Table 2.

Patient Blood Management Recommendations in National and International Obstetric Societies' Postpartum Hemorrhage Guidelines

	ACOG—USA	SOGC—Canada	RCOG—UK	RANZCOG—Australia, New Zealand	D-A-CH—Germany, Austria, Switzerland	International Expert Panela	National Partnership for Maternal Safety	CNGOF—France
Transfusion Indications	The extent of blood loss is significant and ongoing, especially if vital signs are unstable	Not discussed	Blood loss >1000 mL and continuing to bleed or clinical shock	Blood should be considered early to restore oxygen-carrying capacity	Transfuse according to clinical picture. Blood loss is often underestimated	To maintain circulating blood volume and tissue oxygenation if initial treatment unsuccessful with ongoing blood loss >1000 mL	Not discussed	Indications for specific blood components were described for PPH management after vaginal delivery
RBC	Replacement for oxygen-carrying capacity not for volume replacement	Not discussed	Therapeutic goal = Hb >8 g/dL. If fully crossmatched blood is unavailable, in an emergency, use O-negative RhD-negative blood. If the ABO and rhesus group is known, use ABO and D group compatible uncrossmatched blood	Request 4 units RBC or other locally agreed volume. Consider group specific or O-negative RhD-negative blood early	No specific recommendations for RBC transfusion. Therapeutic goal = Hb level between 8 and 10 g/dL	Not discussed	Transfusion protocols are recommended that allow emergency release of blood products. Emergency release products can include O-negative RBCs or type specific RBC	RBC transfusion based principally on clinical signs of PPH severity, without necessarily waiting for laboratory test results. Maintain Hb level >8 g/dL
Plasma	Not discussed	Not discussed	Therapeutic goal = PT < 1.5× mean control, PTT < 1.5× mean control. Transfuse 4 units FFP for every 6 units of RBC or if PT/APTT > 1.5× normal. For “relentless” bleeding, give up to 1 L FFP empirically.	Therapeutic goal = PT/APTT <1.5× normal and INR ≤1.5. Transfuse FFP 15 mL/kg if INR >1.5	FFP >20–30 mL/kg is recommended to correct a coagulation disorder	Not discussed	AB plasma can be provided as an emergency release product. Although no specific advice is given, the bundle makes reference to fixed-ratio transfusion regimens and the use of coagulation/POC testing	If severe PPH or coagulopathy, FFP can be given without awaiting laboratory results
PLTs	Not discussed	Not discussed	Therapeutic goal PLT count >75 × 109/L. Transfuse platelets if PLT count < 50 × 109/L	Therapeutic goal = PLT count > 50 × 109/L. Transfuse 1 adult “dose” PLT if PLT count <50 × 109/L	Therapeutic goal = PLT count > 50 × 109/L. No specific recommendations for PLT transfusion	Not discussed (for patients without inherited PLT function disorders)	Not discussed	Order PLTs early to maintain PLT count >50 × 109/L
Fibrinogen replacement therapies	Not discussed	Not discussed	Transfuse cryoprecipitate if fibrinogen <1 g/L. For “relentless” bleeding, give up to 10 units (2 packs) cryoprecipitate empirically	Therapeutic goal = fibrinogen > 1 g/L. Transfuse 3–4 g cryoprecipitate if fibrinogen <1 g/L. Consider early as DIC often present	Not discussed	Can be considered for fibrinogen supplementation. Maintain fibrinogen concentration >2.0 g/L	Monitor fibrinogen levels and replace with cryoprecipitate	Therapeutic goal = fibrinogen level ≥2 g/L. No clear recommendation for fibrinogen concentrate or cryoprecipitate is described
Massive transfusion protocol	Not discussed	Not discussed	Not discussed	An MTP is describedc	Not discussed	An MTP is recommended for the correction of coagulopathy for ongoing, uncontrolled PPH >2000 mL	Yes; each unit to establish its own MTP	Not discussed
Pharmacological agentsb	Not discussed	Not discussed	Antifibrinolytics not recommended	Tranexamic acid 1 g over 10 min then 1 g over 8 h if massive transfusion protocol activated	If TEG or ROTEM is unavailable and severe PPH (see Table 1): give 2 g of tranexamic acid with fibrinogen concentrate (2–4 g)	In the early treatment of severe PPH, administer tranexamic acid before fibrinogen supplementation (1 g, then repeat 1 g after 30 min followed by a 1 g/h infusion).	Not discussed	Tranexamic acid may be useful although clinical value is unproven. Use at clinician discretion. Recommended for PPH secondary to refractory uterine atony (1 g dose, repeated if ineffective after first dose). Not recommended to prevent PPH during CD
RVIIa	Role undetermined	Cannot be recommended as part of routine practice	Only recommend, after consulting an hematologist, for patients with life-threatening hemorrhage. Fibrinogen level should be >1 g/L and PLT count should be >20 × 109/L before RVIIa is given	Consider if uncontrolled hemorrhage in a salvageable patient, failed surgical or radiological measures to control bleeding AND adequate blood component replacement AND pH >7.2, temperature >34°C	As a last resort (90 μg/kg bolus, if hemorrhage persists repeat after 20 min), only if pH ≥7.2, fibrinogen level >1.5 g/L, temperature >35°C, PLT >50 × 109/L, and hyperfibrinolysis has been excluded	For life-threatening PPH, consider as an adjunct to other surgical treatments (90 μg/kg bolus, repeat if no clinical response within 15–30 min). Adequate levels of PLT and fibrinogen are essential. Check and correct PLT and fibrinogen levels before RVIIa is given	Not discussed	No evidence to support recommending RVIIa for PPH prevention or treatment. Consider only for uncontrolled hemorrhage after failure of conventional treatment and correction of PLT levels and other hemostatic indices
Cell salvage	Cell savers can be considered during cesarean delivery	Not discussed	Current evidence supports the use of cell salvage in obstetrics	Consider cell salvage where appropriate	Not discussed	Not discussed	Not discussed	Not discussed
Other patient blood management strategies	Consider autologous transfusion for patients with rare antibodies. Iron and erythropoietin may be useful in the postpartum period	Not discussed	Special blood filters should not be used as they slow infusions. A maximum of 3.5 L warmed crystalloid or 1–2 L colloid may be given while waiting for blood to arrive	Consider patient's previous hemoglobin and blood volume when assessing severity of hemorrhage. Other therapeutic goals include: base excess <–6; lactate <4 mmol/L; pH >7.2; calcium >1.1 mmol/L. Tolerate permissive hypotension (BP 80–100 mm Hg systolic) until active bleeding controlled	Point-of-care testing for coagulation, such as TEG, suggested for coagulation analysis. Other therapeutic goals include: systolic BP >80 mm Hg; pH > 7.2; temperature >35°C; calcium > 0.8 mmol/L	Perform coagulation screen (including PLT, PT, APTT, and fibrinogen level) when persistent (ongoing) PPH is declared. Assess coagulation status every 45–60 min until bleeding controlled and coagulation defects corrected. If available, point-of-care testing can also be performed	Establish a PPH response team including blood bank	Prevent severe antenatal anemia with iron supplements. Laboratory monitoring of coagulation recommended. All maternity units should be associated with a blood bank, and practitioners should be familiar with local logistics to procure blood products. Blood should be available within 30 min

