Review of recommendations on the intensive care for acute massive hemorrhage in obstetrics

V.A. Sedynkin, O.M. Klygunenko


The article presents current recommendations on the intensive therapy of acute blood loss in obstetrics. Obstetric haemorrhage remains a leading cause of maternal mortality worldwide. New strategies in hemorrhage treatment include the use of hemostatic resuscitation, although the optimal ratio to administer the various blood products is still unknown. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid-based resuscitation. The evidence behind hemostatic resuscitation has changed in the last few years, and debate is ongoing regarding optimal transfusion strategies. The use of tranexamic acid, fibrinogen concentrates, and prothrombin complex concentrates has emerged as new potential alternative treatment strategies with improved safety profiles.


obstetric haemorrhage; blood loss; coagulopathy; infusion-transfusion therapy; intensive care; review


Marr L, Lennox C, McFadyen AK. Quantifying severe maternal morbidity in Scotland: a continuous audit since 2003 Curr Opin Anaesthesiol.2014; 27:275-281.doi: 10.1097/ACO.0000000000000079.

Su LL, Chong YS. Massive obstetric haemorrhage with disseminated intravascular coagulopathy. Best Pract Res Clin Obstet Gynecol. 2012; 26(1):77-90. doi: 10.1016/j.bpobgyn.2011.10.008.

Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014; 2: e323-33. doi: 10.1016/S2214- 109X(14)70227-X.

Alison M, Ayadi El, Nuriya R, et al. Advances in the treatment of postpartum hemorrhage. Obstet Gynecol. 2013;8(6):525-537.

Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet. 2010;375:1762-3. doi: 10.1016/S0140-6736(10)60750-7.

Ashraf N, Mishra SK, Kundra P, et al. Obstetric patients requiring intensive care: a one year retrospective study in a tertiary care institute in India. Anesthesiol Res Pract. 2014;2014:789450. doi: 10.1155/2014/789450

Guillermo Carroli CC, Edgardo Abalos A. Metin Gulmezoglu. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynecol. 2008; 22(6):999-1012. doi: 10.1016/j.bpobgyn.2008.08.004.

Schött Ulf. Principal component analysis to improve treatment of postpartum haemorrhages.J of Case Reports and Clinical Research Studies.2014; 1(1). E2.

Green L, Knight M, Seeney FM, et al. The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study. BJOG. 2016 Dec;123(13):2164-2170. doi: 10.1111/1471- 0528.13831.

Farquhar C, Sadler L, Masson V, et al. Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006–2009. Am J Obstet Gynecol. 2011; 205:331.e1–331.e8.

Driessen M, Bouvier-Colle M-H, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol. 2011; 117:21–31.

Upadhyay K, Scholefield H. Risk management and medicolegal issues related to postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008; 22:1149–1169.

Dupont C, Touzet S, Colin C, et al. Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France. Int J Obstet Anesth. 2009; 18:320–327.

Guasch E., Gilsanz F. Massive obstetric hemorrhage: Current approach to management. Med Intensiva. 2016;40:298-310. doi: 10.1016/j.medin.2016.02.010

WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012 Geneva: World Health Organization; 2012. PMID: 23586122

Royal College of Obstetricians and Gynaecologists.Prevention and management of postpartum haemorrhage.BJOG. 2016; doi: 10.1111/1471-0528.14178.

Saxena R, Saxena A, Raj R, Marcelle T. Cutting-Edge Strategies in Massive Transfusion in Patients of Obstetric Hemorrhage. J Gen Pract (Los Angel).2016; 4:280. doi:10.4172/2329-9126.1000280

Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units. Anesth Analg. 2014 Oct;119(4):906-10.

Girard T, Mörtl M, Schlembach D. New approaches to obstetric hemorrhage: the postpartum hemorrhage consensus algorithm. Curr Opin Anaesthesiol. 2014 Jun; 27(3):267-74.

Llau JV, Acosta FJ, Escolar G et al. Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 2015 Nov;39(8):483-504. doi: 10.1016/j.medin.2015.05.002.

Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013;30:270–382. doi: 10.1097/EJA.0b013e32835f4d5b

Ioscovich A, Shatalin D, Butwick AJ, et al. Israeli survey of anesthesia practice related to placenta previa and accreta. Acta Anaesthesiol Scand. 2015; 24.

Fedorova TA, Serov VN, Rogachevskiy OV, Gribova MV. Metody autogemodonorstva v akusherstve i ginekologii.Kriticheskie sostoyaniya v akusherstve i neonatologii (conference proceedings).Petrozavodsk; 2004. P. 185-188. (In Russ).

Ivens FC, Christiaens F. Human albumin and colloid fluid replacement: their use in general surgery. Acta Anasth Belg. 1995;46:3-18.

