appropriate use of blood transfusion in obstetrics and

appropriate use of blood transfusion in obstetrics and gynecology PRESENTER LAMIN F JARJU 5 th yr medical student school of medicine and allied health sciences clinical presentation in afprc general hospital, farafenni 11 th february 2010

an outline v. HISTORY OF THE PATIENT v. DISCUSSION

biodata ü Name: - MJ ü 33 yr old female ü Fula and living in Maida Biron Penda ü Married ü House wife ü G 8 P 6+1 ü LMP : nine months ago (…/04/09) ü GA: ü EDD: ü Do. A: 22/01/10

history ü Referred from Maida Biron Health Centre ü Informant: Self ü Presenting complaint: Dizziness for 5 days ü History of presenting complaints: ü Index pregnancy: booking at 5 months; red tabs given, BP checked. Then monthly visits; where only red tabs were given, no white tab ü Obstetric history: G 8 P 6+1, 3 alive, 2 boys and 1 girl, well breastfed but can’t remember their ages, 3 preterm and died after delivery, 1 abortion

history ü Gynae history: Menarch at 12 yrs, period 7 days. Bleeding heavier in the first 3 days then it reduce in the remaining days, no discharge ü PMH: No HBP, No DM, No sickle cell disease, hospitalized once due to abortion a year and 6 mths ago in which she was transfused but without no allergic reaction ü Family history: both parents are dead, father died of HBP but can’t remember the cause of death for the mother

Histor. Y ü Psychosocial History: 2 nd wife in a polygamous marriage, cordial relationship with family and friends, neither smokes nor drinks, does little exercise, has little access to vegetables. Eats porridge for Bfast, rice for lunch n dinner and sometime maize “chereh” ü Review of systems: Digestive: no nausea, no vomiting, no diarrhea, no constipation, Resp: no cough, no dyspnoea, no chest pain CVS: no oedema, no tachpnea, no palpitation CNS: no headache, no convulsions, dizziness MSK: no joint pain, swelling or stiffness Urogenital: no dysuria, no polyuria, no hematuria, no discharge Haematological : dizziness, no weakness, no palpitation Endrocrine: no fatigue, no weakness, no polydipsia

e. Xamination and diagnosis ü o/e: pale(+++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration ü CV: pulse 88 beats/min, BP 110/70 mmhg, s 1 and s 2 heard, normal, no murmurs ü Resp: RR 22 cycles/min, VBS, no added sound ü Abd: distended, soft, no tenderness, linear nigra, SFH 36 cm, Presentation cephalic, lie longitudinal, no palpable organomegaly, FHR 120 beats/min ü CNS: conscious and oriented, no neurological deficit ü impression: anaemia in term pregnancy

in. Vestigations ü Hb: 5. 6 g/dl ü Grouping and cross matching: Group O+ ü Abdominal ultrasound

management day 1 ü 2 pints of blood should be cross matched ü Folic acid 1 tab daily 2/52 ü Fefa 1 tab daily 1/12 ü Hb 12 syrup 10 ml BD 2/52 ü Vit C 1 tab daily 2/52 v 1 pint of blood transfused + frusemide 20 mg iv

progress note: day 2 ü Pt seen: no complaint ü o/e: pale(++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration ü CV: pulse 84 beats/min, BP 110/70 mmhg, s 1 and s 2 heard, normal, no murmurs ü Resp: RR 20 cycles/min, VBS, no added sound ü Abd: NAD ü CNS: conscious and oriented, no neurological deficit Plan: - received 2 nd pint of blood + 20 mg iv contd on her medications

progress note: day 3 ü Pt seen: no complaint ü o/e: pale(++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration ü CV: pulse 86 beats/min, BP 110/70 mmhg, s 1 and s 2 heard, normal, no murmurs ü Resp: RR 18 cycles/min, VBS, no added sound ü Abd: NAD ü CNS: conscious and oriented, no neurological deficit Plan: - post-transfusional hb =8. 6 g/dl contd on her medications

progress note: day 4 ü Pt seen: no complaint ü o/e: pale(+), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration ü CV: pulse 84 beats/min, BP 110/70 mmhg, s 1 and s 2 heard, normal, no murmurs ü Resp: RR 20 cycles/min, VBS, no added sound ü Abd: NAD ü CNS: conscious and oriented, no neurological deficit Plan: - Discharged contd on her medications and advice on diet

discussion Ø Background Ø Purpose and Scope Ø Blood group and their likely donors Ø Blood components and blood products Ø Causes of blood transfusion in Maternity Ø Guidelines for the clinical use of Red cell transfusion Ø Prescription of blood/blood products Ø Patient observation Ø Transfusion reactions and their management Ø The end

background ü Transfusion of blood or blood products is an invaluable therapeutic measure ü It should, however, not be given without good reason because of its potential hazards ü Currently whole blood is fractionated into specific components which can be tailored to the physiological needs of the patients

purpose and scope ü Obstetric conditions associated with the need for blood transfusion may lead to morbidity and mortality if not managed correctly. ü The increasingly important issues in blood transfusion are adverse events associated with it, including potential transmission of prions, rising costs and the possible future problems of availability. ü The aim of this presentation is to offer guidance about the appropriate use of blood products that neither compromises the affected woman nor exposes her to unnecessary risk.

