Blood &Blood Components

in ObstetricsDr. Shashwat Jani.

M. S. ( Obs – Gyn )Diploma in Advance Laparoscopy.

Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.E-mail : drshashwatjani@gmail.com

05/02/2023 Dr Shashwat Jani. +91 9909944160.

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Why ???• Commonest Cause of Maternal Mortality and

Morbidity . . .

Two Main Causes Of MaternalMorbidity And Mortality Are

Chronic Anemia Of Pregnancy. Major Obstetric Haemorrhage.

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Why Mothers Die Due To Hemorrhage …???

Inadequate resources and personnel – for example, home delivery attempts.

Failure to prepare for obstetric hemorrhage –for example, no IV site started on admission.

Delay in recognition of hemorrhage. Delay in treatment of hemorrhage. Treatment failures / Expertise not available Delay in transport

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Obstetrical Hemorrhage

New definition: Blood loss associated with pregnancy or

parturition that meets one or more of the following Criteria:

Triggers emergency pathological response Decreases hct by 10 points Requires blood transfusion Causes maternal or perinatal death

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Obstetric Hemorrhage and Maternal Deaths

Abruptio placenta – 19 percent Uterine rupture – 16 percent Uterine atony – 15 percent Coagulation disorder – 14 percent Placenta previa – 7 percent Placenta accreta – 6 percent Retained placenta – 4 percent Chichaki, et al, 1999

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Massive Blood LossMay be defined as…• Loss of blood at a rate in excess of 150 ml.

per minute.• Loss of 50% of blood volume within 3

hours.• Loss of one blood volume within a 24 hour

period.(7% of lean body weight (5 litres in an adult) RCOG 2015 Green-Top Guidelines

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Immediate Effect Of Massive Blood Loss

Tissue Hypoxia Acidosis Release of Proinflammatory Cytokine Development of Systemic Inflammatory

Response Syndrome (SIRS) DIC Death

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Goal Of Transfusion To provide the most appropriate

blood product for the patient.

Variety of components can be obtained from one unit of blood hence many patients may benefit from one unit of blood.

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AimTo restore or maintain :

1. Blood volume2. O2 carrying capacity3. Hemostasis4. Leucocyte function

(Ref. : Blood banking & transfu Med 2nd edi)

Remember…The Decision For Blood Transfusion Should Always Be A Balance Between

Blood Is Life

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‘ WHAT ‘ For Any Procedure

• W - Whether required• H - How much required• A - Actual component required• T - Time duration of transfusion

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What Are Our Options...???

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Whole Blood…450 ml of blood 63 ml of anticoagulant solution.Hct – 36 - 44%No components have been removed.Store at 1-6 oCShelf life – ( Anticoagulants )

• Citrate-Phophate-Dextrose (CPD) - 21 days• CPDA-1 (adenine) - 35 days• AS-1, AS-3, AS-5 – 42 days

Infuse within 4 hours of issue

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…Whole BloodIndications:

– Acute blood loss > 25% TBV– At present there is no role of whole blood except

in acute emergency and in remote area.

Drawbacks:– After storage for >24 hours, platelets and WBC

are non-functional– Factor V and VIII (labile factors) decrease with

storage– Fluid overload

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• Massive transfusion of stored whole blood can aggravate coagulopathy due to: - Dilutional thrombocytopenia - Coagulation factor depletion - Acidosis - HypothermiaSolution:• 1 unit of fresh blood for every 5 – 10 units of stored

blood• IV 10% calcium gluconate 10 mls with every litre of

transfused citrated blood• Warming blood ???• Use Microaggregate blood filters.

Drawbacks…

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Blood Components

• Red Blood Cells (pack cells)• Fresh Frozen Plasma• Platelets• Cryoprecipitate

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Component Therapy Benefits

Allows optimal survival of each constituents Allows transfusion of only specific blood

component required by pt. Avoids the use of unnecessary component

which could be contraindicated in pt. Several patients can be treated with the

blood from one donor

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Packed Red Cells• Made by spinning whole blood and expressing off the

supernatant• 200 mL red blood cell volume.• Hct ~70%.• Do not provide viable platelets or coagulation factors.• One unit ↑Hb by 2.5 g/dl • Must be ABO & Rh compatible• Stored at 1-6 oC• Shelf-life:

• 21 days (CPD)• 35 days (CPDA-1)• 42 days AS-1

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• Mainly used for increasing hemoglobin and O2 carrying capacity.

• In an extreme situation and when the blood group is unknown, group O RhD-negative red cells should be given (although they may be incompatible for patients with irregular antibodies).

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f

Obstetric Indication

< 8 gm

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FFP• Separated from whole blood within 8 hrs. by

centrifugation • Contains all clotting factors• Volume 200-250 cc• Kept at –18°C• Dose : 15 ml/kg or 4 units in an adult• Infusion rate – 10 min – 1 hr.• ABO compatibility required• Contents no platelet

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Indication of FFP in Obstetrics :

• Abruptio placentae• Septic abortion• HELLP• IUFD• Amniotic fluid embolism• Puerperal sepsis• Massive transfusion• Severe PIH/Eclampsia• Placenta acreta• AFLP

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Guidelines: FFP Use• Usual dosing: 10-15ml/Kg• 15-20% rise in factor levels• Evidence for its use as prophylaxis in non bleeding

patients, is limited• 1 FFP after 3 PCV • Subsequent FFP transfusion should be guided by the

results of clotting tests if they are available in a timely manner, aiming to maintain PT and APTT ratios at less than 1.5 x normal.

