BLOOD TRANSFUSIONIN OBSTETRICSAND

GYNAECOLOGYMarcellinus Uchechukwu Nwagu

INTRODUCTIONBlood transfusion can be a life-savingintervention especially in such conditions likepostpartum haemorrhage and massivebleeding following trauma or surgery. In manysettings, blood transfusion is the mostcommonly employed procedure amonghospital in-patients.. However, like alltreatments, it may result in acute or delayedcomplications and carries the risk ofTransfusion Transmissible Infections (TTIs).Great advances in transfusion medicine have,however, reduced the incidence of varioushazards arising from blood transfusionsignificantly. This chapter provides asimplified synopsis of the practical approach toblood transfusion especially as it pertains topatients of Obstetrics and Gynaecology.

ASSESSING THE NEED FORTRANSFUSIONThe patient's haemoglobin value, althoughimportant, should not be the sole decidingfactor in starting transfusion. This decisionshould be supported by the need to relieveclinical signs and symptoms and preventsignificant morbidity and mortality. Bloodtransfusion should only be considered whenthe anaemia is likely to cause or has alreadycaused a reduction in the oxygen supply to alevel that is inadequate for the patient's needs.However, transfusion of blood (red cells) is

usually indicated in adults with decompen-sated severe anaemia: change in mental status,diminished peripheral pulses, congestivecardiac failure, hepatomegaly and poorperipheral perfusion. The decision to transfuseblood or blood products should always bebased on a careful assessment of clinical andlaboratory indications that transfusion isnecessary to savelife or prevent significant morbidity.Transfusion is only one element of the patient'smanagements, the prevention and treatment ofanemia is one of the most important means ofavoiding unnecessary transfusion. Transfusionis rarely needed in chronic anaemias, butchronic anemia increases the need fortransfusion when the patient experiencessudden loss of red cells from bleeding,haemolysis, pregnancy or childbirth.

The principles of treatment of anaemiainclude:

1. Treat the underlying cause of theanaemia.

11. Optimize all the components of theoxygen delivery system in order toimprove the oxygen supply to thetissues.

111. Transfuse only when the anaemia issevere enough to reduce the oxygensuppLy to an extent that is inadequatefor the patient's needs.

Blood Transfusion in Obstetrics and Gynaecology -l-7l)

IV. Treat suspected cases of malaria as amatter of urgency. Starting treatmentpromptly may save the patient's life.

v. In cases of Disseminated IntravascularCoagulopathy (DIC), rapid treatment(e.g post-abortal sepsis) or removal ofthe cause(eg retained placenta)together with supportive care , isessential. Transfusion may be requireduntil the underlying cause has beendealt with.

TYPES OF TRANSFUSION AND THEIRINDICATIONS

The term "blood transfusion" is often usedrather loosely when

'What is meant is the transfusion of red cells.The effect of this linguistic laxity is that blood isoften transfused without sufficient regardeither to the specific requirements of thepatient or to the potentially harmful effects ofthe transfusion.

(A) RED CELL COMPONENTSIPREPARATIONS

To improveflow,SOmls of N/Smay be added using aV-pattern infusion set.

IIComponentc».,_.~c>. . JL Ma~.~.indication IIPrecauti~n

1. Red cell concentrate(packedred cells/plasma reduced blood)

2. Red cell suspension(red cellin additive solution)

3. Washed red cells

4. Washed and Frozen red cells

Replacement of redcells in anaemicpatients. Used withcystalloids in acuteblood loss.

Chronic bloodloss/anaemia. Suitablefor top-up transfusions

Not used for largevolume transfusion inneonates

Patients with rareantibodies.

(B) PLATELET TRANSFUSION

Platelet concentrate are prepared from wholeblood donations or by plateletpharesis andstored at temperature of 20°C to 24°C for up to72hours. Longer storage increases the risk ofbacterial proliferation and. septicaemia in therecipient. It is administered at a dose of

Transfusion reaction to Use within 24hrs ofplasma proteins. preparation

Use within 24 hours

1unit/10kg body weight which raises theplatelet count by 20-40 x 109 /L. It is usedprophylactically to prevent bleeding inthrombocytopenic haematological patients ortherapeutically to stop haemorrhage.Some of its indications include:

480 Foundations of Clinical Obstetrics and Gynaecology in the Tropics

i. Bone Marrow Failure caused bydisease or myelotoxic treatment

ii. Abnormalities of platelet functioniii. Dilutional thrombocytopenia: secon-

dary to marrow transfusioniv. Autoimmune thrombocytopenic pur-

pura (ITP)v. Disseminate Intravascular Coagulati-

on

NB: Alternatively, m most resource poorcentres and hospitals where plateletconcentrate is not available, fresh whole blood(less than 6 hours of donation) can be used.

