Component therapy in obstetrics

Component Therapy in Obstetrics

Dr. V. L. DeshmukhM.D.(Obst.&Gyn)

Associate Professor

Dept. of Obstet. & Gynaec.

Govt. Medical College

AURANGABAD

Introduction

• Goal of transfusion therapy is 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.

Indications

Indications for transfusion of blood or blood products are to restore or maintain :

1. Blood volume

2. O2 carrying capacity3. Hemostasis4. Leucocyte function

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

Components

- Whole blood

- PCV

- Platelets

- FFP

- Cryoprecipitate

- Others

. Animal to animal --- Richard Lower ,1665• Animal to human --- Jean Denis , 1667

. Human to human --1818, James Blundell

-- 1900 The elucidation of the ABO blood

group system by Landsteiner

-- 1914 Lewisohn - used citrate

-- 1940 Landsteiner and Wiener, in, describe Rh typing

Whole Blood

• Indication when O2 carrying capacity is low & associated with clinical symptoms of hypovolumia.

• Limited clinical settings• When blood loss is more than 20% of the

total blood volume e.g. Placenta previa, abruptio placenta.

(Reference : National Guidelines for Transfusion Therapy, Nov. 2002)

Whole blood (Contd..)

1. Identification2. Equipment : 19 Gauge needle & transf. Set.3. NO ADDITION OF ANY DRUG OR

SOLUTION.4. Infusion rate – initially slow, 2-3 hrs.5. Administration 5 ml/min for 15 min then

increase the rate.

(Ref. : Menitove JE. Transfusion : Blood and blood components

IN : Manual of Clinical Hematology, 2nd edi, 1995)

Whole Blood

• Outcome : Hb% - 1 g% Hct – 3%

Take Universal Biohazard Precautions

(Ref : High risk obstet. CE Online. Crit Care Nurse 2006, Aug 24(4):54-61)

PCV

• 250-300 ml • Expiry 35 days• CPDA – preservative• Dose• Infusion Same as whole blood• Outcome• Indication : When O2 carrying capacity is

low & no need to increase the plasma volume

PCV

• PCV in anaemic patient should be used to correct symptoms that are a direct result of anaemia only when it is determined that other treatment regimens are not effective.

e.g. pregnancy at termPatient with labour with Hb < 7 gm%Pregnant patient with Hb < 5 gm%

Ref : Menitove JE. Transfusion : Blood and blood components IN : Manual of Clinical Hematology, 2nd edi, 1995.

Platelets• Indication – thrombocytopenia• Decision to transfuse depends on :

- Clinical condition of patient- Number of platelets in patients body- Function of the platelets in patients body- Cause of thrombocytopenia

• Recommended levels :- Normal delivery – 20,000/dl- LSCS operative - > 50,000/dl

PlateletsThrombocytopenia and pregnancy :• Gestational thrombocytopenia• HELLP• Severe PIH/Eclampsia• Drug induced• Infections – bacterial/viral• TTP• ITP• Massive blood transfusion• APA syndrome• Abrptio placentaRef : Scientific foundation of ObGy, 2nd edi

Platelets• Concept of CCI• Corrected count increment • CCI – 10 min – 1 hr > 7,5000/dl

18 to 24 hrs > 4,600/dl• If CCI less at 10 min to 1 hr causes are : rapid

destruction by antiplatelet antibodies• If CCI less at 24 hrs causes are : sepsis, DIC,

fever(Ref : Menitove JE. Transfusion : Blood and blood components

IN : Manual of Clinical Hematology, 2nd edi, 1995)

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

FFPIndications :• Coagulation factor deficiency• Acute DIC• Treatment of TTP• Documented coagulopathy in setting of massive

transfusion• Liver diseaseEfficacy of transfusion is assessed with PT, APTT

or special factor assay(Ref : Menitove JE. Transfusion : Blood and blood components

IN : Manual of Clinical Hematology, 2nd edi, 1995)

FFP

Indication of FFP in Obstetrics :• Abruptio placentae• Septic abortion• HELLP• IUFD• Amniotic fluid embolism• Puerperal sepsis• Massive transfusion• Severe PIH/Eclampsia• Placenta acreta• AFLP

Cryoprecipitate

• Cold insoluble portion of plasma• FFP – thawed at 1-6°C – cryo is obtained• Content : Factor VIII, fibrinogen, XIII, VIII

WF factor• Dose – 10 bags increase the fibrinogen

level by 75 mg/dl, factor VIII – by 30%• Indication – Acute DIC

Components FactorComponent Coagulation factor Volume

PCV -- 250 cc

FFP All coagulation factors + fibrinogen

200 cc

Platelets Platelets + All coagulation factors

50 cc

Cryo VIII C, Von. Will 5-20 cc

Ref : Obstet Gynecol Clin N Am 2007;34:443-58.

