⚡ Massive Transfusion Activation
1 RECOGNIZE
- Ongoing major obstetric haemorrhage with shock or a predicted rapid substantial transfusion requirement; activate before laboratory confirmation when clinically necessary.
2 CALL FOR HELP
- Activate the named hospital major-haemorrhage protocol and identify one clinician to communicate with the blood bank.
- Senior obstetrician/anaesthetist leads haemorrhage control and resuscitation; request haematology and ICU support early.
3 IMMEDIATE ACTION
- Give emergency red cells when indicated while crossmatched components are arranged. Request balanced component packs under the blood-bank protocol; an adult therapeutic platelet dose is not equivalent to one single-donor component in a literal “1:1:1” count.
- Continue source control, TXA for eligible PPH, active warming and rapid access. Monitor delivered products and total fluids; avoid excessive crystalloid dilution.
- Measure ionised calcium, potassium, blood gas and temperature repeatedly during rapid transfusion. Replace confirmed/suspected clinically important hypocalcaemia using an explicit calcium prescription and reassess, rather than an undefined “calcium after four units”.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Tranexamic acid — PPHWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checked
Dose1 g IV over 10 min; repeat 1 g if bleeding continues after 30 min OR restarts within 24 h
RouteIV only
FrequencyOne initial dose; at most one additional 1 g dose under those criteria
DurationAcute PPH treatment, maximum 2 doses in this regimen
Preparation100 mg/mL: 1 g = 10 mL. Give no faster than 1 mL/min, or dilute in compatible sodium chloride 0.9% and infuse over 10 min. Clearly label IV ONLY; never intrathecal
Max dose2 g total. The 24 h repeat rule does NOT permit a first dose after the 3 h window
- Indication: PPH of any cause; first dose as soon as possible and WITHIN 3 h of birth
- Renal / hepatic: Renal clearance: assess renal function and seek dose advice with impairment; do not repeatedly dose without review
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
Contraindications: Clear contraindication to antifibrinolysis, such as a known thromboembolic event during pregnancy; renal dysfunction needs dose review
Calcium gluconate 10% — hypocalcaemiaMSFchecked
Dose1 g (10 mL of 10% solution) slowly
RouteIV
FrequencyInitial dose followed by ionised-calcium/ECG reassessment; titrate further replacement to the monitored result
DurationDuring the acute deficit and ongoing citrate exposure; stop/reduce when ionised calcium normalises
Preparation10% = 100 mg/mL; 10 mL contains 1 g calcium gluconate, NOT 1 g elemental calcium. Give over at least 5 min through a patent IV line; do not mix with other drugs
Max doseNo fixed every-four-units schedule: reassess calcium and prescribe further doses explicitly
- Indication: Clinically important hypocalcaemia during major transfusion, guided by ionised calcium and physiology
Monitoring
- Continuous ECG/heart rate; respiratory status, reflexes and injection site; serum calcium/magnesium where available
Contraindications: Extravasation can cause tissue injury; take special care with digoxin · Do not confuse calcium gluconate with calcium chloride
4 INVESTIGATIONS (never delaying treatment)
- Serial CBC/platelets, PT/APTT, fibrinogen, blood gas/lactate, ionised calcium, potassium and temperature; viscoelastic testing if locally available.
- Use a rapid repeat/result-feedback loop after component replacement; do not wait for the Hb to fall before treating active haemorrhagic shock.
5 DEFINITIVE MANAGEMENT
- Control the bleeding surgically/obstetrically while blood products restore perfusion and haemostasis.
- In ongoing PPH, aim fibrinogen ≥2 g/L with cryoprecipitate/fibrinogen replacement as appropriate; platelets are generally supported to >50×10⁹/L during major bleeding. Guide FFP by coagulation and the major-haemorrhage protocol.
- Reassess the need for each component as results become available; monitor for fluid overload, hypothermia, acidosis, citrate-related hypocalcaemia and transfusion reactions.
6 ESCALATION
- Persistent bleeding, acidosis/coagulopathy, hypoperfusion or escalating product need requires immediate senior reassessment of source control and ICU support.
