2/21/19

Blood Transfusion on
Obstetrical & Gynecological
Bleedings
Ali Sungkar
Divisi Fetomaternal
Departemen Obstetri dan Ginekologi FKUI / RSUPN - CM

Jakarta, 22 November 2017

Care of the
Critically ill pregnant woman
Level 0 : Patients whose needs can be met through normal ward
care.
Level 1 : Patients at risk of their condition deteriorating and
needing a higher level of observation or those recently relocated
from higher levels of care.
Level 2 : Patients requiring invasive monitoring/intervention that
include support for a single failing organ system (excluding
advanced respiratory support).
Level 3 : Patients requiring advanced respiratory support
(mechanical ventilation) alone or basic respiratory support along
with support of at least one additional organ.

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Example of Care Required at

Critically ill pregnant woman

Physiology And Physical

Changes in Pregnacy

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HAEMATOLOGICAL CHANGES
IN PREGNANCY
Normal Adult 32-34 Weeks Increased /
Characteristic
Women Gestation Decreased
Plasma volume (ml) 2600 3850 1250 in

Red cell mass (ml) 1400 1640-1800* Increased

Haemoglobin (g/dl) 12-14 11-12 Decreased

Red Blood Cells (10*6 /mm*3) 4-5 3-4-5 Decreased

Packed cell volume 0.36-0.44 0.32-0.36 Decreased

Mean corpuscular volume 80-97 70-95 Decreased

Mean corpuscular haemoglobin (pg) 27-33 26-31 Decreased

Mean corpuscular haemoglobin concentration (%) 32-36 30-35 Decreased
Serum Iron (µg/dl) 60-175 60-75 Decreased

Total Iron Binding Capacity (µg/100ml) 300-350 350-400 Increased

Percentage Saturation (%) 30 15 Decreased

Requirements of iron (mg/day) 1.5-2.0 4.0 Increased

Mean corpuscular haemoglobin = MCH Packed cell volume = PCV

Mean corpuscular volume = MCV
Mean corpuscular haemoglobin concentration =
MCHC
Total iron binding capacity = TIBC

Physiologic volume change

of Pregnancy

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Shock
The most common types of shock:

Type of shock Aetiology

Hypovolaemic shock Acute loss of at least 20% of the
circulating volume

Cardiogenic shock Acute disease of the heart, e.g.

severe myocardial infarction

Septic shock Septic condition caused by infectious

agents and their toxic products

Neurogenic shock Head trauma, spinal cord injury

Anaphylactic shock Repeated contact with or injection of

antigenic substances

Shock
Hemorrhagic Shock - Pathophysiology
Stage 1: Compensated Stage
Mechanism: Volume depletion due to bleeding

Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and

Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction Beta = Bronchodilation

and Cardiac Stimulation

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Shock
Hemorrhagic (Classic) shock –
Pathophysiology
Stage 2: Progressive Stage

Mechanism: Kidneys release anti-diuretic hormone which increases

vasoconstriction by closing the capillary sphincters, greatly reducing
peripheral circulation

Increased hypo-perfusion causes increase in metabolic acid build up

Shock
Hemorrhagic (Classic) shock –
Pathophysiology

Stage 3: Irreversible Stage

Mechanism: Compensatory mechanisms fail

Pre-capillary sphincters open releasing metabolic

acids, micro-emboli and other wastes into circulation

Cell damage, organ failure and death occur

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Shock
The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure Heart Rate

Blood Pressure (mm Hg)
Heart rate (min)

150 Bleeding

100

50

0 (Time)
Compensation Decompensation Irreversibility

Shock Phases

Shock
Cerebral Function
Tissue Perfusion (Body Control) Pulmonary Function
(O2 Supply)

Volume Replacement

Liver Function
Renal Function
(metabolism)
Heart Function (Diuresis)
(cardiac output)

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Haemorragic Shock

Step for Control Bleeding

§ Airway

§ Breathing

§ Circulation and hemorrhage control

§ Shock position

§ Replace blood loss

§ Stop / minimize the bleeding process

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Blood Loss
% Loss of blood Equivalent Replacement
Volume Adult fluid Fliud
Volume

< 20 % Up to 1 Liter Crystalloid ( e.g.

