Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Aug 2018

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : UR01 - UR04 Full Version

Protocol Based Blood Management in Major Obstetric Haemorrhage- A Case Series

Published: August 1, 2021 | DOI:
Kannammadathy Poulose Biji, Ravindran Rashmi, Krishnankutty Rekha, Prabhakaran Vineetha, Bengalath Abida

1. Associate Professor, Department of Anaesthesia, Government Medical College, Kozhikode, Kerala, India. 2. Associate Professor, Department of Anaesthesia, Government Medical College, Kozhikode, Kerala, India. 3. Associate Professor, Department of Anaesthesia, Government Medical College, Kozhikode, Kerala, India. 4. Associate Professor, Department of Anaesthesia, Government Medical College, Kozhikode, Kerala, India. 5. Junior Resident, Department of Anaesthesia, Government Medical College, Kozhikode, Kerala, India.

Correspondence Address :
Dr. Prabhakaran Vineetha,
MG Estate, Kaavumpadi, Thirurkkad, Perinthalmanna, Aripra P.O,
Malappuram-679321, Kerala, India.


Major obstetric haemorrhage remains the leading cause of maternal mortality globally. Irrespective of the etiology of haemorrhage, rapid and efficient intervention using proactive standardised protocols should gain precedence in the management of major obstetric haemorrhage. As the available resources vary between institutions, protocol specific to each institution is important for timely intervention. This case series reports a few successfully managed cases of obstetric haemorrhage by the implementation of institution based Massive Transfusion Protocol (MTP). Two antenatally diagnosed patients with placenta percreta had elective hysterectomy with bladder repair. The massive haemorrhages in both these cases were managed efficiently with the use of MTP without any sequelae. Another case of atonic Postpartum Haemorrhage (PPH) which did not respond to first line management also was treated successfully with the prompt activation of protocol. A case of uterine rupture with haemorrhagic shock was managed with massive transfusion according to protocol and vasopressors and she survived with no major side effects. A case of traumatic PPH which presented with severe anaemia (Hb 4.6 gm/dL) could also be successfully resuscitated by the timely activation of MTP.


Blood transfusion, Hysterectomy, Massive transfusion protocol, Postpartum

Worldwide maternal mortality rate ranges from 15 per 1,00,00 live births to 443 per 1,00,00 live births according to the varied socio-demographic index of different countries and haemorrhage is the foremost cause (1). Major Obstetric Haemorrhage (MOH) refers to any kind of excessive bleeding in a parturient and is the most frequent cause of maternal mortality and morbidity worldwide. World Health Organisation (WHO) estimates it to be the single most leading individual cause of maternal death contributing to around 27% of all maternal deaths (2). MOH is defined as a blood loss of more than one litre or a fall in haemoglobin of more than 4 g% after acute blood loss in a parturient or need for transfusion of four or more units of blood (3).

Surgical interventions, interventional radiological techniques and medical management with uterotonic drugs play a significant role in the control of obstetric haemorrhage. But rapid and efficient resuscitation should be the mainstay in such scenarios. Successful resuscitation hinges on timely and appropriate replacement of blood loss. Transfusion practices often vary between institutions depending upon availability of blood, blood products and point of care coagulation testing facilities. Hence, universal guidelines for transfusion management may not be relevant to all. Developing and adopting MTP with well-defined resuscitation goals and strategies individualised to the institution would go a long way to improve maternal morbidity and mortality related to MOH. Five cases of MOH are reported here which were successfully resuscitated according to the MTP developed in our institution.

Case Report

Case 1

Patient was a 34-year-old Gravida 3 Para 2 Live 1(G3P2L1), with history of previous two caesareans. Magnetic Resonance Imaging (MRI) showed placenta percreta with urinary bladder infiltration. She underwent elective caesarean hysterectomy under general anaesthesia with lumbar epidural. Apart from standard monitors, Invasive Blood Pressure (IBP) and Central Venous Pressure (CVP) were monitored. Venous access included 7F triple lumen catheter in right Internal Jugular Vein (IJV) and two 16G peripheral cannulae.

