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Obstetric haemorrhage

See Figure 1a, Figure 1b and Table 18 (below)
 

There were 17 maternal deaths directly due to haemorrhage reported to the UK Confidential Enquiry during 2000−2002. The obstetric conditions were: placenta praevia, placental abruption and postpartum haemorrhage (10 cases of PPH, compared to a single case in the previous three-year period). Five further deaths involved complications in which significant haemorrhage occurred (eclampsia, placenta accreta at termination of pregnancy, amniotic fluid embolism and ruptured uterus). For more information search www.cemach.org.uk

The blood flow to the placenta is about 700 ml/min at term, so bleeding is likely to be rapid. It is often unexpected and difficult to control. Disseminated intravascular coagulation is common in obstetric haemorrhage due to placental abruption, amniotic fluid embolism and intrauterine death. Haemorrhage due to obstetric DIC is usually relieved only by treating the underlying disorder. Supportive treatment with platelets, FFP and cryoprecipitate may be required and should be guided by laboratory tests. Bleeding into the uterine cavity, the uterine wall or the abdomen may conceal the extent of the blood loss. As a result, the patient may decompensate suddenly in the post-delivery period.(PMID15758608)(PMID16028803)(PMID15321566)(PMID11406073)

Table 18   Successful transfusion management of obstetric haemorrhage − key factors

See major haemorrhage protocol, Figure 1a and Figure 1b.

Use of a comprehensive management protocol with which all staff are familiar.

Clear communication between the hospital transfusion laboratory and the labour ward (see major haemorrhage protocol, inside front cover).

An agreed code or form of words that will:

  • alert blood bank staff to the need for urgent delivery of group O RhD negative blood (or blood of the patient’s own ABO and Rh group)
  • avoid life-threatening delay due to performance of a full crossmatch. This is inappropriate when there is life-threatening bleeding.

Regular ‘fire drills’ to familiarise all staff and to test the success of the protocol.

Training and competence assessment of the staff who transport samples and blood.

Rapid and effective transfusion and haematology lab support.

Reliable availability at the blood bank of uncrossmatched, group-compatible blood within 10−15 minutes of receipt of a blood sample.

A standing agreement between the haematologists and obstetricians over the issue of platelets, FFP and/or cryoprecipitate, which reduces the number of phone calls required and speeds response.

Agreement that initial transfusion of blood components does not require to await results of coagulation tests (see major haemorrhage protocol, inside front cover).

Rapidly available coagulation monitoring results, which will help to assess the adequacy of the coagulation support and guide the selection of components.

Availability of intra-operative cell salvage for:

  • Jehovah’s Witness patients, and
  • patients with placenta praevia accreta.

 

[Table 18 resources: View large format or download as Word™ document]