Massive transfusion in obstetric hemorrhage: What are the risk factors and can they be predicted?

Abstract

Objectives: This study aims to identify the risk factors associated with massive transfusion in obstetric hemorrhage and evaluate their predictive value to facilitate early intervention and improve maternal outcomes.

Methods: A retrospective cohort study was conducted on 1305 women who received blood transfusions for obstetric hemorrhage at Etlik City Hospital between October 2022 and December 2024. Patients were categorized into two groups: those who required massive transfusion (≥10 units of blood products) and those who received at least one unit of transfusion. Demographic, clinical, obstetric, and hematological parameters were analyzed. Statistical comparisons were performed using chi-square, Fisher's exact, Mann-Whitney U, and independent sample t-tests.

Results: A history of recurrent miscarriage, two or more previous cesarean sections, congenital uterine abnormalities, and uterine rupture were significantly associated with massive transfusion (P<0.01). Severe anemia (Hb<9 g/dL) and thrombocytopenia were also identified as critical hematological predictors (P<0.001). Socioeconomic factors, including low educational attainment and unemployment, were significantly correlated with the need for massive transfusion (P<0.001). Obstetric complications such as postpartum atony (P<0.001) and premature rupture of membranes (P=0.04) also contributed to increased transfusion risk.

Conclusions: Identifying key risk factors for massive transfusion can aid in early recognition and timely intervention for obstetric hemorrhage. Integrating these predictors into clinical protocols may enhance maternal care by improving preparedness and reducing maternal morbidity and mortality.

Keywords

• Obstetric hemorrhage
• massive transfusion
• risk factors
• postpartum atony
• anemia
• cesarean section
• maternal morbidity.

References

1. 1. Hofmeyr GJ, Qureshi Z. Preventing deaths due to haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2016;36:68-82. doi: 10.1016/j.bpobgyn.2016.05.004.
2. 2. Kogutt BK, Vaught AJ. Postpartum hemorrhage: Blood product management and massive transfusion. Semin Perinatol. 2019;43(1):44-50. doi: 10.1053/j.semperi.2018.11.008.
3. 3. Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol. 2008;22(6):999-1012. doi: 10.1016/j.bpobgyn.2008.08.004.
4. 4. Royal College of Obstetricians and Gynaecologists. Antepartum Haemorrhage (Green-top Guideline No. 63). 2011.
5. 5. Pacagnella RC, Souza JP, Durocher J, et al. A systematic review of the relationship between blood loss and clinical signs. PLoS One. 2013;8:e57594. doi: 10.1371/journal.pone.0057594.
6. 6. Bonnar J. Massive obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2000;14(1):1-18. doi: 10.1053/beog.1999.0060.
7. 7. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization; 2012.
8. 8. Mhyre JM, Shilkrut A, Kuklina EV, et al. Massive Blood Transfusion During Hospitalization for Delivery in New York State, 1998-2007. Obstet Gynecol. 2013;122(6):1288-1294. doi: 10.1097/AOG.0000000000000021.

9. 9. Pacheco LD, Saade GR, Gei AF, Hankins GDV. Cutting-edge advances in the medical management of obstetrical hemorrhage. Am J Obstet Gynecol. 2011;205(6):526-532. doi: 10.1016/j.ajog.2011.06.009.
10. 10. Rajasekhar A, Gowing R, Zarychanski R, et al. Survival of trauma patients after massive red blood cell transfusion using a high or low red blood cell to plasma transfusion ratio. Crit Care Med. 2011;39(6):1507-1513. doi: 10.1097/CCM.0b013e31820eb517.
11. 11. Akseer N, Lawn JE, Keenan W, et al. Ending preventable newborn deaths in a generation. Int J Gynaecol Obstet. 2015;131 Suppl 1:S43-48. doi: 10.1016/j.ijgo.2015.03.017. PMID: 26433505.
12. 12. Burns R, Dent K. editors. In: Managing Obstetric Emergencies and Trauma: A Practical Approach. 4th ed. JohnWiley & Son (Wiley-Blackwell): Manchester. 2022.
13. 13. Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GDV. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol. 2016;214(3):340-344. doi: 10.1016/j.ajog.2015.08.068.
14. 14. Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019. Obstet Gynecol. 2023;141(1):152-161. doi: 10.1097/AOG.0000000000004972.
15. 15. Ouh Y-T, Lee K-M, Ahn KH, et al. Predicting peripartum blood transfusion: focusing on pre-pregnancy characteristics. BMC Pregnancy Childbirth. 2019;19(1):477. doi: 10.1186/s12884-019-2646-3.
16. 16. Muñoz M, Stensballe J, Ducloy-Bouthors A-S, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus. 2019;17(2):112-136. doi: 10.2450/2019.0245-18.
17. 17. Bajwa SP, Haider SMZ, Safdar CA, et al. Rationalization of routine crossmatched blood arrangement for caesarean deliveries and analysis of risk factors requiring blood transfusion. Pak Armed Force Med J. 2015;65(6):809-812.
18. 18. Oya A, Nakai A, Miyake H, Kawabata I, Takeshita T. Risk Factors for Peripartum Blood Transfusion in Women with Placenta Previa: A Retrospective Analysis. J Nippon Med Sch. 2008;75(3):146-151. doi: 10.1272/jnms.75.146.
19. 19. Royal College of Obstetricians and Gynaecologists. Postpartum haemorrhage, prevention and management. 2016. https://www.rcog.org.uk/for-the-public/browse-our-patient-information/heavy-bleeding-after-birth-postpartum-haemorrhage/. Accessed: February 1, 2025
20. 20. Wu E, Jolley JA, Hargrove BA, Caughey AB, Chung JH. Implementation of an obstetric hemorrhage risk assessment: validation and evaluation of its impact on pretransfusion testing and hemorrhage outcomes. J Matern Fetal Neonatal Med. 2015;288(1):71-76. doi: 10.3109/14767058.2014.905532.
21. 21. Naef RW, Chauhan SP, Chevalier SP, Roberts WE, Meydrech EF, Morrison JC. Prediction of hemorrhage at cesarean delivery. Obstet Gynecol. 1994;83(6):923-926. doi: 10.1097/00006250-199406000-00004.
22. 22. Breymann C. Iron Deficiency Anemia in Pregnancy. Semin Hematol. 2015;52(4):339-347. doi: 10.1053/j.seminhematol.2015.07.003.
23. 23. World Health Organization. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. 2008.
24. 24. Lokare PO, Karanjekar VD, Gattani PL, Kulkarni AP. A study of prevalence of anemia and sociodemographic factors associated with anemia among pregnant women in Aurangabad city, India. Ann Niger Med. 2012;6(1):30-34.
25. 25. Montufar-Rueda C, Rodriguez L, Jarquin JD, et al. Severe Postpartum Hemorrhage from Uterine Atony: A Multicentric Study. J Pregnancy. 2013;2013:525914. doi: 10.1155/2013/525914.
26. 26. Tort J, Rozenberg P, Traoré M, Fournier P, Dumont A. Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey. BMC Pregnancy Childbirth. 2015;15:235. doi: 10.1186/s12884-015-0669-y.
27. 27. Beard JL, Hendricks MK, Perez EM, et al. Maternal Iron Deficiency Anemia Affects Postpartum Emotions and Cognition. J Nutr. 2005;135(2):267-272. doi: 10.1093/jn/135.2.267.
28. 28. Corwin EJ, Murray-Kolb LE, Beard JL. Low hemoglobin level is a risk factor for postpartum depression. J Nutr. 2003;133(12):4139-4142. doi: 10.1093/jn/133.12.4139.