Association between fluid management and dilutional coagulopathy in severe postpartum haemorrhage: a nationwide retrospective cohort study

Abstract

Background: The view that 2 l of crystalloid and 1.5 l of colloid can be infused while awaiting compatible blood for patients with major postpartum haemorrhage is based on expert opinion documents. We describe real-world changes in levels of coagulation parameters after the administration of different volumes of clear fluids to women suffering from major postpartum haemorrhage.

Methods: We performed a nationwide retrospective cohort study in the Netherlands among 1038 women experiencing severe postpartum haemorrhage who had received at least four units of red cells or fresh frozen plasma or platelets in addition to red cells. The volume of clear fluids administered before the time of blood sampling was classified into three fluid administration strategies, based on the RCOG guideline: < 2 L, 2-3.5 L and > 3.5 L. Outcomes included haemoglobin, haematocrit, platelet count, fibrinogen, aPTT and PT levels.

Results: Haemoglobin, haematocrit, platelet count, fibrinogen and aPTT were associated with volumes of clear fluids, which was most pronounced early during the course of postpartum haemorrhage. During the earliest phases of postpartum haemorrhage median haemoglobin level was 10.1 g/dl (IQR 8.5-11.6) among the women who received < 2 L clear fluids and 8.1 g/dl (IQR 7.1-8.4) among women who received > 3.5 L of clear fluids; similarly median platelet counts were 181 × 10⁹/litre (IQR 131-239) and 89 × 10⁹/litre (IQR 84-135), aPTT 29 s (IQR 27-33) and 38 s (IQR 35-55) and fibrinogen 3.9 g/L (IQR 2.5-5.2) and 1.6 g/L (IQR 1.3-2.1).

Conclusions: In this large cohort of women with severe postpartum haemorrhage, administration of larger volumes of clear fluids was associated with more severe deterioration of coagulation parameters corresponding to dilution. Our findings provide thus far the best available evidence to support expert opinion-based guidelines recommending restrictive fluid resuscitation in women experiencing postpartum haemorrhage.

Trial registration: Netherlands Trial Register ( NTR4079 ), registration date July 17, 2013.

Keywords: Coagulation parameters; Dilutional coagulopathy; Fluid management; Postpartum haemorrhage.

Fig. 1

Inclusion flowchart for ‘fluid management and dilutional coagulopathy in severe postpartum haemorrhage: a nationwide retrospective cohort study’

Fig. 2

Volume of clear fluids and blood products administered per blood loss category. For example: in the blood loss category 0.0 to 1.0 L 245 women had one or more laboratory parameter tested, and at the time of blood sampling for the laboratory parameters these women had received 674 ml clear fluids, 50 ml blood products, yielding a total volume administered of 723 mL

Fig. 3

Coagulation parameters according to clear fluid administration (0-2 L, 2 L–3.5 L, > 3.5 L) and increasing volume of blood loss (0–1.0, 1.0–1.5, 1.5–2.0 L). Laboratory parameters are presented in box plots. Circles are outliers. The box represents the 25th and 75th percentiles and the whiskers are the upper and lower adjacent values. *Statistics: (1) Patient count; (2) Percentage of women who received blood products; (3) Percentage of women who experienced shock surrounding blood sampling; (4) mean bleeding rate in ml/min surrounding blood sampling