Improper transfusion technique linked to Michigan maternal hemorrhage deaths

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal