|Ahead of print
|Massive transfusion protocol for postpartum hemorrhage case management in Hospital Kuala Lumpur; Five years implementation and outcome
Nor Hafizah Ahmad1, Nabila Ramlan1, Muniswaran Ganeshan2, K Sharmila Bhaskaran3, Fazilah Ismail1, Thohiroh Abdul Razak4, Afifah Hassan1, Noryati Abu Amin1
1 Clinical Transfusion Division, National Blood Centre, Kuala Lumpur, Malaysia
2 Department of Obstetric & Gynaecology Tengku Azizah Hospital, Kuala Lumpur, Malaysia
3 Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
4 Department of Anesthesiology Tengku Azizah Hospital, Kuala Lumpur, Malaysia
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|Date of Submission||18-Jul-2021|
|Date of Decision||23-Jan-2022|
|Date of Acceptance||05-Jun-2022|
|Date of Web Publication||26-Sep-2022|
| Abstract|| |
CONTEXT: Postpartum hemorrhage (PPH) is a global cause of mortality and morbidity and the number remains high despite the advancement in medical field. Literature suggested that the causes of PPH were largely avoidable and measures can be instituted to avoid it. Transfusion service played an integral part to ensure that blood and blood products were supplied in timely manner.
AIMS: The study aimed to look into the role of massive transfusion protocol (MTP) in facilitating blood supply during acute management of bleeding in PPH cases.
SETTINGS AND DESIGN: This was a retrospective study of 5 years on MTP implementation in the management of PPH in Hospital Kuala Lumpur (HKL).
SUBJECTS AND METHODS: We analyzed the patient's clinical records from Transfusion Medicine database starting from April 1, 2015, to December 31, 2019, at the Obstetrics and Gynecology (O and G) Department, HKL.
STATISTICAL ANALYSIS USED: The data were presented as numbers or percentages, mean (standard deviation), and median (interquartile range). Pearson's correlation was used to assess correlation between the total estimated blood loss and the number of red cell concentrates transfused. Multinomial logistic regression analysis was used to study the association of parity and mode of delivery with the transfusion requirement in the MTP cycle.
RESULTS: In total, there were 54,417 deliveries during the study period. MTP activation only occurred in 60 cases with 5 exclusions. Therefore, activation occurred in 55 PPH cases at a rate of 0.001% out of the total number of deliveries. The most common etiology of PPH was uterine atony. Only one patient in the cohort died due to postoperative complication of intra-abdominal sepsis. Morbidities from hysterectomy were documented in 15 cases (27.3%), and there was intensive care unit admission in 22 cases (40%). Wastage of blood and blood products was very minimal; 8/341 units fresh frozen plasma were discarded (2.35%) and 8/332 units platelet were discarded (2.4%).
CONCLUSIONS: The study outcome showed that an MTP designed specific to obstetric service had helped improve patient outcomes and reduce overall transfusion rate as it helped improve blood availability early during the event as part of the hemostatic resuscitation.
Keywords: Clinical outcome, massive transfusion protocol, postpartum hemorrhage, transfusion outcome, transfusion service
|How to cite this URL:|
Ahmad NH, Ramlan N, Ganeshan M, Bhaskaran K S, Ismail F, Razak TA, Hassan A, Amin NA. Massive transfusion protocol for postpartum hemorrhage case management in Hospital Kuala Lumpur; Five years implementation and outcome. Asian J Transfus Sci [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.ajts.org/preprintarticle.asp?id=356849
| Introduction|| |
Postpartum hemorrhage (PPH) is a global cause of mortality and morbidity worldwide and the number remains high despite the advancement in medical field. The Sustainable Development Goals launched in 2015 by the United Nation General Assembly included a target of reducing the global maternal mortality ratio to <70/100,000 live births by 2030. Nevertheless, the WHO reported 295,000 maternal deaths worldwide in 2017, estimated to be 211 deaths per 100,000 live births. In 2017, Malaysia recorded an MMR of 29 maternal deaths per 100,000 live birth, which was almost four times higher than neighboring country, Singapore, with an MMR of eight in the same year. Literature suggested that the causes of PPH were largely avoidable and measures can be instituted to avoid it beforehand.
