ABOUBAKR ELNASHAR

1. Blood
Transfusion in
Obstetrics
Prof. Aboubakr
Elnashar
Benha university Hospital
Egypt
elnashar53@hotmail.com
ABOUBAR ELNASHAR

2. CONTENTS
1. RISKS OF BLOOD TRANSFUSION
2. PROBLEMS SPECIFIC TO PREGNANCY
3. REDUCING RISK OF BLOOD TRANSFUSION
4. GENERAL PRINCIPLES OF BLOOD TRANSFUSION
5. INDICATIONS OF BLOOD TRANSFUSION
1. BLOOD TRANSFUSION FOR ANAEMIA
2. BLOOD TRANSFUSION FOR OBS HGE
ABOUBAR ELNASHAR

3. INTRODUCTION
Obstetric haemorrhage:
major cause of maternal mortality
in the UK: third leading
In Egypt: first leading
Postpartum haemorrhage
25% of all pregnancy-related deaths.
ABOUBAR ELNASHAR

4. Blood transfusion
 one of the 8 essential components to reduce
maternal mortality rates.
As ‘too little, too late’.
Women at high risk of losing 1000 ml:
should deliver in a setting where
blood transfusion
intensive care facilities are available.
Life-saving procedure
ABOUBAR ELNASHAR

5.  In developing countries
 Availability of blood transfusion depends on
 Infrastructure
 Economics
 Social and religious taboos
 Practices
 : transfusion practices vary from those in
the developed countries
ABOUBAR ELNASHAR

6. 1. RISKS OF BLOOD TRANSFUSION
1. Transfusion-transmitted infections
2. Immunological sequelae:
red cell alloimmunisation.
3. The major risk: ‘incorrect blood component’.
Strict adherence to:
 correct sampling
 cross-match
Administration procedures:
paramount importance, even in an emergency.
ABOUBAR ELNASHAR

7. 2. PROBLEMS SPECIFIC TO THE PREGNANT
PATIENT
1. Physiological changes in pregnancy
Haemodilution
Increase in
red cell mass (20-30%)
plasma volume (50%):
patient stay haemodynamically stable with
the normal blood loss during delivery.
 Decrease in platelet levels:
gestational thrombocytopenia.
ABOUBAR ELNASHAR

8. Hypercoagulable state
increase in
coagulation factors:
fibrinogen and factors VII, VIII, and IX
supervening over the increase in the natural
anticoagulants:
Protein A, Protein C, and Antithrombin III.
The fibrinolytic system decreases in activity.
Plasminogen is increased, but its activity is dampened by a
corresponding increase in plasminogen inhibitor type II.
 hypercoagulable state
limit blood loss
can tip the mother into:
DIC and
pulmonary embolism.
ABOUBAR ELNASHAR

9. 2. Difficulty in assessment of blood loss by
Vital signs:
{increased maternal plasma volume}.
 Haemodilution and high cardiac output : large
amount of blood loss in a pregnant female
before the hypotension and fall in Hgb/ Hct
Visual assessment
{large amounts of blood lost may be concealed in
the uterine cavity}.
ABOUBAR ELNASHAR

10. 3. Associated comorbid conditions
 PET, thrombocytopenia and the HELLP syndrome
can bring about catastrophic hge.
ABOUBAR ELNASHAR

11. 4. Risk to foetus
While managing acute haemorrhagic emergencies,
the foetus has to be kept in mind, to prevent
 Infections
 Haemolytic Disease of the Foetus and Newborn
(HDFN) in the current and future pregnancies.
ABOUBAR ELNASHAR

12. 2. REDUCING RISK OF BLOOD TRANSFUSION
1. Optimisation of Hb in ANC
Screening
at booking
at 28 w.
at 20–24 w in multiple pregnancies
Diagnosis
1st T. Hb: ≤11.0 g/l
2nd &3rd T. Hb: ≤ 10.5 g/l
Postpartum Hb: ≤ 10.0 g/l
ABOUBAR ELNASHAR

13. Treatment and management
Inform patient
How to improve dietary iron intake
Factors affecting absorption of dietary iron
Oral iron:
1st TT line.
:if no demonstrable rise in Hb at 2 ws
Check compliance
Further TT
Parenteral iron
indicated when
oral iron is not tolerated
absorbed
patient compliance is in doubt
if the woman is approaching term and there is
insufficient time for oral supplementation to be effective.
ABOUBAR ELNASHAR

14. 2. Active management of the third stage of labour
 to minimise blood loss.
 Involve
 use of uterotonics
 early clamping of the cord
 controlled cord traction
3. Women at high risk of hge
should be advised to deliver in hospital.
ABOUBAR ELNASHAR

