APPROPRIATE USE OF BLOOD TRANSFUSION IN OBSTETRICS AND GYNECOLOGY

1. APPROPRIATE USE OF BLOOD TRANSFUSION IN OBSTETRICS AND GYNECOLOGY PRESENTER LAMIN F JARJU 5th yr medical student School of medicine and allied health sciences CLINICAL PRESENTATION IN afprc general hospital, farafenni 11th February 2010

2. AN OUTLINE • HISTORY OF THE PATIENT • DISCUSSION

3. BIODATA • Name:- MJ • 33yr old female • Fula and living in Maida Biron Penda • Married • House wife • G8 P6+1 • LMP : nine months ago (…/04/09) • GA: • EDD: • DoA: 22/01/10

4. HISTORY • Referred from Maida Biron Health Centre • Informant: Self • Presenting complaint: Dizziness for 5 days • History of presenting complaints: • Index pregnancy: booking at 5 months; red tabs given, BP checked. Then monthly visits; where only red tabs were given, no white tab • Obstetric history: G8 P6+1, 3 alive, 2boys and 1 girl, well breastfed but can’t remember their ages, 3preterm and died after delivery, 1 abortion

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

6. HISTORY • Psychosocial History: 2nd 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” • 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

7. EXAMINATION AND DIAGNOSIS • o/e: pale(+++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration • CV: pulse 88beats/min, BP 110/70mmhg, s1 and s2 heard, normal, no murmurs • Resp: RR 22cycles/min, VBS, no added sound • Abd: distended, soft, no tenderness, linear nigra, SFH 36cm, Presentation cephalic, lie longitudinal, no palpable organomegaly, FHR 120beats/min • CNS: conscious and oriented, no neurological deficit • Impression: Anaemia in term Pregnancy

8. INVESTIGATIONS • Hb: 5.6g/dl • Grouping and cross matching: Group O+ • Abdominal ultrasound

9. MANAGEMENT Day 1 • 2 pints of blood should be cross matched • Folic acid 1 tab daily 2/52 • Fefa 1 tab daily 1/12 • Hb12 syrup 10ml BD 2/52 • Vit C 1 tab daily 2/52 • 1 pint of blood transfused + frusemide 20mg iv

10. PROGRESS NOTE: DAY 2 • Pt seen: no complaint • o/e: pale(++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration • CV: pulse 84beats/min, BP 110/70mmhg, s1 and s2 heard, normal, no murmurs • Resp: RR 20cycles/min, VBS, no added sound • Abd: NAD • CNS: conscious and oriented, no neurological deficit Plan:- received 2nd pint of blood + 20mg iv contd on her medications

11. PROGRESS NOTE: DAY 3 • Pt seen: no complaint • o/e: pale(++), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration • CV: pulse 86beats/min, BP 110/70mmhg, s1 and s2 heard, normal, no murmurs • Resp: RR 18cycles/min, VBS, no added sound • Abd: NAD • CNS: conscious and oriented, no neurological deficit Plan:- post-transfusional hb =8.6g/dl contd on her medications

12. PROGRESS NOTE: DAY 4 • Pt seen: no complaint • o/e: pale(+), acyanosed, anecteric, no finger clubbing, no oedema, no palpable LAP, afebrile to touch, no sign of dehydration • CV: pulse 84beats/min, BP 110/70mmhg, s1 and s2 heard, normal, no murmurs • Resp: RR 20cycles/min, VBS, no added sound • Abd: NAD • CNS: conscious and oriented, no neurological deficit Plan:- Discharged contd on her medications and advice on diet

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

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

15. Purpose and Scope • Obstetric conditions associated with the need for blood transfusion may lead to morbidity and mortality if not managed correctly. • 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. • 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.

16. The ABO system: antigens and antibodies

17. BLOOD GROUP AND THEIR LIKELY DONORS

18. Blood components and blood products • 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. • 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

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

20. 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.

21. Regarding Blood Transfusion in obstetrics: • TWO main causes of maternal morbidity and mortality are : 1- CHRONIC ANEMIA OF PREGNANCY 2- MAJOR OBSTETRIC HAEMORRHAGE

22. UNITS OF BLOOD REQUIRED IN OBS AND GYNAE PROCEDURES

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

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

25. Prescription of blood/blood products • The requesting Medical Officer/ Nurse must prescribe blood and blood products on a blood form • The blood form must contain: • Full name • DOB • Gender • Address • Diagnosis • Consultant • Signature • Date

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

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

28. Complications of blood transfusion

29. IN THE EVENT OF A TRANSFUSION REACTION • Stop the transfusion immediately • Inform medical staff and blood bank staff immediately • In the case of anaphylaxis( bronchospasm, cyanosis, hypotension, etc) • Maintain airway and give oxygen • Give adrenaline IM 0.5mg (0.5ml of 1:1000) • Repeat every 5mins, if needed as guided by BP, pulse and RR until better • Chlorpheniramine (piriton) 10mg iv and hydrocortizone 250mg iv

30. IN THE EVENT OF A TRANSFUSION REACTION contd • Ivi (0.9% saline, eg 500ml over ¼ hour; upto 2L may be needed • Titrate against BP • In case of fluid overload(dyspnoea, hypoxia, raised JVP, basal crepitation) • Give oxygen and a diuretic egfrusemide 40mg iv initially • Send to blood bank: all part/fully transfused blood bags from the transfusion. Two 5ml EDTA samples, a sample of first urine passed • Send a 4.5ml EDTA sample for FBC and citrate sample for clotting screening to haematology, clotted samples for biochemistry investigations and blood culture samples to microbiology.