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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 41-45

A study on transfusion practice in obstetric hemorrhage in a tertiary care centre


1 Department of Transfusion Medicine, KIMS Hospital, Trivandrum, Kerala, India
2 Department of Transfusion Medicine, Government Medical College, Trivandrum, Kerala, India

Date of Web Publication5-Apr-2018

Correspondence Address:
Dr. Shiffi Fazal
Department of Transfusion Medicine, KIMS Hospital, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_48_17

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  Abstract 


Context: Blood Transfusion is identified as one of the essential components of comprehensive emergency obstetric care which has drastically reduced the maternal mortality. Aims: This study retrospectively reviewed blood transfusion pattern in patients with obstetric hemorrhage in our tertiary care center Government Medical College, Trivandrum (Sree Avittam Thirunal is a part of Government Medical College, Trivandrum) and analyzed the obstetric indications and risk factors for transfusion. We also analyzed the ratio of components transfused. Materials and Methods: Transfusion request forms of 310 patients admitted to the Department of Gynaecology and Obstetrics in Sree Avittom Thirunal Hospital from January 2013 to May 2013 were retrospectively reviewed for the types and volume of blood component transfused indication for each blood component transfusion noted. Patients who had massive obstetric hemorrhage (MOH) were further analyzed to estimate the ratio of components transfused. Statistical Analysis: Chi-square test (for categorical variables) was done to assess frequency distribution. Logistic regression analysis was done to identify major risk factors. The analysis was done using SPSS version 16. P < 0.05 was considered to indicate statistically significant. Results: We have experienced 299 obstetric patients who underwent blood component transfusion during the study. 73% (218) and 27% (81) cases needed peripartum and antepartum transfusion, respectively. Anemia correction accounted for the maximum cases in antepartum transfusion. The leading obstetric conditions of intrapartum and postpartum hemorrhage include abruptio placenta (51 cases; 23.4%), atonic postpartum hemorrhage (30 cases; 13.8%), placenta previa (54 cases; 24.8%), and uterine inversion (15 cases; 6.9%). About 87.2% received packed red blood cell transfusion and 43.7% received platelet concentrate transfusion. 48.1% received fresh frozen plasma (FFP) transfusion. Only 14.2% (21) were transfused with cryoprecipitate. Nearly 27.4% (82) of study individuals had MOH. 92.35% of cases with MOH received FFP transfusion. Cryoprecipitate transfusion was given to 5.4% (15) of patients with MOH. Significant risk factors for MOH, identified using a multivariable analysis, were placenta previa (OR 20.7, 95%CI 9.6–44.6); abruptio placenta (odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.2–3.7); atonic postpartum hemorrhage (OR: 1.4, 95% CI: 1.1–3.4); uterine inversion (OR: 1.2, 95% CI: 1.0–1.8); and rupture uterus (OR: 1.84, 95% CI: 1.1–2.4). A significant positive correlation was observed between the number of units of red cell concentrate (RCC) and that of FPP (P < 0.001). The median of FFP/RCC ratio for each patient was 1.42. Conclusions: A preplanned, multidisciplinary protocol yields the best results in the management of obstetric hemorrhage. In conclusion, for MOH where appropriate supplementation of coagulation factors is essential, the transfusion practice of RCC and FFP in the ratio of 1:1.4–2 observed in our institution is acceptable. However, the utilization of cryoprecipitate needs to be improved.

Keywords: Component transfusion, fresh frozen plasma/packed red blood cell ratio, massive obstetric hemorrhage


How to cite this article:
Fazal S, Poornima A P. A study on transfusion practice in obstetric hemorrhage in a tertiary care centre. Glob J Transfus Med 2018;3:41-5

How to cite this URL:
Fazal S, Poornima A P. A study on transfusion practice in obstetric hemorrhage in a tertiary care centre. Glob J Transfus Med [serial online] 2018 [cited 2018 Nov 20];3:41-5. Available from: http://www.gjtmonline.com/text.asp?2018/3/1/41/229333




  Introduction Top


Maternal mortality is recognized as an important global health problem with obstetric hemorrhage being the leading cause in developing countries.[1] Blood transfusion is identified as one of the essential components of comprehensive emergency obstetric care which has drastically reduced the maternal mortality.[2] As per WHO estimates, over a thousand of all maternal deaths are directly due to obstetric hemorrhage. It accounts for 24% of or an estimated 127,000 maternal deaths annually.[3] The reported percentage of massive and life-threatening obstetric hemorrhage nears around 3%–5% and 0.1% of deliveries, respectively. It has been reported that 0.3%–1% required blood component transfusion.[4],[5],[6]

