OG10.2 | Blood Product Use in Obstetric Haemorrhage — Summary & Reflection

KEY TAKEAWAYS

Blood Product Use in Obstetric Haemorrhage — Key Points:

• Indications: PPH (≥500 mL vaginal / ≥1000 mL CS), APH with DIC, severe anaemia, coagulopathy, thrombocytopenia (HELLP, ITP).
• Products and roles: PRBCs (Hb/oxygen-carrying); FFP (all clotting factors, 10–15 mL/kg); Cryoprecipitate (fibrinogen concentrate, ~250 mg/unit — first choice for fibrinogen deficiency in DIC); Platelets (primary haemostasis, room temperature ONLY).
• Thresholds: Transfuse PRBCs if Hb <8 g/dL in active haemorrhage; FFP if PT/aPTT >1.5×; Cryoprecipitate if fibrinogen <1.5 g/L (target >2 g/L); Platelets if <50 × 10⁹/L with active bleeding.
• Emergency blood: O-negative (universal donor); group-specific within 15–20 min; full crossmatch within 45–60 min.
• Massive transfusion: 1:1:1 ratio (PRBCs:FFP:platelets); TXA 1 g IV within 3 hours of haemorrhage onset (WOMAN trial); calcium gluconate after every 4–6 PRBCs; blood warmer.
• Transfusion reactions: Stop transfusion, maintain IV access, call for help. AHTR (ABO mismatch — haemoglobinuria, shock — STOP, recheck labels, IVF, monitor for DIC + AKI); TRALI (non-cardiogenic pulmonary oedema within 6 h — oxygen, notify blood bank); TACO (cardiogenic pulmonary oedema — furosemide, upright); FNHTR (fever/rigors — paracetamol, restart slowly).
• Rh-negative women: O-negative emergency blood + post-event Kleihauer-Betke + anti-D immunoglobulin.

REFLECT

Reflect using Kolb's cycle:

Concrete Experience: Return to Mrs Kavitha from the opening hook — 2,500 mL PPH, oozing from IV sites, BP 60/40 mmHg, no crossmatch sample available. You are the intern.

Reflective Observation: Walk through your decision sequence: emergency O-negative blood first; activate the massive transfusion protocol (1:1:1 ratio); give tranexamic acid 1 g IV immediately; draw blood for FBC, coagulation screen, fibrinogen, group and crossmatch; request cryoprecipitate if fibrinogen returns low. What would you watch for as a sign of a transfusion reaction while all this is happening?

Abstract Conceptualisation: Why does the WOMAN trial's 3-hour window matter so critically? What is the mechanistic explanation for why FFP alone is insufficient to restore fibrinogen in DIC? How does the 1:1:1 protocol prevent dilutional coagulopathy?

Active Experimentation: On your next obstetric ward round, ask a senior colleague to show you the local massive transfusion protocol and the blood bank's emergency transfusion process. Ask how the blood bank is notified in a haemorrhage emergency. Observe how a crossmatch sample is labelled — and why a labelling error is the commonest cause of haemolytic transfusion reactions.