15. 3. GENERAL PRINCIPLES OF BLOOD
TRANSFUSION
1. Consent for blood transfusion
obtained where possible
In an emergency:
information on blood transfusion should be
provided retrospectively.
The reason for transfusion and a note of the consent
discussion should be documented in the patient’s
case notes.
ABOUBAR ELNASHAR

16. 2. Requirements for group and screen samples and
cross-matching
All women should have
blood group and
antibody status
checked at booking and at 28 w.
Group and screen samples used for provision of blood in pregnancy
should be less than 3 days old.
Transfusion or pregnancy may stimulate the production of unexpected
antibodies against red cell antigens through either a primary or secondary
immune response. To ensure that the specimen used for compatibility
testing is representative of a patient’s current immune status, serological
studies should be performed using blood collected no more than 3 days in
advance of the actual transfusion when the patient has been transfused or
pregnant within the preceding 3 months.
ABOUBAR ELNASHAR

17. In a woman at high risk of emergency transfusion:
placenta praevia, and with no clinically significant
alloantibodies
 group and screen samples should be sent once a
week
{exclude or identify any new antibody formation
keep blood available if necessary}.
 Close contact with the hospital transfusion
laboratory is essential.
ABOUBAR ELNASHAR

18. 3. Blood product specification in pregnancy and the
puerperium
ABO-, rhesus D- (RhD-) and K- (Kell-)
compatible red cell units should be transfused.
If clinically significant red cell antibodies are present:
blood negative for the relevant antigen should be
cross-matched before transfusion; close contact with the
transfusion laboratory is essential to avoid delay in transfusion in life-
threatening hge.
CMV seronegative red cell and
Platelet components:
should be provided for elective transfusions during
pregnancy.
ABOUBAR ELNASHAR

19. 5. INDICATIONS OF BLOOD TRANSFUSION IN
OBSTETRICS
I. Anaemia of pregnancy and Haemoglobinopathies
II. Obstetric hge
III. Surgeries where significant blood loss is expected.
ABOUBAR ELNASHAR

20. I. BLOOD TRANSFUSION FOR ANAEMIA
 Antepartum anaemia
 responsible for 15% of maternal mortality.
 Early correction
 avoids the need for transfusion
 reduces maternal mortality.
 The decision for transfusion
 should not be made on the basis of Hgb
estimation alone
 healthy and clinically stable women do not
require blood transfusion even with Hb of <7
g/dl.
ABOUBAR ELNASHAR

21. Indications:
1. Hb <6 g/dl
there are <4 ws for delivery
2. Hb is <7 g/dl
 in labour or
 in immediate postpartum period,
blood transfusion is only indicated if there is
 previous history of bleeding or
 patient is prone for bleeding due to some
medical condition.
3. Hb is 7 g/dl
 continued bleeding or
 at risk of further significant hge or
 presenting with severe symptoms that need
immediate correction (cardiac decompensation).
[Cochrane SR, 2007] ABOUBAR ELNASHAR

22. 4. sickle disease and thalassaemia
 severe situations
{prophylactic transfusion:
 increases in costs,
 number of hospitalizations
 risk of alloimmunisation}.
ABOUBAR ELNASHAR

23. II. BLOOD TRANSFUSION FOR OBSTETRIC
HAEMORRHAGE
 The leading cause of maternal mortality
 13% in developed countries
 33% in Africa.
[WHO, 2006]
 may occur before or after delivery
 >80% of cases occur postpartum
[McLintock , James, 2011]
ABOUBAR ELNASHAR

24. 1. CAUSES OF OBSTETRIC HAEMORRHAGE
 Early pregnancy
 Abortions
 Ectopic pregnancy
 Later pregnancy
 Antepartum haemorrhage
 Placenta praevia, placental abruption
 bleeding from vaginal or cervical lesions
 Primary postpartum haemorrhage
 Tone (uterine atony)
 Tissue (retained products)
 Trauma (cervical and genital tract damage during delivery)
 Thrombin (coagulation disorder)
 Secondary postpartum haemorrhage
 Uterine atony
 retained products
 genital tract trauma,
 uterine inversion ABOUBAR ELNASHAR

25. 2. ESTIMATION OF BLOOD LOSS
1. Visual assessment:
 Inaccurate
 clinicians can underestimate blood loss by 50%.
 PPH
 >500 ml after VD and
 >1000 ml after CS, do not adequately reflect the
clinical response of the patient.
 Massive haemorrhage
 1000-1500 ml
 50% blood volume loss within 3-h or
 rate of loss of 150 ml/min.
ABOUBAR ELNASHAR

26. 2. HCT
 Immediate Hct will not reflect actual blood loss.
 Even blood loss of 1000 ml will reflect a fall
in Hct of only 3% in the 1st h.
3. Urine output
 sensitive to changes in blood volume
 can give an early indication of changes in renal
perfusion and hence perfusion of other organs.
4. Pulse Oximetry
 an imperfect tool in the haemodynamically
unstable patient.
ABOUBAR ELNASHAR

