MEDICAL MANAGEMENT OF POSTPARTUM HAEMORRHAGE

INTRODUCTION

Primary PPH is the most common form of major obstetric haemorrhage.

It is the leading cause of maternal morbidity and mortality.

This is one of the major cause of maternal death.

According to Indian guidelines, third direct cause of maternal death.

Incidence (0.5 to 18%-50 countries data)

•4-6% of all pregnancies.

•3.9% -vaginal deliveries.

•6.4%- cesarean deliveries.

-Recurrence risk : 23-25%.

Primary PPH

Loss of 500ml or more of blood from genital tract within 24 hours of birth of baby. (RCOG)

It is of 2 types-minor & major

Minor PPH-500-1000ml of blood loss

Major PPH- >1000ml blood loss. It is of 2 types-Moderate & Severe PPH

Moderate PPH- 1000-2000ml blood loss

Severe PPH- >2000ml blood loss

Or

Drop in hematocrit of 10%

Or

Any amount of blood loss causing hemodynamic instability

A blood loss of more than 40% of total blood volume (approx 2800 ml) is generally regarded as ‘life-threatening’Secondary PPH

Abnormal or excessive bleeding from birth canal between 24 hours and 12 weeks postnatally.

CAUSES OF PPH

Primary (< 24 hrs) Secondary ( >24hrs)

Tone - Uterine infection

Trauma - Retained placental fragments

Tissue

Thrombin

PREVENTION OF PPH

Active management of third stage of labour

It lowers maternal blood loss and reduces the risk of PPH.

Steps of active management of third stage of labour:

1.Administer prophylactic oxytocics: Palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units intramuscularly(within 1 minute of birth of baby). Prophylactic oxytocics reduce the risk of PPH by about 60%.

For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10 iu by intramuscular injection). For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss.

2. Delayed clamping of the cord is recommended if fetus is healthy. Clamp cord early when indicated.

3.Deliver the placenta by controlled cord traction

Do not wait for signs of placental separation. Deliver by controlled cord traction. If the placenta does not descend during 30-40 sec of controlled cord traction ( It indicates no signs of placental separation), do not continue to pull on the cord

With the next contraction, repeat controlled cord traction with counter traction.

“Never pull on the cord without pushing the uterus up with the other hand”

3.Massage the uterus:.Repeat the uterine massage every 15 min for the first two hours. Ensure that the uterus remains hard after you stop uterine massage.

Risk factors for PPH:

DETERMINE THE AMOUNT OF BLOOD LOSS:

Visual assessment is inaccurate, hence measure the amount of blood loss with pre weighed sponges or pads

Emergency measures should be initiated if more than 1/3rd of women’s blood volume (blood volume=body weight x 80) is lost.

“Rule of 30”-indicates 30% loss in blood volume and is in moderate shock leading to severe shock and the need for acute management of PPH. Fall in systolic BP by 30mmHg, rise in heart rate by 30 beats/min, rise in respiratory rate by 30breaths/min, drop in hemoglobin or hematocrit by 30%, urine output <30ml/hr.

30 ml

60 ml

350 ml

500 ml

1000 ml

1500 ml

Best method to assess blood loss- Blood collection drape

MANAGEMENT OF MINOR PPH:

Primary PPH involving an estimated blood loss of 500–1000 ml (and in the absence of clinical signs of shock)

Alert the nurse in charge

Alert the obstetric and anaesthetic staff.

Intravenous access (14-gauge cannula x 1)

Consider venepuncture (20 ml) for:- group and screen- full blood count- coagulation screen including fibrinogen

Commence crystalloid infusion

Monitor pulse and blood pressure every 15 minutes.

MANAGEMENT OF MAJOR PPH:

If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml (or has clinical signs of shock or tachycardia associated with a smaller estimated loss),

Full protocol of measures to achieve resuscitation and haemostasis.

MANAGEMENT:

1)COMMUNICATION

2)RESUSCITATION

3)MONITORING & INVESTIGATIONS

4)ARRESTING OF BLEEDING

These components must be initiated and progressed simultaneously for optimal patient care.

Make initial assessment and start basic treatment

Call for help (integrated team approach) Call the senior sister. Call senior obstetrician . Call senior anaesthesiologist. Alert the blood transfusion laboratory. Call assistants for delivery of specimens Alert one member of team to record blood and blood products, fluids, drugs and vital

signs

- COMMUNICATION: Communication and Counselling the patient & relatives .