A number of factors should be considered while assessing the risk of massive hemorrhage in the pregnant patient. The challenges faced are difficulty in assessing blood loss, physiological changes in pregnancy, and underlying obstetric condition. Increases in red cell mass and disproportionately greater increase in plasma volume help the patient to tolerate severe blood loss and remain hemodynamically stable. The physiology of hemostasis in pregnancy is unique. The coagulation system is enhanced, and fibrinolytic system is inhibited in late stages of pregnancy. Thus, a hypercoagulable state prevails in pregnancy. Hence, any massive hemorrhage in pregnancy can induce consumptive loss of coagulation factors, which can cause further hemorrhage leading to a vicious cycle resulting in disseminated intravascular coagulation (DIC).[7] The detection of hypovolemia and thus the decision to transfuse early in obstetric hemorrhage is delayed by the inability to evaluate the accurate blood loss and the high-level tolerance of pregnant female to massive hemorrhage.[8] Understanding the uniqueness of obstetric hemorrhage is required for appropriate blood component support, which can effectively improve its pathophysiological condition, reduce the risk of DIC, and avoid the aggravation of hemorrhagic shock.[9] Thus, a complete evaluation of not only blood loss but also the underlying obstetric risk factor, patient's medical condition, age, vital signs, and blood; biochemical parameters are required to determine whether transfusion is necessary.[10] This study retrospectively reviewed blood transfusion pattern in patients with obstetric hemorrhage in our tertiary care center (Sree Avittom Thirunal Hospital, Trivandrum) and analyzed the obstetric indications and risk factors for transfusion. We also analyzed the ratio of components transfused.

Aims and objectives

  1. To describe the blood transfusion pattern in obstetric patients admitted to Sree Avittom Thirunal Hospital, Trivandrum
  2. To assess the underlying obstetric risk factors associated with massive obstetric hemorrhage (MOH).



  Materials and Methods Top


Transfusion request forms of 310 patients admitted to the Department of Gynaecology and Obstetrics in Sree Avittom Thirunal Hospital from January 2013 to May 2013 were retrospectively reviewed for the types and volume of blood component transfused. Indication for each blood component transfusion noted. Patients who had MOH were further analyzed to estimate the ratio of components transfused. Eleven patients were lost from follow-up.

The following parameters were reviewed:

  1. Type and number of blood component transfused
  2. Underlying obstetric risk factor in each case
  3. Indication for each blood component transfusion noted
  4. Patients who had MOH were further analyzed to estimate the ratio of components transfused.


Analysis

Chi-square test (for categorical variables) was done to assess frequency distribution. Logistic regression analysis was done to identify major risk factors. The analysis was done using SPSS version 16 (Spss Inc, Chicago, II, USA). P < 0.05 was considered statistical significance.


  Results Top


Obstetric patients who underwent blood component transfusion

We have experienced 299 obstetric patients who underwent blood component transfusion during the study period. Out of these, 147 (49.2%) and 152 (50.8%) were primigravida and multigravida respectively. The mean age of patients who received transfusion was 29 years. Maximum number of patients was in the age group of 20–29 years.

Obstetric and hematological indications for blood transfusion

[Figure 1] shows the 299 cases with obstetric hemorrhage that required blood component administration. 73% (218) and 27% (81) cases needed peripartum and antepartum transfusion, respectively. On analyzing the indications for antepartum transfusion, it was found that 61.6% (50) cases were for anemia correction which accounted for the maximum cases. This is followed by ectopic pregnancy (34.7%; 28) and vesicular mole (3.7%; 3).
Figure 1: Indications of transfusion

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The obstetric conditions which has led to intrapartum and postpartum hemorrhage include abruptio placenta (51 cases; 23.4%), atonic postpartum hemorrhage (30 cases; 13.8%), placenta previa (54 cases; 24.8%), uterine inversion (15 cases; 6.9%), eclampsia (20 cases; 9.2%), HELLP syndrome (15 cases; 6.9%), amniotic fluid embolism (1 case; 0.4%), gestational thrombocytopenia (2 cases; 0.9%), rupture uterus (20 cases; 9.2%), and acute fatty liver of pregnancy (9 cases; 4.1%). One case of Glanzman''s thrombasthenia was also reported [Figure 1].

