3. Diagnosis
Anaemia in pregnancy is defined as first trimester
haemoglobin (Hb) less than 110 g/l, second/third
trimester Hb less than 105 g/l, and postpartum Hb
less than 100 g/l, in line with British Committee for
Standards in Haematology (BCSH) guidance.
4. For normocytic or microcytic anaemia, a trial of oral
iron should be considered as the first step and
further tests should be undertaken if there is no
demonstrable rise in Hb at 2 weeks and compliance
has been checked.
5. Pregnant women should be offered screening for
anaemia at booking and at 28 weeks. Women with
multiple pregnancies should have an additional full
blood count done at 20–24 weeks.
6. Oral iron should be the preferred first-line treatment
for iron deficiency.
Parenteral iron is indicated when oral iron is not
tolerated or absorbed or patient compliance is in
doubt or if the woman is approaching term and there
is insufficient time for oral supplementation to be
effective.
7. Women should receive information on improvement
of dietary iron intake and factors affecting
absorption of dietary iron.
The role of recombinant human erythropoietin
(rHuEPO) for non-end-stage renal anaemia is still to
be established and it should only be used in the
context of a controlled clinical trial or on the expert
advice of the haematologist.
8. Active management of the third stage of labour is
recommended to minimise blood loss.
Women at high risk of haemorrhage should be
advised to deliver in hospital.
9.
10. Consent for blood transfusion
Valid consent should be obtained where possible
prior to administering a blood transfusion.
In an emergency, where it is not feasible to get
consent, information on blood transfusion should be
provided retrospectively.
The reason for transfusion and a note of the consent
discussion should be documented in the patient’s
case notes.
11. All women should have their blood group and
antibody status checked at booking and at 28 weeks
of gestation.
Group and screen samples used for provision of
blood in pregnancy should be less than 3 days old.
12. In a woman at high risk of emergency transfusion,
e.g. placenta praevia, and with no clinically
significant alloantibodies, group and screen samples
should be sent once a week to exclude or identify
any new antibody formation and to keep blood
available if necessary.
13. Close liaison with the hospital transfusion laboratory
is essential.
Women should have a group and screen sample
taken in line with clear locally agreed protocols for
provision of blood.
14. ABO-, rhesus D- (RhD-) and K- (Kell-) compatible red
cell units should be transfused.
If clinically significant red cell antibodies are
present, then blood negative for the relevant antigen
should be cross-matched before transfusion; close
liaison with the transfusion laboratory is essential to
avoid delay in transfusion in life-threatening
haemorrhage.
15. There should be a clear local protocol on how to
manage major obstetric haemorrhage.
The protocol should be updated annually and
practised in ‘skills drills’ to inform and train relevant
personnel.
16. — Replacement of blood components is more important
than crystalloid infusion if massive hemorrhage has
occurred or is likely .
There are no universally accepted guidelines for
replacement of blood components .
17. Recommendations are usually based upon expert
opinion since there is no strong evidence from
randomized trials, and these opinions are often
extrapolated from data from studies in trauma patients.
18. Before laboratory studies are available, we suggest
transfusing 2 units of pRBCs if hemodynamics do not
improve after the administration of 2 to 3 liters of normal
saline, estimated blood loss is under 1500 mLs, and
continued bleeding is likely.
In addition, aggressive use of plasma replacement is
important to reverse dilutional coagulopathy .
19. One guideline suggests 4 units pRBCs followed by 4
units fresh frozen plasma (FFP) if no laboratory results
are available, bleeding is ongoing, and bleeding is due to
atony; the 1:1 pRBC:FFP ratio is maintained until tests of
hemostasis are available .
20. ]. FFP is begun sooner in patients with abruption,
amniotic fluid embolism, or prolonged hemorrhage as
impaired hemostasis is more likely in these settings.
Whenever transfusing large volumes of blood products,
particularly stored pRBCs.
21. , it is imperative to consider the electrolyte effects of
such massive transfusion, and to take steps to prevent
or ameliorate changes in calcium (hypocalcemia) and
potassium (hyperkalemia) levels.
22. California Maternal Quality Care Collaborative OB
Hemorrhage Protocol: For patients with unstable vital
signs, suspicion of disseminated intravascular
coagulation, or blood loss >1500 mLs, transfuse pRBC,
FFP, and platelets in a ratio of 6:4:1 or 4:4:1. If
coagulopathy persists after 8 to 10 units pRBCs and
coagulation factor replacement, recombinant activated
factor VIIa is a reasonable option.
23. We continue to transfuse RBCs, platelets,
cryoprecipitate, and FFP in women with ongoing
bleeding to achieve the following targets:
●Hemoglobin greater than 7.5 g/dL
●Platelet count greater than 50,000/mm3
●Fibrinogen greater than 200 mg/dL
●Prothrombin time less than 1.5 times the control value
●Activated partial thromboplastin time less than 1.5
times the control value
24. As an example, 4 units of FFP are given if the
prothrombin time is more than 1.5 times the control
value, one apheresis platelet pack is given if the platelet
count is less than 50,000/mm3, and 10 bags of
cryoprecipitate are given if the fibrinogen is less than
100 mg/dL .
Most providers continue to transfuse patients with
hemoglobin values less than 7.5 to 8 g/dL .
25. It is important to stress that critically low fibrinogen levels
cannot be returned to normal using only FFP without the
use of cryoprecipitate, and in some cases of established
coagulopathy, without fibrinogen concentrate.
These substances should be given together in patients
undergoing massive transfusion who have severe
coagulopathy.
26. There is no consensus on the optimal ratio of blood
product replacement; recommendations for
RBC:FFP:platelet ratios vary widely (1:1, 3:2, 6:4) .
