For women with persistent postpartum hemorrhage, correction of coagulopathy by administering plasma is often an inevitable treatment decision. There are little clinical data, however, on whether an early or a late start for plasma transfusion leads to more positive maternal outcomes.

Data presented on Wednesday at the ISTH 2015 Congress by Dacia Henriquez of the Department of Obstetrics and Gynecology at Leiden University Medical Center in Leiden, Netherlands, may help answer that question.

Henriquez

Dacia Henriquez

“Our findings do not support the notion that plasma transfusion within 60 minutes after diagnosing persistent postpartum hemorrhage contributes to the reduction of the risk of adverse maternal outcomes,” Henriquez said in an interview.

The Transfusion Strategies in Women with Major Obstetric Hemorrhage (TeMpOH-1) study included 1,217 women with postpartum hemorrhage (PPH) that was refractory to first-line obstetric interventions. The women were treated at 61 Dutch hospitals in 2011 and 2012.

“With this selection, our study results can be easily translated to daily clinical practice because of this clearly identifiable turning-point in treatment,” she said.

All women included in the study received either at least 4 units of red blood cells or a multicomponent transfusion within 24 hours after delivery (≥ 1000 mL). Median bleeding rate at baseline was 1.1 L at 1 hour, and median total blood loss was 3.0 L. Marginal structural models with inverse probability of treatment weighting were constructed to quantify the difference in maternal outcomes–including arterial embolism, hysterectomy and maternal mortality–between an early (within 60 minutes) and a late (after 60 minutes) start of plasma transfusion (163 women vs. 1,054 women, respectively).

After adjustment for baseline parameters, bleeding severity, and changes over time, no significant differences were seen between the groups (odds ratios, 1.1 and 0.8, respectively).

“It seemed that after adjustment for patient and bleeding characteristics, plasma transfusion within 60 minutes after diagnosis of persistent PPH was not associated with a reduction in adverse maternal outcomes,” she said, noting that analyses are ongoing, and efforts are underway to determine whether time-dependent confounding was handled properly in the study.

Plans are also in place to perform subgroup analyses to assess whether treatment effect will differ between those with the most severe bleeding and those with initially milder hemorrhage, she said.

“With the TeMpOH-1 data, we were also able to demonstrate that dilutional coagulopathy due to volume resuscitation with crystalloids and colloids was associated with greater total blood loss and more adverse maternal outcomes when the clear fluids volume exceeded 4 liters,” Henriquez said. (See P0607-WED, Poster Session Transfusion II.)

“A treatment strategy aiming at prevention rather than correction of coagulopathy in women with persistent PPH in daily clinical practice seems justified, because correction of coagulopathy by administering plasma appears to be of limited value in reducing adverse maternal outcomes,” Henriquez said.

 

By Mike Bock and Sharon Worcester |June 24, 2015