Hemostatic Resuscitation in Peripartum Hysterectomy Pre- and Postmassive Transfusion Protocol Initiation

Abstract

Background Massive transfusion protocols (MTPs) have been examined in trauma. The exact ratio of packed red blood cells (PRBC) to other blood replacement components in hemostatic resuscitation in obstetrics has not been well defined.

Objective The objective of this study was to evaluate hemostatic resuscitation in peripartum hysterectomy comparing pre- and postinstitution of a MTP.

Study Design We conducted a retrospective, descriptive study of women undergoing peripartum hysterectomies from January 2002 to January 2015 who received ≥ 4 units of PRBC. Individuals were grouped into either a pre-MTP institution group or a post-MTP institution group. The post-MTP group was subdivided into those who had the protocol activated (MTP) versus not activated (no MTP). Primary outcomes were estimated blood loss (EBL) and need for blood product replacement. The secondary outcome was a composite of maternal morbidity, including need for mechanical ventilation, venous thromboembolism, pulmonary edema, acute kidney injury, and postpartum infection. A Mann–Whitney U test was used to compare continuous variables, and a chi-squared test was used for categorical variables with significance of p < 0.05.

Results Of the 165 women who had a peripartum hysterectomy during the study period, 62 received four units or more of PRBC. No significant differences were noted in EBL or blood product replacement between the pre-MTP (n = 39) and post-MTP (n = 23) groups. Similarly, the MTP (n = 6) and no MTP (n = 17) subgroups showed no significant difference between EBL and overall blood product replacement. Significant differences were seen in transfusion of individual blood products, such as fresh frozen plasma (FFP) (MTP = 4, no MTP = 2; p = 0.02) and platelets (plts) (MTP = 6, no MTP = 0; p = 0.03). The use of high ratio replacement therapy for both plasma and plts was more common in the MTP group (FFP/PRBC ratio [MTP = 0.5, no MTP = 0.3; p = 0.02]; plts/PRBC ratio [MTP = 0.7, no MTP = 0; p = 0.03]). There were no differences in the secondary outcome between pre- and post-MTP or MTP and no MTP.

Conclusion Initiation of the MTP did result in an increase in transfusion of FFP and plts intraoperatively. At our institution, the MTP is underutilized, but it appears that providers are more cognizant of the use of high transfusion ratios.

Keywords

massive transfusion protocol - peripartum hysterectomy - hemostatic resuscitation - obstetric hemorrhage

Note

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. Drs. Dutta and Poole are military service members. This work was prepared as part of their official duties. Title 17, USC, §105 provides that “Copyright protection under this title is not available for any work of the U.S. Government.” Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person's official duties.

• References

• 1 Main EK, Goffman D, Scavone BM. , et al; National Partnership for Maternal Safety; Council on Patient Safety in Women's Health Care. National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol 2015; 126 (01) 155-162
• 2 American Congress of Obstetricians and Gynecologists. District II. Safe Motherhood Initiative; maternal safety Bundle for obstetric hemorrhage. Available at: http://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-OB-Hemorrhage . Accessed September 17, 2015
• 3 California Maternal Quality Care Collaborative Task Force. OB Hemorrhage Toolkit V2.0. Available at: https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit . Accessed September 16, 2015
• 4 Snegovskikh D, Clebone A, Norwitz E. Anesthetic management of patients with placenta accreta and resuscitation strategies for associated massive hemorrhage. Curr Opin Anaesthesiol 2011; 24 (03) 274-281
• 5 Borgman MA, Spinella PC, Perkins JG. , et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63 (04) 805-813
• 6 Sihler KC, Napolitano LM. Complications of massive transfusion. Chest 2010; 137 (01) 209-220
• 7 Holcomb JB, Tilley BC, Baraniuk S. , et al; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015; 313 (05) 471-482
• 8 del Junco DJ, Holcomb JB, Fox EE. , et al; PROMMTT Study Group. Resuscitate early with plasma and platelets or balance blood products gradually: findings from the PROMMTT study. J Trauma Acute Care Surg 2013; 75 (01) (Suppl. 01) S24-S30
• 9 Pacheco LD, Saade GR, Gei AF, Hankins GD. Cutting-edge advances in the medical management of obstetrical hemorrhage. Am J Obstet Gynecol 2011; 205 (06) 526-532
• 10 Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. The role of massive transfusion protocols in obstetrics. Am J Perinatol 2013; 30 (01) 1-4
• 11 Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol 2016; 214 (03) 340-344
• 12 Bailit JL, Grobman WA, Rice MM. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Morbidly adherent placenta treatments and outcomes. Obstet Gynecol 2015; 125 (03) 683-689