- RESUSCITATION: Assess airway, breathing and circulation (ABC) Connect pulse oximeter , irrespective of saturation provide supplementary oxygen (10-15

litres by face mask or nasal cannula) If she is unconscious, call the anaesthetist to intubate. Monitor PR,BP, SPO2 ,ECG ,Automated BP recording continuosly. Obtain two intravenous lines [IV Cannula 14 guage(Red colour) or 16 guage (grey

colour)] and draw blood (20ml) for laboratory tests Complete blood count

Coagulation screen (Platelets, PT, aPTT & Fibrinogen) Blood group - type and cross matching (4 units) RFT, LFT & Electrolytes for baseline

Start fluid replacement with intravenous crystalloid fluid ( 3-4 ml of fluid for every 1 ml of blood loss)

Catheterize bladder, monitor fluid intake and urinary output. Assess need for blood transfusion Patient should lie flat and she should be kept warm. Get the blood as soon as possible. Infuse 3.5 litres warm crystalloid (2 lt RL), and/or colloid(1-2lt) irrespective of blood

loss),be given before the blood comes. If blood is not available, start colloid as soon as possible. “ BLOOD SHOULD BE STARTED AS SOON AS POSSIBLE AND AS EARLY

AS POSSIBLE” Start blood, but dont use blood filter. Normal IV set should be used.

Fluid therapy and blood product transfusion:Crystalloid: Up to 2 litres Hartmann’s solutionColloid : Up to 1–2 litres colloid until blood arrivesBlood: Crossmatched, If crossmatched blood is still unavailable, give

Uncrossmatched group-specific blood or give ‘O RhD negative’ blood

Fresh frozen plasma: 4 units for every 6 units of red cells or prothrombin time/activated partial thromboplastin time > 1.5 x normal (12–15 ml/kg or total 1litres)

Platelets concentrates: If PLT count < 50 x 109 Cryoprecipitate: If fibrinogen < 1 g/l

When the blood loss reaches about 4.5 litres (80% of blood volume), up to 1 litre of fresh frozen plasma (FFP) and 10 units of cryoprecipitate (two packs) may be given empirically in the face of relentless bleeding,while awaiting the results of coagulation studies

Threapeutic goal in the management of massive blood loss: Hb > 8g/dl Platelet > 75,000/mm3 APTT< 1 1/2 times the normal. Fibrinogen>1g/lt

Recombinant factor VIIa therapy should be based on the results of coagulation. If needed Factor VIIa can be given,90 ug/kg body weight. Should be repeated if there is no clinical response within 15-30 min.

Maximum of two doses can be given.-It is used only in life threatening PPH, Only as an adjuvant to standard treatment.

rFVIIa will not work if there is no fibrinogen and effectiveness may also be suboptimal with severe thrombocytopenia. Hence before giving Factor VIIa we have to make sure that fibrinogen> 1g/l Platelets > 20,000 /mm3.

MONITORING AND INVESTIGATIONS: Continuous PR,BP, SPO2, ECG monitoring Temperature every 15 min Catheterise the bladder ,to monitor the urine output. Arterial line should be considered. Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring

at high dependency unit on delivery suite, if appropriate. Use the MEOWS chart Document the fluid balance, blood, blood products and procedures

Anaesthesia management:

Regional anaesthesia – relative contraindication due to cardiovascular instabilityThe blockage of the sympathetic system can potentially lead to worsening hypotension due to haemorrhage. If cardiovascular stability is achieved and there is no evidence of coagulation failure, regional anaesthesia can be used.

Continuous epidural block is preferred over spinal, as it allows better blood pressure control and for prolonged surgery. When there is continuing bleeding and the cardiovascular stability is compromised, general anaesthesia is more appropriate. Rapid sequence induction is the gold standard to reduce the risk of aspiration.

ARREST OF BLEEDING:

Causes : Tone, Tissue ,Trauma, Thrombin. Most common cause is uterine atony. Exclude traumatic cause, by clinical examination. Examine the placenta for completeness. Explore the genital tract, for any vaginal /cervical laceration (or) haematoma. Broad ligament haematoma and rupture uterus should be excluded. Rule out extragenital bleeding (for example, subcapsular liver rupture) and uterine

inversion.

Bimanual uterine compression and massaging the uterus to stimulate the uterine contractions. Ensure bladder is empty

Syntocinon 5 units by slow intravenous injection (may have repeat dose)

Methyl ergometrine 0.2mg slow IV or IM if she is normotensive.

