Massive Transfusion Protocol: Saving Our Patients Lives

Background: Postpartum Hemorrhage remains the single most significant cause of maternal death world-wide.  It occurs in 2% to 6% of women who deliver vaginally.  It can occur early (<24 hours after birth) or late (>24 hours and < 6 weeks after birth).  The primary cause of early postpartum hemorrhage is uterine atony and is typically devineds as > 500mL following vaginal delivery and >1,000 mL following Cesarean Section or a 10% decrease in hematocrit.  Interventions for postpartum hemorrhage include treating the underlying cause and managing the symptoms with medications, surgical interventions, placement of uterine tamponade and blood volume replacement.  Improved outcomes are seen with coordinated team efforts and established hospital processes. 

Case: A 45 year old, G4, P1 presented to L&D in early labor at term. On admission her HCT was 39.9. Her labor was augmented, she progressed quickly and delivered vaginally. Following delivery of her placenta, she began to hemorrhage.  The patient was treated in the delivery room with fundal massage, Misoprosotol, Hemabate, placement of foley catheter & Bakri balloon.  Anesthesia and second obstetrician were consulsted. DIC panel and 2 units of PRBcs orderd.  Patient became symptomatic and was transferred to OR.   A Code White was called and an interdisciplinary team of obstetricians, laboratory, ICU and spiritual care responded. 

After intubation in the OR, the patient continued to hemorrhage. The decision was made to proceed with a hysterectomy.  A Massive Transfusion Protocol was initiated with the Blood Bank to faciliate preparation and thawing of blood products. During the surgical procedure, the patient developed Ventricular Tachycardia and a Code Blue was activated.  Additional interdisciplinary team members from the ED, pharmacy and ICU responded.   At this time the patient's hematocrit dropped to 21.9, fibrinogen <60, PT= 40, INR= 4.15 and arterial blood gas pH=6.97.

During the surgical case the patient received 11,440mL fluid and 11 units packed red blood cells, 7 units FFP, 3 units of platelets, 4 units cryoprecipitate.  Her DIC stabilized and her heart rhythm returned to sinus tachycardia.  She remained intubated and was transferred to ICU. The following day she was extubated and transferred to postpartum and she was discharged home on post operative day #4.  The patient is now a spokesperson for the community blood bank.

Conclusion: In order to efficiently manage massive postpartum hemorrhage early treatment must be initiated, interdisciplinary teams should be utilized and in this case our Massive Transfusion Protocol was activated.  The coordination of care with the blood bank was critical in receiving the necessary blood products in a timely manner.

Keywords: postpartum hemorrhage, Massive Transfusion Protocol, DIC, Code White