1. Component Therapy in
Obstetrics
Dr. V. L. Deshmukh
M.D.(Obst.&Gyn)
Associate Professor
Dept. of Obstet. & Gynaec.
Govt. Medical College
AURANGABAD
2. 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.
3. Indications
Indications for transfusion of blood or
blood products are to restore or
maintain :
1. Blood volume
2. O2 carrying capacity
3. Hemostasis
4. Leucocyte function
(Ref. : Blood banking & transfu Med 2nd
edi)
5. . 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
6.
7.
8.
9. 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)
10. Whole blood
(Contd..)
1. Identification
2. 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)
11. 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)
12. 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
13. 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 term
Patient 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.
14. 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
15. Platelets
Thrombocytopenia and pregnancy :
• Gestational thrombocytopenia
• HELLP
• Severe PIH/Eclampsia
• Drug induced
• Infections – bacterial/viral
• TTP
• ITP
• Massive blood transfusion
• APA syndrome
• Abrptio placenta
Ref : Scientific foundation of ObGy, 2nd
edi
16. 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)
17. 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
18.
19. FFP
Indications :
• Coagulation factor deficiency
• Acute DIC
• Treatment of TTP
• Documented coagulopathy in setting of
massive transfusion
• Liver disease
Efficacy 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)
21. 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
22. Components Factor
Component 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.
23. • 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
24. DIC
• Multyorgan dysfunction caused by
microthrombi
• Bldg is caused by consumption of
platelet, fibrinogen, factor V,VIII
• Secondary fibrinolysis
25. 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
26. DIC
• ENDOTHELIAL DAMAGE
• Thromboplastin released
• Microthrobi formation
• DIC
• Consumption of all coagulation
factors
27. 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
Prothrom
bin time
17-16 sec. Extrinsic pathway
Common pathway
aPTT 22-37 sec Intrinsic pathway
Common pathway
28. Test for Hemostatic Function
Test 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)
30. 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
32. 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
33. 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
34. 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.
35. Massive Haemorrhage
• Call for senior help early
• Inform blood bank
• Specific :
- Adequate oxygenation
- Patent airway
- Restore circulating blood volume
- Start component therapy
36. 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)
37. 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.
38. Massive Haemorrhage
1. Patent airway
2. 100% O2
3. IV access
4. Laboratory test - Full blood count
- PT
- APTT
- Fibrinogen
- KFT
- Electrolytes
39. 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.
40. 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
41. Massive Haemorrhage
• Restore volume :
The volume
Timing Imp. for good outcome
Extent
• Monitoring depend on ;
CVP
Output
Heart rate
• Increase in B.P. due to inotropes is
deceptive
42. Massive Haemorrhage
• Restore volume : 2 lit. of fluid in adult
Crystalloid Colloid
Cheap 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.)
43.
44. 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
45. 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
46. 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.
47. 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
48. DIC
Should be kept in mind :
- PT
- APTT Diagnosis
- Dilutional thrombocyto.
Give 4-6 units FFP
5 pints of platelets
10 units of cryo
Send blood sample regularly to assess the
coagulation status
Ref : Guidelines National blood users group, Nov. 2002
49. DIC
• Send : Hb, Hct, platelets, PT, APTT,
serum fibrinogen.
• Monitoring & coagulation screening
should be continued
• If bleeding recurs, the monitoring
should be intensified.
50. 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
51. Evaluation
• Evaluate the response
- Pulse
- B.P.
- CVP
- Output
- Hemoglobin
- Hct
Note the details of blood component used
e.g. timing and volume
52. 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
53. Massive Haemorrhage
– new invention
• Used effectively offlable to control PPH
• Effective dose is 50-100 µg/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
54. 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
55. Important Points
1. Errors in transfusion
2. Transfusion transmitted infections
3. Adverse effects associated with
transfusion
4. Autologous transfusion
5. Intraoperative cells salvage
57. Conclusion
• Deaths are avoidable if early and
effective intervention in initial golden
hour is provided
• It has a major impact on eventual
outcome