PPH according to the WHO definition is blood loss of 500 ml or more, whereas severe PPH is blood loss of 1000 ml or more both within 24 h of delivery. Uterine atony accounted for 70%–80% of the cases of PPH. However, other causes can be involved such as genital tract trauma or laceration, retained placenta, or coagulation disorders. Severe PPH can be associated with severe morbidities such as multiorgan failure, multiple blood transfusion, and peripartum hysterectomy.
Health surveillance system was set up in many countries such as the Confidential Enquires into Maternal Deaths program in the United Kingdom to look into the maternal deaths and identify the contributing factors that lead to the death event, and the findings were used to improve patient's care and subsequently reduced number of death. Many reviews suggested that some of the deaths in PPH cases can be prevented by improving patient's care.,
In PPH management, early detection and timely intervention were very pertinent to save patient's lives and reduce morbidity. Despite that, delayed recognition of the clinical signs of hypovolemia was not uncommon due to the underestimation of concealed bleeding and this was also contributed by the fact that young and healthy patients became symptomatic only after a significant blood loss occurred to the point that coagulopathy had already set in. According to a study, morbidities due to PPH were contributed by either system or clinical caregiver related factors in which the most common factor was “delay in treatment” which was documented in 70% of the total cases in association with 'delay in diagnosis' (43%).
Transfusion service played an integral part in the acute management of bleeding in the resuscitation of PPH cases to ensure that blood and blood products were supplied in a timely manner to save patient's life. Issues related to transfusion mainly revolved around the delay in transportation or transit at the porter area, lack of early accessibility, and inadequate blood volume given. Response to PPH must be swift and efficient. Good coordination and communication between multidisciplinary team, patients transportation process, and readiness of the transfusion service were the key aspects to ensure patients received quality care.
The American Congress of Obstetricians and Gynecologist and the Society of Maternal Fetal Medicine had collaborated to organize a National Partnership for Maternal Safety for the “National Maternal Health Initiative: Strategies to Improve Maternal Health and Safety” consensus conference in 2013. They recommended the use of a standard obstetric hemorrhage protocol, which included the Massive Transfusion Protocol (MTP) and hemorrhage cart/kit., MTP is a standardized protocol used to facilitate delivery of blood and blood products during management of massive bleeding., It gives a solution to overcome the system and communication inefficiency in the transfusion process, which may contribute to PPH-related morbidity and mortality.,
Hospital Kuala Lumpur (HKL) is the tertiary referral center which currently is the largest hospital in Malaysia governed by the Ministry of Health. There are 53 departments and units with 83 wards and 2300 beds and also stated to be among the biggest hospital in Asia. According to the record, a total of 759,335 deliveries have been recorded from 1963 in 2002 in HKL; hence, it was also considered one of the busiest maternity centers in the world. The National Blood Center has been providing Transfusion Laboratory Service to HKL since 2002. This study aimed to look into how the implementation of MTP in PPH management effects in terms of the clinical outcome and transfusion outcome.
| Subjects and Methods|| |
This was a retrospective study of 5 years on MTP implementation in the management of PPH in HKL. We analyzed the patient's clinical records and information from Transfusion Medicine database starting from April 1, 2015, to December 31, 2019, at the Obstetrics and Gynecology (O and G) Department, HKL. The development of MTP involved a multidisciplinary team consisted of obstetrician, anesthetist, transfusion medicine specialist, nurses, medical laboratory technologist, and porters. Serial meetings were conducted to finalize the algorithm. Roles and responsibilities of all parties involved were outlined clearly to avoid confusion and miscommunication during activation of MTP. The critical roles of a dedicated blood porters were highlighted and serial trainings were conducted following the discussions. The objectives of this study were to look into the demographic data of PPH cases requiring MTP activation, etiologies of PPH, and also clinical and transfusion outcomes.
