BLOOD & BLOOD COMPONENTS IN OBSTETRICS BY DR SHASHWAT JANI

1. Dr. 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

2. 2/27/2017
Dr Shashwat Jani.
+91 9909944160.
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3. Why ???
• Commonest Cause of Maternal Mortality and
Morbidity . . .
2/27/2017
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4. Two Main Causes Of Maternal
Morbidity And Mortality Are
 Chronic Anemia Of Pregnancy.
 Major Obstetric Haemorrhage.
2/27/2017
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5. 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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6. 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
2/27/2017
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7. 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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8. Massive Blood Loss
May 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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9. 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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10. 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.
2/27/2017
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11. Aim
To restore or maintain :
1. Blood volume
2. O2 carrying capacity
3. Hemostasis
4. Leucocyte function
(Ref. : Blood banking & transfu Med 2nd edi)
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12. Remember…
The Decision For Blood Transfusion
Should Always Be A Balance Between
Blood Is Life

13. ‘ WHAT ‘
For Any Procedure
• W - Whether required
• H - How much required
• A - Actual component required
• T - Time duration of transfusion
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14. What Are
Our Options...???
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15. Whole Blood…
450 ml of blood
63 ml of anticoagulant solution.
Hct – 36 - 44%
No components have been removed.
Store at 1-6 oC
Shelf 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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16. …Whole Blood
Indications:
– 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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17. • Massive transfusion of stored whole blood
can aggravate coagulopathy due to:
- Dilutional thrombocytopenia
- Coagulation factor depletion
- Acidosis
- Hypothermia
Solution:
• 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…
17

18. Blood
Components
• Red Blood Cells (pack cells)
• Fresh Frozen Plasma
• Platelets
• Cryoprecipitate
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19. 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
2/27/2017
Dr Shashwat Jani.
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20. 2/27/2017
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21. 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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22. • 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).
2/27/2017
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23. f
Obstetric
Indication
< 8 gm
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24. 2/27/2017
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25. 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
2/27/2017
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26. 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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27. 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.
2/27/2017
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28. 2/27/2017
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29. 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 29

30. Platelets: Risk of Spontaneous
Hemorrhage
Count Site
> 40,000 Minimal
20-40,000 GI Mucosa
5-20 Skin, Mucus Membranes
< 5 CNS, Lung
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31. Prophylactic Platelet TX Guidelines
Platelet Count/μl Recommendation
0-5,000 Always
5-10,000 If Febrile or Minor Bleeding
11-20,000 If coagulopathy / minor
procedure
>20,000 If Major Bleed / invasive
procedure
>50,000 May or May not give
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32. 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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33. 2/27/2017
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34. 2/27/2017
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35. 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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36. 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.
2/27/2017
Dr Shashwat Jani.
+91 9909944160.
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37. 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
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Dr Shashwat Jani.
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38. D I C
Diagnosis
– D dimer
– Prolong CT
– Prolong PT
– Prolong aPTT
– Platelet
– Fibrinogen
– Early diagnosis essential
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Dr Shashwat Jani.
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39. 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)
2/27/2017
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40. 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.
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41. Blood/ Start infusion Complete infusion
blood product
Whole blood/ within 30 min. of within 4 hour
red cells removing pack (less in high
from ambient temperature)
refrigerator
Platelet immediately within 20 min
concentrates
FFP within 30 min within 20 min
Time Limits for Infusion

42. 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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43. 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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44. LEAKS
DISCOLOURATION
CLUMPING
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 prescribed
Step 2: Undertake baseline observations
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45. 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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Dr Shashwat Jani.
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46. 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. “
2/27/2017
Dr Shashwat Jani.
+91 9909944160.
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47. THANK
YOU…!!!
2/27/2017
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