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

2. 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

3. 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

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

5. 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

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

7. 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

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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

10. DIC is a consequence of delayed or inadequate resuscitation
Dr Mona Shroff

11. 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

12. 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

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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

14. 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

15. 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 mg/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: packs/ 10 kg
(8-10 packs)
normal dose: ml/ 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

16. 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

17. Dr Mona Shroff www.obgyntoday.info
Fresh Frozen Plasma
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

18. Dr Mona Shroff www.obgyntoday.info
Guidelines: FFP Use
Usual dosing: ml/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

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

20. Cryoprecipitate: Dosing
1-2 Units / 10 Kg
Expect mg/dl rise in fibrinogen
Goal: Fibrinogen 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

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

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

23. 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

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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, mcg/kg of body weight) have yet to be established
Cost of rFVIIa is over $3000 / patient
Dr Mona Shroff

25. 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

26. 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

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