The MTP protocol in HKL requires that the decision to activate must come from the obstetrician/anesthetist attending the patient based on clinical judgment, the rate/magnitude of ongoing blood loss, patient's vital signs and general condition, and high index of suspicion during the early phase of bleeding. The decision can only be made by an obstetrician/anesthetist to avoid unnecessary activation of the protocol. A call to transfusion laboratory medical officer (MO) on call must be initiated by an MO from the O and G team. The MO from the O and G team will be assigned as the MTP coordinator for the particular patient and act as the liaison to keep close communication with transfusion team during the MTP activation.
The MTP for PPH comprised a package of red cell concentrates, platelet, fresh frozen plasma (FFP), and cryoprecipitate with a 1:1:1:1 ratio. This ratio was agreed upon during the initial phase of discussion between the multidisciplinary team involved. This was taking into account the MTP design that was commonly used in trauma cases and adopted into PPH management. Cryoprecipitate was added to the protocol because low fibrinogen level had been documented to be an early predictor of severe PPH case in another study.
[Figure 1] illustrates the MTP flowchart, which includes the criteria for activation of MTP, the transfusion laboratory contact number for MTP activation, and the required patient information and the blood samples. The use of 4 units of uncross-matched group O red cell concentrates which were kept in labor room and operation theater was incorporated into the algorithm. The first package consisted of 4 uncross-matched group O red cell concentrates, 4 units of group O platelet, 4 units of group AB FFP, and 4 units of group AB cryoprecipitate for patient in which the blood group is unknown/not tested yet. The second MTP package consisted of similar number of units with group-specific and fully cross-matched red cell concentrates once the blood group is known. However, for patients with at least two previous records in the transfusion laboratory, group-specific red cell concentrates can be given during the first package itself instead of group O uncross-matched red cell concentrates. Time frame for the first package to be ready was within 15 min after transfusion laboratory received the sample, whereas the second package will be ready within 45 min for full cross-matched red cell concentrates.
During the study period, the transfusion laboratory serving HKL was located in a separate building across the main road; hence, this posed a logistic challenge to the MTP implementation. Dedicated porter system was tasked to bring the patient blood samples for cross-match and blood products back and forth between the transfusion laboratory and the clinical area during the MTP activation. Other samples for baseline investigations such as FBC and coagulation profile were sent to pathology laboratory within HKL. An MTP kit which comprised EDTA tubes for sampling, blood ordering forms, and labels to be used was placed in the clinical areas to hasten the blood taking and ordering process during an MTP activation.
The data were extracted from MTP audit form which were filled in by the transfusion laboratory MO for patient review post-MTP activation. The audit form will contain the clinical data extracted from the patients' clinical records and the blood ordering form.
Approval for publication was applied to the Ministry of Health, Malaysia, as all the data were retrieved from patient's medical record, GXM forms, and laboratories data. The study followed ethical standard of MOH, Malaysia. The data recorded remained confidential.
The data were analyzed using Microsoft Excel and SPSS Version 25 (IBM Corporation; Somers, NY, USA). The data were presented as numbers or percentages, mean (standard deviation), and median (interquartile range). Pearson's correlation was used to assess the correlation between the total estimated blood loss (EBL) and the number of red cell concentrates transfused. Microsoft Excel and SPSS Version 25 were used for data entry and analysis. P < 0.01 was considered statistically significant. Multinomial logistic regression analysis was used to study the association of parity and mode of delivery with the transfusion requirement in the MTP cycle.
| Results|| |
In total, there were 54,417 deliveries during the 5-year study period from April 1, 2015, to December 31, 2019. [Figure 2] shows the total deliveries in HKL including both lower section cesarean section (LSCS) and spontaneous vaginal delivery. MTP activation only occurred in 60 cases where two were excluded due to missing data and three were excluded as they were gynecological cases. Therefore, activation occurred in 55 PPH cases at a rate of 0.001% out of the total number of deliveries. Demographic and clinical data are shown in [Table 1]. The most common etiology of PPH was uterine atony [Figure 3]. Majority of the patients with activation of MTP had undergone emergency LSCS (46%) before the onset of PPH.