Syntocinon infusion 40U oxytocin in 500ml of fluid and give it at the rate of 125ml/hr.

Carboprost 0.25 mg IM every 15 min for maximum 8 doses, provided that she is not asthmatic.

Direct intramyometrial injection of 0.5mg carboprost , can be given.

Misoprostol 1000 microgm per rectally

If medical method fails, initiate surgical haemostasis. Intrauterine Balloon tamponade is an appropriate first line surgical intervention for atonic PPH.

balloon tamponade haemostatic brace suturing (such as using procedures described by B-Lynch or

modified compression sutures) bilateral ligation of uterine arteries bilateral ligation of internal iliac (hypogastric) arteries selective arterial embolisation.

Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture).

A second consultant clinician should be involved in the decision for hysterectomy

A non-pneumatic antishock garment may be useful in where women with PPH require transfer from the peripheral centre to a tertiary care hospital.

ALGORITHM FOR MANAGEMENT OF PPH- “HAEMO-STAISIS”

GENERAL MEDICAL MANAGEMENT- ‘HAEMO’

H Ask for Help A Assess (vital parameters, blood loss) and resuscitate E Establish etiology, ecbolics, ensure availability of blood

-Etiology: 4Ts- Tone, Tissue, Trauma, Thrombin -Ecbolics (syntometrine, ergometrine, bolus syntocinon -Ensure availability of blood and blood products

M Massage the uterus O Oxytocin infusion, prostaglandins

(intravenous,intramuscular,intramyometrial, rectal)

SPECIFIC SURGICAL MANAGEMENT- ‘STASIS’

S Shift to operating theatre - Bimanual compression - Anti shock garment, especially if transfer is required

T Tissue and trauma to be excluded and proceed to Tamponade balloon, uterine packing A Apply compression sutures S Systematic pelvic devascularisation (uterine, ovarian, quadruple, internal iliac) I Interventional radiology ,Uterine artery embolization S Subtotal or Total abdominal hysterectomy

Management of Atonic PPH:Stimulate uterine contractions by uterine massageOxytocics

Oxytocics Dose and route

MaintenanceDose

Max dose

Frequency Side effects Contraindications

Oxytocin IV Infusion 10-40U in 500ml crystalloid at 60 drops/min(125ml/hr)

IV Infusion 10U/500ml at 40 drops per min (max.100U)

Not more than 3 litres

Hypotension, Water intoxication

None

Methyl Ergometrine

0.2 mg IM/ Slow IV

0.2 mg after 15min(max.1gm)

5 doses 4th hourly Nausea, vomiting, hypertension

Hypertension,Heart disease,Rh negative,Severe anemia

15 Methyl PGF 2α

250 µg 250µg after 15 min (max.2 mg)

8 doses 15 min Nausea, vomiting, diarrohea, pyrexia, bronchoconstriction

Asthma, heart disease

Misoprostol 1000 µg, rectal or 600 µg sublingual

Shivering, fever, tachycardia,

None

BIMANUAL UTERINE COMPRESSION:

Is indicated when uterine massage is not successful in arresting bleeding. Wear sterile gloves, insert a hand into the vagina and remove any blood clots from the

lower part of the uterus or cervix. Keep the fist into the anterior fornix and apply pressure against the anterior wall of the

uterus . With the other hand, try to antevert the uterus to compress the uterine vessels. Maintain compression until bleeding is controlled and the uterus contracts.

Internal Bimanual compression of the uterus

COMPRESSION OF AORTA:

Apply downward pressure with a closed fist over the abdominal aorta directly through the abdominal wall.

The point of compression is just above the umbilicus and slightly to the left. Aortic pulsations can be felt easily through the anterior abdominal wall in the immediate

postpartum period. With the other hand, palpate the femoral pulse to check the adequacy of compression. If the pulse is palpable during compression, the pressure exerted by the fist is

inadequate. If the femoral pulse is not palpable, the pressure exerted is adequate. Maintain compression until bleeding is controlled.

Uncontrolled bleeding even after 30 min of oxytocics (oxytocin, methergin, PGF2α and Misoprostol) and uterine compression:-maintain intravenous oxytocin infusion and consider uterine tamponade.

UTERINE TAMPONADE

Can use Condom catheter or Foley’s catheter or Sengstaken Blakemore catheter Rusch urological balloon or Bakri balloon can also be used if available Tamponade Test- The concept of this test is to affirm its place as first line of ‘surgical

management’.