0,9 % saline )

> 20 % More than 1 liter Crystalloid and /

or Colloid
Red Cell

American College of Surgeon’s Classes of

Acute Hemorrhage
Class I II III IV
Blood loss (ml) ≤750 750-1500 1500-2000 ≥ 2000
Blood loss (% ≤15% 15-30% 30-40% ≥40%
blood volume)
Pulse rate <100 >100 >120 ≥ 140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or Decreased Decreased Decreased
(mmHg) increased
Capillary refill Normal Positive Positive Positive
test
Respiratory rate 14-20 20-30 30-40 >35
Urine output ≥ 30 20-30 5-15 Negligible
(ml/hr)
CNS-mental Slightly anxious Mildly anxious Anxious and Confused,
status confused lethargic
Fluid Crystalloid Crystalloid Crystalloid + Crystalloid +
replacement Blood Blood
(3:1 rule)

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Estimated Blood Loss

l The 3: 1 Rule,
Replace 3 cc crystalloid : 1 cc blood loss
l The 1:1 Rule,
Replace 1 cc colloid : 1 cc blood loss

Allowable Blood Loss

(Hct present - Hct allowable) + EBV
Hct present
Estimated Blood Volume
Adults: 75 cc/kg
Infants: 80 cc/kg
Neonates: 85cc/kg

Estimating Allowable Blood Loos

Clinical condition
Healthy Average Poor
Percentage Methode

Acceptabel loss 30 % 20 % 10 %
of blood vol
Haemodilution Method

Lowest 9 mg / dl 10 mg / dl 11 mg / dl
Acceptable Hb
Lowest 27 % 30% 33%
acceptable Ht

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Blood components & products

l Cell containing components
l Red cells:
l Whole blood( fresh or not)
l Red cells: packed red blood cells
washed red blood cells
frozen red blood cells
leukocyte – reduced red blood cells
l Platelets: Random donor platelets
Apheresis platelets ( single donor platelets)
l Granulocytes or mononuclear cells
l Peripheral blood progenitor cells

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Deciding blood transfusion

l Severity of symptoms
l Cause of anemia
l Rapidity of anemia or symptoms
l Co-morbidities and the age of the patient
l Can we treat the anemia without transfusion?
l Is there enough time to wait for the response
of such a treatment ?

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Transfusion in Critically care

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Indications for transfusion of blood

or its components
l Whole blood: Acute massive bleeding
1 unit increases Hb: 1g/dl, Hct: 3%

l Fresh whole blood:

l Massively bleeding patient/shock
l Exchange transfusion, open heart surg, severe renal or hepatic failure,

l Red blood cells:

l (To increase the oxygen carrying capacity in case of symptomatic
anemia not treatable by other means or due to urgency of symptoms)
l Symptomatic anemia (May be due to different causes), post-bleeding
hypovolemia
l 1 unit increases Hb: 1g/dl, Hct: 3%

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Indications for transfusion of

blood or its components

l White cells reduced RBC’s: < 5x106 WBC’s per unit

White cell filters (before storage or before transfusion)
l An indication for RBC transfusion +
l To prevent reactions caused by WBC antibodies
l Febrile non-hemolytic transfusion reactions
l To prevent alloimmunization
l To prevent CMV transmission

Indications for transfusion of blood

or its components
Washed RBC’s:
l An indication for RBC transfusion +
l Any need to prevent the recipient allo-immunisation to
WBC’s , plasma antigens or any contraindication to infuse
complement
l PNH
l IgA deficiency
l Prevention of anaphylaxis
l Washed units must be transfused no later than 24 hr
Frozen RBC’s:
l An indication for RBC transfusion +
l Autologous transfusion: rare blood groups,
l Catastrophy etc
Washed before infusion !!

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Indications for transfusion of blood

or its components
l Platelets:
Thrombocytopenia due to decreased platelet production
Platelet count/mm3 Bleeding /surgery Indication for plt transfusion
> 50.000, No No
< 50.000 Yes Yes
10.000-20.000 No No
(if there is bleeding/fever/DIC/plt dysfunction) Yes
< 10.000 Yes or No Yes

Types of platelet concentrates

l Random donor plt concentrate (single unit)
l 5,5 x 1010 plts
l 5.000-6.000/mm3 plt increase after transfusion
l Pooled plt concentrate (eg:6 random units)
l Apheresis plts
l >3x1011 plts
l 30.000-50.000/mm3 increase after transfusion
l WBC reduction of platelets is indicated in the
same situations like red cells.