Blood component transfusion for obstetric and hematological indications

Packed red cell transfusion

Out of 299 patients, 261 (87.2%) received packed red blood cell (PRBC) transfusion.

Platelet concentrate transfusion

Out of 299 patients, 130 (43.7%) received platelet concentrate (PC) transfusion.

Fresh frozen plasma transfusion

Out of 299 patients, 144 (48.1%) received fresh frozen plasma (FFP) transfusion.

Cryoprecipitate transfusion

Out of 299 patients, 14.2% (21) received Cryoprecipitate transfusion.

Classification of study subjects based on transfusion

Individuals with MOH were defined as those who were transfused with more than four PRBC units and other blood components. It was observed that 27.4% (82) of study subjects had MOH. The study population was reclassified based on the degree of MOH [Table 1]. Median number of PRBC units transfused was four ranging from 4 to 12. Median number of PC units transfused was four ranging from 2 to 18. 92.35% of cases with MOH received FFP transfusion. Median number of FFP units transfused was six ranging from 2 to 22. Cryoprecipitate transfusion was given to 5.4% (15) of patients with MOH. Median number of Cryoprecipitate units transfused was three ranging from 2 to 8 [Table 2]. The underlying obstetric conditions observed in patients who had MOH were placenta previa (50%); abruptio placenta (26%); atonic postpartum hemorrhage (12%); rupture uterus (9%); and uterine inversion (3%).
Table 1: Classification of study subjects based on degree of massive obstetric hemorrhage

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Table 2: Type and number of blood products transfused in patients who had MOH

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Analysis of underlying obstetric risk factors for massive obstetric hemorrhage

Significant risk factors for MOH, identified using a multivariable analysis, were: Placenta previa (odds ratio [OR]: 20.7, 95% confidence interval [CI]: 9.6–44.6); abruptio placenta (OR: 3.4, 95% CI: 1.2–3.7); atonic postpartum hemorrhage (OR: 1.4, 95% CI: 1.1–3.4); uterine inversion (OR: 1.2, 95% CI: 1.0–1.8); and rupture uterus (OR: 1.84, 95% CI: 1.1–2.4). Significant P value was obtained for placenta previa (P ~ 0.0001), abruptio placenta (P ~ 0.03), atonic postpartum hemorrhage (P ~ 0.04), and rupture uterus (P ~ 0.02).

Analysis of ratio and correlation of blood components transfused for massive obstetric hemorrhage

A significant positive correlation was observed between the number of units of PRBC and that of fresh frozen plasma (FFP) (P< 0.001). The median of FFP/PRBC ratio for each patient was 1.42 in total, and 2 and 2.5 in subgroups with moderate (7–10 units) and massive (>10 units or more) red cell concentrate transfusion, respectively. The median of FFP/PRBC ratio was not significantly different between underlying obstetric disorders.

Outcome of massive obstetric hemorrhage

About 31.7% (25), 39% (31), and 12.2% (10) of patients who had MOH clinically turned to DIC, needed Intensive Care Unit (ICU) admission and mortality, respectively. On risk factor analysis, it was found that MOH presents a significant risk factor for DIC and ICU Admission (P< 0.001).


  Discussion Top


Due to the erratic pathology of postpartum bleeding, blood transfusion has been identified as one of the eight essential components of comprehensive emergency obstetric care, which has been shown to reduce maternal mortality.[2],[11] Maximum number of patients was in the age group of 20–29 years. The two main factors which contribute to maternal mortality and morbidity in developing country are Major obstetric hemorrhage and anemia of pregnancy. Obstetric hemorrhage can occur either in ante-, intra-, or post-partum period.