Positive test-control of PPH following inflation of balloon (indicates that laparotomy is not required)

Negative test-continued PPH following inflation of balloon (indication to proceed with laparotomy)However, there is no clear evidence how long the tamponade should be left in place. But, in most cases,4-6 hours of tamponade is adequate to achieve hemostasis.Condous et al study showed that tamponade test had a positive result of >87% for successful management of PPH.It should be removed during day time in the presenc of senior staff. Balloon should be deflated but left in place to ensure that bleeding donot reccur.

Condom tamponade

Catheterise the bladder prior to the procedure Under aseptic precautions a size 16 sterile rubber catheter is inserted into sterile

condom(dipped in cidex for 20minutes and wash with saline) and tied near the mouth of the condom by a silk thread, inner end of the catheter remaining within the condom

Cervical lips held with sponge holder Condom tied over the catheter is introduced into the uterine cavity. The outer end of the

catheter is connected with a saline set and saline is kept 60 -70 cms above the level of abdomen and the condom is inflated

Inflate the condom with 250-500 ml of Normal saline Pack the vagina with gauze

Removal of the balloon

After6-8 hours, if the uterine fundus remains at the same level and there is no active bleeding through the cervix or lumen of the catheter, it is safe to remove the balloon provided the woman is stable and adequate blood is replaced.

Deflate the balloon slowly, but do not remove it for 30min. If there is no bleeding after 30 min & remove the balloon catheter. If bleeding starts when the balloon is deflated, re-inflate the balloon and prepare for

surgical line of management.

Foley’s catheter

A balloon of 30 ml capacity is effective in controlling PPH. But the shape of the balloon may not correspond to the elongated uterine cavity. Hence it is not suitable for large post partum cavities.

Additional Foley catheters can be inserted if necessary to control postpartum hemorrhage resulting from atony , may be useful in cases where cervical lacerations have been repaired and if bleeding persists.

Not recommended for PPH

Bakri balloon

Indications:

The Bakri Postpartum Balloon catheter is intended to provide temporary control or reduction of postpartum uterine bleeding when conservative management is warranted.

Contraindications:

- Arterial bleeding requiring surgical exploration or angiographic embolization- Cases indicating hysterectomy- Pregnancy

- Cervical cancer

- Purulent infections of the vagina, cervix or uterus- Untreated uterine anomaly

- Disseminated intravascular coagulation- A surgical site that would prohibit the device from effectively controlling

bleeding

Insertion:

Vaginal Delivery: Transvaginal Placement

Rule out if the uterus is clear of any retained placental fragments, arterial bleeding or lacerations.Determine approximate uterine volume by ultrasound or direct examination.Under ultrasound guidance, insert the balloon portion of the catheter into the uterus, making certain that the entire balloon is inserted past the cervical canal and internal ostium.Note: Avoid excessive force when inserting the balloon into the uterus.If not already indwelling, place a Foley catheter in patient bladder to collect and monitor urine output.To ensure maintenance of correct placement and maximize tamponade effect, the vaginal canal may be packed with iodine- or antibiotic-soaked vaginal gauze at this time.

Cesarean Delivery: Transabdominal Placement

Rule out if the uterus is clear of any retained placental fragments, arterial bleeding or lacerations.Determine uterine volume by intraoperative direct examination or postoperative ultrasound examination.From above (via access of the cesarean incision), pass the tamponade balloon, inflation port first, through the uterus and cervix.Have an assistant pull the shaft of the balloon through the vaginal canal, until the deflated balloon base comes in contact with the internal cervical ostium.

Close the incision per normal procedure, taking care to avoid puncturing the balloon while suturing.If not already indwelling, place a Foley catheter in patient bladder to collect and monitor urine output.NOTE: Inflate the balloon after the hysterotomy incision is closed to avoid balloon puncture.

Inflate the balloon with 500ml sterile liquid

Patient monitoring:Once balloon is placed and inflated, connect the drainage port to a fluid collection bag to monitor hemostasis.

Patient monitoring should include, Blood pressure, pulse, urine output, cramping, pallor and active bleeding.

Signs of deteriorating or unimproving conditions should indicate more aggressive treatment and management of patient uterine bleeding.

Balloon removal:

Maximum indwell time is 24 hours. Balloon may be removed sooner upon physician determination of hemostasis or the need to apply more aggressive treatment.