(C) WHOLE BLOODThis is the complete collection of a singledonation or "unit" of about 450ml of blood intoan anticoagulant solution. It is rarely indicatedin modern transfusion practice and rarelyavailable because plasma is generally removedfor production of plasma products. There isno evidence that fresh whole blood offers anyclinical advantage. There is much greaterbenefit in using components: red cellssupplemented by fresh frozen plasma andplatelet concentrates. In many low resourcecountries, however, where blood fractionationtechnology is yet underdeveloped, wholeblood transfusion still holds sway especially inmanaging peri and post-operative haemorr-hage.

Figure 74.1: Blood bank services

Blood Transfusion in Obstetrics and Gynaecology -+SI

PLASMA PRODUCTS ANDINDICATIONS FOR THEIR USAGE

FRESHFROZENPLASMA (FFP)FFP is obtained either by separation of plasmafrom whole blood or by plasmapharesis. Theplasma is frozen to -25°C as rapidly as possiblewithin 6hours of collection and could be storedfor up to 1year. It contains normal plasmalevels of coagulation factors and is indicated inthe following conditions:

i. Treatment of congenital deficiencies ofcoagulation factors when there is nospecific factor concentrate available.

11. Replacement of multiple coagulationfactor deficiencies eg liver disease,warfarin overdose, depletion ofcoagulation factors in patientsreceiving large vol ume transfusion.

111. Disseminated intravascular coagula-tion.

lV. Thrombotic thrombocytopenic pur-pura.

CRYOPRECIPITATEIt is prepared from FFP by controlled thawingat 4°C - 6°C. The resulting precipitate ("cryo")is then separated from the supernatant andrefrozen for storage at -25°C or colder for up toone year. Cryoprecipitate contains fivecomponents: fibrinogen, facor VIII, vonWille brand factor, factor XIII and fibronectin.Some of its indications:

i. As an alternative to factor concentratein the treatment of inheriteddeficiencies of factor VII(haemophiliaA) and vonWillebrand factor(vonWillebrand disease).

ii. As a source of fibrinogen in acquiredcoagulopathies: eg disseminatedintravascular coagula tion (D IC) .

MASSIVE BLOOD TRANSFUSION"Massive transfusion" is arbitrarily defined asthe replacement of blood loss equivalent to orgreater than the patient's total blood volume inless than 24hours: i.e. 70ml!kg in adults.This means for a woman weighing 70 kg,transfusing about 4900 mls (approximately 5litres or 10 units of blood). It is usually amedical emergency, occurring in the Accident& Emergency department (trauma victims),operating theatre or obstetric departmentwhen a patient presents with overwhelminghaemorrhage and acute hypovolaemic shock.Morbidity and mortality tend to be high amongsuch patients not because of the large volumeinfused but because of the initial trauma andthe tissue and organ damage secondary tohaemorrhage and hypovolaemia.However, administering large volumes ofblood may give rise to the followingcomplications: acidosis, hyperkalemia, Citratetoxicity. hypocalcemia and depletion ofcoagulation factors:

THE RIGHT BLOOD TO THE RIGHTPATIENT AT THE RIGHT TIMEThe above sub-heading captures the firstimportant steps to successful and uneventfulclinical transfusion procedures. Once thedecision to transfuse has been made, everyoneinvolved in the clinical transfusion process hasthe responsibility to ensure the right blood getsto the right patient at the right time. Ideally,each hospital should establish a HospitalTransfusion Committee (HTC) to monitorclinical blood use and investigate any acute anddelayed transfusion reactions. To ensure theright patient is timely getting the correct blood,the following steps are imperative:

1. Assess the patient's clinical need forblood transfusion and when it is

4H2 Foundations of Clinical Obstetrics and Gynaecology in the Tropics

required.2. Inform the patient and/or her relatives

about the proposed transfusiontreatment and record in the patient'scase note that you have done so.

3. Record the indications for transfusionin the patient's notes and select theblood product and quantity required.

4. Complete the blood request formaccurately and legibly. The reasons fortransfusion should be written so thatthe blood bank can select the mostsuitable product for compatibilitytesting.

5. If blood is needed urgently, as in thecase of ruptured ectopic pregnancy oruterine rupture, contact the bloodbank by telephone immediately.

6. Obtain and correctly label a bloodsample for compatibility testing.

7. Without delay, send the collectedblood sample and the completed bloodrequest form to the blood bank.

8. The blood bank laboratory performspre-transfusion antibody screeningand compatibility tests and selectscompatible units.

