CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 66, Number 2, 408–414

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Blood Product
Replacement for
Postpartum
Hemorrhage
JOE EID, MD,* and DAVID STAHL, MD†
*Division of Maternal Fetal Medicine, Department of Obstetrics
and Gynecology, The Ohio State University Wexner Medical
Center; and †Division of Critical Care Medicine, Department of
Anesthesiology, The Ohio State University, Columbus, Ohio

Abstract: Consideration for blood products replace-
ment in postpartum hemorrhage should be given when
blood loss exceeds 1.5 L or when an estimated 25% of
blood has been lost. In cases of massive hemorrhage,
standardized transfusion protocols have been shown
to improve maternal morbidity and mortality. Most
protocols recommend a balanced transfusion involv-
ing a 1:1:1 ratio of packed red blood cells, platelets,
and fresh frozen plasma. Alternatives such as cryo-
precipitate, fibrinogen concentrate, and prothrombin
complex concentrates can be used in select clinical
situations. Although transfusion of blood products
can be lifesaving, it does have associated risks.
Key words: hemorrhage, transfusion, protocol, blood
products
Introduction and Approach to
Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is defined
by blood loss ≥ 1 L (1000 mL) or blood
loss with signs or symptoms of hypovole-
mia within 24 hours after delivery.1 Early
Correspondence: Joe Eid, MD, 395 West 12th Avenue,
Columbus, OH. E-mail: eid07@osumc.edu
The authors declare that they have nothing to disclose.
recognition of PPH is vital in improving
outcomes and guiding the management.
The primary goal should be to detect and
control the source of bleeding. In up to
80% of cases, uterine atony is the cause of
PPH. Other common etiologies include
lacerations, retained placental products,
placenta accreta spectrum, uterine
inversion, and coagulation defects.2
In the postpartum patient, acute
changes in hemoglobin concentration or
hematocrit do not accurately correlate
with the amount of blood loss because of
normal fluid shifts. Signs of hemodynami-
cally significant blood loss such as tachy-
cardia or hypotension do not occur until
at least 25% of the patient’s blood volume
or 1.5 L has been lost.3,4 These signs
should trigger consideration for blood
products replacement particularly in the
setting of continuous blood loss. System-
atic approaches and multidisciplinary pro-
tocols for PPH are now common at the
national and institutional level in an effort

