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Massive OB Hemorrhage Protocol in Private Practice 2012-14: Results and Insights
Abstract Number: F-22
Abstract Type: Original Research
Background: Post-partum hemorrhage remains the major cause of obstetric mortality and morbidity. PPH increased 26% between 1994 and 2006 from 2.3% (n = 85,954) to 2.9% (n = 124,708; P<.001). In massive obstetric hemorrhages, implementation of a standardized massive transfusion protocol often lead to successful management of life-threatening hemorrhages. At Sharp Mary Birch hospital, we reviewed the data on obstetric patients who required emergency massive transfusion over a 3 year period from 2012 to 2014. At Mary Birch, a massive transfusion protocol for OB patients follows the California Maternal Quality Care Collaborative hemorrhage guidelines which specify a higher ratio of plasma to RBCs than trauma cases. The goal ratio of pRBCs : plasma: platelets is 4:4:1, with 2 cryoprecipitate, pooled, which is issued with the 4th massive transfusion pack, but may be ordered earlier if indicated.
Data analysis: Over the 3 years, there were total of 48 cases where emergency massive transfusions were invoked. These cases included both obstetric and gynecologic cases. Obstetric cases were mostly the result of uterine atony or invasive placenta. Amniotic fluid embolism and splenic artery aneurysm rupture were examples of less common causes of obstetrical hemorrhage. In 2012, there were 14 incidences, and on average, each patient required 10.9 units of pRBCs, 6.5 units of thawed plasma, 1.6 units of platelets and 1.7 units of cryoprecipitate, which is equivalent to a ratio of pRBC to plasma to platelets as 6.8 to 4 to 1 with 1 of cryoprecipitate. Of note, these numbers represent the number of products given during intraoperative and postoperative periods. In 2013, there were total of 17 cases, and on average, each patient required 5.2 units of pRBCs, 3.1 unit of plasma, 1 unit of platelets with 0.6 units of cryoprecipitate which is a ratio of 5.2 to 3.1 to 1 with 0.6 of cryoprecipitate. In 2014, there were 17 cases, and on average each patient received 9.7 units of pRBCs, 7.4 units of plasma, 2 units of platelets and 1.4 units of cryoprecipitate which is a ratio of 4.9 to 3.7 to 1 with 0.7 units of cryoprecipitate. Of interest, over an 8-month period from September 2012 to April 2013, there were 11 cases that required massive transfusion, and total of 11 pools of cryoprecipitate (each pool consists of 5 units) were wasted. This led to cryoprecipitate only being provided on the 3rd cycle of transfusion or if a measured fibrinogen level indicated its use.