Sengstaken-Blakemore catheter (after cutting the distal tube to facilitate insertion and retention in the uterine cavity)

It is predominantly used for tamponade of esophageal varices & introduction of contrast media

Hold the balloon catheter with sponge holding forceps and insert it into the uterine cavity

Fill the balloon with warm sterile water or saline until it becomes visible in the cervical canal.When the pressure exceeds that of patient’s BP , no additional fluid needs to be added and bleeding should stop.

If there is no bleeding through the cervix or through the drainage channel of the balloon catheter, the Tamponade Test result is pronounced successful & no further fluid is added.

If the bleeding does not stop, result is unsuccessful and laparotomy is indicated.

Hydrostatic intrauterine balloon tamponade, Hydrostatic intrauterine balloon

glove tamponade

Rusch urologic hydrostatic baloon:

-Used in urology for stretching the bladder and for stemming mucosal hemorrhage

-Technique

•insert into uterus .

•inflate with 400-500cc warm saline.

MANAGEMENT OF PRIMARY PPH

Resuscitation(Including Blood)

Call For Help

Investigations

Monitoring

Establish Cause

Atonic DIC Traumatic

Catheterize Bladder Cervicovaginal Inspection

Simultaneous

Uterine Massage/bimanual compression

Oxytocin Infusion No Injury Injury

+

IV Ergometrine

Uterine Repair

PGE1 Tablets rectally Contour

PGF 2α IM &

Intramyometrial Absent

Uterine Laparotomy

Tamponade

Not successful

Surgical measures

Angiographic Embolisation (prophylactic) eg: placenta accreta

MANAGEMENT OF SECONDARY PPH

Seconadry PPH is often associated with infection (usually endometritis & endomyometritis) Send following investigations

High & low vaginal swabs for culture sensitivity Blood culture if febrile Complete blood count CRP Pelvic ultrasound (to exclude if any retained products of conception)

Conventional treatment with antibiotics and uterotonicsAntibiotics for Endometritis -usually a combination of Ampicillin (Clindamycin if allergic to Penicillin) and Metronidazole is appropriate.Antibiotics for Endomyometritis or Overt sepsis- additional gentamicin is recommended

Surgical measures should be undertaken if there is excessive or continuous bleeding, irrespective of ultrasound findings

A senior obstetrician’s decision & assistance should be taken for evacuation of products of conception as these women carry a high risk for uterine perforation.

NOTE: Accurate documentation is essential which should include- Staff in attendance Sequence of events Time of administration of different pharmacological agents given,their timing &

sequence Time of surgical intervention, where relevant Condition of the mother throughout the different steps Timing of the fluid & blood products given

ONSET & DURATION OF ACTION OF ACTION OF VARIOUS OXYTOCICS

Route Ergometrine

(Ergonovine)

Methergin

(Methyl ergonovine)

Syntometrine(ergometrine+ syntocinon)

Syntocinon

Onset of actionIV 45-60 sec 1 ½ min Not to be used 30 sec

IM 6-7 min 7 min 2 ½ min 2 ½ min

Oral 10 min 10 min - -

Duration of action 3 hours 3 hours 3 hours 8 min

Misoprostol Onset of action (Minute)

Duration of action (Hours)

Oral 8 2 Sublingual 11 3 Vaginal 20 4 Rectal 100 4

STAGES OF SHOCK:

Classification Class 1 Class2 Class 3 Class 4

Blood Loss 10-15% 15-30% 30-40% >40%

(% Volume Lost)

Conscious State Alert, Mild Anxious And Agitated Or Drowsy,Confused

Thirst Restless Confused Unconscious

Respiratory Normal Mildly Elevated Raised Raised

Complexion Normal Pale Pale Markedly Pale

Extremities Normal Cool Pale & Cool Cold

Capillary Refill Normal Slow>2sec Slow>2sec Minimal Or Absent

PR Normal Normal Elevated Fast but Thready

Systolic BP Normal Normal Normal/Low Hypotensive

Urine Output Normal Reduced Reduced Oliguria/anuria

Mild shock- 20% loss of blood volume (decreased perfusion of non-vital organs & tissues -skin,fat,skeletal muscle & bone presenting with pale & cool skin)

Moderate shock- 20-40% loss of blood volume (decreased perfusion of vital organs -liver,gut,kidneys presenting with oliguria &/or anuria,drop in BP,mottling of skin in extremities)

Severe shock- >40% loss of blood volume (decreased perfusion to heart & brain presenting with restlessness,agitation,coma,ECG & EEG abnormalities,cardiac arrest)

Shock index – Heart rate

Systolic BP

Normal-0.5-0.7, Significant hemorrhage-0.9-1.1 (requires immediate management)

