Obstetric haemorrhage may occur before or after delivery, but more than 80% of cases occur postpartum.
Worldwide, massive obstetric haemorrhage, resulting from the failure of normal obstetrical, surgical and/or systemic haemostasis, is responsible for 25% of the estimated 358,000 maternal deaths each year.(1)
Blood loss may be:
- Antepartum: haemorrhage after 24th week of gestation and before delivery
- placenta praevia, placental abruption, bleeding from vaginal or cervical lesions
- Postpartum (Primary): within 24 hours of delivery
- Tone (uterine atony)
- Tissue (retained products)
- Trauma (cervical and genital tract damage during delivery)
- Thrombin (coagulation disorder)
- Postpartum (Secondary): 24 hours to 6 weeks post-delivery
- uterine atony, retained products, genital tract trauma, uterine inversion
Blood loss can be notoriously difficult to assess in obstetric bleeds. Bleeding may sometimes be concealed and the presence of amniotic fluid makes accurate estimation challenging.(2)
Post-partum haemorrhage (PPH) has been defined as a blood loss of 500 mL or more during puerperium and severe PPH as a blood loss of 1000 mL or more.(3)
Goals in the management of transfusion in severe haemorrhage include:
- rapid resuscitation with crystalloids to restore and maintain the circulating blood volume to prevent tissue and organ hypoperfusion
- maintenance of tissue oxygenation using red blood cells and
- reversal or prevention of coagulopathy using appropriate blood and plasma components, ie, platelets, fresh frozen plasma (FFP), for the provision of clotting factors and cryoprecipitate or fibrinogen concentrate as a source of fibrinogen.
Prevention and treatment of hypothermia, acidosis and hypocalemia will ensure optimal function of transfused coagulation factors.(1)
The Royal College of Obstetricians and Gynaecologists’ 'Blood Transfusion in Obstetrics' guideline aims to offer guidance about the appropriate use of blood products that neither compromises the affected woman nor exposes her to unnecessary risk. Strategies to maximise the haemoglobin (Hb) level at delivery as well as to minimise blood loss are also discussed.(4)
- Mclintock C, James, AH. Obstetric Hemorrhage. Journal of Thrombosis and Haemostasis, 2011;9:1441–1451
- Davies K, Rucklidge M. Management of Obstetric Haemorrhage. Anaesthesia UK, 2007.
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of Postpartum Haemorrhage (C-Obs 43). Australia, 2011
- Royal College of Obstetricians and Gynaecologists. Blood Transfusions in Obstetrics (Green-top 47). United Kingdom, 2008.