Karpati PC, Rossignol M, Pirot M, et al. High incidence of myocardial ischemia during postpartum hemorrhage. Anesthesiology 2004; 100:30–36.

So-Osman C, Cicilia J, Brand A, Schipperus M, Berning B, Scherjon S. Triggers and appropriateness of red blood cell transfusions in the postpartum patient - a retrospective audit. Vox Sang. 2010; 98:65–69.

Butwick AJ, Aleshi P, Fontaine M, Riley ET, Goodnough LT. Retrospective analysis of transfusion outcomes in pregnant patients at a tertiary obstetric center. Int J Obstet Anesth 2009; 18:302–308.

Parker J, Thompson J, Stanworth S. A retrospective one-year single-centre survey of obstetric red cell transfusions. Int J Obstet Anesth 2009; 18:309–313.

Jansen AJ, Duvekot JJ, Hop WC, et al. New insights into fatigue and health-related quality of life after delivery. Acta Obstet Gynecol Scand 2007; 86:579–584.

Bonnet MP, Basso O. Prohemostatic interventions in obstetric hemorrhage. Semin Thromb Hemost. 2012; 38:259-64.doi: 10.1055/s-0032-1302441.

Burtelow M, Riley E, Druzin M, et al. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion. 2007;47(9):1564-1572. doi: 10.1111/j.1537-2995.2007.01404.x.

Maegele M, Lefering R, Yucel N, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38(3):298-304. doi: 10.1016/j.injury.2006.10.003.

Shifman E.M., Kulikov A.V., Belomestnov S.R. Intensive therapy and anesthesia for blood loss in obstetrics. Clinical recommendations.Anesthesiology and Reanimatology.2014; 1:76-78. (in Russian)

Kulikov A.V., Schifman E.M., Belomestnov S.R. et al. Blood loss in obstetrics: the main stages of assistance. Gynecology. 2015; 17 (6): 22–26. (in Russian)

Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage.Anaesthesia. 2015 Jan;70 Suppl 1:78-86, e27-8. doi: 10.1111/anae. 12913.

Ekelund K, Hanke G, Stensballe J. et al. Hemostatic resuscitation in postpartum hemorrhage – a supplement to surgery. Acta Obstet Gynecol Scand 2015; 94 (7): 680–92. doi: 10.1111/aogs.12607

Shah M, Wright JD. Surgical intervention in the management of postpartum hemorrhage. Semin Perinatol. 2009 Apr;33(2):109-15.

Saule I, Hawkins N. Transfusion practice in major obstetric haemorrhage: lessons from trauma. Int J Obstet Anesth 2012;21:79-83.

Ryazanova OV, Aleksandrovich Yu.S., Shifman EM, Pshenisnov KV, Reznik VA, Kulikov AV, Drobinskaya AN Modern aspects of therapy of uterine bleeding with placenta previa.Pediatrician. 2016; 7 (3) :117-127. doi: 10.17816 / PED73117-127. (in Russian).

De Lange NM, Lancé MD, de Groot R et al. Obstetric hemorrhage and coagulation: an update. Thromboelastography, thromboelastometry, and conventional coagulation tests in the diagnosis and prediction of postpartum hemorrhage. Obstet Gynecol Surv 2012; 67 (7): 426–35.

Allard S, Green L, Hunt BJ. How we manage the haematological aspects of major obstetric haemorrhage. Br J Haematol 2014; 164:177–88. doi: 10.1111/bjh.12605.

American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology. 2015 Feb;122(2): 241-75.

Jadon A, Bagai R. Blood transfusion practices in obstetric anaesthesia. Indian J Anaesth. 2014 Sep;58 (5):629-36.

Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units. Anesth Analg.2014 Oct;119(4):906-10.

Nebout S, Merbai N, Faitot V, Keita H. Management of major postpartum hemorrhage. Presse Med. 2014 Feb;43(2):111-7. doi: 10.1016/j.lpm.2013.06.026.

Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An Update on the use of Massive Transfusion Protocols in Obstetrics. Am J Obstet Gynecol. 2016 Mar; 214(3):340-4. doi: 10.1016/j.ajog.2015.08.068.

Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015 Mar;212(3):272-80. doi: 10.1016/j.ajog.2014.07.012.

Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, Le Ray C, Senat MV, Winer N, Maillard F, Deneux-Tharaux C. Study protocol. TRAAP –TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. BMC Pregnancy Childbirth. 2015 Jun 14;15:135.

Zarychanski, R., Abou-Setta A. M., Turgeon A. al. Association of hydoxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systemic review and meta-analysis. JAMA 2013;309:678–688.