Anticipating massive haemorrhage, blood bank was already notified regarding the need for MTP and two units Packed Red Blood Cells (PRBC) was issued prior to surgery. Intraoperatively, bleeding started soon after the baby was delivered. Massive transfusion protocol was activated and she was resuscitated with a total of eight units each of PRBC, FFP and platelets, one pool of cryoprecipitate and 2.5 litres of crystalloids. Noradrenaline support was initiated to stabilise blood pressure. Surgical assistance by urologist was also obtained. The total intraoperative blood loss was estimated to be around 4.5 litres. Haemostasis was achieved and coagulation profile was normal towards the end of surgery that lasted for about four hours. Postoperatively, she was shifted to critical care unit and given ventilatory support for six hours and she made a good recovery (Table/Fig 1).

Case 2

A 32-year-old patient, G3P2L2 with history of two caesareans and an uneventful antenatal period was referred as a case of ruptured uterus. She was in haemorrhagic shock with metabolic acidosis, hypothermia and coagulopathy and was taken up for emergency laparotomy under general anaesthesia.

Massive transfusion protocol was activated and four units O negative PRBC and two units AB FFP was issued initially followed by group specific blood. She was resuscitated with a total of nine units each of PRBC and Fresh Frozen Plasma (FFP), seven units of platelets, one pool of cryoprecipitate, 2 L of crystalloids and 0.5 L colloid through IJV catheter and two peripheral IV cannulae. Her BP was stabilised on noradrenaline support and she required sodium bicarbonate infusion for correction of metabolic acidosis. She underwent hysterectomy with internal iliac artery ligation. Estimated blood loss was about five litres. Postoperatively, she made a good recovery after elective ventilation for 12 hours. She did not have any sequelae of massive transfusion.

Case 3

Patient was a 19-year-old primi gravida with history of gestational diabetes on insulin who presented with atonic PPH after expulsion of fetus following intrauterine death at 39 weeks of gestation. She was not responding to uterotonics, uterine massage or rectal misoprostol. She was managed conservatively with Panicker’s vacuum suction for 12 hours. MTP was activated following transfusion of initial four units of PRBC and she required resuscitation with eight units each of PRBC, FFP and platelets, one pool of cryoprecipitate along with crystalloids and noradrenaline infusion.

Case 4

A 33-year-old G3P2L2 and previous two caesareans, was referred as a case of placenta percreta with polyhydramnios. MRI showed placenta percreta with bladder rent of 3 cm. She underwent classical caesarean hysterectomy with bladder rent repair with urological assistance under general anaesthesia with lumbar epidural block. She was resuscitated via IJV catheter and large bore peripheral cannulae using MTP with six units each of PRBC, FFP, PRP and one pool of cryoprecipitate along with 2.5 L crystalloids. After surgery patient was ventilated for four hours and extubated thereafter. She made a good recovery and was followed-up for three months.

Case 5

A 21-year-old primi was rushed to the emergency operation theatre as a case of traumatic PPH following normal delivery. Per vaginal exploration was attempted under subarachnoid block from peripheral hospital, but apex of tear was not visible. Her haemoglobin (Hb) was 4.3 gm/dL and hence referred for expert management. She was transfused with two units PRBC and two units FFP during transport. She underwent exploratory laparotomy under GA. She required noradrenaline support and was resuscitated with six units of PRBC, four units of FFP and four units of PRP along with 2 L of crystalloids and 0.5L of colloid. She was ventilated in the critical care unit for six hours and extubated thereafter without any sequelae of massive transfusion.


Poor outcomes following MOH and Massive Blood Transfusion (MBT) have been attributed to delayed treatment, unavailability of blood and blood products, inaccurate estimation of blood loss, absence of treatment protocols and poor communication among the team members involved in the immediate management (3). A predetermined plan of action ensures timely intervention which is the most important factor that determines successful resuscitation. Blood transfusion strategies have changed over the last decade with emphasis on the use of FFP, platelets and fibrinogen (4). Point of care testing for treating coagulopathies has further revolutionised the management of such cases (5).