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Platelet Concentrate( Random Donor Platelets)

• Differential centrifugation• Volume - 60ml• Store at 20-24 oC with constant & gentle

agitation• Use within 5 days• Bacterial contamination a problem• 1 unit raise the platelet count by 5000 - 10000 / microlitre.• ABO matched platelets preferable• Single donor costly but more effective

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Platelets: Risk of Spontaneous Hemorrhage

Count Site> 40,000 Minimal20-40,000 GI Mucosa5-20 Skin, Mucus Membranes< 5 CNS, Lung

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Prophylactic Platelet TX Guidelines

Platelet Count/μlRecommendation0-5,000 Always5-10,000 If Febrile or Minor Bleeding11-20,000 If coagulopathy / minor

procedure>20,000 If Major Bleed / invasive

procedure>50,000 May or May not give

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Transfused Platelets / Survival• 6 units = 1 single donor unit (SDP);

available as ¼, ½ and full SDP• Dose : Adult 1 unit/8-10 kg• Lifespan: 7-10 Days Native

2-3 Days Transfused• Factors shortening Lifespan:

• Fever, Sepsis• HLA, Platelet Specific Abs• DIC

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Cryoprecipitate• Plasma concentrate, rich in fibrinogen, factor

VIII, vWF, factor XIII & fibronectin• Volume - 15ml/unit• 1 unit contains 100 clotting units of Factor VIII

and 250 mg of fibrinogen• Stored frozen at < - 18oC• Infuse within 6 hrs of thawing• Adult dose is 10 units or 1U/10kg

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Dose• At a standard dose of two 5-unit pools should be

administered early in major obstetric hge. • Subsequent cryoprecipitate transfusion should be

guided by fibrinogen results, aiming to keep levels above 1.5 g/l.

No anti-D prophylaxis is required if a RhD-negative woman receives RhD-positive FFP or cryoprecipitate.

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Indications• Fibrinogen <40 mg/dl• Fibrinogen <100 mg/dl with bleeding or

surgery• DIC in obstetric patient• Abnormal fibrinogen• Factor XIII deficiency• vwD with bleeding or surgery

Dr Shashwat Jani. +91 9909944160.

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D I CDiagnosis

– D dimer– Prolong CT– Prolong PT– Prolong aPTT– Platelet– Fibrinogen – Early diagnosis essential

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Management• Restoration of Blood Volume• Judicious use of Blood Products

– Cryoprecipitate with FFP– Cryoprecipitate is better as replenish

• Fibrinogen• Factor VIII• Factor XIII • Von Willebrand factor (vWF)

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Plasma Derivatives• Factor VIII Concentrate• Factor IX Concentrate• AT-III Concentrate• Factor XIII concentrate• Albumin• IV Immunoglobulin• Rh Immunoglobulin

Recombinant activated factor VII (rFVIIa) is synthesized human factor VII that is available for reconstitution and infusion in patients with massive hemorrhage.Decrease in RBC requirement ,a trend toward improved survival and reductions in critical morbidities.

Blood/ Start infusion Complete infusionblood product

Whole blood/ within 30 min. of within 4 hourred cells removing pack (less in high from ambient temperature)

refrigerator

Platelet immediately within 20 minconcentrates

FFP within 30 min within 20 min

Time Limits for Infusion

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Complications of Blood

Transfusion

• Febrile reactions• Bacterial contamination• Immune reactions• Physical complications

– Circulatory overload– Air embolism– Pulmonary embolism– Thrombophlebitis– ARDS

• Metabolic complications– Hyperkalaemia– Citrate toxicity & hypocalcaemia– Release of vasoactive peptides– Release of plasticizers from PVC-

phthalates• Haemorrhagic reactions

– After massive transfusion of stored blood

– Disseminated intravascular coagulation

• Transmission of disease– Hepatitis, CMV. EBV– AIDS (Factor VIII)– Syphilis– Brucellosis– Toxoplasmosis– Malaria– Trypanosomiasis

• Haemosiderosis– After repeated transfusion in

patients with haematological diseases

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Does Consent Required For Blood Transfusion ?

• The doctor is required to get two separate consents from the patient.

• One for surgery or procedure and another for blood transfusion, if anticipated

• Surgery involves risk and blood transfusion involves additional risk

• Inform all transfusion reactions to a ADR registry

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LEAKSDISCOLOURATIONCLUMPING

EXPIRY DATE

If there is ANY discrepancy – DO NOT transfuse

Pre-administration Procedure

Step 3: Undertake visual inspection

Step 1: Check the blood component has been prescribedStep 2: Undertake baseline observations

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Does hypocalcemia occur with administration of blood?

With 4-5units of transfusion, calcium binds with citrate preservatives.

This is self resolving with metabolism of citrate by liver and kidney.

Hypocalcemia will not impede blood coagulation. Hypocalcemia with hypothermia and acidosis is

dangerous & it will decrease cardiac output, causes bradycardia and dysrhythmia thus calcium gluconate indicated here (WHO).

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Whether blood should warmed prior to transfusion?

• No evidence for slow transfusion• For rapid transfusion of > 50 ml /kg / hr , its

required. ( Ideal is warmer machine ).

“ Blood should never be warmed in a bowl of hot water as this could lead to haemolysis of the red cells which could be life threatening ‐

when transfused. “

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THANK YOU…!!!