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Management of Massive Obstetric Haemorrhage for the workshop on transfusion medicine

Management of Massive Obstetric Haemorrhage

Dr.Sudesh HapughawatteBase HospitalKarawanella.Massive Obstetric HaemorrhageMassive obstetric haemorrhage is variably defined as blood loss from the uterus or genital tract >1500ml,a decrease in haemaglobin of > 4 g/dlacute transfusion of > 4 units blood.Any blood loss seriously compromising life of patient

Massive Hemorrhage in Pregnancy, Oxford Journals Medicine BJA: CEACCP Volume 5,Issue 6 Pp.195-198.Goals of managementRestore circulating volumeContact key personnelArrest bleedingRequest laboratory investigationsRequest suitable red cellsRequest plateletsRequest FFPRequest CryoprecipitateSuspect DICManagement of massive blood loss: A template guideline British Journal of Anaesthesia, 2000;85: 48791

RESUSCITATIONHigh inspired oxygenLeft lateral tilt if antepartum Adequate venous access (2), central line with Rapid infuser kit . Eg. Level 1 Rapid Infuser (can achieve > 500ml/min warmed fluid flow) Pressure bags Crystalloid or colloid until blood available Replace blood; 1:1 if using colloid; 3:1 for crystalloid Vasopressors to maintain BP until circulating blood volume restoredTransfuse blood ideally through fluid warming device. Give group specific blood if cross-matched blood not yet available.O-negative blood if available and life threatening bleedTransfer to theatre

5Restore circulating volume

Insert widebore peripheral cannulae 14G or largerGive adequate volumes of warmed crystalloid, colloid, blood and blood productsMonitor central venous pressureBlood loss is often underestimatedAim to maintain normal blood pressure and urine output>30ml h1Keep patient warm

Replacement Regimen1:1:1:1 RedCell:FFP:Platelet:FibrinogenRequest suitable red cells

Uncross matched group ORh negative.In extreme emergency.No more than 2 unitsRh positive is acceptable if patient is male or post menopausal femaleUncross matched ABO groupspecific when blood group known - Laboratory will complete crossmatch after issueFully crossmatched blood If irregular antibodies presentWhen time permits Further crossmatch not required after replacement of 1 blood volume (810 units)

Request Laboratory InvestigationsFBC, PT, APTT, fibrinogen; bloodbank sample, biochemical profile, blood gases or pulse oximetry Take samples at earliest opportunity as results may be affected by colloid infusionEnsure correct sample identity -Misidentification is commonest transfusion riskRepeat FBC, PT, APTT, fibrinogen every 4h or after 1/3 blood volume replacement - May need to give components before results availableRepeat after blood component infusionRequest platelets

Allow for delivery time from blood centreAnticipate platelet count 100109litre1for multiple/CNS trauma or if platelet function abnormal>75109 litre1 if invasive procedures are being undertaken>50109litre1for other situations Platelets transfusion are given in packs of 5 6 units. 11Request FFP

15 mlkg1body weight=1 litre or 4 units for an adultAllow for 30 min thawing timeAim for PT and APTT 1.5 control mean correlates with increased surgical bleeding

Request cryoprecipitate10-20 Single Donor UnitsReplaces fibrinogen and factor VIIIAim for fibrinogen >1.0glitre1Allow for delivery time plus 30 min thawing timeFibrinogen