Obstetric Hemorrhage: Double the Risk

Written by: Carolyn Burns, MD

Transfusion support for the obstetric patient is complex and demands a significant understanding of the peri-partum physiology, bleeding risk assessment and knowledge of other useful mechanical, pharmacological, and surgical interventions.  Variability in obstetric transfusion practice mirrors that seen in general medical and surgical practices.  Even the definition of what constitutes “significant hemorrhage” is plagued by the underlying difficulty in estimating blood loss and risk stratification.

Pre-disposing conditions such as: uterine atony, placenta previa, placenta accreta, uterine abruption,  retained placental elements, prolonged labor, lacerations occurring with delivery and underlying congenital coagulation disorders, can place patients at risk for associated postpartum hemorrhage.  Hemorrhage is frequently acute in onset, severe, and may be associated with coagulopathy. Postpartum hemorrhage still remains a significant cause of morbidity and mortality even in developed countries.  Thus, the need for detailed and effective protocols is essential.

The California Quality Care Collaborative Task Force, in 2010, reported on their effort to provide comprehensive discussion, guidelines, references and tools for rapid diagnosis and intervention for obstetric hemorrhage.¹ This group advocated team-based continuing education and drills to maintain competency and heightened awareness of obstetric hemorrhage.  This idea of protocol-driven drills was recommended previously by The Joint Commission.²

Goodnough et al. review their institutional processes in the “How Do I..” section of the December, 2011 issue of Transfusion. ³ Their policies and procedures have been based on accumulating evidence and analysis of the needs of this particular patient population.^4-6 Coagulopathy associated with obstetric hemorrhage likely has different inherent initiating events than those associated with trauma.  Ongoing research and evidence-based guidelines will hopefully bridge the gaps in our current knowledge allowing better, more rapid recognition, monitoring, and treatment for these patients.

The single most important feature of obstetric hemorrhage that sets it apart from other clinical scenarios is that it is not just one life that is to be considered, but the lives of two individuals: mother and baby.  Collaborative management of postpartum hemorrhage thus demands coordinated, practiced efforts to consider the risk: benefit ratio and interventions that affect a mother and child.

References:

1. Lyndon A. Improving health care response to obstetric hemorrhage. California Maternal Quality Care Collaborative.
2. The Joint Commission. Healthcare at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury 2005 May27.
3. Goodnough T.  How we treat: transfusion medicine support of obstetric services. Transfusion 2011 Dec; 51(12):2540-48.
4. Butwick AJ.  Retrospective analysis of transfusion outcomes in pregnant patients at a tertiary obstetric center.  Int J Obstet Anesth  2009 Oct; 18(4):302-8.
5. Burtelow M.  How we treat: management of life-threatening primary postpartum hemorrhage with a standard massive transfusion protocol. Transfusion 2007 Sep; 47(9):1564-72.
6. James AH.  Blood component therapy in postpartum hemorrhage. Transfusion 2009 Nov; 49(11): 2430-33.

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