CANNULA SIZE(GAUGE)

COLOUR TIME TAKEN TO INFUSE 1000ml NS UNDER IDEAL CIRCUMSTANCES

FLOW RATE (ml/min)

EXTERNAL DIAMETER (mm)

24 G Yellow 20 0.7 22 G Blue 22min 33 0.9 20 G Pink 15min 62 1.1 18 G Green 10min 95 1.3 17 G White 140 1.5 16 G Grey 6min 200 1.7 14 G Red 3.5min 300 2.1

NON-PNEUMATIC ANTI-SHOCK GARMENT

INTRODUCTION:NASG is a lightweight, relatively inexpensive, washable neoprene suit composed of articulated horizontal segments with three segments on each leg, one segment over the pelvis and another, over the abdomen.

Using the three-way elasticity of neoprene and the tight closure of the Velcro, the garment applies 20–40 mm Hg circumferential counter-pressure to the lower body to reverse hypovolaemic shock by shunting blood to the vital coreorgans

ADVANTAGES OF NASG:1. NASG avoids some PASG-related adverse outcomes due to its design, being non

inflatable and applying a lower pressure to the body (20–40 mm Hgvs. PASG 104 mm Hg).

2. NASG, used for obstetric haemorrhage, would be applied to reduce bleeding in the pelvic region, the region demonstrated to have the greatest effect from compression.

WHEN TO APPLY:1. when women present in shock and with circulatory collapse, the NASG should be applied

as the first step in resuscitation2. In obstetric units where there is access to arterial embolization, the NASG can be applied

to stabilize the woman, maintain vital signs and decrease bleeding

HOW TO APPLY:

1. Place NASG under woman

2. close segments 1 tightly around the ankles

3. close segments 2 tightly around each calf

4. close segments 3 tightly around each thigh, leave knees free

5. close segment 4 around pelvis

6. close segment 5 with pressure ball over the umbilicus

6. Finish closing the NASG using segment

Segments 1, 2, 3 can be applied by two persons simultaneously

segments 4, 5, 6 should only be applied by one.

PATIENT MANAGEMENT

1. Call for help2. Assess vital signs3. Find source of bleeding,4. Administer IV fluids, uterotonics, etc. 5. NASG permits complete perineal access, thus vaginal procedures can be conducted with

the NASG in place. 6. Uterine massage can also be performed with the NASG in place.7. If abdominal surgery is necessary, open only the abdominal/pelvic segments immediately

prior to making the first incision; replace them rapidly as soon as surgery is complete.

Blood pressure drops when abdominal segments are opened.The anaesthesiologist should be prepared to manage the blood pressure with IV fluids.

REMOVAL OF NASG:

1. The NASG must be removed only under skilled supervision in a setting where vitalsigns can be monitored and there are adequate IV fluids.

2. The NASG should not be removed until the woman has been haemodynamically stable for at least 2 hours with blood loss <50 mL/hour, pulse<100 BPM and SBP>100 mm Hg.

3. To safely remove the NASG, start with the ankle segments and proceed upwards.

4. Allow 15minutes between opening each segment for the redistribution of blood, then check vital signs.

5. If SBP falls by 20 mm Hg or the pulse increases by 20 BPM, rapidly replaceall segments and consider the need for more saline or blood transfusions.

6. If there is recurrent bleeding, replace the NASG and determine the source of bleeding andfurther action for treatment.

7. If the NASG is removed incorrectly, by opening the abdominal section first (not inthe surgical setting) or by prematurely removing the NASG before the woman hasachieved haemodynamic stability, the woman will suffer immediate shock.

It is therefore essential to follow the removal instructions exactly.

Blood & components transfusion

1) Whole blood :Indications: Red cell replacement in acute blood loss with hypovolaemia Exchange transfusion Patients needing red cell transfusions where red cell concentrates or suspensions arenot availableContraindications:Risk of volume overload in patients with: Chronic anaemia Incipient cardiac failure

Description Preparation Storage Transfusion Obstetricindication

Quantity :350ml

No functional platelets

No labile coagulationfactors actors (V andVIII)

Tested for HBsAg,HIV, VDRL, malarialparasite and hepatitisC virus

Components preparedfrom whole blood used commonly inobstetrics- Packed red blood cells- Platelet concentrates- Fresh frozen plasma- Cryoprecipitate

For humandonors byvenesection

Collected intoa sterile, disposable,plastic packcontaininganticoagulantCPDA(40ml)14.2%

