What is the role of blood transfusion in the treatment of postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Order blood transfusions if blood loss is ongoing and thought to be in excess of 2000 mL or if the patient’s clinical status reflects developing shock despite aggressive resuscitation. Data from various sources suggest that 1 in 16-40 women experiencing PPH requires a blood transfusion if active third-stage management is used, whereas approximately 1 in 9 requires a transfusion if expectant management is used. Newer studies tend to have lower transfusion rates than older studies. [9]

Whole blood is no longer available in most settings, and, for many reasons, PRBCs are initially used with other blood components and given only if indicated. Most medical units have access to uncrossmatched O-type Rh-negative PRBCs for catastrophic bleeding. In PPH, uncrossmatched ABO- and Rh-compatible blood is usually available because a blood group and antibody screen has already been performed. Have full crossmatched blood available for transfusion within 30 minutes. Clinicians must be aware of the capabilities of their blood bank regarding timing, type, and amount of blood products available in emergencies. Good communication with the blood transfusion service is essential, and the nature of the emergency and the potential amount of blood products required must be stressed.

The goal is to rapidly transfuse 2-4 U of PRBCs to replace lost oxygen-carrying capacity and to restore circulating volume. Administer the blood transfusion through a set with an integrated filter, and use a blood warmer if the infusion rate (>100 mL/min) or the total volume infused is high. A rapid infusion set with an integrated warmer or a pressure cuff may be used to increase the infusion rate. PRBCs are very viscous, reducing the infusion rate. This problem may be overcome by adding 100 mL of NS to each unit. Do not use LRS for this purpose because the calcium contained in the solution may cause clotting.

The risks of transfusion are well known and are covered elsewhere (eg, see Transfusion Reactions or Transfusion and Autotransfusion), but they include infection, transfusion reaction, and development of atypical antibodies. Several other complications may be noted in large-volume transfusions. The risk of hypothermia is minimized by the use of blood warmers. Dilutional coagulopathy may be observed and is discussed below. Hyperkalemia and acidosis related to the use of stored blood are theoretical risks but are seldom clinically important if perfusion of vital organs is maintained. Monitor electrolyte and acid-base status if the situation is ongoing. Hypocalcemia due to citrate intoxication is also seldom observed. [36]

Patients may refuse a transfusion of blood products based on religious or other grounds. A patient's refusal of blood products must be respected and must not be equated with a desire for no intervention or be seen as an excuse for suboptimal care. Several options, including the use of autotransfusion, can be considered for the management of these patients. Ensure that a care plan is in place (see Transfusion and Autotransfusion). An article by Hughes et al reviewed the issues and management options in patients who refuse transfusion. Clinicians should bear in mind that the refusal may not extend to all related products. Products that use recombinant technologies such as human erythropoietin and activated factor VIIa are usually acceptable. [37]

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