A total blood volume or more transfused during pregnancy or after childbirth: Individual patient data from six international population-based observational studies

Stephen J. McCall* (Corresponding Author), Dacia Henriquez, Hellen McKinnon Edwards, Thomas van den Akker, Kitty W. M. Bloemenkamp, Johanna van der Bom, Marie-Pierre Bonnet, Catherine Deneux-Tharaux, Serena Donati, Ada Gillissen, Jennifer J. Kurinczuk, Zhuoyang Li, Alice Maraschini, Aurélien Seco, Elizabeth Sullivan, Simon Stanworth, Marian Knight

*Corresponding author for this work

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Background This study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.  Methods Combined analysis of individual patient data, prospectively collected in six international population-based studies (France, United Kingdom, Italy, Australia, the Netherlands and Denmark). Massive transfusion in major obstetric haemorrhage was defined as transfusion of eight or more units of red blood cells within 24 hours in a pregnant or postpartum woman. Causes, management and outcomes of women with massive transfusion were compared across countries using descriptive statistics. Findings The incidence of massive transfusion was approximately 21 women per 100,000 maternities for the United Kingdom, Australia and Italy; by contrast Denmark, the Netherlands and France had incidences of 82, 66 and 69 per 100,000 maternities, respectively. There was large variation in obstetric and haematological management across countries. Fibrinogen products were used in 86% of women in Australia, while the Netherlands and Italy reported lower use at 35–37% of women. Tranexamic acid was used in 75% of women in the Netherlands, but in less than half of women in the UK, Australia and Italy. In all countries, women received large quantities of colloid/crystalloid fluids during resuscitation (>3·5 litres). There was large variation in the use of compression sutures, embolisation and hysterectomy across countries. There was no difference in maternal mortality; however, variable proportions of women had cardiac arrests, renal failure and thrombotic events from 0–16%. Interpretation There was considerable variation in the incidence of massive transfusion associated with major obstetric haemorrhage across six high-income countries. There were also large disparities in both transfusion and obstetric management between these countries. There is a requirement for detailed evaluation of evidence underlying current guidance. Furthermore, cross-country comparison may empower countries to reference their clinical care against that of other countries.
Original languageEnglish
Article numbere0244933
Number of pages15
JournalPloS ONE
Issue number1
Publication statusPublished - 22 Jan 2021

Bibliographical note

This formed part of Stephen McCall’s DPhil in Population Health, University of Oxford.

Funding: SM was funded by the Medical Research Council (UK) and the Nuffield Department of Population Health, University of Oxford. EPIMOMS was funded by a grant from the French National Research Agency (ANR) and the Ile-de-France Regional Health Agency. The Italian study was funded by the Italian Ministry of Health. The AMOSS study “Life-threatening massive obstetric haemorrhage requiring rapid, high-volume blood transfusion” was funded by the Australian Red Cross Blood Service and the Royal Hospital for Women Foundation. The TeMpOH-1 study in the Netherlands was funded by a grant from Sanquin Research, grant No. PPOC-11-032.


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