Prognosis and successful maternal and neonatal
outcomes of patients admitted to an intensive care unit depend not only on the
patient factors but also on a multidisciplinary team work from obstetricians,
anaesthetists, intensivists, haematologists, transfusion physicians, neonatologists,
and other specialists.4,21

 

The target is
to keep the fibrinogen level above 1.5 g/l.13 The amount of blood
components transfused may vary depending on the local massive transfusion
protocols, although a commonly
followed massive transfusion protocol is RBC: FFP: platelets as 4:4:1 ratio.4,20

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In major
obstetric haemorrhage, FFP at a dose of 12–15 ml/kg should be given for every 6
units of red cells13. Further FFP transfusion would be decided by the
coagulation investigations. The target of transfusions is to maintain the
prothrombin time (PT) and activated partial thromboplastin time (APTT) ratios
at less than 1.5 times normal. Cryoprecipitate is given early in severe
bleeding episodes as two 5-unit pools.

Fresh frozen plasma and cryoprecipitate

 

In an acutely bleeding
patient 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.
13,22,23

A platelet count of
50 × 109/l is usually taken as adequate
for procedures. For epideural anesthesia, a patient requires a platelet count
of 80 × 109/l and in such cases
prophylactic platelet transfusions are given. 13,23

Platelets

 

As per the
RCOG guidelines for blood transfusion in obstetrics, red cells transfusion is
almost always required when the Hb is less than 60 g/l and it is rarely
required when the Hb is greater than 100 g/l. 13

The decision
to initiate transfusion on a patient depends on various factors. There are no given
solid criteria for starting red cell transfusion. This should be individualised
depending on the clinical profile of each patient.13,19,20

Red cells

 

Transfusion triggers

 

 

 

 

 

 

Massive haemorrhage is a well described indication13
for FFP and cryoprecipitate transfusion, while other pregnancy associated
conditions such as thrombotic thrombocytopenic purpura and acute fatty liver of
pregnancy complicated with bleeding conditions as well require FFP transfusion.
4,20

 

Fresh frozen plasma and cryoprecipitate
transfusion

 

Conservative management will be sufficient for most of
the cases while platelet
transfusion may be needed during the first two trimesters only if the patient
is symptomatic, with a low platelet count or when an invasive procedure is
required.13,22,23

Thrombocytopenia is one of the common findings during
pregnancy. Several causes have been identified for the mild reduction in
platelets including gestational thrombocytopenia, Immune thrombocytopenia where
the patient usually will not require a platelet transfusion. There are certain
causes which are specific to pregnancy such as HELLP syndrome, acute fatty
liver of pregnancy and other causes which are associated with pregnancy as
thrombotic thrombocytopenic purpura, haemolytic uremic syndrome and disseminated
intravascular coagulation. 22,23

Platelet transfusion

 

 

The common
conditions 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 and
mortality in obstetric haemorrhage9,10,11. World Health Organization statistics suggest that 60% of
maternal deaths in developing countries are due to PPH.9,10,11 PPH could be primary, if
occurs in the first 24 hours of delivery or secondary if it occurs after 24
hours after and within 6 weeks of delivery. The causes for PPH are uterine
atony, retained placenta or placenta accreta, genital tract trauma and
coagulopathy.4,9,10,11

Obstetric haemorrhage is the leading cause of maternal
mortality1,4,8, about 13% in developed countries to 34% in Africa.12 More than 80% of obstetric haemorrhage cases
are recorded postpartum9, which is responsible for 25% of the
estimated 358,000 maternal deaths each year1,8,10,11,17. Significant
obstetric haemorrhage is defined as blood loss greater than 1000 mL and major
haemorrhage if greater than 2500 mL and/ or the transfusion of five or more
units of blood and/or requiring treatment for coagulopathy. This could be antepartum
or postpartum haemorrhage.

