An observational study enrolling 112 patients was conducted from August 2011 to October 2012. It is a tertiary care hospital and an obstetric center with more than 15,000 deliveries a year. The data was obtained from medical record sheet of the patients. The peri-partum women (with pregnancies more than 28 weeks to 6 weeks post-partum) who required more than 1.5 liters of blood or blood products in 24 hours after admission were recruited in the study. Some of these women presented with hypotension i.e. decrease in blood pressure by 20%, tachycardia of more than 110 beats per minute and in shock or with the clinical or the biochemical evidence of coagulopathy. The patients with severe chronic anaemia, not presenting in labour or with isolated thrombocytopenia at the time of admission were excluded from the study population. In this study, the blood product volume transfused was taken as the criteria and not the units, as some patients would have required only multiple units of fresh frozen plasma (FFP) and not red cell concentrate (RCC) or platelets. One unit of whole blood was taken as 350ml, one unit of RCC as 250 ml, one unit of FFP as 150ml and platelet concentrate as 75ml. The decision for transfusion was based upon the clinical assessment as well as laboratory investigations. The patients’ demographical profile, antenatal care provided and associated medical or obstetrical complications which might have had developed at or after admission and acute cause called for transfusion were evaluated. The investigations done for the patient, blood products required for management, mode of termination of pregnancy as well as the maternal and perinatal outcome were taken into account.

Statistical analysis of the data was performed using chi-squared test. A p-value of <0.05 was considered as statistically significant.

During these 15 months, there were 112 patients out of 2537 women with obstetrical complications who required ≥1.5 liters of transfusion and fulfilled the inclusion criteria and thus constituted the study population. The demographic and the obstetrical data of the patients are shown in [Table/Fig-1]. In this study, women mostly presented in ante partum period and were multigravidas with period of gestation more than 35 weeks. The mean age of the women included was 26.4 years. Being a tertiary care and a referral center, the unit encounters more of unbooked cases (72.3%, n=81) with obstetrical complications like ante partum haemorrhage (APH), atonic or traumatic postpartum haemorrhage (PPH), pregnancy induced hypertension (PIH), rupture uterus, previous lower segment caesarean section (LSCS), obstructed labour, delivery by untrained personnel etc which require emergency care and transfusion therapy. At admission, 33 women (29.5%) presented to the emergency in a state of shock, 67.8% (n=76) peripartum women had severe anaemia (Haemoglobin < 7 gm/dl), 55.3% (n=62) had coagulopathy and 54 presented with thrombocytopenia (platelet count below one lac)

The mode of delivery is shown in [Table/Fig-1]. Amongst the 95 antepartum women, 34(35.7%) had vaginal deliveries, 36(37.8%) caesarean section and 25 (26.3%) underwent obstetrical hysterectomy. Obstetrical hysterectomy was done for six patients after vaginal delivery, 14 after caesarean section and five women had emergency laparotomy with hysterectomy for rupture uterus at the time of presentation. Emergency laparotomy with repair of the uterus was done for three patients. In the postpartum population, eight had undergone obstetrical hysterectomy for postpartum Haemorrhage.

All the patients received blood which was screened, cross-matched and released from the hospital blood-bank. As depicted in [Table/Fig-2], the most common indication for transfusion was postpartum haemorrhage (25%) followed by ante-partum haemorrhage (18.8%). Blood transfusion was given in the form of whole blood (WB) and red cell concentrate (RCC), fresh frozen plasma (FFP) and platelet concentrate. The mean blood transfusion given to these patients in 24 hours was 4.2 units and mean volume replacement in 24 hours was 2.25 litres.

The co-morbidities in the women receiving multiple transfusions are given in [Table/Fig-3]. Maternal mortality was higher in women who underwent obstetrical hysterectomy although it was not statistically significant (p=0.08). Women experienced overlapping co-morbidities varying from wound infection; lower respiratory tract infection, septicaemia, pressure sores due to prolonged immobility to acute renal failure.

The maximum duration of hospital stay of the mother was 65 days, the mean stay being 10.15 days. Close monitoring in intensive care units (ICU) was done for 44 patients with a mean stay of 2.6 days and there were 15.2% (n=17) maternal deaths. Most of the women who expired (13.4%) or presented in shock (27.7%) had severe anaemia (haemoglobin less than 7 gm/dl). None of the patients had multiple gestations. Intra-uterine death at the time of admission was present in 40 patients and 72 had live births. Out of the 72 live-born, 21 babies required transfer to neonatal intensive care units (NICU) soon after delivery, of which six expired. The parity of the women was not significantly associated with maternal mortality (p=0.54) or perinatal outcome (p=0.15). Though this study had greater number of unbooked cases, but it was not significantly associated with increased perinatal (p=0.38) or maternal (p=0.77) mortality. Thus rest of 95 patients (84.8%) were near miss women in this study group, who were managed and saved from the life threatening complications.

