Maternal mortality is recognized as an important global health problem with obstetric hemorrhage being the leading cause in developing countries [1]. Blood transfusion is identified as one of the essential components of comprehensive emergency obstetric care which has drastically reduced maternal mortality [2]. As per WHO estimates, over a thousand of all maternal deaths are directly due to obstetric hemorrhage.

It accounts for 24% of or an estimated 127,000 maternal deaths annually [3]. The reported percentage of massive and life-threatening obstetric hemorrhage near around 3%–5% and 0.1% of deliveries, respectively. It has been reported that 0.3%–1% required blood component transfusion [4,5].

Several factors should be considered while assessing the risk of massive hemorrhage in the pregnant patient. The challenges faced are difficulty in assessing blood loss, physiological changes in pregnancy, and underlying obstetric condition. Increases in red cell mass and a disproportionately greater increase in plasma volume help the patient to tolerate severe blood loss and remain hemodynamically stable. The physiology of hemostasis in pregnancy is unique.

The coagulation system is enhanced, and the fibrinolytic system is inhibited in the late stages of pregnancy. Thus, a hypercoagulable state prevails in pregnancy. Hence, any massive hemorrhage in pregnancy can induce consumptive loss of coagulation factors, which can cause further hemorrhage leading to a vicious cycle resulting in disseminated intravascular coagulation (DIC) [6].

The detection of hypovolemia and thus the decision to transfuse early in obstetric hemorrhage is delayed by the inability to evaluate the accurate blood loss and the high-level tolerance of pregnant female to massive hemorrhage [7].

Understanding the uniqueness of obstetric hemorrhage is required for appropriate blood component support, which can effectively improve its pathophysiological condition, reduce the risk of DIC, and avoid the aggravation of hemorrhagic shock [8]. Thus, a complete evaluation of not only blood loss but also the underlying obstetric risk factor, patient’s medical condition, age, vital signs, and blood; biochemical parameters are required to determine whether a transfusion is necessary [9].

Table-2: Gravida score of patients.

In table 2, Multigravida is at more risk (60%) for requiring transfusion, and (11.5%) grand Multigravida are at least risk for requiring transfusion.

Table-3: Booking status of patients.

In table 3, (76.8%) patients with irregular ANC visits are more prone to obstetric complications, because of lack of awareness of proper ANC care, and 5.2% least were not booked.

Table-4: Haemoglobin level of patients.

In table 4, more than half (55.7%) of the cases had anemia in the moderate range and 3.1% were severe.

Table-5: Indication of blood transfusion.

In table 5, PPH is the commonest indication requiring blood transfusion followed by APH and PIH

Table-6: Mode of delivery.

Platelets or fresh frozen plasma (FFP) is to be given as required. FFP is used in the correction of microvascular bleeding, multiple coagulation factor deficiencies, massive transfusion with coagulation abnormalities and platelet concentrates when the platelet counts fall below 20,000/ mm3. One unit of platelets increases the platelet count by 5000–7000/l. There is no role of prophylactic platelet transfusion; one needs to investigate and treat the cause. If the coagulation profile is not available, four units of FFP are given for four units of blood transfused within 24 hours [13,14].

The transfusion is a lifesaving procedure, but approximately 1% of all transfusions cause an immediate and delayed adverse reaction, despite the measures taken to reduce risks. Transmitted infections, hemolytic reactions, transfusion-associated acute lung injury (TRALI), hypocalcemia, hypomagnesemia, hyperkalemia, problems of massive transfusion such as hypothermia, metabolic acidosis, and abnormalities of coagulation should deter all of us from indiscriminate use of blood components [15,16].

Obstetric hemorrhage is the commonest cause of maternal death, causing one-fourth of maternal deaths yearly. (17) Massive and life-threatening obstetric hemorrhage occurs in 3–5% and 0.1% of deliveries, respectively, and blood product transfusion is required in 0.3–1% [18,19].

During pregnancy, the changes in the coagulation and the fibrinolytic system in form of enhancement and inhibition respectively occur, large-volume blood loss causes consumptive loss of coagulation factors, which causes more bleeding and starts a vicious cycle ending up with DIC [18,19]. These obstetric hemorrhages could be massive and may require replacement of one entire blood volume within 24 h or replacement of 50% of total blood volume (TBV) within 3 h, i.e., massive blood transfusion (MBT).

The setting of massive transfusion protocols (MTPs) describes the process of management of blood transfusion requirements in major bleeding episodes, assisting the interactions of the treating clinicians and the blood bank and ensuring judicious use of blood and blood components [21,22].

Increased capacity to tolerate bleeding due to physiological changes and often inaccurate estimation of blood loss in obstetrics may not show the change in their vital signs, resulting in a delay in the detection and treatment [23].

Dr. Fayaz Khan H: Study design, Literature survey, data analysis, paper writing.

Dr. Swati: Study design, paper writing, Literature survey.

Dr. Manju M: Paper writing, statistical part.