Blood Products in the Management of Abnormal Placentation.

A critical tool in the successful management of patients with abnormal placentation is an established massive transfusion protocol designed to rapidly deliver blood products in obstetrical and surgical hemorrhage. Spurred by trauma research and an understanding of consumptive coagulopathy, the past 2 decades have seen a shift in volume resuscitation from an empiric, crystalloid-based method to balanced, targeted transfusion therapy. The present article reviews patient blood management in abnormal placentation, beginning with optimizing the patient's status in the antenatal period to the laboratory assessment and transfusion strategy for blood products at the time of hemorrhage.

Preventing deaths due to haemorrhage.

Prevention of deaths from obstetric haemorrhage requires effective health systems including family planning, commodities, personnel, infrastructure and ultimately universal access to comprehensive obstetric care for women giving birth. The main causes of death associated with antepartum haemorrhage are placental abruption, placenta praevia and uterine rupture. Preventive measures include preconceptual folate supplementation, management of hypertensive disorders, early diagnosis of placenta praevia and use of uterine stimulants cautiously, particularly misoprostol. Preventive measures for post-partum haemorrhage include routine active management of the third stage of labour. Treatment involves a cascade of increasingly invasive interventions in rapid sequence until the bleeding is stopped. These interventions include fluid resuscitation, removal of the placenta, bimanual uterine compression, uterotonics, tranexamic acid, suturing of lower genital tract injury, blood product replacement, balloon tamponade, laparotomy, stepwise uterine devascularization, uterine compression sutures and hysterectomy. Emergency temporizing measures include application of the non-pneumatic anti-shock garment, and at laparotomy, aortic compression and uterine tourniquet application. The effectiveness of treatment methods and the optimal dosage of misoprostol are research priorities. Interesting new approaches include transvaginal uterine artery clamping and suction uterine tamponade.

Implementation of an obstetric cell salvage service in a tertiary women's hospital.

INTRODUCTION: Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage. METHODS: With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent. RESULTS: A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL. CONCLUSION: The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.

Massive obstetric hemorrhage in a Jehovah's Witness: intraoperative strategies and high-dose erythropoietin use.

A massive obstetric hemorrhage resulting in an extremely low hematocrit (5.9%) required innovative intraoperative and postoperative management. We used a combination of rapid intraoperative volume replacement, aortic compression, chemical coma, high-dose erythropoietin, and enteral iron replacement to elevate the hematocrit in a patient refusing blood transfusions.

Autologous blood transfusion in patients with placenta previa.

BACKGROUND: Several studies have shown that autologous blood storage during pregnancy is relatively safe for mother and fetus. However, the need for reappraisal of autologous blood transfusion in obstetric patients has been proposed. METHODS: We retrospectively reviewed the cases of placenta previa and low-lying placenta among pregnancies at our hospital during an 18-year period, 1985-2002. The utility of autologous blood transfusion program, which started in 1994 for those with placental positional disorders, was evaluated. RESULTS: Of the pregnancies reviewed, there were 158 cases (1.9%) of placenta previa or low-lying placenta. The number of patients transfused with homologous blood decreased from 27.6% (21/76) in the period before implementation of the autologous blood transfusion program to 8.5% (7/82) after its implementation in 1994. In the latter time period, 39.0% (32/82) of patients with placenta previa and low-lying placenta were phlebotomized and had blood stored. Of those, 71.9% (23/32) were reinfused where one patient (3.1%) needed homologous blood as well. The volume of collected blood per phlebotomy was 367 +/- 65 ml, the total volume of collected blood per patient was 803 +/- 350 ml, and the total of estimated blood loss per patient was 1326 +/- 873 ml. The volume of reinfused blood per patient was 578 +/- 326 ml. CONCLUSIONS: The program of autologous blood collection and transfusion in patients with placenta previa resulted in a decrease in homologous blood transfusion. In our program, we recommend starting blood collection and storage at 32 weeks' gestation and phlebotomize 400 ml per week to reach a volume of stored blood of 1200-1500 ml.

Fetal circulatory responses to maternal blood loss.

We examined the fetal circulatory responses to maternal blood loss in pregnant women during the third trimester. Seven healthy women with placenta previa and singleton pregnancies underwent phlebotomies in an autologous donation program. Four hundred milliliters of blood was collected within 15 min at 34 and 35 weeks of gestation. Continuous electric recordings of fetal heart rate were performed during the first blood collection, and the maternal uterine artery (UtA), umbilical artery (UmA) and fetal middle cerebral artery (MCA) Doppler velocity waveforms were recorded before, immediately after and 24 h after the second collection in each patient. The average fetal heart rate, maternal UtA and UmA pulsatility indices did not change measurably during or after maternal blood collections. However, the average fetal MCA pulsatility index decreased significantly 24 h after maternal blood loss. The observation of a decrease in fetal MCA pulsatility index may indicate delayed fetal asphyxia following mild maternal hemorrhage.

Autologous blood donation with placenta previa: is it feasible?

Autologous blood donation has been recommended for patients with placenta previa. We hypothesized that premature delivery, preexisting anemia, and bleeding would limit its utilization. We reviewed the charts of all patients admitted with placenta previa between July 1, 1989, and April 30, 1992. To be eligible for autologous donation we assumed that the patient would need to be asymptomatic with a hematocrit 34% or higher at 32 weeks' gestation. Eighty-eight patients were admitted with placenta previa, 12 (14%) of whom were eligible for autologous donation. Two eligible patients required transfusion at delivery and four delivered prior to 34 weeks. Few patients with placenta previa are eligible for autologous donation and although two would have used their autologous units, twice as many may have been compromised by recent autologous donation. We conclude that autologous donation is not feasible in a majority of patients with placenta previa and is of limited usefulness in its management.

Autologous blood storage in obstetrics.

Autologous transfusion, storage of one's own blood for subsequent infusion if needed, is safe and effective in a variety of scheduled operative procedures. Obstetric involvement in such programs is very limited, however. Thirty pregnant women with placenta previa or other potential complications underwent 55 phlebotomies in an autologous transfusion program. Phlebotomies were performed at an average gestational age of 32.4 weeks (range 13-40). Changes in mean diastolic blood pressure and pulse were minimal. Electronic fetal monitoring tracings were normal during the 34 procedures in which it was used. The frequency of mild donor reactions (4%) was consistent with that in nonpregnant donors. After entry into this program, 15 patients received a total of 29 U of packed red blood cells (23 autologous; six homologous). Homologous transfusion was avoided in 86.7% of patients receiving blood. Selected pregnant women can participate safely in autologous blood collection programs, minimizing the need, and therefore the risks, of homologous transfusion.