A near miss case has been defined as “a woman who nearly died but survived a complication that occurred during pregnancy, child birth or within 42 days of termination of pregnancy” [9]. The present study evaluates the maternal and perinatal outcome in near miss cases requiring multiple transfusions. It is highlighted that if timely adequate management with blood transfusion is done, a life of a woman can be saved. Here, it is also emphasized that there is non-awareness and non-availability of adequate antenatal care at rural level. By the time the patient presents at tertiary care level their condition is critical as in present study 30% cases presented in shock.

In this study, the rate of multiple transfusions in 15 months in our institute was 0.62%, which is in accordance with the incidences reported previously, 0.3–1% [10–12]. The patients requiring transfusion of more than or equal to 1.5 litters in 24 hours in antepartum, intrapartum or postpartum period were included in our study, whereas Butwick et al., evaluated the estimated blood loss in the patients receiving multiple transfusions [13]. A retrospective analysis of transfusion management for obstetric haemorrhage in a Japanese obstetric centre considered haemoglobin concentration <7 g/dL a criteria for blood product transfusion [14]. The visual estimation of blood loss can vary subjectively and it is known to underestimate the actual loss by 30-50% [15]. In the present study, one-third of the patients presented in compromised state, so blood loss criteria were not considered.

The mean age of the patients receiving multiple transfusions was 26.4 years where as in studies by other authors showed that age more than 30 years had an increased risk of obstetrical haemorrhage [8,13,14]. They also found that patients with prime parity were more prone, which is different from the present study. Multiparity in present study was found in 73.7%, which could be due to early marriage, early conception as well as repeated pregnancy without adequate inter pregnancy interval in our country.

As reported by Yadav K et al., this study also had unbooked and unsupervised pregnancies (72.3%) [16]. It also highlights the fact that concept of routine and regular antenatal checkups has still not available to every pregnant women. The most common presentation of patients in the present study was pregnancy induced hypertension and its complications which are consistent with the study by Butwick et al., [13]. The aetiological factors associated with multiple transfusions are postpartum haemorrhage and antepartum haemorrhage which are in accordance with results from the studies assessing the risk factors associated with postpartum haemorrhage [17–20].

Caesarean section and exploratory laparotomy was done in 51.8% patients, whereas 63% and 67% delivered by caesarean section in the studies by Butwick et al and Matsunaga S et al., respectively [13,14]. The most common indication for multiple transfusions in this study was postpartum Haemorrhage which is similar to the study by Matsunaga S et al., [14]. Al-Zirqi et al., and Butwick et al., could not identify the indication for transfusion in one-third of cases [8,13].

The mean volume replacement given to these patients in 24 hours was 2.25 litres and the transfusion was done on the clinical assessment of blood loss and patients’ condition, as in obstetrical emergencies one cannot wait for blood investigation report, although laboratory investigations were sent for these patients [21]. In present study, 76.8% of the patients had haemoglobin less than 7 gm%. Butwick et al., had 23% ICU admissions and no maternal mortality whereas our study reported 39.3% of ICU admissions and 15.2% maternal mortality [13]. Al-Zirqi et al., in their study group had 245 ICU admissions; hysterectomy was done in six patients and two of them developed acute renal failure, whereas 33 patients of our study group had obstetrical hysterectomy and six developed acute renal failure [8].

Neonatal ICU (NICU) admissions in this study was in 21 babies and IUD was as high as 40 which is different from the study by Butwick et al., where 25 babies required NICU care [13]. Adequate antenatal care for every patient is important. Primary health care centres needs to be strengthened with proper and early identification of high risk patients. These women should be timely referred to higher centre which have appropriate facilities.

The limitation of this study is that it is an observational study with a small sample size as well as the obstetricians involved in managing such high risk patients had varying threshold for transfusion of blood and its components.

The physiological changes occurring during pregnancy makes obstetrics a very high risk field of medicine, which alerts the obstetricians that even normal low risk pregnancy, can become high risk at any time and vigilant supervision is required. Prompt availability of blood and components in adequate quantity combined with management by a critical care team can help to avert mortality in considerable number of cases. Long term consequences of multiple transfusions are not of serious concern in managing these life threatening complications. Thus antenatal care, clean safe delivery, essential obstetric care and family planning can give us safe motherhood.