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; APTT, activated partial thromboplastin time; BP blood pressure; CD, cesarean delivery; CNGOF, French College of Gynaecologists and Obstetricians (in collaboration with the French Society of Anesthesiology and Intensive Care); D-A-CH, Germany, Austria, and Switzerland; FFP, fresh frozen plasma; Hb, hemoglobin; INR, international normalized ratio; MTP massive transfusion protocol; OR, operating room; PLT, platelet count; POC, point of care; PPH, postpartum hemorrhage; PT, prothrombin time; RANZCOG, Royal Australian and New Zealand College of Obstetricians and Gynaecologists; RBC, packed red blood cells; RCOG, Royal College of Obstetricians and Gynaecologists; ROTEM, rotational thromboelastometry; RVIIa, recombinant factor VIla; SOGC, Society of Obstetricians and Gynaecologists of Canada; TEG, thromboelastography.

^aMembers of an expert panel were convened in November 2011. Consensus recommendations were published in Transfusion 2014; 54: 1756–68. Financial support for the consensus meeting was provided by CSL Behring (Marburg, Germany). Experts received funding support and honoraria from CSL Behring to attend the consensus meeting. No other conflicts of interest of funding sources were declared.

^bNot including recombinant factor VIIa.

^cThe MTP described in the guidelines from the Royal College of Australian and New Zealand College of Obstetricians and Gynecologists was sourced from the Patient Blood Management Guidelines: Module 1—Critical Bleeding/Massive Transfusion, published by The National Blood Authority, Australia. 2011. URL: http://www.blood.gov.au/system/files/documents/pbm-module-1.pdf (Accessed 11/7/15).