27.  Estimation of blood loss:
 Visual estimation often underestimates blood loss,
 More accurate methods:
1. Weighing packs:
 Hospital keeps scales in delivery rooms to weigh lap sponges
& other materials to estimate blood loss.
 1kg soaked swabs: 1000ml
2. Comparing visual estimation of blood loss with
the use of a collector bag
soda can hold about 350 cc of blood
concluded that the latter did not significantly reduce the risk of
severe PPH.
ABOUBAR ELNASHAR

28. 3. Written guidelines
 Maximum capacity of Swab
 Small (10x10cm): 60ml
 Medium (30x30 cm): 140ml
 Large (45x45 cm): 350ml
 Floor spill
 50 cm diameter: 500ml
 75 cm diameter: 1000ml
 100 cm diameter: 1500ml
 Vaginal PPH
 Limited to bed only unlikely to exceed 1000ml
 Spilling from bed to floor likely to exceed
1000ml
ABOUBAR ELNASHAR

29. 4. Pictorial guidelines
ABOUBAR ELNASHAR

30. 3. MANAGEMENT OF OBSTETRIC HAEMORRHAGE
Multidisciplinary approach to massive blood loss yields
the best results.
ACOG:
The CMQCC protocol
a step-by-step checklist format,
based on the staging of obstetric haemorrhage,
RCOG
lays out therapeutic and monitoring guidelines for
minor and major postpartum haemorrhage.
While there are some individual variations, the broad
outlines remain the same.
ABOUBAR ELNASHAR

31. The 4 mainstay of management of haemorrhage:
1. Rapid resuscitation with crystalloids:
restore and maintain the circulating blood volume
to prevent tissue and organ hypo-perfusion.
2. Blood transfusion in acute hge:
maintain tissue oxygenation and reversal or
prevention of coagulopathy using appropriate
blood components.
3. Prevention and treatment of hypothermia, acidosis
and hypocalcaemia will ensure optimal function of
transfused coagulation factors.
4. Simultaneously, the cause of the bleeding should
be identified and controlled, by medical means,
surgery or invasive radiography.
ABOUBAR ELNASHAR

32. Major PPH >1000 ml or ShockMinor PPH <1000 ml
&Compensated
Airway, Breathing& Circulation
O2 by mask at 10–15 L/M
14-gauge cannula x2
Blood component rapidly
Packed RBC: Fresh frozen plasma:
Platelets= 6:4:1
Until blood is available: IV up to 3.5 L
crystalloid lactated Ringer (± one L of it
is colloid)
Keep patient& infusions warm
IV access one 14-
gauge cannula
Crystalloid infusion:
1-1.5 L lactated Ringer
ABOUBAR ELNASHAR

33. 4. CONTROVERSIES AND CONSENSUS FOR
TRANSFUSION IN OBSTETRICS
1. Colloids or Crystalloids:
 have no advantage over Crystalloids
 high cost
(The SAFE trial and the CRISTAL trial)
Crystalloids
rapidly equilibrate with the extracellular fluid, and
only about 20% remains in the circulation after the
1st h.
The accepted average ratio of Colloid: Crystalloid is
1:1.5.
ABOUBAR ELNASHAR

34. Crystalloid:
NS
D5NS can be given
Ringer
Hartmann
Ringer=lactated Ringer
Nacl: 6.5 g,
Kcl:0.42 g,
Ca cl: 0.25 g,
1 mol of Na bicarbonate
is dissolved in 1 liter of distilled water
Colloids:
Human albumin,
Hydroxyethylstarch (HES)
Dextran
Mannitol
Haemaccel
ABOUBAR ELNASHAR
Hartmann solution= compound
sodium lactate
NaCl
KCl
CaCl dihydrate
Na lactate

35. 2. Whole blood or blood component?
superior to PRBCs or combined transfusions in
preventing acute tubular necrosis and other
complications.
replaces many coagulation factors
its plasma expands blood volume.
 exposing the patient to fewer donors.
The availability of fresh warm blood in developing
countries could provide an alternative to more
expensive and infra structure-dependent blood
components.
ABOUBAR ELNASHAR

36. 3. To cross-match or not to cross-match?
The chances of a clinically significant red cell
antibody being missed in a patient with a negative
antibody screen (false negative) are
1-4/10,000.
Given that the chance of adverse consequences is
small, in cases of acute massive hge, it appears
reasonable to transfuse blood without
type-and-screened red blood cells.
[Rege et al, 2014]
ABOUBAR ELNASHAR

