This document discusses blood loss and transfusion in obstetrics. It notes that pregnant women have increased blood volume compared to non-pregnant women. It provides guidance on signs of blood loss severity and recommendations for fluid or blood product replacement based on percentage of blood volume lost. It also discusses complications of massive transfusion and treatments for disseminated intravascular coagulation that can result from severe blood loss.

1. BLOOD AND BLOOD
PRODUCTS TRANSFUSION
Salso Team
In Obstetrics

2. Pregnancy and blood loss
 Pregnant women has an increased blood volume of about
20-30%
 Blood volume estimation - about 100ml/kg
 60kg = 6 litres of blood
 As such
 1.0L of blood loss in a pregnant woman is not the same as 1.0L of
blood loss in a non-pregnant woman
 1.0L of blood loss in a 80kg woman is different from a 40kg woman

3. Lost of circulating volume in
obstetrics
Circulating
volume lost
Signs
Up to 0.5L-1.0L Mild increase in PR -
1.0-1.5L Increase PR
Increase breathing
Slight fall in BP (80-100
mmHg SBP)
Use crystalloids to replace fluid
loss
1.5-2.0L Use colloids to replace
30-40%
(Over 2 L)
BP drops Need a blood transfusion in
addition to crystalloids
>40% Immediate life threatening Blood transfusion is required
immediately
Need rapid transfusion
Referring to a normal healthy pregnant woman i.e. not anaemic, etc

4. Vital signs
 When abnormal in the context of haemorrhage,
they are useful in assessing the severity of the
hypovolemic shock
 When normal however, they are not reliable in
assessing the severity of the hypovolemic shock
 Remember that a drop in BP is a late sign of
hypovolaemia! Patient has lost at least 30% of her blood
volume!!!
 Should not rely on BP to assess volume loss!!!

5.  <30% blood loss - Red cell transfusion not necessary unless:
 Pre-existing anaemia
 Reduced cardiorespiratory reserve
 Ongoing blood loss

6. Loss of circulating volume
 Replacement with crystalloids - every ml blood loss, 3ml
crystalloids needed
 3 to 1 ratio
 Replacement with colloids – every ml blood loss, 1.5 ml
colloids needed
 3 to 2 ratio

7. Blood transfusion
 Whole blood vs Packed cells
 No data to suggest that the use of whole blood, even
“fresh” is associated with better outcome in acute blood
loss
 Usually used in exchange transfusion
 For acute blood loss,
 Give specific blood components as required:
 Packed cells
 Platelet concentrate
 FFP
 Cryoprecipitate - Factor I, VIII, vWF (+ XIII, fibronectin)
 Cryosupernatant

8. Rapid blood transfusion in life-
threatening condition
 BP cuff (high-pressure infusion devices)
 No blood filters
 With warmers
 O-ve blood

9. DIVC in obstetrics
 Consumption coagulopathy (depletion of
platelets and coagulation factors) that leads to
further haemorrhage
 Can be due to:
 Massive bleeding (e.g. APH, PPH, abruption)
 Sepsis
 Amniotic fluid embolism
 Eclampsia
 IUD

10. DIVC
 Treat the underlying cause (sepsis, massive blood
loss, severe vessel injury, toxins)
 Transfuse platelet if bleeding associated with
thrombocytopaenia. Aim for > 50 x 109 /L (C, IV)
 Platelets should not be allowed to fall <50 x 109 in
acutely bleeding patient

11. DIVC
 If bleeding continues after large volumes red cell
and platelets have been transfused, FFP and
cryoprecipitate may be given (depending on
protocol e.g. after 10 units of RBCs, abnormal
coagulation profile, etc)
 Transfuse FFP and cryoprecipitate so that the PT
and APTT ratios are within 1.5 and a fibrinogen
level of > 1.0 g/ L

12.  Adequate resuscitation from shock - most
important in preventing coagulopathy
 No evidence that prophylactic regimes
prevents or reduce transfusion
requirements

13. Massive Blood Loss
 Replacement of total blood volume (5 L) within
24 hours
 Loss of 50% blood volume in less than or equal
to 3 hours
 150ml/ min blood loss (Loss of half the blood
volume in 20 minutes)
 Transfusion of more than 20 units of
erythrocytes

14. Complications of massive transfusion
 Hypothermia
 Acid-base disturbance – metabolic alkalosis >
acidosis
 Thrombocytopenia & reduced factor I,V,VIII
 Electrolyte imbalance
 Hypokalemia > Hyperkalemia
 Hypocalcemia & citrate intoxication