1. ROLE OF LABORATORY MEDICINE IN CARE OF CRITICALLY ILL MOTHERS AND INFANTS DR ANDREW K. GACHII

2. INTRODUCTION Laboratory tests play a crucial role in practice of medicine Laboratory tests play a crucial role in practice of medicine Estimated that up to 70% of diagnosis in medical practice is made in the lab. Estimated that up to 70% of diagnosis in medical practice is made in the lab. Implies that lab. tests are a necessary tool before treatment is instituted Implies that lab. tests are a necessary tool before treatment is instituted More crucial in Emergencies including management of acute obstetric/neonatal cases More crucial in Emergencies including management of acute obstetric/neonatal cases

3. INTRODUCTION Pregnancy is considered a normal physiologic process. Pregnancy is considered a normal physiologic process. However it is associated with significant alterations in the ‘normal’ values However it is associated with significant alterations in the ‘normal’ values ‘Normal’ values are higher or lower in pregnancy than in non-pregnant state ‘Normal’ values are higher or lower in pregnancy than in non-pregnant state

4. INTRODUCTION Examples of ‘normal values’ affected in pregnancy include. Hb and Haematocrit- reduced by 43% due to haemodilution. Blood urea Nitrogen(BUN) as well as creatinine tend to reduce from 13 and 1.1 to 4-7 and 0.4-0.7 respectively. Due to increased renal clearance.

5. PHYSIOLOGIC CHANGES IN PREGNANCY Test Effect of Pregnancy Test Effect of Pregnancy Bilirubin Unchanged Bilirubin Unchanged ALS & AST Unchanged ALS & AST Unchanged Prothrombin time Unchanged Prothrombin time Unchanged Alkaline phosphates Increase 2 4 fold (2 X ULN) (placenta) 2- Alkaline phosphates Increase 2 4 fold (2 X ULN) (placenta) 2- Bile acids Increase 2 3 fold (glycocholate, taurocholate, chenodeoxycholate) 2- Bile acids Increase 2 3 fold (glycocholate, taurocholate, chenodeoxycholate) 2- Fibrinogen Increases 50% Fibrinogen Increases 50% Globulins Increases alpha & beta; Decreases gamma Globulins Increases alpha & beta; Decreases gamma Alpha fetoprotein Increases (specially with twins) Alpha fetoprotein Increases (specially with twins) Hemoglobin Decrease in late pregnancy Hemoglobin Decrease in late pregnancy

6. PHYSIOLOGIC CHANGES IN PREGNANCY Leukocyte count Increases Leukocyte count Increases Ceruloplasmin Increase Ceruloplasmin Increase Cholesterol Increases 2 fold 2- Cholesterol Increases 2 fold 2- Triglycerides Increase Triglycerides Increase

7. Recommended laboratory tests in the initial prenatal care visit 1. Hct, Hb 2. U/A,U/C 3. BG,Rh 4. Pap smear 5. Antibody screen 6. Rubella status 7. Syphilis screen 8. Hbs Ag 9. Offer HIV testing

8. CRITICALLY ILL MOTHERS Pre-eclampsia Pre-eclampsia HELLP Syndrome HELLP Syndrome Amniotic fluid embolism Amniotic fluid embolism Eclampsia Eclampsia Septic pelvic Septic pelvic Acute Fatty Liver of pregnancy Acute Fatty Liver of pregnancy PeripartumCardiomyopathy PeripartumCardiomyopathy Peripartum Hemorrhage Peripartum Hemorrhage Sheehan’s syndrome Sheehan’s syndrome thrombophlebitis thrombophlebitis Supine hypotension syndrome Supine hypotension syndrome Ectopic pregnancy Ectopic pregnancy DIC after fetal demise DIC after fetal demise

9. BLOOD TRANSFUSION Obstetric emergencies are almost always associated with blood transfusion Obstetric emergencies are almost always associated with blood transfusion A life saving procedure but is not without risks A life saving procedure but is not without risks Recipient may develop transfusion – transmitted infection as well as suffer from immunological sequel e.g. red call alloimmunisation. Recipient may develop transfusion – transmitted infection as well as suffer from immunological sequel e.g. red call alloimmunisation.

10. BLOOD TRANSFUSION Hence strict adherence to correct sampling, cross-match and administration procedures is of paramount importance even in emergency. Hence strict adherence to correct sampling, cross-match and administration procedures is of paramount importance even in emergency. Careful evaluation in utilization of blood and blood products necessary. Careful evaluation in utilization of blood and blood products necessary. At KNH we are able to provide, Whole blood (ideally should not be used unless in dire emergency), red cell concentrates, fresh frozen plasma, platelet concentrates. At KNH we are able to provide, Whole blood (ideally should not be used unless in dire emergency), red cell concentrates, fresh frozen plasma, platelet concentrates.

11. BLOOD TRANSFUSION Lab is able to do initial blood grouping and cross-matching, antibody screening and identification. Lab is able to do initial blood grouping and cross-matching, antibody screening and identification. Investigate blood transfusion reactions Investigate blood transfusion reactions Main challenges in blood transfusion is the availability of blood and blood products, manual procedures with associated delay in release of blood and delays in supplies of reagents. Main challenges in blood transfusion is the availability of blood and blood products, manual procedures with associated delay in release of blood and delays in supplies of reagents. Minimized when the new-blood transfusion centre is opened. Minimized when the new-blood transfusion centre is opened. Host state of the art lab. And transfusion centre. Host state of the art lab. And transfusion centre.