Early detection of anaemia and
investigations to find the cause and correction will avoid the need for
transfusion14,15. As for any other patients, the decision for
transfusion 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 and there are only <4 weeks for delivery. Prophylactic transfusion in patients with sickle disease and thalassaemia is not recommended16 and should only be planned if there are severe situations16 since there is an increased risk of infections, hospitalizations, alloimmunisation and iron overload. Anaemia during pregnancy attributes for about 15% of maternal mortality.1 It is a common finding that complicates pregnancy in the developing countries. According to the BCSH guidelines, Anaemia in pregnancy is defined as first trimester haemoglobin less than 110 g/l, second and third trimester Hb less than 105 g/l, and postpartum Hb less than 100 g/l.13,14 Indications for blood transfusion during pregnancy can be categorised widely as anaemia of pregnancy and haemoglobinopathies, obstetric haemorrhage and surgeries in which significant blood loss is expected1. Red cell transfusion   Indications for transfusion in pregnancy   The indications for ICU admission in the obstetric population due to pregnancy related causes could be widely categorised as cardiovascular disorders of pregnancy, obstetric haemorrhage, respiratory disorders during pregnancy, infections and hepatic disorders of pregnancy4,5,6,21. Other than these, Surgical or medical conditions which are not related to pregnancy such as trauma, diabetes, autoimmune diseases, asthma etc6 could necessitate the admission to the ICU. There are also some medical diseases that may worsen during pregnancy that are, anaemia, congenital heart diseases, rheumatic and non-rheumatic valvular diseases, renal failure, and autoimmune diseases etc.5,21 Intensive care admission of the obstetric patient is infrequent; data from the UK and USA show that admission rates are about 0.9% of all mothers during their pregnancy or puerperium. But maternal mortality of the obstetric patients admitted to an ICU varies from 5-20%.5   The obstetric patient may have any surgical or medical condition necessitating intensive care unit (ICU) admission. There are also pregnancy-specific conditions that could lead to the critical care admission.7,21 There are no well-defined criteria that decide the admission of an obstetric patient to an ICU. Most of the ICU admissions are based on local polices.5,21 Conditions leading to critical care admission   The fetus' wellbeing should also be considered while managing the mother's bleeding or other emergencies1. Haemolytic disease of the fetus and the neonate, infections, premature delivery or an intra uterine death could result from the maternal complications.1   There can be other comorbidities including eclampsia, and the HELLP syndrome which would further lead to severe bleeding. Hypercoagulable state in pregnancy which usually assists in controlling the blood loss may also complicate the condition leading to disseminated intravascular coagulopathy and pulmonary embolism. Assessing the blood loss with the help of vital signs is not reliable in pregnancy.1,4,18 Changes in the vital signs such as hypotension or laboratory findings including the drop in haemoglobin or haematocrit do not occur until a larger amount of blood lost due to the haemodilution and increased cardiac output. There could be concealed haemorrhage in the myometrium and/or broad ligament which would lead the clinician to underestimate the blood loss. Blood mixed with amniotic fluid will also complicate the calculation of blood loss. During a normal pregnancy, the mother undergoes significant anatomical and physiological changes.1 The haematological changes are physiological dilutional anaemia, neutrophilia, mild thrombocytopenia, increased procoagulant factors, and decreased fibrinolysis activity.1 These changes help the mother to stay haemodynamically stable with the normal blood loss during delivery. Red cell mass increases around 20-30% and there is a greater gradual increase in plasma volume around 50% which attribute to the dilutional anaemia of pregnancy. Increased fibrinogen and factors VII, VIII, and IX, Protein A, Protein C, and Antithrombin III with reduced activity of fibrinolytic system lead to the hypercoagulable state of pregnancy.1 Transfusion in obstetric patients is considered to be a unique challenge5, 6 due to various reasons, including physiological changes of pregnancy, difficulty in assessing the blood loss in obstetric patients, risk of alloimmunisation which complicates the further transfusion and future pregnancies and posing a threat to the fetus1, 4, 5   Concerns specific to the obstetric patients   Blood and blood components transfusion therapy is identified as one of the essential components1,2 in emergency management of obstetric patients who are critically ill and admitted to the intensive care unit. In the developing countries, the transfusion management could vary from that of the developed world due to the availability of the components, economy, infrastructure, religious belief and social taboos.3