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..

Blood reservation and utilisation practice for Caesarean section in Ilorin, Nigeria

Most blood units routinely cross-matched for patients undergoing Caesarean section (CS) in Nigeria are not used for transfusion. Over-ordering increases blood wastage, blood bank running costs, surgery costs and waiting times. A one-year review of all CS performed in the University of Ilorin Teaching Hospital (UITH), Nigeria, was thus conducted to evaluate blood reservation and utilisation practice. Efficiency of blood utilisation was evaluated using a cross-match to transfusion (C/T) ratio, transfusion probability (TP) and transfusion index (TI). The overall C/T ratio, TP and blood wastage were, respectively, 3.1, 24.6%, and 68%, indicative of inefficient blood utilisation. Establishing a Maximal Surgical Blood Order Schedule (MSBOS), which estimates the units of blood required for specific CS indications, is recommended to minimise blood over-ordering. Blood grouping alone should be done for patients at low risk for transfusion. For moderate risk patients, blood type and screen without cross-matching should be done, reserving cross-matching for high-risk patients.

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.

Validation of Postpartum Hemorrhage Admission Risk Factor Stratification in a Large Obstetrics Population

OBJECTIVE

This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population.

STUDY DESIGN

Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage.

RESULTS

Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage.

CONCLUSION

We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

Massive transfusion protocols in nontrauma patients: A systematic review and meta-analysis

BACKGROUND

Massive bleeding is a major cause of death both in trauma and nontrauma patients. In trauma patients, the implementation of massive transfusion protocols (MTP) led to improved outcomes. However, the majority of patients with massive bleeding are nontrauma patients.

OBJECTIVES

To assess if the implementation of MTP in nontrauma patients with massive bleeding leads to improved survival.

DATA SOURCES

National Library of Medicine's Medline database (PubMed).

STUDY ELIGIBILITY CRITERIA

Original research articles in English language investigating MTP in nontrauma patients.

PARTICIPANTS

Nontrauma patients with massive bleeding 18 years or older.

INTERVENTION

Transfusion according to MTP versus off-protocol.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic literature review using PubMed. Outcomes assessed were mortality and transfused blood products. Studies that compared mortality of MTP and non-MTP groups were included in meta-analysis using Mantel-Haenszel random effect models.

RESULTS

A total of 252 abstracts were screened. Of these, 12 studies published 2007 to 2017 were found to be relevant to the topic, including 2,475 patients. All studies were retrospective and comprised different patient populations. Most frequent indications for massive transfusion were perioperative, obstetrical and gastrointestinal bleeding, as well as vascular emergencies. Four of the five studies that compared the number of transfused blood products in MTP and non-MTP groups revealed no significant difference. Meta-analysis revealed no significant effect of MTP on the 24-hour mortality (odds ratio 0.42; 95% confidence interval 0.01-16.62; p = 0.65) and a trend toward lower 1-month mortality (odds ratio 0.56; 95% confidence interval 0.30-1.07; p = 0.08).

LIMITATIONS

Heterogeneous patient populations and MTP in the studies included.

CONCLUSION

There is limited evidence that the implementation of MTP may be associated with decreased mortality in nontrauma patients. However, patient characteristics, as well as the indication and definition of MTP were highly heterogeneous in the available studies. Further prospective investigation into this topic is warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

RBC Transfusion Strategies in the ICU: A Concise Review

OBJECTIVES

To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU.

DATA SOURCES

Source data were obtained from a PubMed literature review.

STUDY SELECTION

English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies.

DATA EXTRACTION

Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice.

DATA SYNTHESIS

Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion.

CONCLUSIONS

The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.

How do I manage severe postpartum hemorrhage?

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.

Fibrinogen for the management of critical obstetric hemorrhage

AIM

In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome.

METHODS

We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point-of-care testing.

RESULTS

The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5_FIBTEM . Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload.

CONCLUSION

The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.

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.

National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review

In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.