|Table 1: Demographic and clinical data of massive transfusion protocol cases with massive transfusion protocol activation|
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|Figure 2: Number of total deliveries in Hospital Kuala Lumpur Year 2015–2019 Kuala Lumpur (*LSCS = Lower Section Cesarean Section, SVD = Spontaneous Vaginal Delivery)|
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|Figure 3: Etiology of PPH with MTP Activation. PASD = Placenta accreta spectrum disorder|
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Regarding the blood usage, in 55 cases with MTP activation, 26 patients (47.3%) cases only required 1st MTP cycle. The distribution of blood and blood products used is shown in [Table 2]. There was a fine correlation between the total unit of red cell concentrates transfused and EBL (r = 0.35; P < 0.01) as shown in [Figure 4]. It was also shown from the data that among the 55 cases, 36 patients (65.5%) had pre cross-match blood prior to MTP activation
|Figure 4: Correlation of total estimated blood loss and total number of units of transfused red cell concentrates. R2 linear = Correlation coefficient|
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Due to the logistic issue, the mean total time that we were able to achieve between MTP activation until arrival of blood products was on average of 63.9 min. However, the physicians made used of the uncross-matched red cell concentrates stored in the clinical area and also blood cross-match prior to LSCS before the arrival of the first four units of red cell concentrates in MTP. Out of the 55 cases, 36 patients (65.5%) had cross-matched blood requested prior to deliveries. The mean time taken from receiving the samples until the blood packages were issued by transfusion laboratory in each cycle was only 13.3 min. The mean time taken from MTP activation until the sample reached porter station was 27.5 min and the mean porter transportation time was 23.5 min [Table 3].
The mean hemoglobin for the patient was 10.2 g/dl and platelet was 240 × 109/L. The lowest hemoglobin documented predelivery was 2.8 g/dl. Coagulation parameters of internationalized normalized ratio (INR) and activated partial thromboplastin time (APTT) were within normal range before and postresuscitation [Table 4].
All patients survived except one patient who died on day 22 due to complication of intra-abdominal sepsis postoperatively on day 22.
Hysterectomy was performed in 15 cases (27.3%) and 22 patients required intensive care unit (ICU) admission (40%). A total of 341 units of FFP and 332 units of platelet were transfused. Only eight units of FFP and eight units of platelet were discarded out of all blood products supplied. There was no adverse transfusion event reported in all cases. There were no cases of mothers with red cell antibodies nor mother with Rh D negative blood group.
A multinomial logistic regression analysis was used to study the association between the number of red cell concentrates, FFP, platelet, and cryoprecipitate units transfused to the patients and the parity and mode of delivery. The multinomial regression analysis was selected to predict the different possible outcomes of transfusion of each blood products in MTP cycle. The outcomes of the correlation are shown in [Table 5]. The mode of delivery was a significant factor affecting the number of packed cell and FFP transfused; however, it was not significant in association with the number of platelet and cryoprecipitate transfused during the MTP cycle.
|Table 5: Correlation of parity, mode of delivery with transfusion requirements in massive transfusion protocol cycle|
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| Discussion|| |
The activation of MTP in O and G Department, HKL, was only 0.001% from the total 54,417 deliveries during the study period. The low rate of activation showed that generally, there was good and efficient clinical management instituted which prevented majority of the patients from developing severe hemorrhage requiring MTP utilization. All the cases were transfused with blood and blood products, which indicated justifiable MTP activation. Another paper documented that transfusion was necessary in 84% of the cases, which indicated that MTP was utilized for the right cases and indications in PPH.
