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

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. 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. 2 Dr Mona Shroff

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. 3 Dr Mona Shroff

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

Three primary reasons driving the quest for a substitute for Blood: Quantity Quantity Chronic shortages Chronic shortagesPurity h/o “ooze for booze” leading to tainted blood products h/o “ooze for booze” leading to tainted blood products infections infections Storage Storage blood is perishable blood is perishable long and short term storage is an expensive problem long and short term storage is an expensive problem 5 Dr Mona Shroff

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

SYMPTOMS & SIGNS Blood loss (% B Vol) Systolic BP ( mm of Hg) Signs & Symptoms 10-15Normal postural hypotension slight fall  PR, thirst, weakness pallor,oliguria, confusion anuria, air hunger, coma, death 7 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 9 Dr Mona Shroff

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

3-Obtain and send 2 blood samples : * To blood bank for grouping and crossmatching ( *To lab to obtain baseline for Hb, Htc, PT, PTT,platelet count & fibrinogen levels 4- Inform blood bank that it is an emergency 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 11 Dr Mona Shroff

Give Packed Red Cell 5- Initial packed red cell infusion to restore O 2 delivery to tissues Fully matched blood Fully matched blood Group O Rh –ve cells should be available in 5 minutes Group O Rh –ve cells should be available in 5 minutes Group specific uncrossmatched blood ( Group specific uncrossmatched blood ( 1/3 of the patient’s estimated blood volume has been lost.) 12 Dr Mona Shroff

6-Component replacement therapy according to coagulation screen 7- Continuous lab & clinical monitoring to guide treatment. ( 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.) 13 Dr Mona Shroff

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 14 Dr Mona Shroff

Plasma fractions Blood components Whole blood Cryopreci pitate Fresh Frozrn Plasma platelets Packed red cells - Fresh - old Immunoglobuli n preparations Immunoglobuli n preparations Saline albumin solution Saline albumin solution Clotting factor concentrates Clotting factor concentrates Salt-poor albumin 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 or when massive replacement - Washed RBC’s Pts with allergic reactions to plasma proteins DIVC Massive haemorrha ge Clotting disorders Haemophilia Liver disease dose: packs/ 10 kg (8-10 packs) (8-10 packs) normal dose: ml/ kg (4- 5packs) (4- 5packs) Platelet concentrate (1 pack/10kg) (1 pack/10kg) dose : 6units RDP or 1 unit SDP - Leuko- poor RBC’s Pts with febrile, non- hemolytic reactions to plasma WBC’s 15

8- Massive transfusion of stored whole blood 8- Massive transfusion of stored whole blood can aggravate coagulopathy due to: - Dilutional thrombocytopenia - Coagulation factor depletion - Acidosis - Hypothermia can aggravate coagulopathy due to: - Dilutional thrombocytopenia - Coagulation factor depletion - Acidosis - Hypothermiathus 1 unit of fresh blood for every 5 – 10 units of stored blood 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 IV 10% calcium gluconate 10 mls with every litre of transfused citrated blood Warming blood Warming blood Microaggregate blood filters Microaggregate blood filters 16 Dr Mona Shroff

Fresh Frozen Plasma ml of plasma containing all clotting factors, AT III, Protein C & S ml of plasma containing all clotting factors, AT III, Protein C & S. Compatibility Important Compatibility Important Can Give: A plasma to A or O patient 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 17 Dr Mona Shroff

Guidelines: FFP Use Usual dosing: 10-15ml/Kg Usual dosing: 10-15ml/Kg 15-20% rise in factor levels 15-20% rise in factor levels Usually does not correct laboratory coagulation status to “normal” Usually does not correct laboratory coagulation status to “normal” Evidence for its use as prophylaxis in nonbleeding patients, is limited Evidence for its use as prophylaxis in nonbleeding patients, is limited 18 Dr Mona Shroff

Cryoprecipitate ml per unit (bag) ml per unit (bag) Fibrinogen 250 mg Fibrinogen 250 mg Factor VIII units Factor VIII units Von Willebrand Factor 40-70% of FFP Von Willebrand Factor 40-70% of FFP Factor XIII 20-30% of FFP Factor XIII 20-30% of FFP Fibronectin mg Fibronectin mg 19 Dr Mona Shroff

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

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

Prophylactic Platelet TX Guidelines Platelet Count/μl Recommendation 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 >20,000 If Major Bleed / invasive procedure 22 Dr Mona Shroff

Transfused Platelets/Survival 6 units = 1 single donor unit (SDP); available as ¼, ½ and full SDP 6 units = 1 single donor unit (SDP); available as ¼, ½ and full SDP Dose:adult 1 unit/8-10 kg Dose:adult 1 unit/8-10 kg Lifespan: 7-10 Days Native Lifespan: 7-10 Days Native 2-3 Days Transfused 2-3 Days Transfused Factors shortening Lifespan: Factors shortening Lifespan: Fever, Sepsis Fever, Sepsis HLA, Platelet Specific Abs HLA, Platelet Specific Abs DIC DIC Product Age? Product Age? 23 Dr Mona Shroff

rFVIIa Recombinant activated factor VII (rFVIIa) is synthesized human factor VII that is available for reconstitution and infusion in patients with massive hemorrhage. 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. Decrease in RBC requirement,a trend toward improved survival and reductions in critical morbidities. Thrombosis ?? Thrombosis ?? Dosing guidelines for h’ge (general range, mcg/kg of body weight) have yet to be established Dosing guidelines for h’ge (general range, mcg/kg of body weight) have yet to be established Cost of rFVIIa is over $3000 / patient Cost of rFVIIa is over $3000 / patient 24 Dr Mona Shroff

Types of Replacement Products under research Oxygen Carrying Solutions Oxygen Carrying Solutions Hemoglobin Based Oxygen Carrying Solutions (HBOCS) Hemoglobin Based Oxygen Carrying Solutions (HBOCS) Perflourocarbons Perflourocarbons Other Other Antigen Camouflage Antigen Camouflage Recombinant Plasma Proteins Recombinant Plasma Proteins Transgenic Therapeutic Proteins Transgenic Therapeutic Proteins Platelet Substitutes Platelet Substitutes 25 Dr Mona Shroff

Complications of Blood Transfusion Febrile reactions Febrile reactions Bacterial contamination Bacterial contamination Immune reactions Immune reactions Physical complications Physical complications Circulatory overload Circulatory overload Air embolism Air embolism Pulmonary embolism Pulmonary embolism Thrombophlebitis Thrombophlebitis ARDS ARDS Metabolic complications Metabolic complications Hyperkalaemia Citrate toxicity & hypocalcaemia Release of vasoactive peptides Release of plasticizers from PVC- phthalates Haemorrhagic reactions Haemorrhagic reactions After massive transfusion of stored blood Disseminated intravascular coagulation Transmission of disease Transmission of disease Hepatitis, CMV. EBV AIDS (Factor VIII) Syphilis Brucellosis Toxoplasmosis Malaria Trypanosomiasis 26 Dr Mona Shroff

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Thank you 28 Dr Mona Shroff