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      A Retrospective Analysis of Transfusion Management for Obstetric Hemorrhage in a Japanese Obstetric Center

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          Abstract

          Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation ( P< 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3–1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3–1.4 may be desirable.

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          The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.

          Matthew Borgman, Philip Spinella, Jeremy Perkins … (2007)
          Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units. We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>/=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups. For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12-1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0-1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7-1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14-25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1-35.2). In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.
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            The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage.

            B Charbit, L Mandelbrot, E Samain … (2007)
            Postpartum hemorrhage (PPH) is a major source of maternal morbidity. This study's objective was to determine whether changes in hemostasis markers during the course of PPH are predictive of its severity. We enrolled 128 women with PPH requiring uterotonic prostaglandin E2 (sulprostone) infusion. Two groups were defined (severe and non-severe PPH) according to the outcome during the first 24 hours. According to our criteria, 50 of the 128 women had severe PPH. Serial coagulation tests were performed at enrollment (H0), and 1, 2, 4 and 24 hours thereafter. At H0, and through H4, women with severe PPH had significantly lower fibrinogen, factor V, antithrombin activity, protein C antigen, prolonged prothrombin time, and higher D-dimer and TAT complexes than women with non-severe PPH. In multivariate analysis, from H0 to H4, fibrinogen was the only marker associated with the occurrence of severe PPH. At H0, the risk for severe PPH was 2.63-fold higher for each 1 gL(-1) decrease of fibrinogen. The negative predictive value of a fibrinogen concentration >4 gL(-1) was 79% and the positive predictive value of a concentration
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              Haemostatic changes in pregnancy.

              Benjamin Brenner (2003)
              In normal pregnancy, there is a marked increase in the procoagulant activity in maternal blood characterized by elevation of factors VII, X, VIII, fibrinogen and von Willebrand factor, which is maximal around term. This is associated with an increase in prothrombin fragments (PF1+2) and thrombin-antithrombin complexes. There is a decrease in physiological anticoagulants manifested by a significant reduction in protein S activity and by acquired activated protein C (APC) resistance. The overall fibrinolytic activity is impaired during pregnancy, but returns rapidly to normal following delivery. This is largely due to placental derived plasminogen activator inhibitor type 2 (PAI-2), which is present in substantial quantities during pregnancy. D-dimer, a specific marker of fibrinolysis resulting from breakdown of cross-linked fibrin polymer by plasmin, increases as pregnancy progresses. Overall, there is a 4- to 10-fold increased thrombotic risk throughout gestation and the postpartum period. Local haemostasis at the placental throphoblast level is characterized by increased tissue factor (TF) expression and low expression of the inhibitor TFPI. Microparticles derived from maternal endothelial cells and platelets, and from placental throphoblasts may contribute to the procoagulant effect. Local anticoagulant mechanisms on placental throphoblasts are important for counterbalance of the procoagulant milieu. Disruption of anticoagulant mechanisms, for example, autoantibodies, to annexin V may increase pregnancy complications in patients with antiphospholipid antibodies (APLA).
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                Author and article information

                Journal
                Journal ID (nlm-ta): ISRN Obstet Gynecol
                Journal ID (iso-abbrev): ISRN Obstet Gynecol
                Journal ID (publisher-id): ISRN.OBGYN
                Title: ISRN Obstetrics and Gynecology
                Publisher: International Scholarly Research Network
                ISSN (Print): 2090-4436
                ISSN (Electronic): 2090-4444
                Publication date Collection: 2012
                Publication date (Electronic): 6 February 2012
                Volume: 2012
                Electronic Location Identifier: 854064
                Affiliations
                1Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
                2Department of Transfusion Medicine and Cell Therapy, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama 350-8550, Japan
                Author notes

                Academic Editors: F. M. Reis and C. Romero

                Article
                DOI: 10.5402/2012/854064
                PMC ID: 3302117
                PubMed ID: 22462007
                SO-VID: 57e253ba-de91-4608-889b-6766a99df34f
                Copyright © Copyright © 2012 Shigetaka Matsunaga et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 12 September 2011
                Date accepted : 24 October 2011
                Categories
                Subject: Clinical Study

                ScienceOpen disciplines: Obstetrics & Gynecology
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology

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