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.