• China, 1000 BC The soul was contained in the blood.• Egyptians bathed in blood for their health.• Romans drinking the blood of fallen gladiators to gain strength and

vitality and to cure epilepsy.• The practice of bathing in blood as it

cascaded from a sacrificial bull, was practiced by the Romans.

Blood in History

DIC

• Multyorgan dysfunction caused by microthrombi

• Bldg is caused by consumption of platelet, fibrinogen, factor V,VIII

• Secondary fibrinolysis

DIC

• Whenever exposure of blood to tissue factor takes place, DIC occurs

• Tissue factor is a result of exposure of the endothelial cells to foreign substance e.g. malignancy, placenta, traumatized tissue

• Endotoxins liberated from sepsis act on the endothelial cells

DIC

• ENDOTHELIAL DAMAGE

• Thromboplastin released

• Microthrobi formation

• DIC

• Consumption of all coagulation factors

Test for Hemostatic Function

Test Volume Interpretation

Blood smear

1.2 – 3.8 lac/mm

Platelets

Bleeding time

3-8 min To assess platelet plug formation deranged in throbocyto. Function defect of platelets. Von Will def.

Normal in coagulation factor defect

Prothrombin time

17-16 sec. Extrinsic pathway

Common pathway

aPTT 22-37 sec Intrinsic pathway

Common pathway

Test for Hemostatic FunctionTest Volume Interpretation

TT 10-12 sec. Fibrinogen to fibrin conversion

CT 4-11 min Prolonged only in severe deficiency

Fibrinogen 150-600 ng/dl

Hypofibrinogenemia

FDP -- Fibrinolysis

CRT 1 hr – 40-60% clot retracts

Prolonged in thrombocytopenia & platelet dysfunction

Ref : Obs & Gynae today, ISSN 0971-8133 Vol V(4), 2000)

REMEMBER…REMEMBER…THE DECISION FOR BLOOD TRANSFUSION SHOULD ALWAYS BE A BALANCE BETWEEN

Haemorrhage• Rapid & continuing blood loss is life

threatening.• Ensure tissue oxygenation is maintained at a

level consistent with avoidance of critical ischaemic organ damage or irreversible organ failure.

• Blood grouping & Rh typing• Co-ordinated effort between clinician & blood

bank• Massive haemorrhage protocol outlined in

every institute

Haemorrhage

• Management demands

- Skill

- Speed

- Knowledge

- Prompt action

- Good communication

Haemorrhage• Haem in obs may be due to acute blood

loss • Secondary to placenta previa, rupture

uterus• Or it may be due to DIC• In conditions like HELLP, severe PIH• ABRUPTIO PL -blood loss may be due to

DIC +acute blood loss• All this conditions can lead to massive

haem

Blood Volume

% Supine Sitting

B.P P B.P P

N 100 N N N N

- 500 -5 N N N N or ^

-1000 -10 : 15 N N or ^ N or ^ ^

- 1500 -20 N or v ^ v ^ or v

- 2000 - 30 v ^ or v vv ^ or v

Response Of BP and P to Hypovolemia

Massive Haemorrhage

Definition :

• Ongoing blood loss in adult > 150 ml/min• Replacement of > 50% of blood volume in

3 hrs.• In 24 hrs – 10 units of blood transfusion

required e.g. Atonic PPH, Rupture uterus(Ref : Am Soc Anaes Pract. Guidelines for Obst Anaes – An

Updated Report 2007;106(4):1-21.

Massive Haemorrhage

• Call for senior help early• Inform blood bank• Specific :

- Adequate oxygenation- Patent airway- Restore circulating blood volume- Start component therapy

Component Therapy

• Early RBC transfusion

• Anticipate coagulopathy

• Maintain or restore normothermia

• Evaluate therapeutic response

(Ref : Need for maternal critical care in Obst : A population based analysis. Int J Obstet Anaesth 2003;11(4):260-64)

Massive Haemorrhage

1. Direct contact and briefing 2. Good communication between

anaesthetist, haematologist and surgical colleauges.

3. Management of patient should be tailored according to cause of haemorrhage and disturbed hemostatic system.

4. Metabolic disturbances from gradual loss of large blood will differ from that of a acute massive loss.

Massive Haemorrhage

1. Patent airway2. 100% O23. IV access

4. Laboratory test - Full blood count- PT- APTT- Fibrinogen - KFT- Electrolytes

Massive Haemorrhage

• Send laboratory tests every 4 hourly or after replacement of 1/3rd of blood volume to access the efficacy of treatment.

