Review Article VOL. 11 | NO.

4 | ISSUE 44 | OCT-DEC 2013

Blood Transfusion in Obstetrics

Nigam A,1 Prakash A,2 Saxena P1

Department of Gynecology and Obstetrics

1
ABSTRACT
Department of Medicine
2
Transfusion of blood and blood components is a common practice in obstetric
Lady Hardinge Medical College and Smt. Sucheta wards but it is not without risk. The incidence of transfusion reactions varies from
Kriplani Hospital, New Delhi 4 in every hundred transfusions for non-haemolytic reactions to one in every
India 40,000 for haemolytic transfusion reactions. The physiological basis of blood
transfusion is outlined in this article. Most of the donated blood is processed into
components: packed red cells (PRBCs), platelets, and fresh frozen plasma (FFP)
Corresponding Author or cryoprecipitate. Various alternatives to blood transfusion exist and include
autotransfusion, pre-autologous blood storage, use of oxygen carrying blood
Aruna Nigam substitutes and intraoperative cell salvage. Despite the risks associated with
Department of Gynecology and Obstetrics transfusions, obstetricians are frequently too aggressive in transfusing blood and
blood products to their patients. Acute blood loss in obstetrics is usually due to
Lady Hardinge Medical College and Smt. Sucheta placenta praevia, postpartum blood loss and surgery related. An early involvement
Kriplani Hospital, New Delhi
of a consultant obstetrician, anaesthetist, haematologist and the blood bank is
India essential. There are no established criteria for initiating red cell transfusions and
the decision is purely based on clinical and haematological parameters, which have
E-mail: prakashanupam@[Link]
been discussed along with the general principles of blood transfusion in obstetrics
and some practical guidelines.

Citation

Nigam A, Prakash A, Saxena P. Blood Transfusion in KEYWORDS

Obstetrics. Kathmandu Univ Med J 2013;44(4):355-
359. Cryoprecipitate, fresh frozen plasma, packed cells, platelets

INTRODUCTION
Transfusion of blood and blood components is a common but the major risk associated with blood transfusion is
practice in obstetric wards. Moreover, obstetric conditions of a patient receiving an ‘incorrect blood component.1
associated with the need for blood transfusion are Strict adherence to correct sampling, cross-match and
associated with considerable morbidity and mortality, if administration procedures is most important way to
not properly managed. Obstetric haemorrhage continues avoid these complications. The present article deals with
to be a major cause of maternal mortality in India with the basis of blood transfusion, its indications in routine
‘substandard management’ being a contributor in 80% of obstetric practice and component therapy.
the cases.1 High risk pregnancies with an anticipated loss
greater than 1000 ml should be strongly advised to deliver Physiological Basis of Transfusion
in a setting where transfusion support and intensive care The blood and its components are transfused primarily to
facilities are available.
• Enhance oxygen carrying capacity of blood.
Blood transfusion may be a life-saving procedure but it is
not without risk. The incidence of transfusion reactions • Replace clotting factors which are either lost, consumed
varies from 4 in every hundred transfusions for non or not produced.
haemolytic reactions to one in every 40,000 for haemolytic Under normal circumstances the oxygen delivery to the
transfusion reactions. Although, recipients can develop tissues is 1000ml/min and the oxygen consumption is
transfusion-transmitted infections as well as suffer 200ml/min. Hence, the ratio of oxygen delivery to oxygen
immunological sequelae such as red cell alloimmunisation; consumption is 5:1. In patients with anaemia, hypoxia or

