Blood transfusion in obstetrics and gynaecology

Red Flags

Massive obstetric haemorrhage (>1500 mL or rapid bleeding) — activate massive transfusion protocol; PRBC:FFP:platelets in ~1:1:1 ratio with cryoprecipitate^[1]
Acute haemolytic transfusion reaction (fever, flank pain, dark urine, hypotension within minutes) — STOP transfusion, maintain IV access, send unit + recipient sample to lab, supportive care^[1]
TACO (transfusion-associated circulatory overload) — slow rate, diuretic, oxygen; common in older or fluid-overloaded women^[1]
TRALI (transfusion-related acute lung injury) — stop transfusion, oxygen/ventilation; report to blood bank for donor review^[1]

First-line treatment

Interventions

Patient blood management framework^[1]
Three pillars: (1) optimise endogenous red cell mass (treat anaemia, iron repletion, ESA where indicated), (2) minimise blood loss (meticulous surgery, tranexamic acid, intra-op cell salvage), (3) tolerate anaemia (restrictive transfusion threshold)
Restrictive transfusion threshold^[1]
Hb <70 g/L for haemodynamically stable; <80 g/L if cardiac disease or symptomatic; transfuse one unit at a time and reassess; avoid trigger transfusion in stable asymptomatic anaemia
Massive transfusion protocol^[1]
Activate when expected blood loss ≥4 units in 1 hour or ≥10 units in 24 hours: PRBC:FFP:platelets 1:1:1; cryoprecipitate when fibrinogen <2 g/L; calcium replacement; ROTEM-guided where available
Intra-operative cell salvage^[1]
Selected high-risk obstetric surgery (placenta accreta spectrum, prior major PPH); reduces allogeneic transfusion; leukocyte-depletion filter for return to maternal circulation
Anti-D prophylaxis^[1]
RhD-negative women: routine antenatal at 28 weeks (1500 IU IM or 500 IU at 28+34); at any sensitising event (CVS, amniocentesis, miscarriage, antepartum haemorrhage, ECV, abdominal trauma); within 72 hours of delivery if baby RhD-positive

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tranexamic acid (perioperative)^[1]	Antifibrinolytic	1 g IV at induction; repeat 1 g IV after 4 h or with major bleeding	—	Reduces transfusion need in major obstetric and gynaecological surgery; WOMAN trial showed mortality reduction in PPH within 3 hours of onset
Iron sucrose or ferric carboxymaltose (preoperative iron)^[1]	Parenteral iron	Iron sucrose 200 mg IV per session × 5–10; ferric carboxymaltose 1000 mg IV single dose (max 2000 mg total)	—	Preoperative anaemia correction reduces transfusion; FCM convenient single-dose; avoid first trimester unless severe anaemia; monitor for hypophosphataemia
Erythropoiesis-stimulating agent^[1]	Recombinant erythropoietin	Epoetin alfa 600 U/kg SC once weekly × 3 doses pre-op + IV iron in selected high-risk surgery	—	Selected refractory or severe pre-operative anaemia where blood transfusion declined or unsafe; combine with iron repletion

Tranexamic acid (perioperative)^[1]

Antifibrinolytic

Adult: 1 g IV at induction; repeat 1 g IV after 4 h or with major bleeding
Paediatric: —

Reduces transfusion need in major obstetric and gynaecological surgery; WOMAN trial showed mortality reduction in PPH within 3 hours of onset

Iron sucrose or ferric carboxymaltose (preoperative iron)^[1]

Parenteral iron

Adult: Iron sucrose 200 mg IV per session × 5–10; ferric carboxymaltose 1000 mg IV single dose (max 2000 mg total)
Paediatric: —

Preoperative anaemia correction reduces transfusion; FCM convenient single-dose; avoid first trimester unless severe anaemia; monitor for hypophosphataemia

Erythropoiesis-stimulating agent^[1]

Recombinant erythropoietin

Adult: Epoetin alfa 600 U/kg SC once weekly × 3 doses pre-op + IV iron in selected high-risk surgery
Paediatric: —

Selected refractory or severe pre-operative anaemia where blood transfusion declined or unsafe; combine with iron repletion

Safety-net

Pre-operative anaemia is correctable in most cases — bring up to date with iron and B12 before scheduled surgery to reduce transfusion need^[1]
If you have RhD-negative blood and become pregnant, never miss anti-D prophylaxis at 28 weeks or after a sensitising event — protects future pregnancies^[1]
After transfusion, watch for fever, rash, breathlessness, chest tightness, or dark urine and report immediately — these can signal a reaction^[1]

Referral criteria

Severe anaemia (Hb <70 g/L) at any gestationJoint obstetric and haematology review^[1]
Refractory or unusual reaction to transfusionHaematology; report to haemovigilance/transfusion medicine^[1]
Anticipated major obstetric bleed (placenta accreta spectrum, prior PPH, severe pre-eclampsia)Tertiary unit with massive transfusion protocol, IR, and cell salvage capability^[1]
Patient declining blood transfusion (e.g., Jehovah's Witness)Senior obstetric and anaesthetic counselling pre-operatively; advance bloodless management plan^[1]

Clinical summary

Indications, blood-product choice, and patient blood management for obstetric and gynaecological haemorrhage and anaemia.

References

1.FOGSI-ICOG Good Clinical Practice Recommendations on Blood Transfusion in Obstetrics and Gynecology (2024); RCOG Green-top 47 Blood Transfusion in Obstetrics (2024)