Various definitions of MBT have been published in the medical literature such as (6):

• Replacement of entire blood volume within 24 hour
• Transfusion of >10 units of PRBCs in 24 hour
• Transfusion of >20 units of PRBCs in 24 hour
• Transfusion of >4 units of PRBCs in one hour when on-going need is foreseeable
• Replacement of 50% of Total Blood Volume (TBV) within three hours.

Massive blood transfusion using proactive standardized protocols is the key to volume resuscitation in MOH. A systematic review of four retrospective observational studies on obstetric haemorrhage by Tanaka H et al., proposed a transfusion strategy optimised to the setting of MOH (7). Revised guidelines by American college of obstetrician and gynaecologists on MTP recommended important protocol items to be determined at each institution (8).

Compiling the information from various MTPs in literature, a MTP (Table/Fig 2) suited to the resource setting of the study institution was framed and the same was used in all the aforementioned cases (4),(9),(10). Early identification of the need for massive transfusion, good team work with assignment of specific roles to the team members, activation of blood bank personnel, preparation of essential equipment, monitors and drugs as well as resuscitation aimed at set targets with regular reassessments at regular intervals form the key elements of MTP.

The clinician determines the need for MTP activation if ≥4 units of PRBC transfusion is needed or expected. As soon as decision is made, blood bank is to be intimated verbally for initial release of four units O negative PRBC and two units AB FFP in case group specific products are not available immediately and also for further release of group specific blood. Baseline laboratory and cross-matching sample are to be sent immediately. In the meantime, resuscitation should be started with crystalloids along with inotropic or vasopressor support to maintain mean arterial blood pressure. If more than two litres of crystalloids are infused and still blood is not available colloids may be used up to a maximum of 20 mL/kg (11). Tranexamic acid should be given, as soon as possible in a dose of 1 g over 10 minutes and then over 8 hours (12),(13). Preparations for massive transfusion include securing adequate vascular access with 14G/16G peripheral IV cannulas and establishing CVP, IBP, urine output and temperature monitoring in addition to standard monitoring (14).

Regular reassessment of relevant laboratory investigations is important. Prompt communication with blood bank and manpower with assigned roles should be ensured. Inotrope or vasopressor drugs may be used to avoid critical hypoperfusion and to buytime for fluid resuscitation. Effective resuscitation is facilitated with rapid infusion pumps and warming devices. Resuscitation is continued with group specific blood and blood products as soon as available and depending on laboratory or clinical guidelines (4),(9),(15). A multidisciplinary approach with prompt and proper communication between anaesthetists, obstetricians, surgeons and blood bank personnel is also of prime importance in successful resuscitation. Availability for postoperative ICU care should be ensured beforehand. Patient has to be reassessed after every four units of PRBC transfusion regarding the need for continuing MTP.

Setting of targets to stop MTP also is important because it helps prevent problems of over transfusion like circulatory overload, dilutional coagulopathy, electrolyte imbalances, hypothermia, transfusion related lung injury, sepsis etc., and allows judicious use of available resources. The proposed targets of resuscitation are as follows (14).

1. Mean Arterial Pressure (MAP)≥60, SBP ≥80-100 mmHg
2. Haemoglobin-7-9 g%
3. International Normalised Ratio (INR) <1.5, APTT <42 sec
4. Fibrinogen >1-1.5 g%
5. Platelet >50000/mm3
6. pH 7.35-7.45
7. Core temperature >35 degree C
8. Lactates <2 mEq/L
9. Ionised Calcium (iCa) >1.1 mmol/L

There are many case reports of successful management of major haemorrhage using MTP in the literature. Jain N et al., in his report of a near-miss case of MOH highlights the importance of early use of point-of-care Thromboelastogram (TEG), tranexamic acid, timely activation of MTP, damage control resuscitation and surgery as well as multidisciplinary team work in the management of MOH (16). Successful resuscitation was achieved in a 30-year-old G3P2 who developed atonic PPH and haemorrhagic shock following vaginal delivery after being managed with prompt MTP activation, use of TEG-guided correction of coagulopathy, and early hysterectomy. Postoperative intensive management of ventilatory function, haemodynamics, kidney function and sepsis contributed to a favourable outcome. TEG is not available in the index institution and laboratory results are not fast enough but the lesson learned from the case series is having an MTP in place and use of standardised supply of blood and products can help anaesthesiologist function well in a critical situation without major adverse sequelae of massive transfusion.