Page 355
KATHMANDU UNIVERSITY MEDICAL JOURNAL

myocardial failure in whom the delivery of oxygen cannot factors occur within 24-48 hours of storage.
be increased and in whom the consumption is increased,
• Levels of 2-3 DPG may decrease by 30% in blood stored
this 5:1 ratio will fall with the patient using up the inherent
for greater than two weeks, by 60-70% in three weeks,
oxygen reserves. This scenario persists until the ratio falls
thus significantly diminishing the ability to release oxygen
to 2:1 up to which level the patient remains stable. Thus
to tissues.
the recommendation to transfuse a patient must focus
on compensatory ability of the patient and physiologic Packed Red Blood Cells ( PRBC) : This is prepared by removing
parameters and not only on the packed cell volume (PCV) 200 cc of plasma from fresh whole blood, to achieve a
as is the case generally. Transfusion therefore, is only final hematocrit of 70-80%. They are stored in liquid state
necessary when patients cannot compensate for their at 40 C or frozen at –800 C. It is kept anticoagulated with
anaemia. CPD (citrate, phosphate, dextrose). Survival rate of blood
cells decreases from 90% with immediate transfusion
When the compensatory mechanisms are normal with
to 65% at six weeks of storage. Pre-storage leucocyte
an adequate oxygen delivery it may not be necessary
reduction of PRBCs is recommended universally to prevent
to transfuse patients until the PCV drops below 16%
certain adverse reactions i.e. posttransfusion fever,
(Hemoglobin, Hb < 5.3 g/dL) and in patients with poor
cytomegalovirus (CMV) infections, and alloimmunization.4
compensatory mechanisms may only be advised when the
Prestorage filtration appears superior to bedside filtration
PCV drops below 25% (Hb < 8.3 g/dL).2,3
as smaller amount of cytokine is generated in the stored
Release of the oxygen to tissues mainly depends on oxygen product.
saturation of Hb besides other factors. As saturation
Cryopreserved RBC : This technique utilizes rapid cooling
increases, the decreasing affinity will cause the enhanced
of PRBC to –800 C in 40% glycerol. 2-3 DPG level remains
release of oxygen to tissues. Partial pressure of oxygen
normal. Antigenic reactions are minimum in this technique.
required to saturate 50% of the Hb molecule is called
Large quantities of red cells can be stored for many years.
P-50. This is increased with fever, acidosis, increased 2-3
But high expense is a significant disadvantage.
diphosphoglycerate (DPG) , thus oxygen is released to
tissues with greater ease in these circumstances. However Platelets : It is collected by repeated centrifugation of fresh
with hypothermia, alkalosis and decreased 2-3 DPG, affinity whole blood, and suspension in 30-50 cc of plasma at 220 C.
of oxygen is increased and release is decreased. It remains viable for up to five days and is most efficacious
if used within 24-48 hours of pooling as they lose ability
Hb normally ranges between 12-18 g/dL depending on race,
to produce thromboxane A-2, a potent vasoconstrictor and
age, sex and medical condition. The capacity of tolerating
platelet aggregator gradually over five days. It should be
the lower concentrations of Hb depends on
ABO and Rh compatible, since donor plasma is present. Risk
• the rate and magnitude of blood loss of infectious complications are proportionate to number of
donors.
• state of tissue perfusion
Apheresis technology is used for collection of multiple units
• pre-existing cardiopulmonary disease.
of platelets from single donor. These single donor apheresis
Different Components of Blood Transfusion platelets (SDAP) contain the equivalent of at least 6 units
Blood components intended for blood transfusion are of random-donor platelets and have fewer contaminating
routinely collected as anticoagulated whole blood (450 ml). leukocytes than pooled random-donor platelets.
Most of the donated blood is processed into components: The threshold for the prophylactic platelet transfusion
packed red cells (PRBCs), platelets, and fresh frozen plasma is 10,000/mL. In patients without fever or infections,
(FFP) or cryoprecipitate. Whole blood is first separated a threshold of 5000/mL may be sufficient to prevent
into PRBCs and platelet rich plasma by slow centrifugation. spontaneous hemorrhage. For invasive procedures 50,000/
The platelet rich plasma is then centrifuged at high speed ml is the usual target level.
to yield one unit of random donor (RD) platelet and one
Platelets are given either as pools prepared from five
unit of FFP. Cryoprecipitate is produced by thawing FFP to
to eight random-donor platelets or as a single SDAP.
precipitate the plasma proteins, and then separated by
In an unsensitized patient without increased platelet
centrifugation.
consumption, six to eight units of RD platelets (about 1
Whole Blood: It is stored at 40C to sustain erythrocyte unit per 10 Kg body weight) are transfused and each unit is
viability. It is the ideal component for the patients who anticipated to increase the platelet count by 5000 to 10000/
have sustained acute haemorrhage (blood loss >25% of mL. Patients receiving multiple transfusions usually get
total blood volume) as it improves the oxygen carrying alloimmunized to many HLA and platelet specific antigens
capacity and results in blood volume expansion. and have little or no increase in their post transfusion platelet
Disadvantages of whole blood are that counts. Patients who may require multiple transfusions are
best served by SDAP and leukocyte reduced components
• Platelet dysfunction and degradation of some clotting to reduce their risk of alloimmunization. Refractoriness to

Page 356
Review Article VOL. 11 | NO. 4 | ISSUE 44 | OCT-DEC 2013

multiple transfusions may be evaluated by using corrected recommended in pregnancy.

count increment (CCI):
Oxygen carrying blood substitutes: i.e. perfluorocarbons
CCI= [posttransfusion count-pretransfusion count/number and aggregated hemoglobin solutions are presently in
of platelets transfused x1011] x (Body surface area in square various stages of trials.
metres)
Intraoperative cell salvage (IOCS) is the process by which
The platelet count performed one hour after the transfusion blood shed within the surgical field is retrieved by an
is acceptable if the CCI is 10x109/ml, and after 18-24 hours anticoagulated suction apparatus and collected within a
an increment of 7.5x109/ml is expected. Patients who have reservoir from where it is centrifuged, washed and pumped
suboptimal responses are likely to have received multiple into an infusion bag. This salvaged blood can then be
transfusions and have antibodies directed against Class 1 returned to the patient. This process is effective in reducing
HLA antigens. Refractoriness can be detected by anti-HLA the need for allogenic red cell transfusion and has been
antibodies in the recipient’s serum. These patients are best widely used in adult orthopaedic and cardiac surgeries
served by SDAP if needed. without complications. Cell salvage is recommended for
women in whom an intraoperative blood loss of more than
Fresh Frozen Plasma : FFP contains components of the
1500 ml is anticipated.
coagulation, fibrinolytic, and complement systems. It
is obtained from single donor. It is frozen at 80C, this The use of IOCS in obstetric practice has been limited,
temperature protects Factor V and VII mainly. It carries the owing to concerns about contamination by amniotic fluid,
same risk of HIV and Hepatitis as PRBC. It is useful in treating specifically the risks of amniotic fluid embolism, and by
deficiencies in 2, 5, 7, 8, 9, 10, 11, also in Coumarin reversal, fetal blood cells, particularly the risk of anti-D formation.
antithrombin III deficiency. Type and Rh specific plasma Common markers of amniotic fluid contamination can be
should be used. Urticaria and fatal pulmonary edema can found in the maternal circulation after most deliveries. The
occur. Plasma may also be collected by apheresis. IOCS, together with the use of modern leucocyte depletion
filters, has been shown to be effective at removing the
Plasma derivatives such as albumin, intravenous
common markers of amniotic fluid embolism.5 However, it
immunoglobulin, antithrombin, and coagulation factors
will not remove fetal blood cells and therefore adequate
are prepared from pooled plasma from many donors and
anti-D immunisation (as determined by Kleihauer test one
are treated to eliminate infectious agents.
hour after the procedure) will be required to prevent rhesus
Cryoprecipitate : immunisation in Rh D-negative women.6 IOCS has been
It is used to replenish Factor VIII or fibrinogen. It is formed as used during caesarean section in a number of case series
a plasma concentrate that consists primarily Factor VIII and and trials without any reported complications related to
fibrinogen. In addition, it also contains Factor XIII, vWF and receiving salvaged blood.7
fibronectin. It is stored at 370C since higher temperatures The National Institute for Health and Clinical Excellence
destroy Factor VIII. The main disadvantage is the increased NICE guideline on intraoperative blood cell salvage in
risk of hemolytic reactions due to small amounts of anti-A, obstetrics (IOCS) in obstetrics recommends that, when
anti-B, and Rh antibodies left over in preparation as it is used, it should be used by healthcare teams who use it
obtained from multiple donors. regularly and have built up expertise and experience,
Alternatives to Transfusion that patients should consent to its use, and this should be
subject to audit and monitoring.7
Autotransfusion: It involves collection and immediate
reinfusion of patient’s own blood for volume replacement Blood Transfusion in Major Obstetrics Hemorrhage
and to increase red cell mass. Massive exsanguinations Despite the risks associated with transfusions, obstetricians
from either blunt or penetrating trauma without gross are frequently too aggressive in transfusing blood and blood
enteric contamination are best candidates. It eliminates products to their patients. Acute blood loss in obstetrics
risk of histocompatibility reactions and transfusion is usually due to placenta praevia, postpartum blood loss
transmitted infections. The most common complication is and surgery related. This demands early involvement of a
thrombocytopenia. When patients receive more than 4L consultant obstetrician, anaesthetist, haematologist and
of blood, platelet count may drop to less than 50,000/mL, the blood bank.
and risk of acute tubular necrosis increased from debris
There are no established criteria for initiating red cell
of plasma-free Hb. There also exist increased risks of air
transfusions. Decision should be based on clinical and
embolism, particulate microemboli, and disseminated
haematological parameters.
intravascular coagulation(DIC).
• Transfusion is advocated when the PCV is less than 21%
Pre-Autologous blood storage: It is similar to PRBC (42 days
(in patients without any cardiac pathology) and is generally
maximum). Contraindications include significant coronary
infused in a ratio of 3 volumes of crystalloid to 1 volume
artery disease, chronic obstructive pulmonary disease,
of blood. In severe shock this ratio may increase up to 8:1.
and existence of a hematologic disorder. This is not

Page 357
KATHMANDU UNIVERSITY MEDICAL JOURNAL

• Infusion of FFP should be considered before one blood neutrophil cytotoxicity which is now regarded as a key
volume is lost. mechanism in multiple organ failure (MOF) and early
transfusion has been shown to be a strong independent
• Fibrinogen deficiency is the earliest haemostatic
risk factor for MOF.11 Thus in acute blood loss, with
abnormality encountered when packed red cell
moderate haemorrhagic shock, either normal saline or
concentrates are used to replace major blood loss. Clinically
Ringer’s lactate may be used for volume replacement and
significant fibrinogen deficiency develops after a loss of
in massive hemorrhagic shock, Ringer’s lactate may be
about 150% of blood volume.
the fluid of choice.12 Colloids have been largely replaced
• The platelet count should not be allowed to fall below by crystalloids due to the propensity of the former to leak
50 x 109/mL in the acutely bleeding patient. A platelet from permeable capillary membranes thereby worsening
transfusion trigger of 75 x 109/mL is recommended to oedema and impairing tissue oxygenation. However, large
provide a margin of safety. A platelet count of 50 x 109/mL volumes of crystalloids have been implicated in the etiology
may be anticipated when approximately two blood volumes of adult respiratory distress syndrome and the abdominal
have been replaced by fluid or red cell components. compartment syndrome, which colloids may not cause, but
• Anti-Rh D (250 IU) will be needed if the platelets are overall crystalloids provide the best survival.13
Rh D positive and the recipient Rh D negative. This is not General Principles of Blood Transfusion in Obstetric
necessary if a caesarean hysterectomy has been performed. Patient
• The FFP and cryoprecipitate should ideally be of the same • Red cell alloimmunisation is most likely to occur in the
group as the recipient. If unavailable, FFP of a different last trimester, therefore no pre-transfusion sample should
ABO group is acceptable, provided that it does not have a be more than seven days old and ideally should be freshly
high titre anti-A or anti-B activity.9 No anti-D prophylaxis is drawn.14
required if an Rh D negative woman receives Rh D positive
• Only Kell-negative blood should be used for transfusion
FFP or cryoprecipitate.
in women of childbearing age, owing to the high risk of
• In the bleeding woman with DIC, a combination of FFP, alloimmunisation and subsequent hemolytic disease of the
platelets and cryoprecipitate is indicated. newborn (unless a woman is known to be Kell positive).
• Fibrinogen levels should be maintained above 1.0 g/L by • In pregnancy, pre-autologous deposit is not recommended.
the use of FFP.10
• Cell salvage should only be used by healthcare teams
• Dilution of coagulation factors is the primary cause who use it regularly and have the necessary expertise and
of coagulopathy in major blood loss following volume experience.
replacement with crystalloid or colloid and transfusion of
• If the Hb is less than 7 g/dL in labour or in the immediate
red cell components.
postpartum period, the decision to transfuse should be
• Women who have been exposed to prolonged hypoxia, made according to the individual’s medical history, age and
hypovolaemia or hypothermia (for instance, owing to symptoms.
inadequate resuscitation), amniotic fluid embolism,
• If the Hb is less than 7–8 g/dL in postnatal period, where
placental abruption and pre-eclampsia are at risk of DIC.
there is no continuing or threat of bleeding, the decision
If DIC is strongly suspected in these women and clotting
to transfuse should be made on an informed individual
studies take a long time, transfusion of FFP should be
basis. In fit, healthy, asymptomatic patients there is little
considered before results are available if hemorrhage is
evidence of the benefit of blood transfusion.
otherwise difficult to control.
• If unexpected severe bleeding is encountered during
• DIC should be suspected when there is profuse bleeding
delivery, investigations should be made post-natally to rule
from the site of trauma and oozing from the sites of
out a bleeding diatheses. These investigations should be
venepuncture and intravenous line insertions. There are no
performed on a non-urgent basis at least 3–6 months after
data to substantiate transfusion triggers for clotting factors
delivery.
but common practice is to administer FFP 12-15 mL/kg to
keep the activated partial thromboplastin time (aPTT) and Practical guidelines
prothrombin time ratios less than 1:5.
• PCV may be converted to Haemoglobin in gm/dL by
• The use of rFVIIa (recombinant factor VIIa) may be dividing it by 0.03.
considered as a treatment for life-threatening postpartum
• One unit of blood lost is compensated by 3 units of
haemorrhage but it is not a substitute for life-saving
electrolytes. A blood loss of 1500 mL is thus compensated
procedures like embolisation or surgery; which need to be
by 1500 X 3 = 4500mL Ringer or normal saline infusion.
performed promptly or alternatively, the patient needs to
be transferred to a referral centre for the same. • In serious hypovolemia, volume therapy with Ringer
lactate or normal saline infusion is immediately started.
• Blood transfusion of banked blood results in provoking
If her circulatory state does not stabilize prompt and

Page 358
Review Article VOL. 11 | NO. 4 | ISSUE 44 | OCT-DEC 2013

permanently as a response to 3000 ml infusion, blood expanding fluids or red cells as appropriate.
transfusion (or plasma expander) is indicated.
• Platelets may be transfused via an unused blood-giving
• Once the FFP has been ordered, the blood bank takes set, although a platelet-giving set reduces wastage because
at least 30 minutes to thaw and issue the same. During it has less dead space. Transfusion of platelets through
this time, resuscitation should be continued with volume a transfusion set previously used for red cells is not
recommended.

REFERENCES
1. Serious Hazards of Transfusion Steering Group. Serious Hazards of 8. British Committee for Standards in Haematology, Blood Transfusion
Transfusion (SHOT) Annual Report 2004. London: Royal College of Task Force. Guidelines for the Clinical Use of Red Cell Transfusions. Br
Pathologists; 2004. J Haematol. 2001;113:24–31.
2. Practice strategies for elective red blood cell transfusion. American 9. British Committee for Standards in Haematology Blood Transfusion
College of Physicians. Ann Intern Med. 1992;116:403-406. Task Force. Guidelines for the use of FFP, cryoprecipitate and
3. Innes G. Guidelines for red blood cells and plasma transfusion for cryosupernatant. Br J Haematol. 2004;126:11–28.
adults and childred: an emergency physician’s overview of the 10. Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. British
1997 Canadian blood transfusion guidelines. Part 1: red blood cell Committee for Standards in Haematology. Guidelines on the
[Link] Medical Association Expert Working Group. J managementof massive blood loss. Br J Haematol. 2006;135:634–41.
Emerg Med. 1998;16:129-131.
11. Botha AJ, Moore FA, Moore EE. Postinjury neutrophil priming and
4. Dzieczkowski JS, Anderson KC. Transfusion Biology And Therapy. In: activation: an early vulnerable window. Surgery. 1995;118:358-365.
Kasper DL, Fausi AS, Longo DL, Braunwald E, Hauser SL, Jameson
JL (eds). Harrison’s Principles of Internal Medicine. 17th edition. 12. Healy MA, Davis RE, Liu FC. Lactated Ringer’s is superior to normal
McGraw HiIl: New York; 662-67. saline in a model of massive hemorrhage and resuscitation. J trauma
1998; 45:894-899.
5. Waters JH, Biscotti MD, Potter PS, Phillipson E. Amniotic fluid removal
during cell salvaged in the caesarean section patient. Anesthesiology 13. Moore FA, Mckinley BA, Moore EE. The next generation in shock
2000;92:1531–6. resuscitation. Lancet. 2004;363:1988-1996.

6. Catling SJ, Williams S, Fielding AM. Cell salvage in obstetrics: an 14. British Committee for Standards in Haematology. Blood Transfusion
evaluation of the ability of cell salvage combined with leucocyte Task Force. Guidelines for compatibility procedures in blood trans-
depletion filtration to remove amniotic fluid from operative blood fusion laboratories. Working Party of the British Committee for
loss at caesarean section. Int J Obstet Anesth. 1999;8:79–84. Standards in Haematology. Blood Transfusion Task Force. Transfusion
Medicine. 2004;14:59–73.
7. National Institute for Health and Clinical Excellence. Intraoperative
Blood Cell Salvage in Obstetrics. Interventional Procedure Guidance
144. London: NICE; 2005.

Page 359