7 POST-EVENT CARE
- Stop the major-haemorrhage protocol explicitly when haemostasis is achieved; reconcile products, samples and ongoing monitoring.
- Assess delayed transfusion complications, anaemia/iron deficit, organ recovery and VTE risk; document and debrief.
Admission & discharge after the acute event
Care setting: Emergency admission; major bleeding may need theatre/critical care
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit and treat ongoing heavy bleeding, abnormal haemodynamics, suspected retained tissue/infection or coagulopathy. Transfer to theatre/critical care according to bleeding and organ-support requirements.
When clinic, day care or home care may be suitable
- Active PPH, shock or suspected secondary PPH with systemic illness is not suitable for routine outpatient management.
Before going home
- The bleeding source is controlled; uterine/perineal/wound assessment is satisfactory and there is no recurrent concerning loss.
- Haemodynamics, consciousness, urine output, oral intake, mobility and pain control support home care. Review anaemia symptoms, Hb trend and any coagulopathy/organ injury; there is no single Hb value that alone certifies safe discharge.
Discharge medicines and treatment changes
- Prescribe iron replacement when iron deficiency/anaemia is present, using a documented formulation, dose and response plan; assess whether IV treatment or transfusion is needed before discharge.
- Uterotonics and TXA used for the acute event are not automatically continued at home. Reassess VTE prophylaxis after bleeding risk has fallen.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Only for diagnosed postpartum iron-deficiency anaemia after bleeding is controlled.
Oral iron and folic acid — postpartum anaemia treatmentWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checked
Dose120 mg ELEMENTAL iron plus 400 micrograms folic acid per day
RouteOral
FrequencyDaily; tailor administration for tolerance without accidentally changing the prescribed total
DurationWHO postpartum anaemia treatment: until Hb normalises. Then document any continuing preventive/repletion course and review; the preventive 6–12-week recommendation is a different indication.
PreparationUse the product’s ELEMENTAL iron content, not salt weight: two tablets each containing 60 mg elemental iron provide 120 mg. Check the combined-tablet folate separately. Separate iron from calcium by several hours and levothyroxine by 4–5 hours.
Max dose120 mg/day elemental iron in this WHO treatment schedule; do not add duplicate antenatal/OTC iron or overlap oral and IV courses without an explicit plan.
- Indication: Diagnosed postpartum iron-deficiency anaemia after haemorrhage is controlled and outpatient oral treatment is suitable
- The WHO 2025 supportive-care recommendation supplies the postpartum dose/endpoint. Preparation and response monitoring reuse the checked oral-iron reference; breastfeeding is compatible with indicated maternal supplementation.
Monitoring
- Arrange Hb response review after 2–4 weeks, tolerance and adherence; investigate non-response or ongoing bleeding and reassess the replacement route.
- Review the cause of anaemia and any coexisting B12/folate deficiency or haemoglobinopathy.
Contraindications: Iron overload or anaemia without iron deficiency; oral iron alone is inadequate for unstable bleeding or cardiovascular compromise.
Tests, pending results and their reviewer
- Record quantified loss, procedures, transfusion and latest relevant CBC/coagulation/renal results; assign a reviewer/date for outstanding investigations.
Home care and counselling
- Explain the cause and treatment, expected lochia, worsening-bleeding warnings, fatigue/feeding support and the future-birth haemorrhage plan. Offer a debrief and emotional support.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before leaving | Book anaemia/Hb response review and communicate any organ-injury or transfusion follow-up to the responsible team. |
Early postnatal contacts and 6-week review | Review bleeding, recovery, mental health and the future-pregnancy plan; review sooner for symptoms or major anaemia. |
Return urgently
- Sudden/heavy or increasing bleeding, fainting, breathlessness, fever, offensive discharge or worsening abdominal pain require immediate assessment.
Sources
WHO / FIGO / ICM · Consolidated edition (supersedes fragmented prior guidance incl. 2012 PPH recs; incorporates 2017 TXA recs, 2018 uterotonics, 2023 blood-loss assessment/treatment bundle)summary checkedMSFcheckedMSFcheckedWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checkedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedWHOsummary checkedWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checkedRCOG · Current public recovery informationcheckedNICE · CG50, recommendationschecked