(385) “Keep transfusing until the bleeding stops” – massive transfusion and circulatory overload in obstetric hemorrhage

Hemodynamic support and blood replacement during massive hemorrhage is critical to survival, but high-volume massive transfusion (MTP) increases risk of transfusion associated circulatory overload (TACO). When faced with cardiac arrest from hemorrhagic shock restriction of fluid resuscitation may not be an option, and management of MTP goes beyond the moment bleeding is finally controlled. We aim to assess the risk and morbidity of TACO due obstetric hemorrhage managed with MTP.

Study Design:

This retrospective cohort quality improvement study of parturients who suffered obstetric hemorrhage requiring large volume transfusion of blood products with more than four units of PRBC transfused as part of a MTP from June 2023 to July 2024 at our level IV center. Those cases with TACO were compared to those without.

Results:

There were 5690 deliveries, 176 (3.1%) had PPH/MTP activation, of which 51 (28.9%) had > 4U MTP blood products transfused. The rate of TACO with MTP was 40% (N = 20/51). Placenta accreta spectrum alone was not a risk factor for TACO, neither was average estimated blood loss. Those with TACO had significantly more blood component volume/units transfused (Table 2). Patients with TACO had more diffuse intravascular coagulation (DIC) (75% vs 6%; p < 0.001), hemolysis (35% vs 3%; p = 0.002), ICU admission (75% vs 35%; p = 0.006), and acute kidney injury (50% vs 9%; p = 0.001). Post-transfusion hemoglobin and nadir fibrinogen were similar between groups, despite more baseline anemia in the TACO group. The only maternal death in this study occurred in the TACO group.

Conclusion:

High volume MTP in obstetric patients shows increased rates of TACO and other serious morbidity, mostly related to transfusion volume and development of DIC. There are few reliable predictors of morbidity. Those with TACO were not grossly more medically complicated at baseline, which underscores that TACO can happen to any parturient. Future investigation of techniques to limit hemorrhage, improve resuscitation quality, reduce volume administered, and mitigate sequalae of massive transfusion is warranted.