Lima SK et al., discuss the management of a 24-year-old complicated obstetric patient with profuse bleeding following caesarean who required massive transfusion (17). She was resuscitated with total 117 units of blood products in spite of which she recovered fully with minimum complications as they followed the near standard blood transfusion protocol. In another successfully managed case of massive transfusion, Jain K et al., reports and comments that MTP is essential for the judicious use of blood products (18).

Thus, protocol-based management should be the dictum in all massive transfusions. The protocol developed in the study institution is based on recent recommendations modified to the resource setting and it emphasises the need for early identification of need for massive transfusion, need for adequate personnel each with assigned roles to optimise all aspects of care, avoids undue dependence on lab results, specific targets to avoid critical hypo perfusion as well as complications of over transfusion.


A well defined hospital specific MTP allows trained providers to recognise patients at risk of high volume blood loss early, initiate MTP quickly and has specific end points to limit over transfusion. Through this case series, author recommend that each hospital should formulate MTPs suited to their needs and resources to improve survival in MOH.


GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775-812.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. The Lancet Global Health. 2014;2(6):e323-33. [crossref]
Trikha A, Singh PM. Management of major obstetric haemorrhage. Indian J Anaesth. 2018;62:698-703. [crossref] [PubMed]
Muñoz M, Stensballe J, Ducloy-Bouthors AS, Bonnet MP, De Robertis E, Fornet I, et al. Patient blood management in obstetrics: Prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus. 2019;17(2):112-36.
Collis R. Coagulation point-of-care testing on the labour ward should be mandatory. Int J Obstet Anesth. 2016;27:66-69. Doi: 10.1016/j.ijoa.2016.06.006. Epub 2016 Jul 1. PMID: 27444972. [crossref] [PubMed]
Raymer JM, Flynn LM, Martin RF. Massive transfusion of blood in the surgical patient. Surg Clin North Am. 2012;92:221-34. [crossref] [PubMed]
Tanaka H, Matsunaga S, Yamashita T, Okutomi T, Sakurai A, Sekizawa A, et al. A systematic review of massive transfusion protocol in obstetrics. Taiwanese Journal of Obstetrics and Gynecology. 2017;56(6):715-18. [crossref] [PubMed]
The American College of Obstetricians and Gynecologists. Safe Motherhood Initiative. Maternal Safety Bundle for Obstetric Hemorrhage. 2015. Available at:
Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol. 2017;6(1):14-21. [crossref]
Chavan R, Latoo MY. Recent advances in the management of major obstetric haemorrhage. Br J Med Pract. 2013;6:a604.
Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, et al. On behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG. 2016;124:e106-49. [crossref] [PubMed]
Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. The CRASH-2 trial: A randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):01-79. [crossref] [PubMed]
Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-16. [crossref]
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014;58:590-95. [crossref] [PubMed]
Edwards HM. Aetiology and treatment of severe postpartum haemorrhage. Dan Med J. 2018;65(3):B5444.
Jain N, Gupta AK, Sood J, Khillan K. A maternal near-miss case of massive obstetric hemorrhage: Recent trends in management of hemostatic failure. J Obstet Anaesth Crit Care. 2018;8:46-49. [crossref]
Lima SK, Begum M, Gupta AK, Aziz L, Mitra SP. Management of massive blood transfusion- A case study. Pulse. 2011;5(1):39-43. [crossref]
Jain K, Jain S, Sood N, Puri A. Massive blood transfusion: A case report of transfusion of 70 units of blood and blood products in 24 hours. J Transfus Med. 2018;3:68-71. [crossref]

DOI and Others


Date of Submission: May 22, 2021
Date of Peer Review: Jun 10, 2021
Date of Acceptance: Jul 14, 2021
Date of Publishing: Aug 01, 2021

Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: May 27, 2021
• Manual Googling: Jul 07, 2021
• iThenticate Software: Jul 23, 2021 (18%)

Etymology: Author Origin

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