12. BLOOD TRANSFUSION Plasma fractionsBlood componentsWhole blood CryoprecipitateFresh Frozrn PlasmaplateletsPacked red cellsFreshCryoprecipitateFresh Frozrn PlasmaplateletsPacked red cellsFresh - old Clotting factor concentratesClotting factor concentrates Immunoglobulin preparationsImmunoglobulin preparations Saline albumin solutionSaline albumin solution Salt-poor albumin when fibrinogen level is less than 80-100mg/dlSalt-poor albumin when fibrinogen level is less than 80-100mg/dl Initially a tx for VW Dz, Hemophilia Now a source of fibrinogen in obstetric emergencies when PT & PTT are higher than 1.5 times control levels All clotting factors; no platelets Can supplement RBC’s when whole blood not available for exchange transfusion when platelet. count less than 50000/cmm or when massive blood loss or replacement has occurred -Washed RBC’s or when massive blood loss or replacement has occurred -Washed RBC’s Pts with allergic reactions to plasma proteins -Leuko-poor RBC’s Pts with febrile, non-hemolytic reactions to plasma WBC’s DIVC Massive haemorrhage Major liver trauma Bleeding associated with liver disease Clotting disorders Haemophilia Liver disease dose: 1- 1.5 -2 packs/ 10 kg (8-10 packs) normal dose: 12 - 15ml/ kg (8-10 packs) normal dose: 12 - 15ml/ kg (4-5packs) Platelet concentrates (4-5packs) Platelet concentrates (1 pack/10kg) (1 pack/10kg) dose : 6units RDP or 1 unit SDP

13. OTHER HAEMATOLOGICAL INVESTIGATIONS Total white cell counts especially in patients with sepsis Total white cell counts especially in patients with sepsis Platelet counts in cases of thrombocytopenia and DIC Platelet counts in cases of thrombocytopenia and DIC Coagulation factors including monitoring of fibrinogen and d- dimers level in cases of DIC. Coagulation factors including monitoring of fibrinogen and d- dimers level in cases of DIC.

14. MICROBIOLOGY Of major importance in cases of sepsis both in mothers and neonates. Of major importance in cases of sepsis both in mothers and neonates. Tests include direct staining of micro-organisms e.g. gram stain- may provide quick diagnosis Tests include direct staining of micro-organisms e.g. gram stain- may provide quick diagnosis Cultures are the hall-mark- include urine, csf, and most important blood cultures. Cultures are the hall-mark- include urine, csf, and most important blood cultures. Main challenge is the cost of reagents and in particular the bottles Main challenge is the cost of reagents and in particular the bottles Cost cannot be sustained by the KNH charges. Cost cannot be sustained by the KNH charges. Ideal is to automate cultures and sensitivity testings. Ideal is to automate cultures and sensitivity testings. Blood culture --

15. IMMUNOLOGY Rapid tests for pregnancy especially in cases of suspected ectopic pregnancy. Rapid tests for pregnancy especially in cases of suspected ectopic pregnancy. Testing for viral infections including Hepatitis B as C as well as HIV. Testing for viral infections including Hepatitis B as C as well as HIV. Especially crucial in in acutely ill mothers who may require dialysis. Especially crucial in in acutely ill mothers who may require dialysis. Main challenge is the supply of reagents and outdated equipment. Main challenge is the supply of reagents and outdated equipment.

16. CLINICAL CHEMISTRY Forms backbone of laboratory support in diagnosis and management of critically ill mothers and neonates. Forms backbone of laboratory support in diagnosis and management of critically ill mothers and neonates. Ranges from liver function tests, renal function tests to endocrinology. Ranges from liver function tests, renal function tests to endocrinology. At KNH we have been able to place Clinical Chemistry Equipment at no cost. At KNH we have been able to place Clinical Chemistry Equipment at no cost. The supply of reagents is through contract with the owner’s of the equipment. The supply of reagents is through contract with the owner’s of the equipment. Through these equipment we are able to do liver function tests within minutes. Through these equipment we are able to do liver function tests within minutes.

17. CLINICAL CHEMISTRY We are able to reduce the turn-around time from two day to one hour or less We are able to reduce the turn-around time from two day to one hour or less Main advantage is the back-up whereby several equipments are available in various labs that utilize the same reagents Main advantage is the back-up whereby several equipments are available in various labs that utilize the same reagents Main challenge is reagent supply. Main challenge is reagent supply. Maintaining the Internal and external quality control (IQA and EQA) due to cost. Maintaining the Internal and external quality control (IQA and EQA) due to cost.

18. CLINICAL CHEMISTRY-CT Of importance in neonatal jaundice and sepsis Of importance in neonatal jaundice and sepsis Levels of bilirubin can be availed within 5-10 minutes Levels of bilirubin can be availed within 5-10 minutes We have developed an SOP on communicating on critical values We have developed an SOP on communicating on critical values Clinician should be informed immediately such values are detected. Clinician should be informed immediately such values are detected.

19. CLINICAL CHEMISTRY Main challenge is the delay in communicating the results. Main challenge is the delay in communicating the results. We are in the process of automating at least six of its key laboratories including chemistry and microbiology. We are in the process of automating at least six of its key laboratories including chemistry and microbiology. Clinicians will be able to receive and retrieve the results from their workstations. Clinicians will be able to receive and retrieve the results from their workstations.

20. CLINICAL CHEMISTRY Complete automation likely to be complete this financial year. Complete automation likely to be complete this financial year. Delayed reports can be avoided through introduction of more POINT OF CARE testing. Delayed reports can be avoided through introduction of more POINT OF CARE testing. Already familiar with use of Hb meters glucometers-can more tests e.g bilirubin be introduced. Already familiar with use of Hb meters glucometers-can more tests e.g bilirubin be introduced. Main challenge is calibration and quality control. Main challenge is calibration and quality control.

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