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

Users Online : 76307

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



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)
E-mail: drrajendrak1@rediffmail.com
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.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

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
E-mail: anuradha2nittur@gmail.com
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: https://doi.org/10.7860/JCDR/2021/50467.15209
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.
E-mail: dr.vineethasijin@gmail.com

Abstract

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.

Keywords

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.

Discussion

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.

Conclusion

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.

References

1.
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.
2.
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]
3.
Trikha A, Singh PM. Management of major obstetric haemorrhage. Indian J Anaesth. 2018;62:698-703. [crossref] [PubMed]
4.
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.
5.
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]
6.
Raymer JM, Flynn LM, Martin RF. Massive transfusion of blood in the surgical patient. Surg Clin North Am. 2012;92:221-34. [crossref] [PubMed]
7.
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]
8.
The American College of Obstetricians and Gynecologists. Safe Motherhood Initiative. Maternal Safety Bundle for Obstetric Hemorrhage. 2015. Available at: https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage.
9.
Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol. 2017;6(1):14-21. [crossref]
10.
Chavan R, Latoo MY. Recent advances in the management of major obstetric haemorrhage. Br J Med Pract. 2013;6:a604.
11.
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]
12.
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]
13.
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]
14.
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014;58:590-95. [crossref] [PubMed]
15.
Edwards HM. Aetiology and treatment of severe postpartum haemorrhage. Dan Med J. 2018;65(3):B5444.
16.
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]
17.
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]
18.
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

10.7860/JCDR/2021/50467.15209

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

Etymology: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com