• If coagulopathy detected expert advice from haematologist for interpretation and optimum correction.

Ref : A multicenter randomized control clinical trial of transfusion requirement in critical care. N Engl J Med 1999;6:409-17.

Massive Haemorrhage

Restore volume :• Perfusion pressure should be maintained • Prolonged hypoperfusion leads to

- Increase capillary permeability- Consumption of coagulation factor

in microvasculature.- Release of inflammatory mediators

• Leading to coagulopathy & secondary end organ injury

Massive Haemorrhage

• Restore volume :The volume Timing Imp. for good outcomeExtent

• Monitoring depend on ;CVPOutputHeart rate

• Increase in B.P. due to inotropes is deceptive

Massive Haemorrhage

• Restore volume : 2 lit. of fluid in adultCrystalloid ColloidCheap Expansion of BV efficiently

Easy to admin. microvascular flow

No adv. Effect Better preserv. Of oncotic pressure

No effect on coagu. Can cause allergic reaction

Short lived in circu. Adverse effect on coagulation & renal function

(Ref : Hippala S. Replacement of massive blood loss. Vox Sang 1998;74:399-407.)

Component Therapy

• Start component therapy• Decision by senior, experience staff• Supply RBCs• Request platelets• Request FFP - When blood loss I > 1.5

times of blood volume 15 mg/kg = 1 lit or 4 units till PT, APTT is < 1.5 times normal

• Request cryo if fibrinogen is < 100 mg/dl

Component Therapy

• Hemostatic defects in large transfusions is due to dilution & consumption

• Massive transfusion leads to dilution of coagulation factors

• Reduction in platelets, and clotting factors • Prolonged of PT & APTT• Sequence –

Deficiency of fibrinogen & coagulation factors, thrombocytopenia

Component Therapy

• In emergency – checking and administration of blood products should be strictly carried out.

• Most transfusion related morbidity is due to incorrect blood transfusion.

• Hemodyanamic, hemostatic and metabolic derangements occur with the clinical condition and speed and effectiveness of resuscitation.

Component Therapy

• Early use of FFP may eliminate the use of cryoprecipitate, but if fibrinogen level < 100 mg/dl – cryoprecipitate is given.

• Minimum dose in adult of cryoprecipitate is 10 packs gives 1.5 – 3.0 gm of fibrinogen.

• Platelets if < 50,000/dl - supply

DIC

Should be kept in mind :- PT- APTT Diagnosis- Dilutional thrombocyto.

Give 4-6 units FFP 5 pints of platelets10 units of cryo

Send blood sample regularly to assess the coagulation status

Ref : Guidelines National blood users group, Nov. 2002

DIC

• Send : Hb, Hct, platelets, PT, APTT, serum fibrinogen.

• Monitoring & coagulation screening should be continued

• If bleeding recurs, the monitoring should be intensified.

Normothermia

• Restore normothermia• Hypothermia is exaberated due to cold

blood infusion and low ambient temp.• Hypothermia leads to increase blood loss,

prolonged PT, APTT, platelet dysfunction, enhance fibrinolysis & increase release of potassium.

• Monitor core temperature because it is important reversible hemostatic factor

Evaluation

• Evaluate the response - Pulse- B.P.- CVP - Output- Hemoglobin- Hct

Note the details of blood component used e.g. timing and volume

Massive Haemorrhage – New invention

• Promising new alternative drug.• Identical in structure & function to

human factor VIIa• Used in uncontrolled bleeding which is

life threatening.

• rFVIIa it augments the intrinsic clotting

pathway by binding with tissue factor &

directly activating factor IX & X

Massive Haemorrhage – new invention

• Used effectively offlable to control PPH• Effective dose is 50-100 g/kg IV every 2

hrly. Until hemostasis is achieved.• Ensure adequate platelet & clotting factors

are present.• Give in early phases of shock, good in

action • Action decreased by hypothermia and

acidosis• No risk of viral transfusion

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

Important Points

1. Errors in transfusion

2. Transfusion transmitted infections

3. Adverse effects associated with transfusion

4. Autologous transfusion

5. Intraoperative cells salvage

REMEMBER…REMEMBER…THE DECISION FOR BLOOD TRANSFUSION SHOULD ALWAYS BE A BALANCE BETWEEN

Conclusion

• Deaths are avoidable if early and effective intervention in initial golden hour is provided

• It has a major impact on eventual outcome