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Transfusion and coagulation management in major obstetric hemorrhage

Butwick, Alexander J.a; Goodnough, Lawrence T.b,c

Current Opinion in Anaesthesiology: June 2015 - Volume 28 - Issue 3 - p 275–284
doi: 10.1097/ACO.0000000000000180

Purpose of review Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage.

Recent findings Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9–2.3%), and investigators have questioned whether a predelivery ‘type and screen’ is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels.

Summary A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.

aDepartment of Anesthesiology

bDepartment of Pathology

cDepartment of Medicine, Stanford University School of Medicine, Stanford, California, USA

Correspondence to Dr Alexander J. Butwick, Department of Anesthesiology (MC: 5640), 300 Pasteur Drive, Stanford University School of Medicine, Stanford, CA 94305, USA. Tel: +1 650 736 8513; fax: +1 650 725 8544; e-mail:

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