Surveillance of massive transfusion in major obstetric haemorrhage

Summary

Key points

Postpartum haemorrhage (PPH) remains a common cause of maternal morbidity and mortality worldwide, however, little is known about the incidence, management and outcomes of women with severe PPH undergoing massive transfusion.

• The aims of this study were to ascertain the incidence of massive transfusion in obstetrics in the UK, and describe the current management practices and clinical outcome for these women.
• The study identified 181 women who had undergone massive transfusion, giving an estimated incidence of 23 per 100 000 maternities (95%CI 19–26).
• The median estimated blood loss was 6 l (interquartile range 4.5–8.0 l) and the principle causes of haemorrhage were uterine atony (40%), placental abnormalities (33%) and trauma including uterine rupture (19%).
• At presentation, the median platelet count was lowest for placenta accreta, compared with other causes, while the median prothrombin time and fibrinogen were <1·5 × mean normal and <3 g/l, respectively for all aetiologies.
• The median platelet count and fibrinogen fell to <75 × 10⁹ /l and <2 g/l, respectively for all causes during bleeding, except for trauma.
• In total, 45% of women underwent hysterectomy; women with placenta accreta had the highest hysterectomy rate. Two women died, 82% were admitted to intensive care/high-dependency units, and 28% developed major morbidities.
• This study showed that massive transfusion due to PPH is associated with high rates of morbidity and hysterectomy. The coagulopathy in women with PPH undergoing massive transfusion differs significantly depending on its cause, suggesting that more targeted transfusion strategies are required.

Publications

Journal Articles

• Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, Simpson NAB, Weeks A, Stanworth SJ. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol. 2015;172(4):616-24.
• Green L, Knight M, Seeney FM, Hopkinson C, Collins PW, Collis RE, Simpson NAB, Weeks A, Stanworth SS. The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study. BJOG. 2015;123(13):2164-70.
• Knight M, Seeney FM, Hopkinson C, Collins PW, Collis RE, Simpson NAB, Weeks A, Stanworth SS, Green L. Authors' reply re: The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study. BJOG. 2017;124(1):167-8.