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Indications for transfusion of blood

or its components/products

l Fresh frozen plasma ( contains all coag. Factors)

l Congenital or acquired coag.Factor deficiency
(bleeding or surgery)
l Oral anticoagulant overdose
l Plasma exchange (eg:TTP)
l After massive transfusion
l 10-20 ml/kg : to increase deficient factor level
about 20-30% from baseline

Indications for transfusion of blood

or its components/products

l Cryoprecipitate
l Includes FVIII, vWF, FXIII, fibrinogen and
fibronectin
l 80-120 units of FVIII,
≥150 mg fibrinogen and 20-30 % of FXIII that is in
one unit of plasma
l Can be used for the purpose of replacing the
deficient state of these factors in case of
bleeding or surgery

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Practical Issues
l Is there a need for transfusion?
l Which product should be used?
l Number of units?
l Re-check the blood types of the patient and donör
and be sure about the cross match
l Read label, ID, inspect the product
l Is irradiaton necesssary?
l Temperature?
l Filters?
l Flow rate ? (start 5 ml/min-15 minutes , the rest 200-500ml/hr)
l Drugs ?

Massive Transfusion
Definition:
l Replacement of a blood volume equivalent within 24hr

l >10 unit within 24 hr

l Transfusion > 4 units in 1 hr

l Replacement of 50% of blood volume in 3 hrs

l A rate of loss >150ml/hr

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Massive transfusion protocol (MTP) template

The information below, developed by consensus, broadly covers areas that should be included in a local MTP. This
template can be used to develop an MTP to meet the needs of the local institution's patient population and resources

Senior clinician determines that patient meets criteria for MTP activation
OPTIMISE:
• oxygenation
• cardiac output
Baseline: • tissue perfusion
Full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistry, • metabolic state
arterial blood gases

MONITOR
Notify transfusion laboratory (insert contact no.) to: (every 30–60 mins):

‘Activate MTP’ • full blood count

• coagulation screen
• ionised calcium
• arterial blood gases
Senior clinician
Laboratory staff • Request:a
• Notify haematologist/transfusion specialist o 4 units RBC AIM FOR:
• Prepare and issue blood components o 2 units FFP
as requested • temperature > 350C
• Consider:a
• Anticipate repeat testing and
o 1 adult therapeutic dose platelets • pH > 7.2
blood component requirements • base excess < –6
o tranexamic acid in trauma patients
• Minimise test turnaround times
• Include:a • lactate < 4 mmol/L
• Consider staff resources
o cryoprecipitate if fibrinogen < 1 g/L • Ca2+ > 1.1 mmol/L
Haematologist/transfusion a Or locally agreed configuration • platelets > 50 × 109/L
specialist • PT/APTT < 1.5 × normal
• Liaise regularly with laboratory • INR ≤ 1.5
and clinical team Bleeding controlled? • fibrinogen > 1.0 g/L
• Assist in interpretation of results, and
advise on blood component support
YES NO
Notify transfusion laboratory to:
‘Cease MTP’

Suggested criteria for activation of MTP

• Actual or anticipated 4 units RBC in < 4 hrs, + haemodynamically unstable, +/– anticipated ongoing bleeding
• Severe thoracic, abdominal, pelvic or multiple long bone trauma
• Major obstetric, gastrointestinal or surgical bleeding

Initial management of bleeding Resuscitation

• Identify cause • Avoid hypothermia, institute active warming
• Initial measures: • Avoid excessive crystalloid
- compression • Tolerate permissive hypotension (BP 80–100 mmHg systolic)
- tourniquet until active bleeding controlled
- packing • Do not use haemoglobin alone as a transfusion trigger
• Surgical assessment:
- early surgery or angiography to stop bleeding
Special clinical situations
Specific surgical considerations • Warfarin:
• add vitamin K, prothrombinex/FFP
• If significant physiological derangement, consider • Obstetric haemorrhage:
damage control surgery or angiography • early DIC often present; consider cryoprecipitate
• Head injury:
Cell salvage • aim for platelet count > 100 × 109/L
• permissive hypotension contraindicated
• Consider use of cell salvage where appropriate

Dosage Considerations for use of rFVIIab

The routine use of rFVIIa in trauma patients is not recommended due to
Platelet count < 50 x 109/L 1 adult therapeutic dose its lack of effect on mortality (Grade B) and variable effect on morbidity
INR > 1.5 FFP 15 mL/kga (Grade C). Institutions may choose to develop a process for the use of
rFVIIa where there is:
Fibrinogen < 1.0 g/L cryoprecipitate 3–4 ga • uncontrolled haemorrhage in salvageable patient, and
• failed surgical or radiological measures to control bleeding, and
Tranexamic acid loading dose 1 g over 10
• adequate blood component replacement, and
min, then infusion of 1 g
over 8 hrs • pH > 7.2, temperature > 340C.
Discuss dose with haematologist/transfusion specialist
a Local transfusion laboratory to advise on number of units
b rFVIIa is not licensed for use in this situation; all use must be part of practice review.
needed to provide this dose