Majority of the patients with MTP activation were multipara (58%). Out of total of 55 MTP cases, 64% were from an age range of 31–40 years old. Out of 55 cases, almost half of them (46%, 25 cases) had undergone emergency LSCS before the onset of PPH. The etiologies of PPH varied; however, uterine atony was the main cause of PPH in the patient cohort. Other common causes were placenta abnormalities such as placenta praevia, placenta accreta spectrum disorder, and placenta abruption. These findings were consistent with other studies.,
Challenges of distance and time
The transfusion laboratory serving HKL was located across the main road from the hospital; hence, this posed as the main challenge in the MTP implementation. Due to this reason, most of the patients who were identified in the high-risk categories during admission to HKL will have had their blood grouped and cross-matched prior to delivery or the surgery. This was especially true in emergency or elective LSCS. In our study, 36 patients (65%) had blood cross-matched available before MTP activation.
Among the strategies that we instituted to prevent delay and ensure smooth activation of MTP were keeping adequate uncross-match red cell concentrates in the labor room fridge. We stored six units of uncross-match red cell concentrates, which will be immediately replaced after use.
The transfusion laboratory supplied uncross-match group O or group-specific red cell concentrates during the first cycle of MTP to avoid delay. We cannot afford to do emergency cross-match during the first cycle due to the blood bank distance to the hospital. However, for the second cycle, we will do full cross-match considering the time the porter will take to collect the second cycle. Therefore, emergency cross-match was not included in our MTP algorithm.
As mentioned earlier, as most of the patients already had pre cross-match blood before MTP activation, this had helped in the transfusion management as we can immediately provide full cross-match blood during the first cycle itself. The mean timing to process was 13.3 min well within the 15 min turnaround time (TAT). However, the mean time taken for the whole activation process until delivery of blood and blood products to the patient was 63.9 min. This was far from ideal, but it had helped hasten the time of delivery compared to the time taken prior to MTP implementation. The only way to improve the delivery timing in our situation was by having an on-site blood bank to reduce blood transportation time.
As the blood transportation system depended on the porter system, we also made a rule that during MTP activation, there must be a dedicated porter who will attend to MTP case only and should not be handling other nonurgent cases. This was to ensure smooth and efficient delivery of the system.
Communication and coordination
The challenging part of MTP process was to coordinate the communication and work process between different groups of personnel in different disciplines. Hence, we conducted training for everyone involved to ensure every level of personnel understand their roles and responsibilities before MTP was officially launched.
Another step that we took was to elect an MTP coordinator in each MTP case. MTP coordinator must be a MO in the clinical area and must not be involved in the surgery. The coordinator was responsible to maintain the communication with MO in transfusion laboratory to keep track of the whole flow and gave instruction when to deactivate MTP once bleeding was secured and the patient was stabilized. This was to avoid unnecessary process to prepare the next blood packages, which can lead to wastage if end up not being transfused. The deactivation of MTP will depend on the clinical judgment of the clinicians (anesthetists and surgeons). There are a few criteria that would be assessed in order to deactivate MTP. Bleeding must be secured with no visualized oozing from the surgical field. Patients' vital signs considered to be stabilized if the vital signs showed improvement; less tachycardia and improved Mean Arterial Pressure (>65 mm Hg). Since we did not have whole blood viscoelastic hemostasis assays in place, we relied on the basic point of care testing that we had which was the Haemacue for hemoglobin (Hb) reading (Hb >7 for patients without heart disease and Hb >10 for patients with heart disease. The MTP coordinator will convey the decision to deactivate MTP to MO in transfusion laboratory upon instruction from the specialist or consultant of the clinical team managing the patients.
All MTP activation decision must only came from specialist or consultant to ensure no abuse of the protocol and avoid blood wastage.
During MTP activation, a call will be made to porter unit which was located in the maternity building in HKL. Once porter was informed on the MTP activation, a specific porter will be assigned to handle the case until MTP was deactivated. He will be responsible to send the blood sample to transfusion laboratory and bring back the blood and blood products. He will be responsible to go back and forth until MTP was deactivated. This dedicated porter should not handle other cases during that time and will be focusing solely on his responsibility to handle the MTP case. The porter unit had also designed a form to document the time upon receiving the call and the time for each cycle of MTP products was supplied to the ward. This particular form was very useful during audit to trace loopholes for future improvement in case there was a delay in blood supply.
