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COMPONENT THERAPY IN MASSIVE OBSTETRIC HAEMORRHAGE

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

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COMPONENT THERAPY IN MASSIVE OBSTETRIC HAEMORRHAGE

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

  2. DEFINITIONAny blood loss occurring in the peripartum period, revealed or concealed, that is likely to endanger lifeN.B.Physiological & hematological changes induced by pregnancy can hide signs of hypovolemic shock & patient can collapse suddenly. MASSIVE OBSTETRIC HAEMORRHAGE Dr Mona Shroff www.obgyntoday.info

  3. 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. Dr Mona Shroff www.obgyntoday.info

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

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

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

  7. SYMPTOMS & SIGNS Dr Mona Shroff www.obgyntoday.info

  8. 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 Dr Mona Shroff www.obgyntoday.info

  9. DIC is a consequence of delayed or inadequate resuscitation Dr Mona Shroff www.obgyntoday.info

  10. 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 levels4- Inform blood bank that it is an emergency Dr Mona Shroff www.obgyntoday.info

  11. Give Packed Red Cell 5-Initial packed red cell infusion to restore O2 delivery to tissues • Fully matched blood • Group O Rh –ve cells should be available in 5 minutes • Group specific uncrossmatched blood (1/3 of the patient’s estimated blood volume has been lost.) Dr Mona Shroff www.obgyntoday.info

  12. 6-Component replacement therapyaccording to coagulation screen7- Continuous lab & clinical monitoring to guide treatment.( REPEAT AS SERIAL ESTIMATIONS every 4 hours or more often, as necessary after component therapy.) Dr Mona Shroff www.obgyntoday.info

  13. 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 Dr Mona Shroff www.obgyntoday.info

  14. 8-Massive transfusion of stored whole blood can aggravate coagulopathy due to:-Dilutional thrombocytopenia- Coagulation factor depletion - Acidosis- Hypothermia thus • 1 unit of fresh blood for every 5 – 10 unitsof stored blood • IV 10% calcium gluconate 10 mls with every litre of transfused citrated blood • Warming blood • Microaggregate blood filters Dr Mona Shroff www.obgyntoday.info

  15. Fresh Frozen Plasma • 200-250 ml of plasma containing all clotting factors, AT III, Protein C & S. • Compatibility Important • 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 Dr Mona Shroff www.obgyntoday.info

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

  17. Cryoprecipitate • 10-15 ml per unit (bag) • Fibrinogen 250 mg • Factor VIII 80-120 units • Von Willebrand Factor 40-70% of FFP • Factor XIII 20-30% of FFP • Fibronectin 20-40 mg Dr Mona Shroff www.obgyntoday.info

  18. Cryoprecipitate: Dosing • 1-2 Units / 10 Kg • Expect 60-100 mg/dl rise in fibrinogen • Goal: Fibrinogen 70-100 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. Dr Mona Shroff www.obgyntoday.info

  19. Platelets: Risk of Spontaneous Hemorrhage CountSite > 40,000 Minimal 20-40,000 GI Mucosa 5-20 Skin,Mucus Membranes < 5 CNS, Lung Dr Mona Shroff www.obgyntoday.info

  20. Prophylactic Platelet TX Guidelines Platelet Count/μlRecommendation 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 Dr Mona Shroff www.obgyntoday.info

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

  22. rFVIIa • 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. • Thrombosis ?? • Dosing guidelines for h’ge (general range, 90-120 mcg/kg of body weight) have yet to be established • Cost of rFVIIa is over $3000 / patient Dr Mona Shroff www.obgyntoday.info

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

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

  25. Thank you Dr Mona Shroff www.obgyntoday.info

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