Postpartum haemorrhage: are we following the guidelines on coagulation monitoring and transfusion support?

Abstract

Background Postpartum haemorrhage (PPH) may be associated with early hypofibrinogenaemia and disseminated intravascular coagulation (DIC), and therapy with fresh frozen plasma (FFP), cryoprecipitate (for fibrinogen replacement) and platelets may be required in addition to red blood cell (RBC) transfusion. National patient blood management (PBM) on critical bleeding guidelines recommend early and frequent coagulation testing to guide therapy. Aim/Method A retrospective audit of PPH transfusion support was undertaken during two 6-month periods (2011 and 2013) at a major metropolitan obstetric service. Results In 157 PPH episodes, 154 (98%) patients had >1 risk factor (RF) for bleeding and 59 (38%) had >4 RF. Median estimated blood loss (EBL) was 1000 mL (300 mL to >9000mL). Correlation between EBL, haemoglobin (Hb) fall and Hb nadir was very poor. Ninety-five percent of patients received RBC, with 47% receiving 1000mL, 46% had no coagulation testing (2011, 42%; 2013, 50%). Of 31 who received >4 units RBC, 26% had no coagulation testing. Only 10% received FFP, 8% platelets and 3% cryoprecipitate. Conclusion Although most patients were young and had minor/ moderate PPH, nearly all received RBC. Conversely, coagulation testing was not performed in nearly half the patients with major bleeding. Very few received non-RBC components, even when hypofibrinogenaemia was documented. More work is required to align our practice with current national guidelines on management of critical bleeding.