Obstetric interventions and maternal morbidity among women who experience severe postpartum hemorrhage during cesarean delivery

BACKGROUND

Compared to vaginal delivery, women undergoing cesarean delivery are at increased risk of postpartum hemorrhage. Management approaches may differ between those undergoing prelabor cesarean delivery compared to intrapartum cesarean delivery. We examined surgical interventions, blood component use, and maternal outcomes among those experiencing severe postpartum hemorrhage within the two distinct cesarean delivery cohorts.

METHODS

We performed secondary analyses of data from two cohorts who underwent prelabor cesarean delivery or intrapartum cesarean delivery at a tertiary obstetric center in the United States between 2002 and 2012. Severe postpartum hemorrhage was classified as an estimated blood loss ≥1500mL or receipt of a red blood cell transfusion up to 48h post-cesarean delivery. We examined blood component use, medical and surgical interventions and maternal outcomes.

RESULTS

The prelabor cohort comprised 269 women and the intrapartum cohort comprised 278 women. In the prelabor cohort, one third of women received red blood cells intraoperatively or postoperatively, respectively. In the intrapartum cohort, 18% women received red blood cells intraoperatively vs. 44% postoperatively (P<0.001). In the prelabor and intrapartum cohorts, methylergonovine was the most common second-line uterotonic (33% and 43%, respectively). Women undergoing prelabor cesarean delivery had the highest rates of morbidity, with 18% requiring hysterectomy and 16% requiring intensive care admission.

CONCLUSION

Our findings provide a snapshot of contemporary transfusion and surgical practices for severe postpartum hemorrhage management during cesarean delivery. To determine optimal transfusion and management practices in this setting, large pragmatic studies are needed.

Transfusion and coagulation management in major obstetric hemorrhage

PURPOSE OF REVIEW

Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage.

RECENT FINDINGS

Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels.

SUMMARY

A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.

Considerations of red blood cell molecular testing in transfusion medicine

The field of transfusion medicine is on the threshold of a paradigm shift, as the technology for genotyping of red blood cell antigens, including US FDA-approved arrays, is now moving into standard practice. Access to cost-efficient, high-resolution genotyping has the potential to increase the quality of care by decreasing the risk for alloimmunization and incompatible transfusions in individuals on long-term blood transfusion protocols, including patient groups with hemoglobinopathies and other chronic diseases. Current and future applications of molecular methods in transfusion medicine and blood banking are discussed, with emphasis on indications for genotyping in various clinical scenarios. Furthermore, limitations of the current gold standard methodology and serology, as well as of contemporary molecular methodology, are examined.

Massive hemorrhage: a report from the anesthesia closed claims project

BACKGROUND

Hemorrhage is a potentially preventable cause of adverse outcomes in surgical and obstetric patients. New understanding of the pathophysiology of hemorrhagic shock, including development of coagulopathy, has led to evolution of recommendations for treatment. However, no recent study has examined the legal outcomes of these claims. The authors reviewed closed anesthesia malpractice claims related to hemorrhage, seeking common factors to guide future management strategies.

METHODS

The authors analyzed 3,211 closed surgical or obstetric anesthesia malpractice claims from 1995 to 2011 in the Anesthesia Closed Claims Project. Claims where patient injury was attributed to hemorrhage were compared with all other surgical and obstetric claims. Risk factors for hemorrhage and coagulopathy, clinical factors, management, and communication issues were abstracted from claim narratives to identify recurrent patterns.

RESULTS

Hemorrhage occurred in 141 (4%) claims. Obstetrics accounted for 30% of hemorrhage claims compared with 13% of nonhemorrhage claims (P < 0.001); thoracic or lumbar spine surgery was similarly overrepresented (24 vs. 6%, P < 0.001). Mortality was higher in hemorrhage than nonhemorrhage claims (77 vs. 27%, P < 0.001), and anesthesia care was more often judged to be less than appropriate (55 vs. 38%, P < 0.001). Median payments were higher in hemorrhage versus nonhemorrhage claims ($607,750 vs. $276,000, P < 0.001). Risk factors for hemorrhage and coagulopathy were common, and initiation of transfusion therapy was commonly delayed.