9. If the blood unit is not immediatelyrequired for transfusion, it is stored incorrect storage conditions awaitingcollection by clinical staff

RED CELL COMPATIBILITY TESTINGAll blood is tested before transfusion in order.to:

1. Ensure that transfused red cells areblood group ABO compatible with theABO group of the recipient.

11. Avoid stimulating the production ofnew red cells antibodies in therecipient, particularly anti- RhD.

ui, Ensure there are no detectableirregular antibodies in the patient'sserum that will react with the donor'sred cells, causing their destruction orreducing their normal survival. Thissegment of compatibility testing isoften referred to as cross-matching:these procedures normally take about 1hour to complete. Shortenedprocedures are possible, but may fail todetect some incompatibilities.

COMPATIBILITY PROBLEMS1. If the patient's sample has a clinically

significant red cell antibody, thelaboratory may need more time andmay require a further blood sample inorder to select compatible blood. It istherefore imperative that non-urgenttransfusions and surgeries that :arelikely to require transfusion should bedelayed until suitable blood is found.

2. If transfusion is urgently needed, theblood bank and the doctor responsiblefor the patient must balance the risk ofdelaying for full compatibility againstthe risk of transfusing blood that maynot be completely compatible.

COLLECTING BLOOD UNITS PRIOR TOTRANSFUSION

. A common cause of transfusion reactions is.thetransfusion of an incorrect unit of blood thatwas intended for a different patient. This ismostly due to clerical errors and mistakes whencollecting blood from the blood bank. To avoidthese mistakes, the following precautionarymeasures must be adhered to:

i. Bring written documentation toidentify the patient.

11. Check that the following details on the

Blood Transfusion in Obstetrics and Gynaecology -+~3

compatibility label attached to theblood pack exactly match the details onthe patient's documentation:a. Patient's given namesh. Patient's hospital reference

numberc. Patient's ward, operating room or

clinicd. Patient's ABa and RhD group

iii. Fill in the information required in theblood collection register.

STORING BLOOD PRODUCTS PRIOR TOTRANSFUSION

1. Once issued by the blood bank, thetransfusion of whole blood or packedred cells should be commenced within30minutes of their removal fromrefrigeration.

2. If the transfusion cannot be startedwithin this period, they must be storedin an approved blood refrigerator at atemperature of 2°C to 6°C.

3. The temperature inside every refrige-rator used for blood storage in wardsand operating rooms should bemonitored and recorded daily toensure that the temperature remainsbetween 2°C and 6°C.

4. The lower limit of20C is essential toprevent haemolysis which can causefatal bleeding problems or renal failurewhile the upper limit of 60C isimportant to minimize the growth ofany bacterial contamination in the unitof blood.

5. If the ward or operating room does nothave a refridgerator that is appropriatefor storing blood, the blood should notbe released from the blood bank until

immediately before transfusion.6. All unused blood products should be

returned to the blood bank so that theirreturn and reissue or safe disposal canbe recorded.

,ADMINISTERING BLOOD PRODUCTS1. On arrival in the ward or operating

room or before transfusion (if not usedimmediately), the blood pack shouldalways be inspected for signs ofdeterioration.

2. Discoloration or signs of any leakagemay be the only warning that the bloodhas been contaminated by bacteria andcould cause a severe or fatal reactionwhen transfused.

3. Check for any signs ofhaemolyis in theplasma indicating that the blood hasbeen contaminated, allowed to freezeor become too warm.

4. Check for any sign of contamination,such as a change of colour in the redcells, which often look darker orpurple/black when contaminated.

5. Any clots? This may mean that theblood was not mixed properly with theanticoagulants when it was collected ormight also indicate bacterial contami-nation due to the utilization of citrateby proliferating bacteria.

6. Please, do not administer the transfusi-on if the blood pack appears abnormalor damaged or it has been (or may havebeen) out of the refrigerator for longerthan 30minutes. Inform the bloodbank immediately.

Foundations of Clinical Obstetrics and Gynaecology in the Tropics

MONITORING THE TRANSFUSEDPATIENT

1. It is essential to take basic observationsand to ensure that the patient is beingmonitored during and after thetransfusion in order to detect anyadverse events as early as possible. Thiswill ensure that potentially life-savingaction can be taken quickly.

2. Severe reactions most commonlypresent during the first 15 minutes of atransfusion. All patients and, inparticular, unconscious patientsshould be monitored during thisperiod and for the 15 minutes of eachsubsequent unit.