the abo system: antigens and antibodies PHENOTYPE GENOTYPE ANTIGENS ANTIBODIES FREQUENCY UK (%) O OO None Anti-A and Anti- 44 B A AA or AO A Anti-B 45 B BB or BO B Anti-A 8 AB AB A and B None 3

blood group and their likely donors BLOOD GROUP POSSIBLE DONORS Group 0 - (universal donor) O- Group O+ O+, O- Group A- A-, 0 - Group A+ A+, A-, O+, O- Group B- B-, O- Group B+ B+, B-, O+, O- Group AB-, A-, B-, O- Group AB+ (universal recipient) AB+, AB-, A+, A-, B+, B-, O+, O-

blood components and blood products Ø Blood components, such as red cell and platelet concentrates, fresh frozen plasma (FFP) and cryoprecipitate, are prepared from a single donation of blood by simple separation methods such as centrifugation and are transfused without further processing. Ø Blood products, such as coagulation factor concentrates, albumin and immunoglobulin solutions, are prepared by complex processes using the plasma from many donors as the starting material

blood components and blood products ü Whole blood ü Red cell concentrates ü Washed red cell concentrate ü Platelet concentrate ü Granulocyte concentrate ü Fresh frozen plasma ü Cryoprecipitate ü Factor VIII and IX concentrates ü Albumin

autologous transfusion • Predeposit. The patient donates 2 -5 units of blood at approximately weekly intervals before elective surgery. • Preoperative haemodilution. One or two units of blood are removed from the patient immediately before surgery and retransfused to replace operative losses. • Blood salvage. Blood lost during or after surgery may be collected and retransfused. Several techniques of varying levels of sophistication are available. The operative site must be free of bacteria, bowel contents and tumour cells.

regarding blood transfusion in obstetrics: Ø t. Wo main causes of maternal morbidity and mortality are : 1 - CHRONIC ANEMIA OF PREGNANCY 2 - MAJOR OBSTETRIC HAEMORRHAGE

units of blood re. Quired in obs and gynae procedures CONDITION NO. OF UNITS Lower segment caesarian section Group and save Ante partum haemorrhage 2 -6 Postpartum haemorrhage 2 -6 Evacuation of retained products Group and save Hydatidiform mole 2 Hysterectomy Group and save Myomectomy 2 Endometrial resection Group and save Radical oophorectomy 2 Pre-eclampsia Group and save Multiple gestation Group and save Ectopic Pregnancy 2 -4

guidelines for the clinical use of red cell transfusion For patients who are anaemic for reasons other than acute blood loss: Ø Blood transfusion is not indicated when the Hb is >10 g/dl Ø Red cell transfusion is generally indicated when the Hb is <7 g/dl Ø Patients with Hb levels between 7 and 10 g/dl should be clinically assessed and only transfused if clinically indicated

guidelines for red cell administration in acute blood loss v Objective: to maintain circulating blood volume and Hb conc >7 g/dl in otherwise fit patients, and >9 g/dl in older patients and those with cardiovascular dz: v Loss of blood volume Ø 15 -30% (800 -1500 ml in an adult): transfuse crystalloids or synthetic colloids. Red cell transfusion (RCT) is unlikely to be necessary Ø 30 -40% (1500 -2000 ml in an adult): rapid volume replacement is required with crystalloids or synthetic colloid. RCT will probably be required to maintain recommended Hb levels Ø >40% (> 2000 ml in an adult): rapid volume replacement including RCT transfusion required

prescription of blood/blood products ü The requesting Medical Officer/ Nurse must prescribe blood and blood products on a blood form ü The blood form must contain: § Full name § DOB § Gender § Address § Diagnosis § Consultant § Signature § Date

patient observation Ø vital signs relating to transfusion should be recorded from routine observations and clearly dated and timed Ø Pre-transfusion: temperature, pulse and BP Ø After 15 mins: temperature and pulse Ø On completion of each unit transfused: temperature, pulse and BP

transfusion reactions q typical symptoms: chest/back/abdominal/bone/muscle pain, headache, restlessness/agitation, flushing, breathlessness/coughing, generally feeling on well q typical signs: pyrexia, tachycardia, hypotension, haematuria (hemoglobinuria), vomiting/diarrhoea, urticaria, rigors, collapse

complications of blood transfusion immunological • Alloimmunization and incompatibility Red cells • Immediate haemolytic transfusion reactions • Delayed haemolytic transfusion reactions • Leucocytes and platelets • Non-haemolytic (febrile) transfusion reactions • Post-transfusion purpura • Poor survival of transfused platelets and granulocytes • Graft-versus-host disease • Lung injury (TRALI) • Plasma proteins • Urticarial and anaphylactic reactions non-immunological • Transmission of infection Viruses: • HAV, HBV, HCV • HIV • CMV, EBV, HTLV-1, West Nile virus • Parasites: • malaria, trypanosomiasis toxoplasmosis • Bacteria • Prion - v. CJD • Circulatory failure due to volume overload • Iron overload due to multiple transfusions • Massive transfusion of stored blood may cause bleeding reactions and electrolyte changes • Physical damage due to freezing or heating • Thrombophlebitis Air embolism

in the event of a transfusion reaction 1. Stop the transfusion immediately 2. Inform medical staff and blood bank staff immediately 3. In the case of anaphylaxis( bronchospasm, cyanosis, hypotension, etc) § Maintain airway and give oxygen § Give adrenaline IM 0. 5 mg (0. 5 ml of 1: 1000) § Repeat every 5 mins, if needed as guided by BP, pulse and RR until better § Chlorpheniramine (piriton) 10 mg iv and hydrocortizone 250 mg iv

in the event of a transfusion reaction contd § Ivi (0. 9% saline, eg 500 ml over ¼ hour; upto 2 L may be needed § Titrate against BP Ø In case of fluid overload(dyspnoea, hypoxia, raised JVP, basal crepitation) § Give oxygen and a diuretic eg frusemide 40 mg iv initially 4. Send to blood bank: all part/fully transfused blood bags from the transfusion. Two 5 ml EDTA samples, a sample of first urine passed 5. Send a 4. 5 ml EDTA sample for FBC and citrate sample for clotting screening to haematology, clotted samples for biochemistry investigations and blood culture samples to microbiology.