SHOCK IN OBSTETRICS, BLOOD TRANSFUSION & ALTERNATIVE TO BLOOD TRANSFUSION

MIKAH S

OUTLINE

• SHOCK IN OBSTETRICS

DEFINITION

TYPES/CAUSES/CLASSES

CLINICAL FEATURES

MANAGEMENT

COMPLICATIONS

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OUTLINE

• BLOOD TRANSFUSION

INTRODUCTION

INDICATIONS

REDUCTION OF TRANSFUSION RATE

CRITERIA FOR DONATION

BLOOD FRACTIONS

PROCEDURE

COMPLICATIONS/MGT

ALTERNATIVE TO BLOOD TRANSFUSION

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SHOCK

DEFINITION

• a state of circulatory impairment characterized by defective tissue perfusion resulting in abnormal cellular function and metabolism
• inadequate tissue perfusion from circulatory failure leading to hypoxia, nutritional deficiency and accumulation of metabolites

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SHOCK

• Leads to clinical syndrome characterized by signs of decreased perfusion of vital organs with possible alteration of mental function and oliguria

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Types

• Hypovolaemic( Haemorrhagic) – blood loss
• Cardiogenic- inefficient myocardial contraction
• Anaphylactic - allergy
• Neurogenic - pain
• Endotoxic - toxins
• Others

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Causes in obstetrics

Haemorrhagic

-Eary cyesis

• APH
• PPH

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Cardiogenic

CCF

MI

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Causes

• Neurogenic

-Ectopic gestation

-Evacuation

-Abruption placenta

Uterine inversion

Forceps/breech delivery

Precipitate labour

Uterine rupture

Rough internal version

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Causes

• Endotoxic – infection by bacteria as in PROM, abortion, instrumentation, trauma, puerperal sepsis, pyelonephritis due to release of toxins
• Anaphylactic – Drugs

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• Others – Embolism, combination

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Clinical features

• Symptoms

-weakness

-Air hunger

- Confusion

-loss of consciousness

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Clinical features

• Signs
• Pallor
• Anxiety
• Restlessness

- Sweating, Cold clammy extremities, cyanosis

• Pulse – small volume , fast, thready, absent
• BP- low, absent
• Tachypnea
• Altered consciousness

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Phases

Compensation

Blood loss 25% of blood volume= sympathetic stimulation ( pallour, tarchycardia, tarcypnea)

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Decompensation

blood loss > 25% = Symptoms of shock

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Cellular damage and danger of death

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CLASSES OF SHOCK

• CLASS I < 15%

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• CLASS II 15-30%

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• CLASS III 30- 40%

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• CLASS IV >40%

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Management

• Call for help
• Clear airway and ensure breathing
• Oxygen therapy
• Elevate legs – anti shock garment
• Secure intravenous line ( Wide bore canula)
• Restoration of blood volume – crystalloid, colloids, blood or components
• Drugs- hydrocortisone, analgesics, Sodium bicarbonate, vasopressor agents
• Treat specific cause

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Management

• Monitoring
• Pulse
• BP
• Urine output
• Central venous pressure
• Pulmonary artery pressure – in some cases

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complications

• ARF
• Sheehan’s syndrome
• DIC
• Death

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BLOOD TRANSFUSION

• An invaluable therapeutic measure

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• Obstetric haemorrhage remains the major cause MM

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• Life -saving

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• Potential complications- Must be given with very good reasons

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Blood transfusion

• Decision to transfuse based on both clinical and laboratory assessment
• Appropriate use – its expensive and scarce
• Blood components required for therapy should be used
• Blood transfusion policies must be strictly adhered to.

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Indications in Obstetrics

• APH OR PPH leading to shock

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• Large blood loss at operative delivery

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• Severe anaemia in late pregnancy

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How to reduce rate of transfusion and MM

• Treat anaemia
• Reduce blood loss at delivery
• Hospital delivery with facility for blood transfusion
• Optimal management of patients on anti - coagulants

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Criteria for blood donation

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-Hb >13.5 (males) or >12.5 (females).

- No major operation in 6 months.

- No pregnancy within 12 months.

- No blood donation in 6 months.

- No clinical malaria in 1 month in endemic areas.

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Criteria for blood donation

- No blood transfusion in the past 12 months.

- Free from severe hypertension, splenomegaly, bleeding disorder or allergic conditions e.g. asthma.

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- No evidence of HIV, Hepatitis ( B &C), syphilis, Trypanosomiasis or Brucellosis.

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- Occupation must not be high risk.

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- No vaccination in the past 3 months.

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TRANSFUSION PROCEDURE

• Counselling.
• Physical examination .
• Clear communication between clinical and lab staff

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• Cross-checking of blood and patient records.
• Documentation of transfusion procedure and indications.
• Premedication.
• Write-up of first aid management of transfusion reactions.
• Transfusion monitoring.
• Post transfusion medication.

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BLOOD FRACTIONS

• Whole blood.
• Packed red blood cells.
• Platelet concentrate.
• Fresh frozen plasma.
• White cell concentrate.
• Factor VIII concentrate.
• Factor II concentrate.
• Cryoprecipitate.
• Salt poor albumin concentrate.

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BLOOD FRACTIONS

• Human plasma protein fraction.
• Albumin concentrate.
• Hyper-immune globulins.
• Fibrinogen concentrate.
• Factor IX concentrate.
• Anti-thrombin III protein concentrate.

BLOOD TRANSFUSION COMPLICATIONS

• Haemolytic reactions (ABO, Rh).
• Anaphylactic reactions (Ig antibodies).
• Non-haemolytic febrile reactions.
• Massive blood transfusion.
• Air embolism.
• Cardiac arrest.
• Transfusion transmissible infections.
• Circulatory overload.

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MANAGEMENT OF TRANSFUSION COMPLICATIONS

• Stop transfusion immediately.
• Send blood and its content for re-screening.
• Resuscitate patient.
• Re-evaluate patient.
• Venepuncture (for circulatory overload).
• Drugs- diuretics, inotropic drugs, calcium gluconate, antibiotics (for bacterial contamination), plasma substitutes.

ALTERNATIVE TO BLOOD TRANSFUSION

• Blood transfusion though useful may not be the best option
• Usage can be restricted by patient’s choice or religious believe
• Effective alternative remains the only option

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Alternatives to transfusion

• 1. Manage anaemia conservatively – Stable patients can tolerate some degree of anaemia without any medication but would require close monitoring
• 2. Haematinics- medications like ferrous sulphate, folic acid, Vitamin B12, erythropoietin , Granulocyte colony stimulating factors. Others in the pipeline with oxygen carrying capacity- Hemopure, Hemolink, Oxygent

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Alternatives to transfusion

• 3. Acute Normovolaemic haemodilution- crystalloids, colloids
• 4 . Autologous blood transfusion –
• predeposit ?, Intraoperative cell salvage, PCS,
• 5. Topical Medications to stop bleeding- oxidized cellulose,fibrin glue, Haemacele, platelet gel etc
• 6. Systemic medications to stop bleeding- Tranexamic acid, aminicaproic acid, Vit K, Activated factor VII, Factor VIII concentrate

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ALTERNATIVES TO TRANSFUSION

• Meticulous surgical technique

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• Avoid excessive blood collection for investigations

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THANK YOU

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