Abstract
BackgroundThis study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.MethodsCombined analysis of individual patient data, prospectively collected in six international population-based studies (France, United Kingdom, Italy, Australia, the Netherlands and Denmark). Massive transfusion in major obstetric haemorrhage was defined as transfusion of eight or more units of red blood cells within 24 hours in a pregnant or postpartum woman. Causes, management and outcomes of women with massive transfusion were compared across countries using descriptive statistics.FindingsThe incidence of massive transfusion was approximately 21 women per 100,000 maternities for the United Kingdom, Australia and Italy; by contrast Denmark, the Netherlands and France had incidences of 82, 66 and 69 per 100,000 maternities, respectively. There was large variation in obstetric and haematological management across countries. Fibrinogen products were used in 86% of women in Australia, while the Netherlands and Italy reported lower use at 35–37% of women. Tranexamic acid was used in 75% of women in the Netherlands, but in less than half of women in the UK, Australia and Italy. In all countries, women received large quantities of colloid/crystalloid fluids during resuscitation (>3·5 litres). There was large variation in the use of compression sutures, embolisation and hysterectomy across countries. There was no difference in maternal mortality; however, variable proportions of women had cardiac arrests, renal failure and thrombotic events from 0–16%.InterpretationThere was considerable variation in the incidence of massive transfusion associated with major obstetric haemorrhage across six high-income countries. There were also large disparities in both transfusion and obstetric management between these countries. There is a requirement for detailed evaluation of evidence underlying current guidance. Furthermore, cross-country comparison may empower countries to reference their clinical care against that of other countries.
Highlights
The most common form of major obstetric haemorrhage (MOH), postpartum haemorrhage (PPH) remains a major cause of maternal mortality and morbidity
Denmark reported the highest incidence of massive transfusion at 82 women per 100,000 deliveries; followed by France and the Netherlands with an incidence of 69 per 100,000 deliveries and 66 per 100,000 deliveries, respectively
The United Kingdom (UK), Australia and Italy had a similar incidence of massive transfusion at approximately 21 women per 100,000 deliveries (Table 2)
Summary
The most common form of major obstetric haemorrhage (MOH), postpartum haemorrhage (PPH) remains a major cause of maternal mortality and morbidity. Management of MOH, often defined pragmatically as transfusion of a total body blood volume (8–10 units of red blood cells) or more within 24 hours of delivery [10,11,12] and referred to as massive transfusion, focusses on transfusion and fluid resuscitation, alongside planning for definitive obstetric and surgical interventions [13]. The literature in major haemorrhage caused by trauma has emphasised the importance of damage control resuscitation, including timely transfusion support, early use of coagulation factors and minimising use of crystalloids, which have all contributed to improved clinical outcomes. It is unclear how far these protocols should be applied in an obstetric setting [14]. This study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth
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