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 66 / NUMBER 2 / JUNE 2023

408 | www.clinicalobgyn.com
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
 Transfusion in Postpartum Hemorrhage
to decrease severe maternal morbidity and
mortality, as well as intensive care unit
admissions associated with PPH.5,6
Blood Products and
Alternatives
The initiation and selection of blood prod-
ucts for transfusion is vital in the resusci-
tation process during PPH, especially
when ongoing blood loss is encountered.
Modern resuscitation generally eschews
whole blood for the improved safety and
efficiency of component products.7 Packed
red blood cells (pRBCs), fresh frozen
plasma (FFP), platelets, and cryoprecipi-
tate can be yielded from 1 unit of whole
blood.8
pRBCs
One unit of pRBCs usually has a volume
of 200 to 300 mL and could be stored for
35 to 42 days.8,9 In nonbleeding adults,
the transfusion of one unit of pRBC will
usually increase hemoglobin concentra-
tion by 1 g/dL.9 Typed and cross-matched
pRBCs are preferable when available.
However, in emergent situations this
might not be feasible because of prepara-
tion time that can take up to 20 minutes.8
In these cases, type O negative blood
should be used.
FFP
FFP is the liquid portion of whole blood
after RBCs and platelets are removed or
when separated by plasmapheresis and is
usually stored at temperatures between
−18 and −30°C.8,9 FFP is typically pack-
aged in 150 to 250 mL aliquots and
contains all of the coagulation factors as
well as anticoagulation proteins.10,11 FFP
is generally ABO—but not Rh matched
to recipient.12 FFP should be considered
in cases of active bleeding abnormal
coagulation studies (prothrombin time
or activated partial thromboplastin time
> 1.5 times of normal)13,14 and in cases of
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
409
active hemorrhage it is generally accepted
that FFP should be transfused as part of a
balanced transfusion strategy or where
needed, a massive transfusion protocol
(MTP).11,15
PLATELETS
Platelets are essential to stabilize clot
formation and facilitate hemostasis. Gen-
erally, platelets are usually prepared by
apheresis from a single donor or pooled
from multiple donors of whole blood.16
They can be stored up to 5 days at room
temperature.9 The volume of 1 platelets
unit is 50 mL and they are often pooled into
4 to 6 units.16 Platelet count should increase
50,000 to 60,000 with a pooled pack of
transfused platelets.9,17 Platelets should be
transfused in actively bleeding patients
when count goes below 50,000 cells/mm3
or when platelet dysfunction is suspected
and active bleeding exists.16,18 Unmatched
platelets can be used in transfusions,8 how-
ever, the lifespan of ABO incompatible
platelets is decreased.16
CRYOPRECIPITATE
Cryoprecipitate is prepared from plasma
and has a volume of 15 mL.8,10 It contains
fibrinogen, factor VIII, von Willebrand
factor, and factor XIII.10 Because of the
small volume of plasma present in cryo-
precipitate, ABO compatibility is not
required.12 In cases of massive transfusion
or coagulopathy, cryoprecipitate may be
used to address hypofibrinogen-associated
microvascular bleeding or to overcome
platelet dysfunction.19
FIBRINOGEN CONCENTRATE
Fibrinogen (factor I) plays a central role
in homeostasis.20 In cases of massive
PPH, low levels of fibrinogen have been
associated with an increased risk of mor-
bidity and mortality, however, fibrinogen
replacement has not been shown to im-
prove outcomes.21,22 Historically, fibrino-
gen repletion has been achieved with
FFP and cryoprecipitate. Cryoprecipitate
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410 Eid and Stahl
contains 15 to 30 g/L of fibrinogen while
FFP contain 2 to 4.5 g/L.23,24 Fibrinogen
concentrate is a purified form of fibrino-
gen and contains 20/L.25 Fibrinogen con-
centrate is indicated for cases of
congenital afibrogenemia26 and has been
more recently used in cases of acquired
hypofibrogenemia such as trauma and
cardiac surgery.25 Compared with FFP,
fibrinogen concentrate has less plasma
volume as well as higher fibrinogen con-
centration and is beneficial in cases where
volume overload is of concern.27 Fibri-
nogen concentrate is easily stored as a
powder and can be readily available as it
does not require thawing compared with
cryoprecipitate.25,28 It is also associated
with lower rates of infection when com-
pared with FFP and cryoprecipitate.29 No
significant difference has been found in
mortality during massive hemorrhages
when fibrinogen concentrate was used
instead of cryoprecipitate.30,31 From a
cost standpoint, cryoprecipitate use
has a sizeable advantage compared with
fibrinogen concentrate.32
TRANEXAMIC ACID
Tranexamic acid (TXA) is an antifibrino-
lytic lysine analog that acts by inhibiting
plasmin mediated fibrin degradation.33
Its use has increased in recent years for
obstetrical hemorrhage. A randomized
controlled trial showed a significant de-
crease in the relative risk of death from
bleeding in patients who received TXA
versus placebo for PPH (1.9% vs. 1.5%;
Relative Risk, 0.81; 95% CI: 0.65-1.0;
P = 0.045).34 The benefit was mostly sig-
nificant when TXA was administered
within 3 hours after delivery (1.2% com-
pared with 1.7%; Relative Risk: 0.69, 95%
CI: 0.52-0.91; P = 0.008).34 TXA did not
show benefit compared with placebo in
reducing the risk of blood transfusion or
hysterectomy to control PPH.35,36 The
current recommended dose for TXA in
PPH is 1 g intravenously that can be
repeated in 30 minutes if bleeding is
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ongoing.33,34 Current evidence does not
show a significant increase in arterial or
venous thrombosis with TXA use in
PPH.37,38
PROTHROMBIN COMPLEX
CONCENTRATES
Prothrombin complex concentrates (PCC)
is comprised of multiple vitamin K de-
pendent clotting factors including factors
II, VII, IX, and X.9,39 It also contains
proteins C and S. PCC is sold in both
activated and inactivated forms, and in 3
or 4 factor preparations.9 In its activated
form, it is used in cases of severe bleeding
with acquired hemophilia and hemophilia
A.39 Inactivated PCC is used in patient
with persistent bleeding and known vita-
min K deficiency or for the reversal of
anticoagulants such as warfarin.39,40 Its
use in these setting has been associated
with decreased severity of bleeding and
mortality.41 The use of PCC in obstetrical
hemorrhage has limited evidence.
Massive Transfusion
Massive transfusion is defined by the trans-
fusion of 10 units of pRBCs within
24 hours or 4 units within 1 hour with
ongoing blood loss.2,42 MTPs have been
developed and have shown improved
outcomes.2,17,43 Extrapolated from mili-
tary and civilian trauma literature, early
administration of coagulation products is
recommended in MTP to avoid the “lethal
triad” of hypothermia, acidosis, and
coagulopathy.17,44 Administration of high
levels of pRBCs without coagulation fac-
tors during hemorrhage can exacerbate the
coagulopathy by dilution of clotting fac-
tors and platelets.45 Improved outcomes
have been associated with early adminis-
tration of coagulation factors (FFP) and
platelets.15,43,46 As a result, most institu-
tional MTPs recommend a balanced trans-
fusion involving a 1:1:1 ratio of pRBCs,
platelets, and FFP (Table 1).2,47 In patients
with suspected consumptive coagulopathy