3. For each unit of blood transfused,monitor the patient:i. Before starting the transfusionii. As soon as the transfusion is startediii. 15minutes after starting the

transfusioniv. At least every hour during the

transfusionv. On completion of the transfusionvi. 4 hours after completing the

transfusion4. At each of these stages , record the

following information on the patient'schart:i. Patient's general apperaranceii. Temperatureiii. Pulseiv. Blood pressurev. Respiratory ratevi. Fluid balance: oral and N fluid

intake, urinary output5. Record and write down the following:

I. Time the transfusion was startedii. Time the transfusion was

completed

iii. Volume and type of producttransfused

iv. Unique donation numbers oftransfused product

v. Any adverse effects or reactions

6. The transfusion of each unit of theblood or blood component should becompleted within Four Hours of thepack being punctured.

7. If a unit of blood is not completedwithin four hours, discontinue its useand dispose of the remainder throughthe clinical waste system.

GUIDELINES FOR THE RECOGNITIONAND MANAGEMENT OF ACUTETRANSFUSION REACTIONS

1. Signs: rigors, febrile, restlessness,hypotension (fall of 20% in systolicBP), tachycardia(rise of 20% in HR),haemoglobinuria (red urine),unexplained bleeding (DIe).

2. Symptoms: anxiety, chest pains, painnear infusion site, shortness of breath,loin/back pains, headache, dyspnoea.

3. Possible causes:

a. Acute intravascular haemolysish. Bacterial contamination and septic

shockc. Fluid overloadd. Anaphylaxise. Transfusion-associated acute lung

injury(TRALI)

4. Imme~iate management:a. Stop the transfusion: replace the

infusion set and keep N line open

Blood Transfusion in Obstetrics and Gynaecology 4~5

with normal saline.b. Infuse normal saline (initially 20-

30mllkg) to maintain systolic BP. Ifhypotensive, give over 5 minutesand elevate patient's legs.

c. Maintain airway and give highflow oxygen by mask.

d. Give adrenaline (1:1000 solution)O.Olmglkg by slow I.M injection.

e. Give IV corticosteroid andbronchodilators if there are ana-phylactoid features (e.g bronchos-pasm, stridor).

f Give diuretic: e.g frusemide1.0mglkgN or equivalent.

g. Notify the doctor responsible forr

the patient and the blood bankimmediately.

h. Send blood unit with infusion set,fresh urine sample and new bloodsample(l clotted and 1 anticoa-gulated) from vein oppositeinfusion site with appropriaterequest form to blood bank forinvestigations.

1. Check a fresh urine visually forsigns ofhaemoglobinuria.

J. Start a 24-hour urine collectionand fluid balance chart and recordall intake and output. Maintainfluid balance.

k. Assess for bleeding from puncturesites or wounds. If there is clinicalor laboratory evidence of DIC,give platelet concentrate (5-6units) and either Fresh frozenplasma (3 units) or cryoprecipitate(12 units).

1. In centres where the above bloodproducts are not available, fresh

whole blood (less than 6 hours ofdonation) can be used.

m. Reassess. Ifhypotensive:i. give further normal saline 20-

30mllkgover 5 minutes11. Give initrope (e.g dopamine),

if availablen. If urine output falling or labora-

tory evidence of Acute renal failure(rising K+,urea, creatinine):I. maintain fluid balance accura-

tely11. Give further frusemideiii. Consider dopamine infusion,

if availableIV. Seek expert help: the patient may

need renal dialysiso. If bacteremia is suspected (rigors,

fever, collapse, no evidence of ahaemolytic reaction), start broad-spectrum antibiotics N

Please take note of the following:1. If an acute transfusion reaction occurs,

first check the blood pack labels andthe patient's identity. If there is anydiscrepancy, stop the transfusionimmediately and consult the bloodbank.

2. In an unconscious or anaesthesizedpatient, hypotention and uncontrolledbleeding may be the only signs of anincompatible transfusion.

3. In a conscious patient undergoing asevere haemolytic transfusion reac-tion, signs and symptoms may appearvery quickly-within minutes ofinfusing only 5-10mls of blood. Closeobservation at the start of the infusionof each unit is essential.

4K6 Foundations of Clinical Obstetrics and Gynaecology in the Tropics

REFERENCES1. World Health Organization. The

clinical use of blood handbook, WHO,Geneva 2001.

2. Norma BL, Majed AR, Neil B. Redcell transfusion. In: Kaushansky K,Lichtman MA, Beutler E, Kipps T],Seligsohn U, Prchal ]T (eds),Williams Hematology, 8th edn, NewYork, McGraw Hill, 2010,2287-2298.

3. Monica Cheesbrough. District Labo-ratory Paractice in Tropical countries,part 2, Cambridge university press,2000

4. Dacie and Lewis Practical haemato-logy; 9th edn, Lewis SM, Bain B], BatesI(Editors), Churchill livingstone,London,2001.