Patient safety and quality of care
Apart from that, to prevent transfusion error in the midst of chaos, we ensure all wards, labor room, and OT have a transfusion kit. The kit contained forms, tubes, and tube label that were needed to be filled up. This was implemented to prevent mix up and avoid transfusion error. We also ensure all MTP cases will be followed up the next day and audit will be done on the whole process, the patients' outcomes will be reviewed, and the transfusion outcomes in term of wastage and timing of delivery will be audited. This was done to find loopholes and implement immediate corrective action to improve the system.
Blood conservation and avoiding wastage
In the initial phase, we provided the blood in automatic cycle where the second FFP was thawed immediately after the first cycle was supplied. However, we noticed that in majority of the patients, they only required one cycle of MTP. We then changed our practice where the second package will only be prepared upon receiving instruction from the coordinator depending on patient's clinical condition and ongoing blood loss. Our 5-year data showed that 26 patients (47.3% of cases) required only one MTP cycle. Basically, by activating MTP early enough and securing the bleeding early, we were able to reduce unnecessary transfusion in almost half of the cases. We greatly depended on the communication between the coordinator and the transfusion laboratory MO as this was also to ensure in cases where the second cycle was indicated the products were prepared without delay.
Description of estimated blood loss and products received
EBL correlated with the total number of transfused red cell. This was considered an important element to justify MTP activation as the nature of PPH were generally unpredictable; hence, EBL was one of the red alerts for physician to activate MTP in PPH cases (r = 0.355, P < 0.01) [Figure 4]. A previous study on MTP in PPH also showed that there was a strong correlation between EBL and the total number of red cell concentrates transfused, which indicated that physicians used EBL in the decision-making steps to decide on red cell concentrates transfusion. Out of 55 cases, 10 patients received ≥9 units of red cell concentrates, 24 patients received 5–8 units of red cell concentrates, 17 patients received 3–4 units of red cell concentrates, and only 4 patients received 1–2 units. There was higher use of red cell concentrates compared to other blood products, which indicated the need to continue preparing pre-cross-match red cell concentrates in cases identified as high risk. This highlighted the importance of having uncross-match red cell concentrates in clinical area.
In terms of other blood products transfused, only 9 patients received ≥9 units of FFP, platelet, and cryoprecipitate, 35 patients received 3–4 units of FFP and 3–4 units of platelet, and 31 received 3–4 units of cryoprecipitate, which indicated that one cycle of MTP was generally enough in majority of patients [Table 2]. Our MTP helped ensure that large volume of blood and blood products was available on time by releasing the fixed ratio MTP packages to the bleeding patient. There was a significant correlation in terms of the mode of delivery and factor affecting the number of packed cell and FFP transfused; however, it was not significant in association with the number of platelet and cryoprecipitate transfused during the MTP cycle [Table 5]. Therefore, the mode of delivery was a significant factor that should be considered in term of MTP activation and increased transfusion requirement or MTP cycle. However, parity of the patients did not seem to have a significant association with the number of red cell concentrates, FFP, platelet, and cryoprecipitate transfused.
Laboratory parameters monitoring
The laboratory values for hemoglobin, platelet, INR, and APTT were taken pretransfusion and post resuscitation. There was a favorable outcome in terms of the laboratory values indices, which indicated that the blood and blood products helped achieve hemostasis in those patients. The same paper mentioned earlier also showed favorable hematologic and coagulation parameters investigations postresuscitation, which suggested the important role of making the blood and blood products readily available in adequate amount during PPH management. Empiric transfusion of blood and blood products in MTP helped avoid dilutional coagulopathy and progression to disseminated intravascular coagulopathy as illustrated in one serial PPH case study. We were not able to analyze fibrinogen level as fibrinogen level was only available in five patients post resuscitation [Table 4].
