An observational study of the fresh frozen plasma: red blood cell ratio in postpartum hemorrhage

Anesth Analg. 2013 Jan;116(1):155-61. doi: 10.1213/ANE.0b013e31826f084d. Epub 2012 Dec 7.


Background: Postpartum hemorrhage is the leading cause of maternal death worldwide. Recent data from trauma patients and patients with hemorrhagic shock have suggested that an increased fresh frozen plasma:red blood cell (FFP:RBC) ratio may be of benefit in massive bleeding. We addressed this issue in cases of severe postpartum hemorrhage.

Methods: We reviewed data from all patients diagnosed with severe postpartum hemorrhage during a 4-year period (2006-2009). Patients who were treated with sulprostone and required transfusion within 6 hours of delivery were included in the study and were divided into 2 groups according to their response to sulprostone: bleeding controlled with sulprostone alone (sulprostone group) and bleeding requiring an additional advanced interventional procedure including arterial angiographic embolization and/or surgical procedures (arterial ligation, B-Lynch suture, or hysterectomy; intervention group). The requirement or no requirement for advanced procedures constituted the primary end point of the study. Propensity scoring was used to assess the effect of a high FFP:RBC ratio on bleeding control.

Results: Among 12,226 deliveries during the study period, 142 (1.1%) were complicated by severe postpartum hemorrhage. Bleeding was controlled with sulprostone alone in 90 patients (63%). Advanced interventional procedures were required for 52 patients (37%). Forty-one patients were transfused with both RBCs and FFP. The FFP:RBC ratio increased over the study period (P < 0.001), from 1:1.8 at the start to 1:1.1 at the end of the study period. After propensity score modeling (inverse probability of treatment weighting), a high FFP:RBC ratio was associated with lower odds for advanced interventional procedures (odds ratio [95% confidence interval], 1.25 [1.07-1.47]; P = 0.008). There were no deaths, severe organ dysfunction, or other complications as a consequence of severe postpartum hemorrhage.

Conclusions: In this retrospective study, a higher FFP:RBC ratio was associated with a lower requirement for advanced interventional procedures in the setting of postpartum hemorrhage. The benefits of transfusion using a higher FFP:RBC ratio should be confirmed by randomized-controlled trials.

MeSH terms

  • Adult
  • Anesthesia, Obstetrical
  • Angiography
  • Birth Weight
  • Cesarean Section
  • Dinoprostone / analogs & derivatives
  • Dinoprostone / therapeutic use
  • Embolization, Therapeutic
  • Erythrocyte Count
  • Erythrocytes / physiology*
  • Female
  • Humans
  • Infant, Newborn
  • Menstruation-Inducing Agents / therapeutic use
  • Odds Ratio
  • Plasma*
  • Postpartum Hemorrhage / blood*
  • Postpartum Hemorrhage / surgery
  • Postpartum Hemorrhage / therapy*
  • Pregnancy
  • Propensity Score
  • Risk Factors


  • Menstruation-Inducing Agents
  • sulprostone
  • Dinoprostone