COMPONENT THERAPY IN MASSIVE OBSTETRIC HAEMORRHAGE Dr. Mona Shroff, M.D.(O&G) Dr Mona Shroff www.obgyntoday.info

MASSIVE OBSTETRIC HAEMORRHAGE DEFINITION Any blood loss occurring in the peripartum period, revealed or concealed, that is likely to endanger life N.B. Physiological & hematological changes induced by pregnancy can hide signs of hypovolemic shock & patient can collapse suddenly. Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Massive transfusion Massive blood loss may be defined as: Loss of one blood volume within a 24 hour period. (7% of lean body weight (5 litres in an adult) Loss of 50% of blood volume within 3 hours. Loss of blood at a rate in excess of 150 ml. per minute. Dr Mona Shroff www.obgyntoday.info

Purpose of Blood transfusion Maintenance of oxygen-carrying capacity of the blood Replacement of clotting factors Replacement of vascular volume Dr Mona Shroff www.obgyntoday.info

Three primary reasons driving the quest for a substitute for Blood: Quantity Chronic shortages Purity h/o “ooze for booze” leading to tainted blood products infections Storage blood is perishable long and short term storage is an expensive problem Dr Mona Shroff www.obgyntoday.info

REMEMBER… THE DECISION FOR BLOOD TRANSFUSION SHOULD ALWAYS BE A BALANCE BETWEEN

Dr Mona Shroff www.obgyntoday.info SYMPTOMS & SIGNS Blood loss (% B Vol) Systolic BP ( mm of Hg) Signs & Symptoms 10-15 Normal postural hypotension 15-30 slight fall PR, thirst, weakness 30-40 60-80 pallor,oliguria, confusion 40+ 40-60 anuria, air hunger, coma, death Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info 1-Every obstetric unit should have a current protocol for major obstetric haemorrhage and all staff should be trained to follow it. 2-Initial resuscitation with replacement fluids (crystalloid (RL)-3ml / ml of blood loss) is a priority to restore blood volume Dr Mona Shroff www.obgyntoday.info

DIC is a consequence of delayed or inadequate resuscitation Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info 3-Obtain and send 2 blood samples: *To blood bank for grouping and crossmatching (crossmatch is not required after replacement of 1 blood volume (8 Units in adults) as the cells by then are unrepresentative.) *To lab to obtain baseline for Hb, Htc, PT, PTT ,platelet count & fibrinogen levels 4- Inform blood bank that it is an emergency Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Give Packed Red Cell 5- Initial packed red cell infusion to restore O2 delivery to tissues Fully matched blood Group O Rh –ve cells should be available in 5 minutes Group specific uncrossmatched blood (1/3 of the patient’s estimated blood volume has been lost.) Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info 6-Component replacement therapy according to coagulation screen 7- Continuous lab & clinical monitoring to guide treatment. ( REPEAT AS SERIAL ESTIMATIONS every 4 hours or more often, as necessary after component therapy.) Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Base treatment on need to:– – Maintain fibrinogen level above 1 g/l. – Maintain PT and APPT less than 1.5 times control value – Stop persistent active bleeding Dr Mona Shroff www.obgyntoday.info

Plasma fractions Blood components Whole blood Cryoprecipitate Fresh Frozrn Plasma platelets Packed red cells Fresh old Immunoglobulin preparations Saline albumin solution Clotting factor concentrates Salt-poor albumin when fibrinogen level is less than 80-100mg/dl when PT & PTT are higher than 1.5 times control levels when pl count < 50000/cmm or when massive replacement -Washed RBC’s Pts with allergic reactions to plasma proteins DIVC Massive haemorrhage Clotting disorders Haemophilia Liver disease dose: 1- 1.5 -2 packs/ 10 kg (8-10 packs) normal dose: 12 - 15ml/ kg (4-5packs) Platelet concentrate (1 pack/10kg) dose : 6units RDP or 1 unit SDP -Leuko-poor RBC’s Pts with febrile, non-hemolytic reactions to plasma WBC’s

Dr Mona Shroff www.obgyntoday.info 8- Massive transfusion of stored whole blood can aggravate coagulopathy due to: - Dilutional thrombocytopenia - Coagulation factor depletion - Acidosis - Hypothermia thus 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 Microaggregate blood filters Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Fresh Frozen Plasma 200-250 ml of plasma containing all clotting factors, AT III, Protein C & S. Compatibility Important Can Give: A plasma to A or O patient B plasma to B or O patient O plasma to O patient AB plasma to anyone Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Guidelines: FFP Use Usual dosing: 10-15ml/Kg 15-20% rise in factor levels Usually does not correct laboratory coagulation status to “normal” Evidence for its use as prophylaxis in nonbleeding patients, is limited Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Cryoprecipitate 10-15 ml per unit (bag) Fibrinogen 250 mg Factor VIII 80-120 units Von Willebrand Factor 40-70% of FFP Factor XIII 20-30% of FFP Fibronectin 20-40 mg Dr Mona Shroff www.obgyntoday.info

Cryoprecipitate: Dosing 1-2 Units / 10 Kg Expect 60-100 mg/dl rise in fibrinogen Goal: Fibrinogen 70-100 mg/dl Patients on massive transfusion protocol and receiving greater than 10 units of FFP generally do not need additional cryoprecipitate, having received an adequate bolus of fibrinogen in the large quantity of FFP. Dr Mona Shroff www.obgyntoday.info

Platelets: Risk of Spontaneous Hemorrhage Count Site > 40,000 Minimal 20-40,000 GI Mucosa 5-20 Skin,Mucus Membranes < 5 CNS, Lung Dr Mona Shroff www.obgyntoday.info

Prophylactic Platelet TX Guidelines Platelet Count/μl Recommendation 0-5,000 Always 5-10,000 If Febrile of Minor Bleeding 11-20,000 If coagulopathy / minor procedure >20,000 If Major Bleed / invasive procedure Dr Mona Shroff www.obgyntoday.info

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 Product Age? Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info rFVIIa 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. Thrombosis ?? Dosing guidelines for h’ge (general range, 90-120 mcg/kg of body weight) have yet to be established Cost of rFVIIa is over $3000 / patient Dr Mona Shroff www.obgyntoday.info

Types of Replacement Products under research Oxygen Carrying Solutions Hemoglobin Based Oxygen Carrying Solutions (HBOCS) Perflourocarbons Other Antigen Camouflage Recombinant Plasma Proteins Transgenic Therapeutic Proteins Platelet Substitutes Dr Mona Shroff www.obgyntoday.info

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 Dr Mona Shroff www.obgyntoday.info

Dr Mona Shroff www.obgyntoday.info Thank you Dr Mona Shroff www.obgyntoday.info