Observational data had shown activation of maternal fibrinolytic pathway could already be detected upon delivery and it will be increased during placental separation. The fibrinolysis is defined as degradation of the blood clots that were formed into fibrin degradation products to create balance in hemostasis and prevented microcirculatory occlusion. In the randomized placebo controlled multicenter trial (WOMAN), transnexamic acid was given to attenuate hyperfibrinolysis in PPH cases and the number of death and surgical morbidity was assessed in 20,060 patients. However, most of the hyperfibrinolysis test markers were limited and not easily performed as they were more deemed suitable in research environment. Hence, the use of whole blood viscoelastic hemostasis assays, e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM) in PPH cases were being explored in many literatures to help in the transfusion management. In one paper, the fibrinogen level was measured in comparison with the FIBTEM test of the ROTEM (modified rotation thromboelastogram analyzer) in 91 woman (37 with PPH and 54 in control group) and the results correlated well. The use of ROTEM will help provide early parameter to guide early fibrinogen replacement. By using the conventional coagulation test (prothrombin time (PT), APTT, INR and fibrinogen level), the TAT of the results were longer hence delaying the introduction of fibrinogen concentrates or cryoprecipitate to treat early hypofibrinogenemia or the initiation of platelet and FFP transfusion during the acute management phase.
Patient outcomes and transfusion outcomes
There was a favorable outcome in terms of patients' outcomes where only one patient in the cohort died due to postoperative complication of intra-abdominal sepsis. Morbidities from hysterectomy were documented in 15 cases (27.3%). There was ICU admission in 22 cases (40%); however, majority were discharged to general ward the next day. Wastage of blood and blood products was very minimal; 8/341 units of FFP were discarded (2.35%) and 8/332 units of platelet were discarded (2.4%). This was contributed to the active follow-up and audit post-MTP activation and also because MTP was generally activated for real indications. Despite our concern on the risk of transfusion error during the chaotic environment, no transfusion error or even near miss occurred. This perhaps was contributed to the training given and also the use of MTP kit. There was also no transfusion reaction documented for all cases.
Limitation of the study
This study had limitation as it was a retrospective study and no comparison was made with non-MTP PPH due to difficulties to select patients with similar characteristics in the two arms. Furthermore, as mentioned in a previous study, there were many variables which may contributed toward the study outcome such as patients selection, clinicians' choices in transfusion decisions, and patients' underlying medical conditions. The sample size was small and none of the patients had pre-MTP fibrinogen results and only five had postresuscitation fibrinogen results; therefore, proper analysis could not be performed in terms of the efficiency of the MTP products to increase the fibrinogen level. Our center did not have whole blood viscoelastic hemostasis assays such as TEG ROTEM; therefore, the monitoring of the patients was based on clinical judgment and the standard coagulation parameters which had long TAT.
| Conclusions|| |
MTP study in PPH population was limited due to the difficulty to conduct clinical trial in PPH. Most of the algorithms used were developed from trauma population studies where MTP had demonstrated improve outcomes. Its utilization had been expanded outside trauma setting to allow nontrauma patients to receive benefit from the efficient delivery of blood and blood products.
The implementation of MTP in our study focused on facilitating the transfusion process in dire emergency during PPH management and provided large volume of blood and blood products in a timely manner. The study outcome showed that an MTP designed specific to obstetric service had helped improve patient outcomes and reduce overall transfusion rate as it helped improve blood availability early during the event as part of the hemostatic resuscitation.
In future, a larger scale multicenter study will help compare the outcome of PPH cases with a different ratio of MTP to find the best evidence in managing obstetrics hemorrhages. A scoring system might be useful to have a better risk assessment and objective evaluation of each case in terms of assessing the MTP outcomes. More importantly, the use of TEG or ROTEM would be most helpful to reduce unnecessary transfusion and helped reduce transfusion-related morbidities when improving patients' clinical outcomes.
We would like to thank the Director General of Health Malaysia for his permission to publish this article.
We also would like to thank Dr T.P. Baskaran , Dr Zalina Mahmood for general support.
Also Staffs of Clinical Transfusion Division and Hospital Transfusion Team HKL for technical help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Nor Hafizah Ahmad,
Clinical Transfusion Division, National Blood Centre, Jalan Tun Abdul Razak, 50400 Kuala Lumpur
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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