.A pragmatic approach is 1 unit FFP for every 2 to 3 units
of RBCs or 4 units FFP for every 6 units of RBCs .
27. Although FFP contains a small amount of fibrinogen,
cryoprecipitate and fibrinogen concentrate are preferable
for treatment of hypofibrinogenemia because they have
a higher fibrinogen concentration per infused volume.
28. Cryoprecipitate is primarily used for correcting fibrinogen
deficiency, but also contains other clotting factors. The
dose depends on the measured and target fibrinogen
levels; dosing is described in the table .
If no laboratory results are available and 8 units of
pRBCs and 8 units of FFP have been transfused, one
guideline advises infusion of two pools of cryoprecipitate
.
29. Fibrinogen Concentrate (RiaSTAP), a heat-treated,
lyophilized fibrinogen (Factor I) powder made from
pooled human plasma, may be available in some
institutions. Each vial of RiaSTAP contains 900 to 1300
mg fibrinogen and 400 to 700 mg human albumin, and
can be used in combination with cryoprecipitate.
30. It may be used when fibrinogen levels are critically low
(ie, <100 mg/dL), and FFP and cryoprecipitate are not
available. It can be administered sooner than
cryoprecipitate since thawing is not required and it is
effective, but there are few data that it improves outcome
compared with cryoprecipitate.
31. Recombinant human activated factor VII (rFVIIa) is used
for treatment of individuals with bleeding related to
hemophilia A and B inhibitors, acquired inhibitors, and
congenital factor VII deficiency.
It has also been used successfully off-label for control of
bleeding in other situations, such as intractable bleeding
associated with postpartum uterine atony, placenta
accreta, or uterine rupture .
32. Although this therapy appears promising for patients with
hemorrhage refractory to standard therapy, the drug is
very expensive, failed in 50 percent of patients, and may
have increased the risk of thrombotic events, as reported
by others
thus, we suggest reserving its use for women with
postpartum hemorrhage and coagulopathy unresponsive
to standard therapies.
33. The optimal dose is unclear. Doses of 16.7 to
120 mcg/kg as a single bolus injection over a few
minutes every two hours until hemostasis is achieved
have been effective, and usually control bleeding within
10 to 40 minutes of the first dose.
34. It is preferable to start with a low dose (40 or
60 mcg/kg) to reduce the risk of thromboembolic events;
doses of 40 mcg/kg to 90 mcg/kg have been suggested
for obstetric hemorrhage.
The dose may be repeated once in 15 to 30 minutes if
there is no response. Additional doses are unlikely to be
effective.
35. The efficacy of rFVIIa depends on the levels of other
coagulation factors present, patient temperature, and
pH. For maximal effectiveness, the patient should have
an adequate platelet count (>50,000/mm3) and
fibrinogen level (>50 to 100 mg/dL), and near normal
temperature, pH, and calcium levels .
Thus, major sources of bleeding should be controlled
and blood products administered to correct major
deficiencies before administering rFVIIa.
36. Three factor (II, IX, X) and four factor (II, VII, IX, X)
prothrombin complex concentrates (PCC) are available
and have been suggested as an alternative to FFP. The
perceived advantages are a reduced risk of volume
overload, no need for thawing or blood group typing, and
a reduced risk for transfusion-related acute lung injury
and allergic reactions.
Disadvantages include cost and increased risk of
thrombosis.
37. We would caution those using PCC in women with
postpartum hemorrhage to have evidence (or strong
suspicion) of a specific factor deficiency that would be
alleviated by PCC because of the risk of thrombosis and
the lack of data of efficacy in this population, and
because deficiencies in factors II, VII, IX, and X are not
common in this setting.
The most likely scenario where PCC might be of benefit
is in a massive transfusion situation with ongoing DIC
unresponsive to all of the usual therapies.
38. A similar dilutional effect on the platelet concentration
can be seen with massive transfusion [21]. In an adult,
each 10 to 12 units of transfused RBCs are associated
with a 50 percent fall in the platelet count; thus,
significant thrombocytopenia can be seen after 10 to 20
units of blood, with platelet counts below50,000/microL.
39. . For replacement therapy in this setting, six units of
whole blood derived platelets or one apheresis
concentrate should be given to an adult; each unit
should increase the platelet count
by 5000/microL or 30,000/microL for a full six unit adult
dose.
40.
41. Tranexamic acid is an anti-fibrinolytic drug that has been
useful for prevention and treatment of bleeding in various
clinical settings, but it is not a standard therapy for either
prevention or treatment of obstetrical hemorrhage. A pilot
trial in women with PPH >800 mL at vaginal delivery
reported tranexamic acid 4 g in 50 mL of saline IV over 1
hour, followed by maintenance IV infusion
of 1 g/hour for 6 hours decreased progression to severe
PPH compared with no use of tranexamic acid .
42. Diagnosis of severe PPH required one of the following
criteria: peripartum hemoglobin decrease >4 g/dL (using
last hemoglobin value before delivery as the reference),
transfusion of at least 4 units of red blood cells, invasive
hemostatic intervention, or death.
43. The World Maternal Antifibrinolytic Trial (WOMAN)
(Clinicaltrials.gov ID: NCT00872469) is a large,
pragmatic, randomized, double-blind, placebo-controlled
trial evaluating the effect of early administration
of tranexamic acid (1 g by intravenous injection) on
mortality, hysterectomy, and other morbidities in women
with clinically diagnosed PPH .
We are waiting for the results of this trial before
considering routine use of tranexamic acid in women
with PPH.
44. The World Health Organization considers use of
tranexamic acid for the treatment of PPH a reasonable
approach if oxytocin and other uterotonics do not stop
bleeding or if bleeding is partly due to trauma .
