SAMPLE

981 801 records of births between 1^st April 2015 and 31^st March 2017 in a national clinical database.

METHODS

Multivariable logistic regression analyses with multiple imputation to account for missing data and robust standard errors to account for clustering within hospitals.

MAIN OUTCOME MEASURES

Postpartum haemorrhage of 1500ml or more (PPH).

RESULTS

28 268 (2.9%) of births were complicated by PPH. Risks were higher in women from black (3.9%) and other (3.5%) ethnic backgrounds. Following adjustment for maternal and fetal characteristics, and care at birth, there was evidence of an increased risk of PPH in women from all ethnic minority groups, with the largest increase seen in black women (adjusted odds ratio 1.54 (1.45 to 1.63)). The increase in risk was robust to sensitivity analyses which included changing the outcome to PPH of 3000ml or more.

CONCLUSIONS

In England, women from ethnic minority backgrounds have an increased risk of PPH, when maternal, fetal and birth characteristics are taken into account. Factors contributing to this increased risk need further investigation. Perinatal care for women from ethnic minority backgrounds should focus on preventative measures to optimise maternal outcomes.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States

BACKGROUND

Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed.

OBJECTIVE

This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States.

STUDY DESIGN

This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation.

RESULTS

Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1).

CONCLUSION

Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

Epidemiology of Massive Transfusion - A Common Intervention in Need of a Definition

While massive transfusion (MT) recipients account for a small proportion of all transfused patients, they account for approximately 10% of blood products issued. Furthermore, MT events pose organizational and logistical challenges for health care providers, laboratory and transfusion services. Overall, the majority of MT events are to support major bleeding in surgical patients, trauma and gastrointestinal hemorrhage. The clinical context in which the bleeding event occurred, the number of blood products required, patient age and comorbidities are the most important predictors of outcomes for short- and long-term survival. These data are important to inform blood services, clinicians and health care providers in order to improve care and outcomes for patients with major bleeding. There is no standard accepted definition of MT, with most definitions based on number of blood components administered within a certain time-period or activation of MT protocol. The type of definition used has implications for the clinical characteristics of MT recipients included in epidemiological and interventional studies. In order to understand trends in incidence of MT, variation in blood utilization and patient outcomes, and to harmonize research outcomes, a standard and universally accepted definition of MT is urgently required.

Incidence, trends and risk factors for obstetric massive blood transfusion in China from 2012 to 2019: an observational study

OBJECTIVES

This study aims to use the high-quality national monitoring data from the China's National Maternal Near Miss Surveillance System (NMNMSS) to ascertain the incidence, trends and risk factors of obstetric massive blood transfusion (MBT) from 2012 to 2019 in China and determine its clinical outcomes.

SETTINGS

Observational study of hospitalised pregnancies who had given birth or ended their pregnancy among member hospitals of NMNMSS.

PARTICIPANTS

11 667 406 women were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

We screened for the incidence, trends, risk factors and main reasons for obstetric MBT, and the outcomes after obstetric MBT. MBT was defined as the transfusion of ≥5 units of red blood cells or ≥1000 mL of whole blood. The incidence of MBT was defined as the MBT cases per 10 000 pregnancies.

RESULTS

Obstetric MBT occurred in 27 626 cases, corresponding to an incidence of 23.68 per 10 000 maternities, which exhibited an increasing trend in China during 2012-2019 (14.03-29.59 per 10 000 maternities, p for trend <0.001). Obstetric MBT was mainly associated with amniotic fluid embolism, uterine atony, abnormal placenta, severe anaemia, ectopic pregnancy, abortion, caesarean section, advanced maternal age and multiparous from biological effect. While from sociological effects, uterine atony, severe anaemia and placenta previa are the top three complications which more likely to undergo obstetric MBT in the Chinese population. Overall, the secular trends of hysterectomy incidence (25.07%-9.92%) and MMR during hospitalisation (21.41‰-7.48‰) among women who underwent MBT showed decreasing trends (p for trend <0.001).

CONCLUSION

To minimise the incidence of obstetric MBT, more attention should be paid to education on the importance of the antenatal visit, evidence-based transfusion practice and females who are multiparous and have an advanced age, amniotic fluid embolism, uterine atony, severe anaemia and placenta previa.

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.

Place of birth and outcomes associated with large volume transfusion: an observational study

BACKGROUND

Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals.

METHODS

The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission.

RESULTS

Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells.

CONCLUSIONS

Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.