Geoghegan J, Middleton L, Moore P, Subseson G, Khan K, Daniels J. Routine cell salvage during elective caesarean section: a pilot randomised trial. Int J Obstet Anesth 2015;24:86–7. doi: 10.1016/j.ijoa.2014.08.003

Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. British Journal of Anaesthesia 2010; 105: 401-16.

Goucher H, Wong CA, Patel SK, Toledo P. Cell Salvage in Obstetrics. Anesth Analg. 2015 Aug;121(2):465-8.

Milne ME, Yazer MH, Waters JH. Red blood cell salvage during obstetric hemorrhage Obstet Gynecol. 2015; 125:919-923 doi: 10.1097/AOG.0000000000000729.

Malik S, Brooks H, Singhal T. Cell saver use in obstetrics. J Obstet Gynaecol 2010; 30:826–828.

McDonnell NJ, Kennedy D, Long LJ, Gallagher-Swann MC, Paech MJ. The development and implementation of an obstetric cell salvage service. Anaesth Intensive Care 2010; 38:492–499.

Parry N, Junghans C, Skelton V, Okunuga A. Audit of cell salvage use in obstetric patients: adding experience. Int J Obstet Anesth 2010; 19:238–239.

Lockhart E. Postpartum hemorrhage: a continuing challenge. Hematology Am Soc Hematol Educ Program. 2015;2015:132-7.

Hunt BJ, Allard S, Keeling D, Norfolk D, Stanworth SJ, Pendry K. A practical guideline for the haematological management of major haemorrhage Br J Haematol.2015; 170:788-803. doi:/10.1111/bjh.13580.

Goobie S. M. Tranexamic acid: still far to go Br J Anaesth. 2017; 118 (3): 293-295. doi: 10.1093/bja/aew470.

Uharcek P, Mlyncek M, Kellner M, Lajtman E. The use of recombinant factor VIIa on the therapy of massive bleeding after cesarean section. Ceska Gynekol. 2007;72(3):200-2.

Moscardo F, Pеrez F, de la Rubia J, et al. Successful treatment of severe intra-abdominal bleeding associated with disseminated intravascular coagulation using recombinant activated factor VII. Br J Haematol. 2001;114(1):174-6. doi: 10.1046/j.1365- 2141.2001.02878.x.

Breborowicz GH, Sobieszczyk S, Szymankiewicz M. Efficacy of ecombinant activated factor VII (rFVIIa, NovoSeven) in prenatal medicine. Arch Perinat Med. 2002;8:21-27.

Vincent JL, Rossaint R, Riou B, Ozier Y, Zideman D, Spahn DR. Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective. Crit Care 2006;10:R120

Ahonen J. The role of recombinant activated factor VII in obstetric hemorrhage. Curr Opin Anaesthesiol. 2012;25:309-14. doi: 10.1097/ACO.0b013e 3283532007.

Alison M, El Ayadi, Nuriya R, et al. Advances in the treatment of postpartum hemorrhage. Obstet Gynecol. 2013;8(6):525-537.

Kinugasa M, Tamai H, Miyake M, Shimizu T. Uterine balloon tamponade in combination with topical administration of tranexamic acid for management of postpartum hemorrhage. Case Rep Obstet Gynecol. 2015:195036. doi: 10.1155/2015/195036.

Schröder L, Pötzsch B, Rühl H, Gembruch U. Tranexamic acid for hyperfibrinolytic hemorrhage during conservative management of placenta percreta. Obstet Gynecol. 2015 Nov;126(5):1012-5. doi: 10.1097/AOG.0000000000000915.

Ng WC, Jerath A, Wasowicz M. Tranexamic acid: a clinical review. Anaesthesiol Intensive Ther. 2015;47(4):339-50. doi: 10.5603/AIT.a2015.0011.

Guasch E, Gilsanz F. Treatment of postpartum hemorrhage with blood products in a tertiary hospital: outcomes and predictive factors associated with severe hemorrhage. Clin Appl Thromb Hemost. 2016 Oct; 22(7):685–692.doi. 10.1177/1076029615573303.

Onwuemene O, Green D, Keith L. Postpartum hemorrhage management in 2012: predicting the future. Int J Gynecol Obstet. 2012;119(1):3-5. doi: 10.1016/j. ijgo.2012.07.001.

Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5:266- 73. doi: 10.1111/j.1538-7836.2007.02297.x.

Makino S, Takeda S, Kobayashi T, et al. National survey of fibrinogen concentrate usage for post-partum hemorrhage in Japan: investigated by the Perinatology Committee, Japan Society of Obstetrics and Gynecology. J Obstet Gynecol Res. 2015;41(8):1155-60. doi: 10.1111/jog.12708.

Ahmed S, Harrity C, Johnson S, Varadkar S, McMorrow S, Fanning R, et al. The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage - an observational study. Transfus Med 2012;22:344–9.