37. 5. BLOOD TRANSFUSION; HOW MUCH TO GIVE AND
WHEN TO STOP?
 The decision for blood transfusion
 Hb≤6.0 g/dl
 almost always required
 Hb≥10.0 g/dl
 rarely required
 Hb is normal but acute hge
 required
 Single Hb/ hct
 ±misleading
 ±:delay initiating red cell transfusion
 Serial measurements helpful
ABOUBAR ELNASHAR

38.  Goals of management of massive blood loss:
 Most protocols recommend maintaining a target
 Hct of 21-24%.
 Restrictive transfusions and liberal transfusions were of equivalent
value in critically ill patients while relatively stable patients undergoing
liberal transfusions had a higher 30-day mortality.
 [Hébert et al, 2012]
Hb ≥8 g/dl
Platelet 50x 109/L
PT ≤1.5 times normal
APPT ≤1.5 times normal
Fibrinogen 2g/L
ABOUBAR ELNASHAR

39. The risk of dilutional coagulopathy
 needs to be borne in mind when multiple units of
PRBCs and crystalloids/colloids are used.
Patients receiving <10 units of PRBCs rarely need
component replacement
The lowest mortality occurs in the patients where
ratio of plasma and PRBCs is 1:1.
Recommend ratio of PRBC, fresh frozen plasma and
Platelet of 6: 4:1 in cases of massive haemorrhage.
ABOUBAR ELNASHAR

40. 6. MANAGEMENT OF OBSTETRIC HAEMORRHAGE
WITH BLOOD COMPONENTS
There should be a clear local protocol on how to
manage major obstetric hge.
The protocol should be updated annually and practised
in ‘skills drills’ to inform and train relevant personnel.
ABOUBAR ELNASHAR

41. 1. Clinicians should familiarise themselves with
mechanical strategies that can be employed to
reduce postpartum blood loss.
rubbing up the fundus’,
bimanual uterine compression
emptying the bladder to stimulate uterine
contraction
ABOUBAR ELNASHAR

42. 2. Blood components used for obstetric hge
Red cell transfusion
There are no firm criteria for initiating red cell
transfusion. The decision to provide blood
transfusion should be made on clinical and
haematological grounds.
Blood transfusion
almost always required when Hb ≤60 g/l
rarely required when the Hb≥100 g/l.
Patients with acute hge can have normal Hb: cl
evaluation of the patient is extremely important.
ABOUBAR ELNASHAR

43. 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).
Staff working in obstetric units should be aware of the location of the satellite
blood fridge (where available) and should ensure that access is possible for
blood collection.
ABOUBAR ELNASHAR

44. FFP
Dose:
12–15 ml/kg should be administered for/6 units of
red cells during major obstetric hge.
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.
It is essential that regular full blood counts and
coagulation screens (PT, APTT and fibrinogen) are
performed during the bleeding episode.
ABOUBAR ELNASHAR

45. Cryoprecipitate
Dose:
two 5-unit pools should be administered early in
major obstetric hge.
Subsequent transfusion should be guided by
fibrinogen results, aiming to keep levels above 1.5 g/l.
ABOUBAR ELNASHAR

46. The FFP and cryoprecipitate
should ideally be of the same group as the
recipient.
If unavailable, FFP of a different ABO group is
acceptable providing that it does not have a
high titre of anti-A or anti-B activity.
No anti-D prophylaxis is required if a RhD-
negative woman receives RhD-positive FFP or
cryoprecipitate.
ABOUBAR ELNASHAR

47. Platelets
Aim:
maintain the platelet count above 50 x 109/l in
the acutely bleeding patient.
A platelet transfusion trigger of 75 x 109/l is
recommended to provide a margin of safety.
The platelets should ideally be group compatible.
RhD-negative women should also receive RhD-
negative platelets.
ABOUBAR ELNASHAR

48. SUMMARY
Blood transfusion is an essential component of
obstetric care and at times lifesaving.
Inappropriate transfusions during pregnancy and the
postpartum period expose the mother to the risk of
HDFN.
In the situation of obstetric haemorrhage early
resuscitation is done with crystalloids with oxygenation
while simultaneously taking all steps to control bleeding
and reduce the transfusion requirement.
A preplanned, multidisciplinary protocol yields the best
results in the management.
ABOUBAR ELNASHAR

49. The decision to perform a blood transfusion should be
made on both clinical and haematological grounds.
The majority of protocols recommended that Hct be
maintained minimally at 21-24%; however, in actively
bleeding patient, target Hct should be 30%.
To avoid dilutional coagulopathy, concurrent
replacement with coagulation factors and platelets may
be necessary.
Whole blood may be preferred in acute massive hge,
especially where blood components are not readily
available.
In an extreme situation and when the blood group is
unknown, O RhD negative red cells should be given.
ABOUBAR ELNASHAR

50. ABOUBAR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
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2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura