Transfusion medicine in obstetrics and gynecology

Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes

This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques.

Massive Blood Loss and Transfusion in Obstetrics and Gynecology

Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning.

OBJECTIVES

After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

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.

A survey of physicians' attitudes toward blood transfusion in patients undergoing cesarean section

OBJECTIVE

This study was undertaken to evaluate the attitude of anesthesiologists and gynecologists to the use of blood during cesarean section operation and, on the basis of the results, to ascertain the need for improvement of current transfusion guidelines.

STUDY DESIGN

A scenario-based survey was performed.

RESULTS

The response rate was 94% (327/347) among anesthesiologists and 91% (355/391) among gynecologists. The majority of responders selected a hemoglobin threshold ranging from 7.5 to 8.5 g/dL (62%). Threshold hemoglobin concentration differed significantly (P<.001) between anesthesiologists (median, 7.5 g/dL) and gynecologists (median, 8 g/dL). At that threshold, 56% of anesthesiologists compared with 86% of gynecologists administered 2 units of blood (P<.05). When transfusing packed cells, most practitioners would give 2 units regardless of the transfusion threshold.

CONCLUSION

Our findings demonstrate differing approaches to current transfusion protocols. Transfusion consensus recommendations should be improved and unified to enhance red blood cell transfusion practices for relatively young and healthy patients undergoing anesthesia and surgery.

Planning for hemorrhage. Steps an anesthesiologist can take to limit and treat hemorrhage in the obstetric patient

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

Autotransfusion for ruptured ectopic pregnancy

OBJECTIVES

Clinical outcomes following the exclusive use of autotransfusion in the management of ruptured ectopic pregnancy are reviewed.

METHODS

A MEDLINE search (1966-2002) for relevant articles documenting the exclusive use of autotransfusion, and data collection and analysis was made.

RESULTS

There were 21 studies, 16 from developing and five from developed countries, involving 632 cases of ruptured ectopic pregnancies. Hypovolemic shock with significant hemoperitoneum (>500 ml) was the most common complication. The procedure was performed completely manually in developing countries and with the help of a device in developed countries. The mean volume of autotransfused blood was over 1000 ml, with mean hemoglobin levels ranging from 6 to 12.5 g/dl. Mean posttransfusion hemoglobin levels were higher than pretransfusion levels. There was one death, thought to be due to pulmonary embolism, and nine major and minor complications.

CONCLUSIONS

Autotransfusion is useful in the management of ruptured ectopic pregnancy.

Transfusion rate associated with hysterectomy for benign disease

The transfusion rate associated with hysterectomy for benign disease is an indirect indicator of haemorrhage. It is used in quality assurance activities and is one measure of standard of care. This retrospective study was conducted to determine the transfusion rate for these operations in a tertiary referral hospital. In addition, it was considered that the information could be used in deciding the need for a routine preoperative group and save policy (G and S). The Blood Bank records of all women undergoing hysterectomy for benign disease from 1993-1998 were examined and the number of women transfused was recorded. A total of 1220 hysterectomies were performed. Of women having vaginal hysterectomies only 0.38% required transfusion compared with 2.18% for abdominal hysterectomies. These data suggest that there is no need for a strict policy of preoperative G and S for all patients. In addition, this information can be used as a benchmark when reviewing morbidity associated with hysterectomy and in particular when various methods of hysterectomy are compared.

Surgical blood loss in abdominal hysterectomy

OBJECTIVE

The aim of this study was to evaluate additional error in estimating red cell loss during abdominal hysterectomy.

METHODS

Eighty patients admitted consecutively for abdominal hysterectomy were recruited. The surgeries were done after heparinizing the suction tubing system to prevent clotting and reducing the vacuum pressure to reduce red cell lysis. At the end of the surgery, hematocrit was measured and compared with the patient's venous blood and the blood from the suction container. The Mann-Whitney test evaluated statistical significance.

RESULTS

Eight patients were excluded for having a hemolyzed blood sample, receiving a blood transfusion, and having incomplete data. The study cohort consisted of 72 patients: 54 had a simple hysterectomy and 18 had a radical hysterectomy with pelvic and periaortic lymphadenectomy. The hematocrit (mean +/- standard deviation) in the suction container (19.8 +/- 8.8%) was lower than the hematocrit from the venous blood sample (32.4 +/- 6%) (P < 0.001). The hematocrit in the suction container decreased as the duration of the surgeries increased. Although the volume of blood in the suction container was used to estimate blood loss, the concentration of red cells in the container was consistently lower than those in the venous blood sample. The magnitude of dilution increased as the length and radical nature of the surgery increased.

CONCLUSIONS

These findings suggest that other fluid, probably lymph, contributes to the dilution of red cells in the container and increases the estimated blood volume loss during surgery. Estimation of red cell surgical blood loss becomes less accurate as the length and radical nature of the surgery increase.

Effect of hemodilution on tissue perfusion and blood coagulation during radical hysterectomy

OBJECTIVE

The goal of this study was to evaluate the safety of hemodilution on global and splanchnic perfusion and blood coagulation during radical hysterectomy.

METHODS

A pulmonary artery catheter and a gastric tonometry catheter were placed in 16 patients with cervical carcinoma. Global perfusion indices, splanchnic perfusion index, and coagulation tests were obtained. Blood was removed to achieve a hemoglobin measurement of 8-9 9 g/dL. Three more measurements were repeated after hemodilution, at the end of surgery, and after the retransfusion of blood. Analysis of variance was used to determine statistical significance.

RESULTS

Sixteen patients with cervical carcinoma had 1.0 +/- 0.3 L (mean +/- SD) of blood removed and had a blood loss of 0.8 +/- 0.7 L. Hemodiluted preoperative hemoglobin was 8.7 +/- 1 g/dL. All of the global perfusion indices, except for arterial pH and oxygen consumption, decreased after hemodilution and recovered with the retransfusion of blood (P < or = 0.004). Splanchnic perfusion and coagulation tests were unchanged (P > or = 0.1). Major complication was pulmonary edema in one patient.

CONCLUSION

Hemodilution during radical hysterectomy, in this select group of patients, does not appear to compromise tissue perfusion or coagulation.

The safety of intraoperative autologous blood collection and autotransfusion during cesarean section

OBJECTIVE

We evaluated the safety of intraoperative autologous blood collection and autotransfusion during cesarean section.

STUDY DESIGN

A multicenter historical cohort study identified 139 patients in whom autologous blood collection autotransfusion during cesarean section was performed. We also identified 87 control patients who underwent similar surgical procedures at the same centers without autotransfusion. The outcome variables we compared were acute respiratory distress syndrome, amniotic fluid embolism, disseminated intravascular coagulation, need for ventilatory support, infectious morbidity, and the length of postpartum hospitalization.

RESULTS

Demographic and obstetric characteristics were similar in both groups. The ranges of autotransfused volumes were 200 to 11,250 mL at Yale, 225 to 1160 mL at Good Samaritan, and 125 to 4750 mL at Hinsdale. No statistically significant differences existed between the two groups in any of the outcome variables analyzed. No case of acute respiratory distress syndrome or amniotic fluid embolism was identified in either group.

CONCLUSIONS

Our multicenter experience reveals no demonstrably increased risk of complications in patients receiving autologous blood collection autotransfusion during cesarean section.

Blood transfusion requirements for abdominal hysterectomy: 3-year experience in a district hospital (1993-1995)

Two hundred and thirty six women who underwent abdominal hysterectomy for benign disease at Fairfield District Hospital were studied retrospectively. Eleven patients received a total of 28 units of blood. The transfusion rate was 4.7%. The average number of units transfused per operation was 0.12. Each transfused patient received an average of 2.5 units with a range of 1-4 units. Only 27% of cross-matched blood was actually transfused. Patients with preoperative anaemia, prolonged operation time and a larger uterus were more likely to require blood transfusion. The group and screen procedure is an adequate preoperative blood order for patients having abdominal hysterectomy.