Collins PW, Solomon C, Sutor K, Crispin D, Hochleitner G, Rizoli S, et al. Theoretical modelling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. Br J Anaesth 2014;113:585–95.

Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, et al. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol. 2016;172:616–24.

Mercier FJ, Bonnet MP. Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage.Curr Opin Anaesthesiol. 2010;23(3):310-6. doi: 10.1097/ ACO.0b013e32833835a2.

Wikkelsø AJ, Edwards HM, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, et al.; FIB-PPH trial group. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial. Br J Anaesth. 2015;114: 623–33. doi: 10.1093/bja/aeu444.

Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth. 2010;19(2):218-23. doi: 10.1016/j. ijoa.2009.08.004.

Thorarinsdottir HR, Sigurbjornsson FT, Hreinsson K, et al. Effects of fibrinogen concentrate administration during severe hemorrhage. Acta Anaesthesiol Scand. 2010;54(9):1077-1082. doi: 10.1111/j.1399- 6576.2010.02289.x.

Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, et al. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth. 2008;101:769-73. doi: 10.1093/bja/aen270.

Mallaiah S, Barclay P, Harrod I, et al. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015;70(2):166-75. doi: 10.1111/ anae.12859.

Levy, J.H., Tanaka K.A., Dietrich W. Perioperative hemostatic management of patients treated with vitamin K antagonists. Anaesthesiology. 2008;109:918-926.

Bruce D., Nokes T.J.C. Prothrombin complex concentrate (Beriplex P/N) in severe bleeding: experience in a large tertiary hospital. Crit. Care. 2008;12. R105. doi:10.1186/cc6987.

Larrain C. Congenital blood coagulation factor X deficiency. Successful result of the use of prothrombin concentrated complex in the control of caesarean section hemorrhage in 2 pregnancies. RevistaMedica de Chile 1994; 122:1178-1183.

Shobeiri SA, West EC, Kahn MJ, Nolan TE. Postpartum acquired hemophilia (factor VIII inhibitors): a case report and review of the literature. ObstetrGynecolSurv. 2000;55:729-737.

Klein A. A., Arnold P., Bingham R. M., Brohi K., Clark R., Collis R., Gill R., McSporran W. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia.2016; 71:829–842. doi:10.1111/anae.13489.

Hardy JF, De Moerloose P, Samama M. Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Can J Anaesth. 2004;51(4):293-310. doi: 10.1007/BF03018233.

Uijttewaal WS, Nijhof EJ, Bronkhorst PJ, et al. Nearwall excess of platelets induced by lateral migration of erythrocytes in flowing blood. Am J Physiol. 1993;264(4 Pt 2): H1239-44.

Windsperger K, Lehner R. The fibrinogen/CRP ratio as a new parameter for the diagnosis of disseminated intravascular coagulation in patients with HELLP syndrome and as a predictive factor for neonatal outcome. Am J Obstet Gynecol. 2013;208(2):118.e1-7. doi: 10.1016/j.ajog.2012.11.025.

Karlsson O, Jeppsson A, Hellgren M. Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both? Int J Obstet Anesth. 2014;23(1):10-7. doi: 10.1016/j.ijoa.2013.07.003.

Scarpelini S, Nascimento B, Tien H, Netto FACS, Tremblay L, Rizoli S. Overview on the use of recombinant factor VIIa in obstetrics and gynecology. Expert Rev. Obstet. Gynecol. 2007; 2(2):217-226.

Dutta TK, Verma SP. Rational Use of Recombinant Factor VIIa in Clinical Practice. Indian J Hematol Blood Transfus. 2014 Jun;30(2):85-90.

Lavigne-Lissalde G, Aya AG, Mercier FJ, Roger-Christoph S, Chauleur C, Morau E, et al. Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial. J Thromb Haemost 2015;13:520–9. doi: 10.1111/jth.12844.

Ghorashian S, Hunt BJ. Off-license use of recombinant activated factor VII. Elsevier Blood Reviews. 2004, 18: 245-259.

Logan AC, Yank V, Stafford RS Off-label use of recombinant factor VIIa in U.S. hospitals: analysis of hospital records. Ann Intern Med. 2011, 154(8): 516-522.

Johansson PI. Off-label use of recombinant factor VIIa for treatment of haemorrhage: results from randomized clinical trials. Vox Sang. 2008; 95(1):1-7.

WHO guidelines for the management of postpartum haemorrhage and retained placenta. 2009; 56.

Welsh A, McLintock C, Gatt S et al. Guidelines for the use of recombinant activated factor VII in massive obstetric hemorrhage. Australian and New Zealand Journal of Obstetrics and Gynecology, 2008; 48:12-16.



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