Prognosis and successful maternal and neonataloutcomes of patients admitted to an intensive care unit depend not only on thepatient factors but also on a multidisciplinary team work from obstetricians,anaesthetists, intensivists, haematologists, transfusion physicians, neonatologists,and other specialists.4,21 The target isto keep the fibrinogen level above 1.5 g/l.13 The amount of bloodcomponents transfused may vary depending on the local massive transfusionprotocols, although a commonlyfollowed massive transfusion protocol is RBC: FFP: platelets as 4:4:1 ratio.
4,20In majorobstetric haemorrhage, FFP at a dose of 12–15 ml/kg should be given for every 6units of red cells13. Further FFP transfusion would be decided by thecoagulation investigations. The target of transfusions is to maintain theprothrombin time (PT) and activated partial thromboplastin time (APTT) ratiosat less than 1.5 times normal. Cryoprecipitate is given early in severebleeding episodes as two 5-unit pools.Fresh frozen plasma and cryoprecipitate In an acutely bleedingpatient platelet count should be maintained above 50 x 109 /l and the trigger of trigger of 75 x 109/l is recommended by the RCOG guidelines for blood transfusion in obstetrics.
13,22,23A platelet count of50 × 109/l is usually taken as adequatefor procedures. For epideural anesthesia, a patient requires a platelet countof 80 × 109/l and in such casesprophylactic platelet transfusions are given. 13,23Platelets As per theRCOG guidelines for blood transfusion in obstetrics, red cells transfusion isalmost always required when the Hb is less than 60 g/l and it is rarelyrequired when the Hb is greater than 100 g/l.
13The decisionto initiate transfusion on a patient depends on various factors. There are no givensolid criteria for starting red cell transfusion. This should be individualiseddepending on the clinical profile of each patient.13,19,20Red cells Transfusion triggers Massive haemorrhage is a well described indication13for FFP and cryoprecipitate transfusion, while other pregnancy associatedconditions such as thrombotic thrombocytopenic purpura and acute fatty liver ofpregnancy complicated with bleeding conditions as well require FFP transfusion.4,20 Fresh frozen plasma and cryoprecipitatetransfusion Conservative management will be sufficient for most ofthe cases while platelettransfusion may be needed during the first two trimesters only if the patientis symptomatic, with a low platelet count or when an invasive procedure isrequired.13,22,23Thrombocytopenia is one of the common findings duringpregnancy. Several causes have been identified for the mild reduction inplatelets including gestational thrombocytopenia, Immune thrombocytopenia wherethe patient usually will not require a platelet transfusion. There are certaincauses which are specific to pregnancy such as HELLP syndrome, acute fattyliver of pregnancy and other causes which are associated with pregnancy asthrombotic thrombocytopenic purpura, haemolytic uremic syndrome and disseminatedintravascular coagulation.
22,23Platelet transfusion The commonconditions that lead to antepartum haemorrhage are placental abruption,placenta previa, vasa praevia, ectopic pregnancy and uterine rupture.Post-partum haemorrhage is responsible for the majority of morbidity andmortality in obstetric haemorrhage9,10,11. World Health Organization statistics suggest that 60% ofmaternal deaths in developing countries are due to PPH.9,10,11 PPH could be primary, ifoccurs in the first 24 hours of delivery or secondary if it occurs after 24hours after and within 6 weeks of delivery. The causes for PPH are uterineatony, retained placenta or placenta accreta, genital tract trauma andcoagulopathy.4,9,10,11Obstetric haemorrhage is the leading cause of maternalmortality1,4,8, about 13% in developed countries to 34% in Africa.
12 More than 80% of obstetric haemorrhage casesare recorded postpartum9, which is responsible for 25% of theestimated 358,000 maternal deaths each year1,8,10,11,17. Significantobstetric haemorrhage is defined as blood loss greater than 1000 mL and majorhaemorrhage if greater than 2500 mL and/ or the transfusion of five or moreunits of blood and/or requiring treatment for coagulopathy. This could be antepartumor postpartum haemorrhage. Early detection of anaemia andinvestigations to find the cause and correction will avoid the need fortransfusion14,15. As for any other patients, the decision fortransfusion should not be made only by considering the haemoglobin13,15,since clinically stable women do not require blood transfusion even with Hb of<7 g/dl13,19. Transfusion would be necessary if Hb <6 g/dl andthere are only <4 weeks for delivery.
