Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

• Published in: British journal of haematology Vol. 190; no. 4; pp. 618 - 628
• Main Authors: Lasica, Masa, Sparrow, Rosemary L., Tacey, Mark, Pollock, Wendy E., Wood, Erica M., McQuilten, Zoe K.
• Format: Journal Article
• Language: English
• Published: England Blackwell Publishing Ltd 01-08-2020
• Subjects: Adult; Afibrinogenemia - etiology; Australia - epidemiology; Blood Component Transfusion - statistics & numerical data; Cesarean Section; coagulopathy; Critical Care - statistics & numerical data; Delivery, Obstetric - adverse effects; Erythrocytes; Factor VIII - therapeutic use; Female; fibrinogen; Fibrinogen - analysis; Fibrinogen - therapeutic use; Gestation; Hematology; Hemorrhage; Hospital Mortality; Humans; Hysterectomy; Hysterectomy - statistics & numerical data; Length of Stay - statistics & numerical data; massive transfusion; Morbidity; Mortality; Multiple Organ Failure - etiology; New Zealand - epidemiology; obstetric haemorrhage; Obstetrics; Placenta; Placenta Previa - epidemiology; Placenta Previa - surgery; Postpartum; Postpartum Hemorrhage - blood; Postpartum Hemorrhage - epidemiology; Postpartum Hemorrhage - therapy; Pregnancy; Pregnancy Complications, Hematologic - blood; Pregnancy Complications, Hematologic - epidemiology; Pregnancy Complications, Hematologic - therapy; Procedures and Techniques Utilization; Respiration, Artificial - statistics & numerical data; Trauma; Uterine Hemorrhage - blood; Uterine Hemorrhage - epidemiology; Uterine Hemorrhage - therapy; Uterine Inertia - epidemiology; Uterus; New Zealand; Australia; obstetric haemorrhage; coagulopathy; fibrinogen; massive transfusion
• ISSN: 0007-1048; 1365-2141
• DOI: 10.1111/bjh.16524

Summary
Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world‐wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi‐national cohort study of MOH defined as bleeding at ≥20 weeks’ gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4 h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2 g/l) occurred in 52% of cases in the first 24 h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7–7·2), placenta praevia (OR 7·2, 95% CI: 2·0–26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0–11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.