The Efficacy of Transarterial Embolization for Postpartum Hemorrhage Complicated with Disseminated Intravascular Coagulation: A Single-Center Experience

Indications for the use of transarterial embolization (TAE) for postpartum hemorrhage (PPH) have been established. However, the efficacy of TAE for PPH complicated by disseminated intravascular coagulation (DIC) remains controversial. In this study, we investigated the efficacy of TAE for PPH complicated by DIC. A database review was conducted to identify patients who were treated with TAE for PPH at our hospital. TAE was performed in 41 patients during the study period. Effective hemostasis was achieved in all cases, but additional procedures, such as re-embolization or hysterectomy, were required in five patients (12.2%). The typical causes of PPH included uterine atony (18 cases), placenta previa (15 cases), amniotic fluid embolism (DIC-type) (11 cases), and placenta accreta spectrum (10 cases). The mean blood loss was 3836 mL. The mean obstetrical DIC and the International Society on Thrombosis and Hemostasis DIC scores were 7.9 and 2.6, respectively. The efficacy of hemostasis was comparable between patients with and without DIC. However, the complete success rate of TAE was lower in patients with DIC as the condition worsened than that in non-DIC patients. Overall, TAE is effective as a minimally invasive treatment for PPH complicated by DIC.

Analysis of early and late maternal complications associated with delivery using propensity score

OBJECTIVE

To analyze early and late maternal complications associated with the mode of delivery in a birth cohort in Brazil, using the propensity score technique for analysis.

METHODS

This is a prospective cohort study, using data from the Pelotas Birth Cohort, RS, 2004. A total of 4,189 women were included and a descriptive analysis of the data and subsequent calculation of the propensity and pairing score of vaginal delivery women and cesarean delivery women with similar scores (1,366 pairs). We then assessed the difference in outcome risk between the groups.

RESULTS

Women in the cesarean group had 2.9 percentage points (pp) more risk of postpartum infection, 1.13 p.p. more risk of urinary infection, 1.10 p.p. more risk of anesthetic complications and 1.24 p.p. higher risk of headache compared to vaginal delivery, but less risk of anemia (-2.43 pp) and hemorrhoids (-1.24 p.p.). The use of propensity scores is extremely useful for reducing bias and increasing accuracy in observational studies when experimental studies cannot be performed.

CONCLUSION

Cesarean sections have been associated with a higher prevalence of postpartum and urinary tract infections, anesthetic complications and headache and lower prevalence of anemia and hemorrhoids, so they should be performed with clear indications and when their benefits outweigh potential risks.

Cesarean delivery rates for overall and multiple pregnancies in Japan: A descriptive study using nationwide health insurance claims data

AIM

Due to the lack of national perinatal registries, population-wide descriptive statistics on cesarean deliveries in Japan are unknown. We aim to describe cesarean deliveries for overall and multiple pregnancies using the Japan National Database of health insurance claims.

METHODS

We calculated the national and prefectural cesarean delivery rates for overall and multiple pregnancies in 2014. We described maternal morbidities (e.g., blood transfusion) and the place and type of the institutions providing prenatal and perinatal care.

RESULTS

The national cesarean delivery rates were 18.6% overall and 82.7% for women with multiple pregnancies. Prefectural cesarean delivery rates for overall and multiple pregnancies varied from 12.5% to 24.2% and from 49.2% to 100%, respectively, showing a moderate positive correlation (r = 0.59, p < 0.001). Overall, 1.4% of cesarean patients received an allogeneic blood transfusion, compared to 3.2% for those with multiple pregnancies. In addition, 65.9% of overall cesarean deliveries occurred at hospitals with ≥20 beds, whereas 94.6% of cesarean patients with multiple pregnancies delivered at hospitals. Older patients were more likely to receive their cesarean section at a different institution than their first visit within the same prefecture, but trans-prefectural movement during pregnancy covered by health insurance was most frequent among those in their early thirties: 7.0% overall and 10.7% for multiple pregnancies.

CONCLUSIONS

The overall cesarean delivery rate in Japan was optimal, but the rate was high for multiple pregnancies, with large regional differences. Data on patient movement across institutions and areas would help to improve the perinatal care system.

When and how should I transfuse during obstetric hemorrhage?

The incidence of maternal hemorrhage and blood transfusion has increased over time. Causes of massive hemorrhage, defined as a transfusion > 10 units of erythrocytes, include abnormal placental insertion, preeclampsia, and placental abruption. Although ratio-based transfusion has been described for managing massive hemorrhage, a goal-directed approach using laboratory or point-of-care data may lead to better outcomes. Autotransfusion, which involves the collection, washing, and filtration of maternal shed blood, avoids many of the complications associated with allogeneic blood transfusion. In this review, we provide an overview of transfusion practices related to the management of obstetric hemorrhage.

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.

