Predictive Factors Analysis In Postpartum Hemorrhage Patients With Massive Blood Transfusion

Objective Postpartum hemorrhage(PPH)is still one of the most common causes of perinatal hysterectomy and maternal mortality in the worldwide.It’s attributed to around 30% of maternal deaths every year.A recently multicenter epidemiological survey found that the incidence rate of PPH in low-income and middle-income countries is higher.The prevalence of PPH in this survey is 1.2%.The risk of PPH patients massive blood transfusion is high in ICU.Blood transfusion is an important measure to maintain the coagulation and the effective circulation capacity for PPH patients in ICU.However,insufficient identifying and delay intervention will contribute to increase the incidence of adverse clinical outcomes in PPH patient who required massive blood transfusion.Therefore,this study collected the clinical data of PPH patients in ICU,described the clinical characteristics of patients requiring massive blood transfusion,and ensured the independently predictive factors of PPH patients who required of massive blood transfusion,which can help clinicians to make decisions accurately.Method In this retrospective descriptive case-cohort study,women who underwent postpartum hemorrhage between January 1,2013 and July 30,2018 in our intensive care unit at a tertiary comprehensive hospital were enrolled.The baseline demographic and clinical characteristics,hemodynamics and laboratory indicators and the first 24 hours after delivery,the main treatment and clinical outcomes during ICU were included.According to whether transfusion ≥ 10 units of red blood cells within 24 hours after delivery,the patients were divided into two groups: massive blood transfusion group(MT group)and non-massive blood transfusion group(non-MT group).The clinical characteristics and clinical outcomes of the two groups were compared,and the predictors of massive blood transfusion in PPH patients were analyzed by multivariate Logistic regression model.Results A total of 60 patients with PPH over the study period were enrolled.The average age of women was 30.67±5.49 years and the body mass index 24.88±3.50 kg/m2.Of these,30(50.0%)patients required massive transfusion(MT group).non-MT group included 30 cases(50.0%).Compared with non-MT group,patients in MT group have higher incidence of disseminated coagulation dysfunction,lower baseline systolic blood pressure,higher lactate level,lower count of erythrocyte and fibrinogen,longer activated partial thromboplastin time,higher SOFA score and Apache II score,there was significant difference between the two groups(P<0.05).The total amount of cryoprecipitate and fresh frozen plasma infused during the first 24 hours after delivery and hospitalization in MT group was significantly higher than that in non-MT group(P < 0.001).Multiple-stepwise logistic regression analysis showed that admission off working hours and combined with DIC were independently predictive factors of PPH patients required massive blood transfusion.In terms of treatment,patients in the MT group used catecholamines accounted for 50.0%,while the non-MT group accounted for 23.3%.The proportion of patients received hysterectomy in MT group was significantly higher than that in non-MT group(12 cases in MT group(40.0%)vs 2 cases in non-MT group(6.7%),P < 0.05).There was no significant difference in mortality between the two groups(1 case in MT group(3.3%)vs 1 case in non-MT group(3.3%),P=1.000).The etiological analysis of postpartum hemorrhage showed that the proportion of PPH patients caused by placental accreta,uterine atony,placental abruption and trauma of genital tract was 36.7%,26.7%,11.7% and 6.7%,respectively.All PPH patients caused by trauma of genital tract received more than 10 units of red blood cells within first 24 hours in ICU,the proportion of received fresh frozen plasma more than 1000 ml and received cryoprecipitate in those patients are 75% and 75% respectively.25.0% of the PPH patients caused by uterine atony need platelet transfusion.During the hospitalization,patients with PPH caused by trauma of genital tract had the highest demand for blood products.All of these patients need transfusion of more than 10 units of red blood cells.Compared with the first 24 hours after delivery,the proportion of large amount of red blood cells transfusion and platelet transfusion in PPH patients caused by uterine atony increased from 32.5% to 55% and from 25% to 48% respectively during hospitalization.Conclusion In conclusion,PPH patients combined with DIC are more likely to have a large number of blood transfusion events.The incidence of massive blood transfusion in ICU during working hours was lower than that off-working hours.The etiology of postpartum hemorrhage has a significant impact on blood product infusion in PPH patients.Therefore,for PPH patients with DIC,early correction of DIC may reduce the incidence of massive blood transfusion,thus reducing the burden of blood products application.