On analyzing the antepartum transfusion, it was found that 61.6% cases were for anemia correction which accounted for the maximum cases. This is in accordance with the findings reported by Patel et al. and Chhabra and Namgyal.[12],[13] Obstetric and medical condition for blood transfusion during intra- and post-partum period was analyzed. The indications observed in our study include abruptio placenta (51 cases; 23.4%), atonic postpartum hemorrhage (30 cases; 13.8%), placenta previa (54 cases; 24.8%), uterine inversion (15 cases; 6.9%), eclampsia (20 cases; 9.2%), HELLP syndrome (15 cases; 6.9%), amniotic fluid embolism (1 case; 0.4%), gestational thrombocytopenia (2 cases; 0.9%), rupture uterus (20 cases; 9.2%), and acute fatty liver of pregnancy (9 cases; 4.1%). One case of Glanzman's thrombasthenia was also reported. The indications noted are in accordance with similar studies.[5] Regarding component transfusion in the whole study population, 87.2%, 43.7%, and 48.1% received packed red cell, platelet, and FFP transfusion, respectively. Single unit transfusion was given to 28.8% which can be avoided. 27.4% (82) of study subjects had MOH which was defined as those who were transfused with more than four PRC units and other blood components. In these patients who had MOH, the percentage of patients with mild (PRBC: 4–6 units), moderate (PRBC: 7–10 units), and severe (PRBC: >10) MOH was 85%, 10%, and 5%, respectively. These observed frequencies are much lower than the previously reported ones. This may be due to the better antenatal management of obstetric risk factors.[6]

About 92.35% of cases with MOH received plasma transfusion which highlights the significance of coagulation factors in blood transfusion for obstetric hemorrhage. A significant positive correlation was noted between the number of PRBC transfused and that of FFP irrespective of underlying obstetric disorders (P< 0.001). The median of FFP/PRBC ratio for each patient was 1.42 in total, and 2 and 2.5 in subgroups with moderate (7–10 units) and massive (>10 units or more) PRBC transfusion, respectively. The median of FFP/PRBC ratio was not significantly different between underlying obstetric disorders. This PRBC FFP ratio observed in this study is correlating with the report of Borgman et al. who recommended the transfusion of PRBC and plasma at a ratio of 1:1.4 for massive hemorrhage.[14] The underlying obstetric conditions observed in patients who had MOH were placenta previa (50%); abruptio placenta (26%); atonic postpartum hemorrhage (12%); rupture uterus (9%); uterine inversion (3%); and these are in concurrence with with the observations in similar studies.[8] MOH presents a significant risk factor for DIC and ICU Admission (P< 0.001).


  Conclusion Top


Blood transfusion is lifesaving essential component of obstetric care. Acute obstetric blood loss is usually unpredictable and sudden. The decision to transfuse should be time taken to maintain adequate tissue oxygenation in the face of acute hemorrhage. Identifying the risk factors for hemorrhage in antenatal period and anticipating bleeding is essential in managing obstetric hemorrhage. A preplanned, multidisciplinary protocol yields the best results in the management. Overall incidence of blood component utilization has significantly increased in the recent years, but still, the use of whole blood is preferred by many clinicians because of its easy availability in the blood banks. Furthermore, the use of single unit transfusion should be avoided. The decision to perform, a blood transfusion should be made on both clinical and hematological grounds keeping in mind the high-level tolerance of pregnant females to hemodynamic instability. To avoid dilutional coagulopathy in massive transfusion, concurrent replacement with coagulation factors and platelets may be necessary. In conclusion, for MOH where appropriate supplementation of coagulation factors is essential, the transfusion practice of PRBC and FFP in the ratio of 1: 1.4–2 observed in our institution is acceptable. However, the utilization of cryoprecipitate needs to be improved. We still need to train the medical fraternity regarding indications for transfusion and selecting appropriate component for management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Thachil J, Toh CH. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev 2009;23:167-76.  Back to cited text no. 9
    
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Nuttall GA, Stehling LC, Beighley CM, Faust RJ; American Society of Anesthesiologists Committee on Transfusion Medicine. Current transfusion practices of members of the American society of anesthesiologists: A survey. Anesthesiology 2003;99:1433-43.  Back to cited text no. 10
    
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Chandy BK. World Health Organization Fact sheet. Kuwait Med J 2007;39:298-302.  Back to cited text no. 11
    
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Patel VP, Patel RV, Shah PT, Patel CK. Study of role of blood transfusion in obstetric emergencies. Int J Reprod Contracept Obstet Gynaecol 2014;3:1002-5.  Back to cited text no. 12
    
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Chhabra S, Namgyal A. Rationale use of blood and its components in obstetric-gynecological practice. J Mahatma Gandhi Inst Med Sci 2014;19:93-9.  Back to cited text no. 13
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14.
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13.  Back to cited text no. 14
    


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