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OBSTETRICS
Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto ON
Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
Abstract
Objective: To describe the common characteristics, clinical
management, and outcome of patients requiring blood transfusion
within 24 hours of delivery.
Methods: We conducted a retrospective cohort study of patients who
received blood transfusion for postpartum hemorrhage (PPH) in
the first 24 hours post-delivery, over a five-year period
(20002005). The medical records of patients were reviewed to
obtain information about demographics, pregnancy and delivery
characteristics, transfusion data, and complications.
Results: The overall blood transfusion rate for PPH was 0.31%
(104/33 631 deliveries). The rate of blood transfusion in women
who had a Caesarean section during labour was 0.49%, whereas
in women who had a vaginal delivery or elective Caesarean
section it was 0.28% and 0.23%, respectively. Antenatal risk
factors for PPH were identified in 61% of patients, and 39% of
patients developed intrapartum risk factors. The most important
etiological factors were uterine atony (38.5%) and retained
products of conception (33.7%). Twenty-one percent of the
patients developed coagulopathy, and 24% required admission to
the intensive care unit.
Conclusion: Severe primary PPH requiring blood transfusion can be
predicted in the majority of patients on the basis of antenatal risk
factors, while the remaining patients require vigilant monitoring for
risk factors during labour and delivery. In the multidisciplinary
effort to prevent and control major PPH, we should re-evaluate the
pharmacotherapy for PPH and ensure careful removal of retained
placental tissue after delivery.
Rsum
Objectif : Dcrire les caractristiques, la prise en charge clinique et
les issues courantes en ce qui concerne les patientes ncessitant
une transfusion sanguine dans les 24 heures suivant
laccouchement.
Mthodes : Nous avons men, sur une priode de cinq ans
(20002005), une tude de cohorte rtrospective portant sur des
patientes qui avaient reu une transfusion sanguine motive par
une hmorragie postpartum (HPP) au cours des 24 premires
heures suivant laccouchement. Les dossiers mdicaux des
Key Words: Postpartum hemorrhage, blood transfusion, risk
factors, vaginal delivery, Caesarean section
Competing Interests: None declared.
Received on January 28, 2008
Accepted on April 3, 2008
INTRODUCTION
The interdisciplinary management of PPH involves resuscitation using fluid replacement, administration of uterotonic
Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review
Caesarean section
PPH
postpartum hemorrhage
PRBC
OBSTETRICS
Table 1. Demographics, obstetric details, and etiology of postpartum hemorrhage requiring blood
transfusion
Total
(n = 104)
Vaginal deliveries
(n = 67)
Elective CS
(n = 12)
CS during labour
(n = 25)
Demographics
Age in years, SD
33.6 4.8
33.3 4.9
35.0 5.0
33.7 4.8
Weight in kg, SD
75.9 13.3
75.4 13.7
78.9 15.7
75.6 8.6
35.8 6.1
35.0 7.0
37.3 2.2
36.9 4.7
Primipara, n (%)
56 (53.8)
38 (56.7)
3 (25)
15 (60)
Multipara, n (%)
48 (46.2)
29 (43.3)
9 (75)
10 (40)
Spontaneous
44 (47.8)
33 (49.2)
11 (44)
Induced
24 (26.1)
16 (23.9)
8 (32)
Augmented
24 (26.1)
18 (26.9)
6 (24)
12 (13)
12 (52)
6 (6.5)
4 (6.0)
2 (8)
1 (1.1)
1(1.5)
Normal
86 (82.6)
61 (91)
6 (50)
19 (76)
Previa
7 (6.7)
2 (3)
2 (16.7)
3 (12)
Accreta
7 (6.7)
4 (6)
1 (8.3)
2 (8)
Percreta
3 (2.9)
3 (25)
Abruption
1 (0.9)
1 (4)
Atony
40 (38.5)
18 (26.9)
5 (41.7)
17 (68)
Retained tissues
35 (33.7)
28 (41.8)
5 (41.7)
2 (8)
13 (12.5)
12 (17.9)
1 (8.3)
Coagulopathy
7 (6.7)
4 (6.0)
3 (12)
Undetermined
9 (8.7)
5 (7.5)
1 (8.3)
3 (12)
Placentation, n (%)
The mean lowest hemoglobin concentration during bleeding was 63 15 g/L, the mean lowest hematocrit was 0.19
0.44%, and the mean lowest platelet count was 128 000
74 000/mm3 (Table 3). All patients received transfusions of
PRBCs (median 3 units; 900 mL). Recombinant factor VII
was administered in one patient. The use of other blood
products is shown in Table 4. Details of the uterotonic
agents used are shown in Table 5. All four uterotonic agents
(oxytocin, ergometrine, carboprost, and misoprostol) were
administered concomitantly in only 20% of the cases, while
about 50% of the patients received an additional drug other
than oxytocin. Dilatation and curettage (26.9%) and manual
removal of the placenta (17.3%) were the most common
surgical procedures performed, and hysterectomy and gel
foam embolization of uterine arteries were each performed
in 16.3% of patients (Table 5).