ABG arterial blood gas FFP fresh frozen plasma APTT activated partial thromboplastin time
INR international normalised ratio BP blood pressure MTP massive transfusion protocol
DIC disseminated intravascular coagulation PT prothrombin time FBC full blood count
RBC red blood cell rFVlla activated recombinant factor VII

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P
R
MANAGEMENT of MASSIVE TRANSFUSION (MMT) for TRAUMA
Hospital MMT alert confirmation
E Pre-hospital MMT alert: (patient requiring urgent transfusion)
V - SBP < 90
E
•Systolic BP < 90 - HR > 100

N •Poor response to initial MMT ACTIVATION - Ph < 7.35

- BE < - 2
T fluid resuscitation For Trauma - Obvious signs of uncontrollable active
bleeding
•Suspected active - Poor responder to fluid resuscitation
H (Trauma Team leader must declare
Y haemorrhage MMT Activation to blood bank ,WHH
If so activate MMT (match 3 of the ocriteria)
P PATIENT ARRIVAL Bleep no:8662)
O Take bloods (FBC, U&E, Clotting,
T fibrinogen and X-match and ABG) Co-ordinate Porter urgently to standby for
Collection of MMT pack one
H HAEMOSTASIS Send pink bottle with X-match form to
blood bank urgently ( please obtain 2
E samples for x-match at different time if
R possible)
M THERAPY TARGET end point:
I
MMT PACK 1
A HAEMORRHAGE CONTROL:
4 x O –ve RBC ( female) or O+ve(Male)
Surgery
Stabilize fractures 4 x AB FFP (or Group specific if possible)
Hb: 8-10 g/dl
A Pelvic brace
PREVENT HYPOTHERMIA
Platelets > 100
C
I PT&APTT (INR)< 1.5
D
O
RE-ASSESSMENT
Fail to
reach Fibrinogen > 1.0 g/l
HAEMOSTATIC DRUGS: ABCDE
S Consider the following if bleeding persist If haemorrhage continue
targets
Ca²⁺ > 1 mmol/l
I despite surgical interventions:
S Activated factor VII pH: 7.35-7.45
Beriplex (consider when patient who is on
anti-coagulant)
Activate MMT PACK 2
BE: ± 2
Antifibrinolitic agents
C
O
Please discuss any of these therapeutic
Please, specify location of
patient
Tª > 36 °C
measures with Haematologist on call)
A
G 2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l

U INTRA-OPERATIVE CELL SALVAGE: MMT PACK 2

L Transfuse 1 x FFP every 250 ml of blood Once administered check:
O Transfuse 1 x ATD platelets every 1000 4 X RBC 1 X ATD FBC, Clotting, fibrinogen and ABG
ml of blood 4 X FFP Platelets
P
A
T When MMT stops
H Notify blood bank Return any unused products Resume standard ordering practices
Y

Warming Blood
l Warming of blood is not necessary for routine tx . Warming
increasing metabolism, reduce 2,3-DPG & risk bacterial
growth

l Indication for warming blood:

l Adult receiving over 50 ml/kg/hr
l Child receiving over 14 ml/kg/hr
l Exchange tranfusion
l Rapid infusion CVP lines
l Presence of cold aglutinines

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Starting Transfusion
„ Prohibited to addition drugs & medications to
blood bag/set EXCEPT normal Saline.
„ Do not use dextrose 5% or Ringer Lactate.
„ Use 170 u standard filter.
„ Transfusion must be completed in 4 hours.
„ Hemodynamically stable 2 hours
„ Hemodynamically unstable 4 hours

Don’ts for Blood Transfusion

l Don’t Use blood from non-licensed.

l Don’t delay initiation of blood

transfusion.

l Don’t Warm blood in an monitored

fashion.

l Don’t Use routine pre-transfusion

medication.

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Don’ts for Blood Transfusion

l Don’t transfuse over more 4 hours.

l Don’t leave patients unmonitored.

l Don’t add any medication to blood bag

l Don’t forget to return unused blood to

blood bank for disposal

Don’ts for Blood Transfusion

l Don’t ask for all the blood bag at one time

l Don’t Use unmonitored refrigerator for

storage

l Don’t Use one transfusion set for more

than 4 hours / more than 4 unit of blood

l Don’t wet outlet port of blood bag while

warming or thawing

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