CONCLUSIONS

Hemorrhage is a rare, but serious, cause of anesthesia malpractice claims. Understanding which patients are at risk can aid in patient referral decisions, design of institutional systems for responding to hemorrhage, and education of surgeons, obstetricians, and anesthesiologists.

[Anesthetic management of severe or worsening postpartum hemorrhage]

INTRODUCTION

Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH.

METHODS

A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read.

RESULTS

When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus).

CONCLUSION

The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.

Never-frozen liquid plasma blocks endothelial permeability as effectively as thawed fresh frozen plasma

BACKGROUND

Thawed fresh frozen plasma (TP) is a preferred plasma product for resuscitation but can only be used for up to 5 days after thawing. Never-frozen, liquid plasma (LQP) is approved for up to 26 days when stored at 1°C to 6°C. We have previously shown that TP repairs tumor necrosis factor α (TNF-α)-induced permeability in human endothelial cells (ECs). We hypothesized that stored LQP repairs permeability as effectively as TP.

METHODS

Three single-donor LQP units were pooled. Aliquots were frozen, and samples were thawed on Day 0 (TP0) then refrigerated for 5 days (TP5). The remaining LQP was kept refrigerated for 28 days, and aliquots were analyzed every 7 days. The EC monolayer was stimulated with TNF-α (10 ng/mL), inducing permeability, followed by a treatment with TP0, TP5, or LQP aged 0, 7, 14, 21, and 28 days. Permeability was measured by leakage of fluorescein isothiocyanate-dextran through the EC monolayer. Hemostatic profiles of samples were evaluated by thrombogram and thromboelastogram. Statistical analysis was performed using two-way analysis of variance, with p < 0.05 deemed significant.

RESULTS

TNF-α increased permeability of the EC monolayer twofold compared with medium control. There was a significant decrease in permeability at 0, 7, 14, 21, and 28 days when LQP was used to treat TNF-α-induced EC monolayers (p < 0.001). LQP was as effective as TP0 and TP5 at reducing permeability. Stored LQP retained the capacity to generate thrombin and form a clot.

CONCLUSION

LQP corrected TNF-α-induced EC permeability and preserved hemostatic potential after 28 days of storage, similar to TP stored for 5 days. The significant logistical benefit (fivefold) of prolonged LQP storage improves the immediate availability of plasma as a primary resuscitative fluid for bleeding patients.

Volume replacement following severe postpartum hemorrhage

Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence-based team response to this life-threatening condition.

Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation

BACKGROUND

Women with placenta increta (PI) and placenta percreta (PP) are at high risk of obstetric hemorrhage; however, the severity of hemorrhage and perioperative morbidity may differ according to the degree of placental invasion. We sought to compare blood component usage and perioperative morbidity between women with PI versus PP undergoing cesarean hysterectomy (CH).

STUDY DESIGN AND METHODS

We identified 77 women who underwent CH for PI or PP from the NICHD MFMU Network Cesarean Registry, which sourced data from 19 centers from 1999 to 2002. We examined demographic, obstetric, and surgical data and rates of transfusion and perioperative morbidity. We performed statistical tests for between-group analyses; p values less than 0.05 were significant.

RESULTS

Rates of intraoperative or postoperative red blood cell (RBC) transfusion were similar between groups (PI 84% vs. PP 88%; p=0.7). We observed no between-group differences in rates of fresh-frozen plasma (FFP) transfusion (intraoperative FFP-PI 30% vs. PP 41%; p=0.3; postoperative FFP-PI 28% vs. PP 18%; p=0.4) or platelet (PLT) transfusion (intraoperative PLTs-PI 14% vs. PP 29%; p=0.2; postoperative PLTs-PI 9% vs. PP 9%; p=1.0). Among the morbidities, a higher proportion of PP women underwent cystotomy (PI 14% vs. PP 38%; p=0.02) and postoperative mechanical ventilation (PI 14% vs. PP 35%; p=0.03).

CONCLUSION

Rates of intraoperative RBC, FFP, and PLT transfusion are similar for PI and PP women, and perioperative outcomes are worse for PP women. We suggest the same mobilization transfusion medicine support for both groups, including blood ordering (type and cross-match for CH) and availability of emergency blood protocols including fibrinogen-containing preparations.