Invasive monitoring with arterial line and central vein
cannulation was carried out in 37.5% and 14.4% of patients,
respectively, and both of these procedures were used in
1004 l NOVEMBER JOGC NOVEMBRE 2008
Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review
n (%)
22 (21.2)
Antepartum hemorrhage
21 (20.1)
Multiple gestation
18 (17.3)
Macrosomia
17 (16.3)
Abnormal placentation
17 (16.3)
14 (13.5)
Chorioamnionitis
9 (8.7)
Blood disorders/anticoagulation
8 (7.7)
History of PPH
5 (4.8)
In our study, the patients requiring blood transfusion represented only 10% of the total patients with PPH. The incidence of transfusion for primary PPH (occurring within 24
hours of delivery) was 0.31%. This result is consistent with
the data of Reyal et al., which showed a frequency of transfusion of 0.23% during the period 19921998.13 The rates
of blood transfusion vary in different institutions because
of a great variance in physicians attitudes toward blood
transfusions. Ransom et al. reported a frequency of transfusion of 0.47% in patients undergoing vaginal deliveries, but
Rouse et al. found a rate of 3.2% in patients having a primary CS and 2.2% in those having a repeat CS.14,15 This
high incidence of transfusion could perhaps be due to lack
of standardized transfusion strategies in the authors institution. Various national health care organizations have introduced new policy guidelines for PRBC transfusions,1618 as
a result of which there has been an overall decline in the
number of PRBC transfusions in the current decade.19
Despite this low rate of transfusion in our patient population, morbidity in the form of DIC, cardiac and pulmonary
complications, and a need for ICU admission was seen in
about 32% of patients requiring blood transfusion. The
markers for this major maternal morbidity were the transfusion of more than five units of PRBCs, emergency hysterectomy, and/or uterine artery embolization.
The results of our study prompted us to review the current
protocols for the pharmacologic and surgical management
of PPH in order to minimize the risk for potential blood
transfusions. The prophylactic administration of oxytocin
after delivery is the current standard for prevention of PPH,
because of its rapid onset of action and the lack of serious
adverse effects if administered appropriately.20 Nevertheless, in clinical practice this drug is often administered in
excessive amounts, especially in the event of postpartum
bleeding, which can lead to several undesirable
hemodynamic effects such as hypotension and circulatory
OBSTETRICS
Baseline
Lowest
Post-transfusion
Hemoglobin, g/L
117 15
63 15
91 15
0.35 0.42
0.19 0.44
0.27 0.44
Platelets, 000/mm3
216 84
128 74
170 81
INR
1.0 0.1
1.4 0.9
1.1 0.1
Hematocrit, %
104 (100)
3 (126)
44 (42.3)
4 (122)
Platelets
19 (18.2)
5 (120)
Cryoprecipitate
10 (9.6)
5.5 (115)
1 (1)
Blood products
Mean dose SD
Drugs
104 (100)
47 19
59 (57)
450 260
Carboprost (mg)
51 (49)
730 421
Misoprostol (mg)
25 (24)
976 167
Oxytocin (IU)
Ergometrine (mg)
Surgical Procedures
Dilatation and curettage
28 (26.9)
18 (17.3)
Hysterectomy
17 (16.3)
17 (16.3)
Repair of lacerations
14 (13.5)
6 (5.8)
3 (2.9)
and early detection of retained tissue by the use of ultrasound may help to reduce the incidence of retained
products of conception after delivery.
Our study was not intended to identify risk factors for PPH,
since these have already been described; rather, we compiled common characteristics seen in patients with major
bleeding episodes requiring blood transfusions. The current
study was also limited by the retrospective data collection
and a lack of case-control design; however, it gives us a profile of the patients requiring blood transfusions postpartum,
and it provides details of the pharmacological management,
transfusion requirements and patient outcomes in these
patients, which have not been described previously.
Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review
CONCLUSION
12. Baskett TF, OConnell CM. Severe obstetric maternal morbidity: a 15-year
population-based study. J Obstet Gynaecol 2005;25(1):79.
13. Reyal F, Sibony O, Oury JF, Luton D, Bang J, Blot P. Criteria for transfusion in
severe postpartum hemorrhage: analysis of practice and risk factors. Eur J
Obstet Gynecol Reprod Biol 2004;112:614.
14. Ransom SB, Fundaro G, Dombrowski MP. The cost-effectiveness of routine
type and screen admission testing for expected vaginal delivery. Obstet Gynecol
1998;92:4935.
15. Rouse DJ, MacPherson C, Landon M, Varner MW, Leveno KJ, Moawad AH,
et al. Blood transfusion and cesarean delivery. Obstet Gynecol 2006;108:8917.
16. Expert Working Group. Guidelines for red blood cell and plasma transfusion for
adults and children. CMAJ 1997;156:S125.
17. Practice guidelines for blood component therapy: a report by the American
Society of Anesthesiologists Task Force on Blood Component Therapy.
Anesthesiology 1996;84:73247.
18. British Committee for Standards in Haematology. Guidelines for the clinical use
of red cell transfusions. Br J Haematol 2001;113:2431.
19. Eogan M, OConnell MP, Collins R, Murphy K, Keane DP. Trends in blood
transfusion in obstetrics at the National Maternity Hospital 19912001. Ir Med J
2003;96:2478.
20. Cotter A, Ness A, Tolossa J. Prophylactic oxytocin for the third stage of labour.
Cochrane Database Syst Rev 2001;4:CD001808.
21. Pinder AJ, Dresner M, Calow C, Shorten GD, ORiordan J, Johnson R.
Haemodynamic changes caused by oxytocin during Cesarean section under
spinal anesthesia. Int J Obstet Anesth 2002;11:1569.
22. Weis FR Jr, Markello R, Mo B, Bochiechio P. Cardiovascular effects of oxytocin.
Obstet Gynecol 1975;46:2114.
23. Why Mothers Die 19971999, the fifth report of the confidential enquiries into
maternal deaths in the United Kingdom. London (UK):
RCOG Press;2001:13449.
24. Balki M, Ronayne M, Davies S, Fallah S, Kingdom J, Windrim R, et al. Minimum
oxytocin dose requirement after cesarean delivery for labor arrest. Obstet
Gynecol 2006;107:4550.
25. Carvalho JC, Balki M, Kingdom J, Windrim R. Oxytocin requirements at elective
cesarean delivery: a dose-finding study. Obstet Gynecol 2004;104:100510.
26. Robinson CR, Schumann R, Zhang P, Young RC. Oxytocin-induced
desensitization of the oxytocin receptor. Am J Obstet Gynecol
2003;188:497502.
27. Phaneuf S, Rodriguez Linares B, TambyRaja RL, MacKenzie IZ, Lopez Bernal A.
Loss of myometrial oxytocin receptors during oxytocin-induced and
oxytocin-augmented labour. J Reprod Fertil 2000;120:917.
28. Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and
outcome of pregnancies complicated with early postpartum hemorrhage: a
population-based study. J Matern Fetal Neonatal Med 2005;18:14954
29. Baksu A, Kalan A, Ozkan A, Baksu B, Tekeliolu M, Goker N. The effect of
placental removal method and site of uterine repair on postcesarean endometritis
and operative blood loss. Acta Obstet Gynecol Scand 2005;84:2669.
30. Carroli G, Bergel E. Umbilical vein injection for management of retained
placenta. Cochrane Database Syst Rev 2001;4.
31. Habek D, Franievi D. Intraumbilical injection of uterotonics for retained
placenta. Int J Gynaecol Obstet 2007;2:1059.
10. Confidential Enquiry into Maternal and Child Health. Why Mothers Die
20002002. Available at: http://www.cemach.org.uk. Accessed August 12, 2008.
32. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical
technique for the control of massive postpartum haemorrhage: an alternative to
hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:3725.
33. Thomas BF. Uterine compression sutures for postpartum hemorrhage: efficacy,
morbidity, and subsequent pregnancy. Obstet Gynecol 2007;110:6871.