TABLE 1. Proposed Massive Transfusion Protocols
pRBCs
Protocol 1 4 units
Protocol 2 6 units
Protocol 3* 6 units
*Cryoprecipitate to be added when consumptive coagulopathy is suspected.
FFP indicates fresh frozen plasma; pRBCs, packed red blood cells.
or disseminated intravascular coagulation
(DIC), cryoprecipitate should also be
considered for hypofibrinogen-associated
microvascular bleeding due its content of
the factors listed above.
Other Considerations
In addition to the timely administration
of blood products, hypothermia should be
avoided as it can exacerbate coagulop-
athy and decrease tissue perfusion.45 Dur-
ing massive transfusion, hypocalcemia
can occur because of calcium binding by
citrate that is present as a preservative
in blood products. Hypocalcemia com-
bined with acidosis and hypothermia can
worsen the coagulopathy.48 Intravenous
calcium chloride can be used to correct
the hypocalcemia.49 Hyperkalemia can
also develop as potassium can diffuse
out of RBCs during storage.49 Hyper-
kalemia should be treated especially if
electrocardiogram changes such as
peaked T waves are noted.49 Judicious
administration of crystalloids should be
considered as excess fluid can cause dilu-
tional coagulopathy and pulmonary
edema.50 Finally adequate intravenous
access is essential to every resuscitation
and where possible should include short,
large-bore peripheral catheters to max-
imize flow rates.
Resuscitation Endpoint
During active PPH, transfusion should
be guided by perceived blood loss and risk
of ongoing bleeding. Clinical indices of
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Transfusion in Postpartum Hemorrhage 411
Platelets FFP Cryoprecipitate
4 units 4 units —
6 units 6 units —
6 units 6 units 6 units
perfusion such as blood pressure, urine
output, and acid-base status have limited
specificity but may helpful in determining
overall adequacy of resuscitation.51 Lactate
or base deficit can be used as a marker for
tissue perfusion, hence persistent lactic
acidosis can signify ongoing tissue
hypoperfusion in cases of massive
hemorrhage.52,53 Lactate levels can be fol-
lowed during hemorrhage while hemostasis
is ensured.
During PPH, viscoelastic hemostatic
assays such as thromboelastography and
rotational thromboelastometry can be used
to differentiate between coagulopathic and
surgical bleeding.54,55 These have the ad-
vantage of the test potentially being done
at bedside giving faster results (usually
within 20 min) when compared with
traditional coagulation labs.56,57 throm-
boelastography and rotational thromboe-
lastometry provide qualitative assessment
of hemostasis and provide graphic infor-
mation of clot lysis and formation.54,55
Their use has been reported in cases of
obstetrical hemorrhage.58,59
Complications of Blood
Transfusion
Although blood transfusion can be life-
saving in cases of PPH, there are risks
associated with it especially when massive
transfusions are needed. As stated previ-
ously, transfusion of compatible and
matched blood is always first choice,
however in cases of MTP compatible
blood might not be readily available
necessitating the use of incompatible
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412 Eid and Stahl
blood. Acute hemolytic transfusion reac-
tions are rare and occur in 0.19 per 1000
units transfused.2,60 In general, acute
hemolytic reactions occur during or within
24 hours of administration of blood prod-
ucts and can present with hypotension,
fever, renal failure, chills, and DIC.61
When detected, transfusion should be
stopped immediately as this kind of reac-
tions can be life threatening. Hemody-
namic support and stabilization of
patient are the mainstay in management
and cardiac monitoring might be required.
Laboratory tests for ABO compatibility,
presence of antibodies, hemolysis, and
DIC should be sent.62
Transfusion-related acute lung injury
occurs in 0.1 per 1000 units of
transfused.60 It is more commonly seen in
transfusion of plasma but can occur with
the transfusion of any blood product. It is
the leading cause of death from transfusion
and usually occur within 6 hours from
transfusion administration.49 It presents
as noncardiogenic pulmonary edema asso-
ciated with hypoxemia, fever, hypotension,
as well bilateral infiltrates on chest
imaging.63 Transfusion-associated circula-
tory overload presents as volume overload
causing pulmonary edema. Like transfu-
sion-related acute lung injury it occurs
within 6 hours of transfusion of large
volume of plasma, however, with hyper-
tension and acute respiratory distress.64
The management of these 2 conditions is
usually supportive and involves diuresis
and in severe cases might require mechan-
ical ventilation.
Conclusion
Blood products administration can be a
lifesaving intervention in cases of massive
PPH. Use of blood products should be
judicious and only when clinically indi-
cated as does not come without risks.
Institutions should develop their own
standardized MTP, as the application of
those has been shown to be associated
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with decreased maternal mortality and
morbidity.
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