Between 2˚C6˚C in approvedblood bank

If stored <2˚Cfreezing injury to RBC

>8˚C growthof bacteria

Shelf life:35days

One unit ofwhole bloodincreases Hbby 0.75 to1g/dl andhaematocritby 3 to 5%

Administerwithoutwarming

Transfusionshould bestarted within30 minutes ofissue

Completetransfusionideally within2 hours notmore than 4hours

- Post partumhemorrhage

- Ectopicpregnancy

- Antepartumhemorrhage

- DIC

In an extreme situation and when the blood group is unknown, O Rh D negative red cellsshould be given (although these may be incompatible for patients with irregularantibodies).The decision to perform blood transfusion should be made on both clinical and

haematological grounds.

2) Red cell concentrates:

Description Preparation Storage Transfusion Obstetricindication

Quantity :150 - 200ml

Haemoglobinapproximately20g/100ml

Haematocrit 55% -70%

Prepared from single blood donor, collected in plastic bags

Plasma is separated from RBC’s by eithercentrifugationor undisturbedsedimentation

Preparationtime : 20minutes

Between 2˚C6˚C in approvedblood bank

Shelf life:35days

Single unit ofPRBC raises theHb% by 1g andhaematocrit by 3%in a non bleedingpatient

Transfusionshould be startedwithin 30 minutesof issue

Give 1 ampoule ofcalcium after each5 units of PRBC

For Hb <6g/dl– severe anemia

In acute bloodloss

2) FFPs/ Cryoprecipitate: It is essential that regular full blood counts (CBC) and coagulation screens areperformed during the bleeding episode. FFP, cryoprecipitate and platelets should not begiven on clinical suspicion alone unless there is delay in obtaining blood results. FFP contains stable clotting factors, albumin, immunoglobulin and no platelet FFP takes 30 minutes to thaw, once thawed used in 6 hours. In the bleeding woman with disseminated intravascular coagulation (DIC), acombination of FFP, platelets and cryoprecipitate is indicated. The FFP and cryoprecipitate should ideally be of the same group as the recipient. Ifunavailable, FFP of a different ABO group is acceptable, provided that it does not havea high titre anti-A or anti-B activity. No anti-D prophylaxis is required if an Rh D negative woman receives Rh D positiveFFP or cryoprecipitate. Fibrinogen levels should be maintained above 1.0 g/l by the use of FFP or two pools ofcryoprecipitate. There is insufficient evidence to suggest that FFP is useful in major blood loss in theabsence of DIC. Its use should be guided by the use of coagulation tests.

RCOG recommends- Infusion of FFP ideally before 1 blood volume is lost.- FFP indicated when fibrinogen is <100mg/dl and maintain fibrinogen >1g/dl.- FFP administered as 12-15ml/kg, to keep the activated partial thrombhoplastin time (aPTT)and PT time ratio <1:5.- Contraindicated for augmentation of plasma volume or albumin concentration.

Fresh frozen plasma

Description Preparation Storage Transfusion Obstetricindication

Quantity :100ml

Contains all thecoagulationfactors speciallyfibrinogen

Plasmaseparated fromone whole blooddonation within6 hours ofcollection

At -25oC orcolder

Shelf life:12months

1 unit raises thefibrinogen levelby 5-10mg%

Thawing takes20 minutes

DIC

TTPLiver diseases

INR>2x normal

Factor VIII levelat least 70% of normal fresh plasma level

No platelets

Plasma placed at-65oC to -75oC for30min to 1hrand frozen sold

Completetransfusionwithin 20min

Issued in thawedform for immediatetransfusion(1FFP for every 4to 5 units ofwhole blood/packedcells)

Activated partialthromboplastintime >1.5xnormal

Followingmassive blood

Cryoprecipitate- It is cold precipitable protein fraction derived from thawed FFP AT 1- 6º C. Contains factor VIII, fibrinogen, fibrinonectin, vW factor and factor XIII.- 1unit/kg body weight raises plasma fibrinogen by approximately 50mg/dl in the absence of consumption or massive bleeding.Cryoprecipitate indicated in (ACOG)- in von Willebrand’s, unresponsive to Desmopressin and congenital fibrinogen deficiency inperioperative or peripartum period- Bleeding with fibrinogen of 80-100mg/dl.

