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Transfusion Protocol for Massive Obstetric Hemorrhage - Should There be One?
Abstract Number: T 70
Abstract Type: Case Report/Case Series
Introduction: Current transfusion practices vary widely among OB-GYN departments. Conventional massive obstetric hemorrhage protocols may underestimate the optimal plasma and platelet to red blood cell (RBC) ratios. We present 3 cases of massive obstetric hemorrhage where different transfusion regiments resulted in different operative courses and different blood loss.
Case 1: A 44 y/o female G1P1001 underwent a primary C-Section under CSE. Patient became progressively hypotensive in PACU and was taken back to the OR for exploratory laparotomy. Due to a complete lack of coagulation, immediate transfusion of PRBC was started with FFP paralleling PRBC. 10 U PRBC, 8 U FFP and 6 U of platelets were given. Bleeding was controlled by total abdominal hysterectomy (TAH). The INR values during surgery were 1.1, indefinite, 2.4, 2.1 and 1.6. The hemoglobin values were 11.6, 6.4, 7.5, 6.6 and 7.2. The total blood loss was 8,000 ml. The patient was discharged on post-operative day (POD) 8.
Case 2: A 37 y/o female G3P3002 with placenta previa underwent a primary C-Section under CSE. Decision was made to perform a TAH after difficulty in controlling bleeding medically. Immediate transfusion of PRBC was started with FFP paralleling PRBC. 10 U PRBC, 8 U FFP, 2 U cryoprecipitate and 2 U of platelets were given. The INR values during surgery were 1.1, 1.6, 2.1, 1.8, 1.4, 1.3 and 1.2. The hemoglobin values were 11.0, 7.7, 8.2, 8.3, 8.7, 7.0 and 7.3. The total blood loss was 5,600 ml. Patient was discharged on POD 5.
Case 3: A 37 y/o female G2P1001 with history of myomectomy underwent a repeat C-Section under CSE. Decision was made to perform supra-cervical hysterectomy after difficulty controlling bleeding medically. Transfusion of PRBC was started with FFP paralleling PRBC. 11 U PRBC, 8 U FFP, 1 U cryoprecipitate and 1 U of platelet were given. The INR values during surgery were 0.9, 1.2, 1.1, 1.0, 1.0 and 1.0. The hemoglobin values were 12.8, 5.6, 7.0, 11.4, 10.4 and 10.5. The total blood loss was 3800 ml. Patient was discharged home on POD 6.
Discussion: Post partum hemorrhage following C-Section, is associated with significant morbidity and mortality, with blood loss as a leading cause of early death. Our 3 cases differ mostly in the timing of the transfusion of FFP. The first patient went into full DIC while the second and third patients had only minimal or no coagulation disturbances - INR 2.1 and INR 1.2 respectively. Earlier plasma transfusions would probably have decreased or prevented consumption coagulopathy in our first patient, as happened in the second and third patients. Transfusion protocol 6:6:1 of PRBC/FFP/Platelets was pretty efficient in our second and third patients. However, even this regimen may become obsolete as new data is emerging on the role of fibrinogen concentrate in massive obstetrical bleeding. We will need more studies in the future to determine the optimal transfusion guidelines for massive obstetric hemorrhage.