Prophylactic transfusion in patientswith sickle disease and thalassaemia is not recommended16 and shouldonly be planned if there are severe situations16 since there is an increasedrisk of infections, hospitalizations, alloimmunisation and iron overload.Anaemia during pregnancy attributesfor about 15% of maternal mortality.1 It is a common finding thatcomplicates pregnancy in the developing countries. According to the BCSHguidelines, Anaemia in pregnancy isdefined as first trimester haemoglobin less than 110 g/l, second and thirdtrimester Hb less than 105 g/l, and postpartum Hb less than 100 g/l.13,14 Indications for blood transfusion during pregnancy can be categorisedwidely as anaemia of pregnancy andhaemoglobinopathies, obstetric haemorrhage and surgeries in which significantblood loss is expected1.Red cell transfusion Indications for transfusion in pregnancy The indications for ICU admission in the obstetric population due topregnancy related causes could be widely categorised as cardiovasculardisorders of pregnancy, obstetric haemorrhage, respiratory disorders duringpregnancy, infections and hepatic disorders of pregnancy4,5,6,21. Otherthan these, Surgical or medicalconditions which are not related to pregnancy such as trauma, diabetes,autoimmune diseases, asthma etc6 could necessitate the admission tothe ICU.
There are also some medical diseases that may worsen during pregnancythat are, anaemia, congenital heart diseases, rheumatic and non-rheumaticvalvular diseases, renal failure, and autoimmune diseases etc.5,21Intensive care admission of the obstetric patient is infrequent; datafrom the UK and USA show that admission rates are about 0.9% of all mothersduring their pregnancy or puerperium. But maternal mortality of the obstetricpatients admitted to an ICU varies from 5-20%.5 The obstetric patient may have any surgical or medical conditionnecessitating intensive care unit (ICU) admission. There are alsopregnancy-specific conditions that could lead to the critical care admission.7,21There are no well-definedcriteria that decide theadmission of an obstetric patient to an ICU.
Most of the ICU admissions are based on local polices.5,21Conditions leading to critical care admission Thefetus’ wellbeing should also be considered while managing the mother’s bleedingor other emergencies1. Haemolytic disease of the fetus and theneonate, infections, premature delivery or an intra uterine death could resultfrom the maternal complications.1 Therecan be other comorbidities including eclampsia, and the HELLP syndrome whichwould further lead to severe bleeding.
Hypercoagulable state in pregnancy whichusually assists in controlling the blood loss may also complicate the conditionleading to disseminated intravascular coagulopathy and pulmonary embolism.Assessingthe blood loss with the help of vital signs is not reliable in pregnancy.1,4,18Changes in the vital signs such as hypotension or laboratory findings includingthe drop in haemoglobin or haematocrit do not occur until a larger amount ofblood lost due to the haemodilution and increased cardiac output. There couldbe concealed haemorrhage in the myometrium and/or broad ligament which would lead the clinician to underestimate the bloodloss. Blood mixed with amniotic fluid willalso complicate the calculation of blood loss. During a normalpregnancy, the mother undergoes significant anatomical and physiologicalchanges.1 The haematological changes are physiological dilutionalanaemia, neutrophilia, mild thrombocytopenia, increased procoagulant factors,and decreased fibrinolysis activity.1 These changes help the mother to stay haemodynamicallystable with the normal blood loss during delivery.
Red cell mass increases around 20-30% and there is a greater gradual increasein plasma volume around 50% which attribute to the dilutional anaemia ofpregnancy. Increased fibrinogen and factors VII, VIII, and IX, Protein A,Protein C, and Antithrombin III with reduced activity of fibrinolytic systemlead to the hypercoagulable state of pregnancy.1Transfusion in obstetricpatients is considered to be a unique challenge5, 6 due to variousreasons, including physiological changes of pregnancy, difficulty in assessingthe blood loss in obstetric patients, risk of alloimmunisation whichcomplicates the further transfusion and future pregnancies and posing a threatto the fetus1, 4, 5 Concerns specific to the obstetric patients Blood andblood components transfusion therapy isidentified as one of the essential components1,2 in emergency managementof obstetric patients who are critically ill and admitted to the intensive careunit. In the developing countries, the transfusion management could vary fromthat of the developed world due to the availability of the components, economy,infrastructure, religious belief and social taboos.3