Description Preparation Storage Transfusion Obstetricindication

Quantity: 15mlAs muchfibrinogen as inFFP but in avolume of only15mlFactor VIII XIII& von willebrandfactor

From FFP bycollecting theprecipitate duringcontrolledthawing at 20C to 60C andresuspending it in 10 to 20ml ofplasma

Frozen within1hr afterprecipitation at -10C or colder

Shelf life:12months

Each unitincreasesfibrinogen by 5to 10 units

A large amountof fibrinogen can be administeredthrough smallvolume ofcryoprecipitate

To infuse within 6hrs of thawing

Transfusion time:within 20 min

DIC(as a source of fibrinogen)

Administer whenfibrinogen is < 100mg/dl

Clinicalhaemorrhage andfibrinogen<150ml/dl

Von willebrandfactor deficiency

Factor XIIIdeficiency

3) Platelets: The platelet count should not be allowed to fall below 50 x 109/l in the acutelybleeding patient. A platelet transfusion trigger of 75 x 109/l is recommended to provide a marginof safety. Platelets may not be on-site in many units, so their need should be anticipated and good communication with the transfusion laboratory maintained. Rh D-negative women should receive Rh D-negative platelets. The platelets should ideally also be group compatible.

50x109/l anticipated when 2 volume replaced by fluids or 5-10 units of red cell component transfusion Platelet transfusion not effective when thrombocytopenia is due to plateletdestruction as in ITP, TTP, untreated DIC.

Offer prophylactic platelet transfusions to patients with a platelet count below 10×109 perlitre who are not bleeding or having invasive procedures or surgery, and who do not have any of the following conditions:- chronic bone marrow failure- autoimmune thrombocytopenia- heparin-induced thrombocytopenia- thrombotic thrombocytopenic purpura.DosesContraindications: Not generally indicated for prophylaxis of bleeding in surgical patients,unless known to have significant pre-operative platelet deficiency

Dosage: 1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6singledonor units containing at least 240 x 109 platelets should raise the platelet count by 20–40 x109/L Increment will be less if there is: Splenomegaly Disseminated intravascular coagulation Septicaemia

Administration : After pooling, platelet concentrates should be infused as soon as possible,generally within 4 hours, because of the risk of bacterial proliferation Must not be refrigerated before infusion as this reduces platelet function

Description Preparation Storage Transfusion Obstetric indication

Random donorplatelets (RDP)Quantity: 50-100ml

Separated fromsingle blooddonor unit,suspended in50ml of plasma

Preparation time:1hour

200C to 240C

Do not store at20-60 reducesplatelet function

Should beinfused at 1-2ml/min

With/without activebleed if platelet count<20,000/mm3

Active bleed andplatelet count less than50,000

One unitincreases theplatelet count by6,000-8,000 cells

Single donorplatelets (SDP)Quantity: 300-

Readily availablefrom blood bankOnly platelets areobtained from adonor byApheresis

Preparation

Continuousgentle agitationis maintainedthrougout thestorage period to prevent plateletaggregation

4-6 units ofplateletconcerntratesinfused over aperiod of 30minutes

Platelet functiondefects- DIC-Gestationalthrombocytopenia- Severe

350mlOne unitincreases theplatelet count by30,000-60,000cells

time:24-48hrs Short selflife:72hrs

preeclampsia- HELLP syndrome- ITP- SLE

Single donor platelets offer several advantages over random donor platelets. Theyare: Fewer donor exposures, fewer follow ups and investigations posttransfusion Risk of bacterial contamination reduced by 10 fold, risk of septic transfusion reaction reduced by 5 fold When multiple transfusions are indicated SDPs are preferred Disadvantage: They have a higher processing fee than RDPsAdvantage of RDP: they are readily available for infusionComplications: Febrile non-haemolytic and allergic urticarial reactions are notuncommon,especially in patients receiving multiple transfusions.

Administering blood products: Check unit of blood details against transfusion slip Check patient details against blood unit. Attach unit of blood to transfusion set and run through blood correctly and remove theair column Aseptically attach blood transfusion set to cannula; Ensure blood is flowing and set at correct rateDisposable equipment for blood administration Cannulae for infusing blood products:Must be sterile and must never be reused Use flexible plastic cannulae, if possible, as they are safer and preserve the veins A doubling of the diameter of the cannula increases the flow rate of most fluids by afactor of 16.

Time limits for transfusionComponent Start infusion Complete infusion

Whole blood and packed redblood cells

Within 30min of removingpack from refrigerator

Ideally within 2hrs, not morethan 4hrs

Platelet concerntrates Immediately Within 20 minFFP and cryoprecipitate As soon as possible Within 20 min