Massive Transfusion Protocols and Postpartum Hemorrhage

How I Practice Video Series
Elliott K. Main, MD, FACOG

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When I see a patient with postpartum hemorrhage, there are 2 new principles that I take into account. The first is the difference between resuscitation and treatment. As we were taught in our residencies by internal medicine we used to treat people with blood products based on laboratory values alone, i.e., if the hematocrit was low we'd use red cells, if the coagulation factors were abnormal we'd use FFP's or platelets. When one is faced with traumatic hemorrhage or postpartum hemorrhage, though, those rules don't apply. We need apply the rules of resuscitation, which is to treat with blood products until vital signs have become normalized and then revert to treatment based on lab values. The second new principle in the treatment of postpartum hemorrhage is that of trying to replace the whole blood lost through rapid hemorrhage with whole blood, or the modern equivalent thereof which is a combination of red cells and coagulation products. This was brought home by our experience in Iraq. In ever war we have new lessons in medicine. The lesson from our army surgeons in Iraq, was that with rapid blood loss from road side bombs, which was the major source of casualties in Iraq, the treatment of choice was a massive transfusion with both red cells and fresh frozen plasma of FFP. It's 1:1 ratio was associated with a three-fold reduction in mortality in Iraq as opposed to red cells alone. This has been rapidly transferred into civilian practice in our emergency rooms with traumatic injuries and in labor delivery with massive postpartum hemorrhage. So every obstetric unit should have a massive transfusion protocol and after the first unit or two the red cells you should move to replace with whole blood or its equivalent which is a 1 to 1 ratio of red cells and FFP and every fifth unit with platelets. There are resources that give further details on this, The California Maternal Quality Care Collaborative or website. And we are happy to give out any further information if you contact that site. This is how I practice. 


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