Postpartum Hemorrhages: Prevention

The strict correlation between abnormal invasive placentation and postpartum hemorrhage suggests that a widespread antenatal diagnosis of placental anomalies would improve the management of these challenging patients; acting preventive solutions at the moment of delivery reduces blood loss and avoid hysterectomies. The role of endovascular procedures in this field has been encouraged by multiple studies reporting prophylactic uterine arteries embolization and iliac/aortic balloon catheters positioning. This paper aims to review the main imaging diagnostic findings of placental implant anomalies and summarize the principal preventive endovascular strategies proposed in literature.

Placenta accreta spectrum disorders-experience of management in a German tertiary perinatal centre

PURPOSE

Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a tertiary perinatal centre to compare the outcome of different individual management strategies.

METHODS

A monocentric retrospective analysis was performed in patients with clinically confirmed diagnosis of PAS between 07/2012 and 12/2019. Electronic patient and ultrasound databases were examined for perinatal findings, peripartum morbidity including blood loss and management approaches such as (1) vaginal delivery and curettage, (2) caesarean section with placental removal versus left in situ and (3) planned, immediate or delayed hysterectomy.

RESULTS

46 cases were identified with an incidence of 2.49 per 1000 births. Median diagnosis of placenta accreta (56%), increta (39%) or percreta (4%) was made in 35 weeks of gestation. Prenatal detection rate was 33% for all cases and 78% for placenta increta. 33% showed an association with placenta praevia, 41% with previous caesarean section and 52% with previous curettage. Caesarean section rate was 65% and hysterectomy rate 39%. In 9% of the cases, the placenta primarily remained in situ. 54% of patients required blood transfusion. Blood loss did not differ between cases with versus without prenatal diagnosis (p = 0.327). In known cases, an attempt to remove the placenta did not show impact on blood loss (p = 0.417).

CONCLUSION

PAS should be managed in an optimal setting and with a well-coordinated team. Experience with different approaches should be proven in prospective multicentre studies to prepare recommendations for expected and unexpected need for management.

Maternal morbidity and mortality due to placenta accreta spectrum disorders

Placenta accreta spectrum (PAS) disorders are an increasing health problem in many parts of the world. They are an important risk factor for adverse maternal outcomes related to delivery, with a reported 18-fold increase in maternal morbidity. Profuse haemorrhage after attempting to remove the placenta is the most frequent complication and can lead to major maternal morbidity and ultimately to maternal death. Morbidity can also arise from the multiple procedures required to treat PAS disorders. Intensive care unit admission, mechanical ventilation, infection, and prolonged hospitalization are common in these patients. Long-term complications related to infertility and psychological disturbances can also occur and may have a strong and long-lasting impact on women's health. Antenatal diagnosis allows for appropriate scheduling of delivery and referral to a specialized centre and has been shown to reduce maternal morbidity and mortality.

Emergency-release blood transfusions after postpartum hemorrhage at the Intermountain Healthcare hospitals

BACKGROUND

Most low-risk obstetric patients do not have crossmatched blood available to treat unexpected postpartum hemorrhage. An emergency-release blood transfusion (ERBT) program is critical for hospitals with obstetrical services. We performed a retrospective analysis of obstetrical ERBTs administered in our multihospital system.

DESIGN AND METHODS

We collected data from the past 8 years at all Intermountain Healthcare hospitals on every ERBT after postpartum hemorrhage; logging circumstances, number and type of transfused products, and outcomes.

RESULTS

Eighty-nine women received ERBT following 224,035 live births, for an incidence of 3.97 transfused women/10,000 births. The most common causally-associated conditions were: uterine atony (40%), placental abruption/placenta previa (16%), retained placenta (11%), and uterine rupture (5%). The mean number of total units transfused was 7.9 (range 1-76). The mean number of red blood cells (RBCs) transfused was 4.8, the median 4, and SD was ±4.4. Massive transfusion protocols (MTPs) for trauma recommend using a ratio of 1:1:1 or 2:1:1 of RBC:FFP:Platelets, however the ratios varied widely for postpartum hemorrhage. Only 1.5% received a 1:1:1 ratio and 7.5% received a 2:1:1 ratio. Nineteen percent (17/89) of women underwent hysterectomy, 7% (6/89) had uterine artery embolization, 36% (32/89) had an intensive care unit admission, and 1% (1/89) died.

CONCLUSION

Emergency transfusion for postpartum hemorrhage occurred after 1/2500 births. Most women received less FFP and platelets than recommended for traumatic hemorrhage. A potentially better practice for postpartum hemorrhage would be a balanced ratio of blood products, transfusion of low-titer, group O, cold-stored, whole blood, or inclusion in a MTP.