A major drawback of treatment for massive hemorrhage with crystalloid solutions and packed red blood cells is depletion of platelets and clotting factors. his can lead to a dilutional coagulopathy that is clinically indistinguishable from DIe (Hossain, 2013). Thrombocytopenia is the most frequent coagulation defect found with blood loss and multiple transfusions (Counts, 19 9). In addition, packed red cells have only very small amounts of soluble clotting factors, and stored whole blood is deicient in platelets and in factors V, VIII, and XI. As discussed, massive replacement with red cells only and without factor replacement can also cause hypoibrinogenemia and prolongation of the PT and PTT. Because many causes of obstetrical hemorrhage also cause consumptive coagulopathy, the distinction between dilutional and consumptive coagulopathy can be confusing. Fortunately, treatment for both is similar.
A blood type and antibody screen should be performed for any woman at significant risk for hemorrhage. Screening involves mixing maternal serum with standard reagent red cells that carry antigens to which most of the common clinically signiicant antibodies react. Crossmatching involves the use of actual donor erythrocytes rather than the standardized red cells. This process is eicient, and only 0.03 to 0.07 percent of patients identiied as having no antibodies are subsequently found to have antibodies (Boral, 1979). Importanty, administration of screened blood rarey results in adverse clinical sequelae.
One unit of packed erythrocytes is derived from one unit of whole blood to have a hematocrit of 55 to 80 volume percent. One unit will increase the hematocrit by 3 to 4 volume percent.
With surgical delivery or with lacerations, platelet transfusions are considered with ongoing obstetrical hemorrhage when the platelet count falls below 50,000/�L (Kenny, 2015). In the nonsurgical patient, bleeding is rarely encountered if the platelet count is 10,000/�L or higher (Murphy, 2010). The preferable source of platelets is one "bag" obtained by single-donor apheresis. This contains the equivalent of six units from six individual donors. Depending on maternal size, each single-donor apheresis six-unit bag raises the platelet count by approximately 20,000/�L (Schlicter, 2010). If these bags are not available, then individual-donor platelet units are used, and six to eight such units are generally transfused one at a time.
Importantly, the donor plasma in platelet units must be compatible with recipient erythrocytes. Further, because some red blood cells are invariably transfused along with the platelets, only units from D-negative donors should be given to D-negative recipients. If it is necessary to give these, however, adverse sequelae are unlikely (Lin, 2002).
This component is prepared by separating plasma from whole blood and then freezing it. Approximately 30 minutes are required for frozen plasma to thaw. It is a source of all stable and labile clotting factors, including fibrinogen. Thus, it is often used for treatment of women with consumptive or dilutional coagulopathy. Plasma is not appropriate or use as a volume expander in the absence of speciic clotting actor deiciencies. It should be considered in a bleeding woman with a fibrinogen level < 150 mg/dL or with an abnormal PT or PTT.
An alternative to frozen plasma is liquid plasma (LQP). This never-frozen plasma is stored at 1 to 6°C for up to 26 days, and in vitro, it appears to be superior to thawed plasma (Matijevic, 2013),.