A reappraisal of plasma, prothrombin complex concentrates, and recombinant factor VIIa in patient blood management

Plasma therapy and plasma products such as prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa) are used in the setting of massive or refractory hemorrhage. Their roles have evolved because of newly emerging options, variable availability, and heterogeneity in guidelines. These factors can be attributable to lack of evidence-based support for a defined role for plasma therapy, variability in coagulation factor content among PCCs, and uncertainty regarding safety and efficacy of rFVIIa in these settings. This review summarizes these issues and provides insight regarding use of these options in management of refractory or massive bleeding.

Postpartum hemorrhage treated with a massive transfusion protocol at a tertiary obstetric center: a retrospective study

BACKGROUND

A massive transfusion protocol may offer major advantages for management of postpartum hemorrhage. The etiology of postpartum hemorrhage, transfusion outcomes and laboratory indices in obstetric cases requiring the massive transfusion protocol were retrospectively evaluated in a tertiary obstetric center.

METHODS

We reviewed medical records of obstetric patients requiring the massive transfusion protocol over a 31-month period. Demographic, obstetric, transfusion, laboratory data and adverse maternal outcomes were abstracted.

RESULTS

Massive transfusion protocol activation occurred in 31 patients (0.26% of deliveries): 19 patients (61%) had cesarean delivery, 10 patients (32%) had vaginal delivery, and 2 patients (7%) had dilation and evacuation. Twenty-six patients (84%) were transfused with blood products from the massive transfusion protocol. The protocol was activated within 2h of delivery for 17 patients (58%). Median [IQR] total estimated blood loss value was 2842 [800-8000]mL. Median [IQR] number of units of red blood cells, plasma and platelets from the massive transfusion protocol were: 3 [1.75-7], 3 [1.5-5.5], and 1 [0-2.5] units, respectively. Mean (SD) post-resuscitation hematologic indices were: hemoglobin 10.3 (2.4)g/dL, platelet count 126 (44)×10(9)/L, and fibrinogen 325 (125)mg/dL. The incidence of intensive care admission and peripartum hysterectomy was 61% and 19%, respectively.

CONCLUSIONS

Our massive transfusion protocol provides early access to red blood cells, plasma and platelets for patients experiencing unanticipated or severe postpartum hemorrhage. Favorable hematologic indices were observed post resuscitation. Future outcomes-based studies are needed to compare massive transfusion protocol and non-protocol based transfusion strategies for the management of hemorrhage.

Postpartum hemorrhage: when uterotonics and sutures fail

Systemic bleeding at the time of postpartum hemorrhage (PPH) is usually the result of coagulopathy that has developed acutely as a result of massive hemorrhage after uterotonics and sutures have failed. Occasionally, the patient has a preexisting coagulopathy, but more often, coagulopathy arises acutely as the result of massive hemorrhage, which is usually related to obstetrical and less often surgical bleeding. Despite being able to identify risk factors for PPH in the antenatal and intrapartum period, the majority of women who ultimately develop PPH do not have any such factors and every pregnancy is at risk. The coagulopathy associated with massive PPH may be due to hemodilution, failure of liver synthetic function as occurs with acute liver failure of pregnancy, or disseminated intravascular coagulation (DIC). There are no data from clinical trials to help guide management of transfusion in PPH, although the management of blood component therapy in severe PPH is similar to that in other massive hemorrhage. Standard practice is to replace fibrinogen to maintain a level of ≥ 100 mg/dL, yet recent evidence suggests that the level of fibrinogen needed to prevent PPH is at least 400 mg/dL. Recombinant activated factor VIIa (rFVIIa) has been used in the management of severe PPH unresponsive to blood component therapy. Coagulation laboratory evaluation may be useful in guiding hemostatic management during massive PPH, but for the results to be useful, they must be rapidly available and provide information that would not be available from clinical assessment alone. The hematologist or hemostasis expert has the opportunity to make the difference between life and death for the patient experiencing massive PPH.