UNC Chapel Hill Chapel Hill, North Carolina, United States
Background/Case Studies: The United States has the highest maternal mortality rate among industrialized countries. More American women are dying of pregnancy-related complications than any developed country and the rate is rising. In 2021, 1,205 women died of maternal causes compared with 861 in 2020 and 754 in 2019. Causes of pregnancy-related death include cardiovascular conditions, sepsis, embolism, and hemorrhage, among others. Obstetric hemorrhage is one of the most common obstetrical complications of childbirth precipitated by risk factors such as multiple gestation, placenta previa, and therapeutic anticoagulation. However, many cases have no identifiable risk factor. When pregnancy results in hemorrhage, the need for massive transfusion is high and a well-defined massive transfusion protocol (MTP) is essential to streamline care. Pilot data from hospital-based transfusion services with labor and delivery units in one US state indicate that not all facilities have an MTP and those with protocols are not adhering to established best practices.
Study
Design/Methods: Sixteen best practices for MTPs for obstetric patients were identified from professional organization guidelines and the scientific literature. An online survey was created to gather facility characteristics and adherence to best practices. The voluntary and anonymous survey link was posted on the AABB Community discussion board. Descriptive data was collated and analyzed.
Results/Findings: Thirty-one survey responses were collected from facilities across the United States with the largest number coming from the Northeast (52.0%). Facilities were primarily accredited by the Joint Commission (83.9%), greater than 500 beds (51.6%), providing tertiary care (55.2%), desginated as a trauma center (85.7%), and a teaching hospital (75%). Some respondents (17.9%) indicated that they did not have an MTP for obstetric patients. Facilities with >500 beds reported larger inventories for each blood product (e.g., an average of 193 units red blood cells versus 75 units of red blood cells). Across all best practices, only 4 had 100% compliance from all responding facilities: uncrossmatched blood was identified with a special sticker or tag, O negative blood was used for emergency release, the medical director was accessible on-site, on-call or both, and a type and crossmatch was collected as soon as possible. Various levels of compliance were reported for the other best practices. Conclusions: Established procedures that aid in the management of blood loss during obstetric hemorrhage decrease morbidity, mortality and improve overall patient safety and outcomes. These data indicate there is room for improvement regarding adherence to best practices for obstetric MTPs. Review and update of protocols is the first step to reducing maternal mortality related to hemorrhage.
Importance of research: The US has the highest maternal mortality rate among high-income countries and it is rising. One of the highest causes is hemorrhage. Obstetric hemorrhage should be managed with a well-defined protocol based on best practices to expedite the provision of blood products. No study to date has examined the compliance of US hospital-based transfusion service MTPs with best practices. This study may help facilities consider review of current procedures and in turn, improve patient care and outcomes.
