This document provides information about various blood products used in obstetrics, including red blood cells, platelets, frozen plasma, and cryoprecipitate. It discusses the components and properties of each product, as well as transfusion triggers and indications. It also briefly touches on complications of transfusions and the use of recombinant factor VIIa in obstetric hemorrhage.

1. USE OF
BLOOD PRODUCTS
& rFVIIa in
OBSTETRICS
Navneet Magon

2. Should
BLOOD
be an
Essential Medicine?NM 2

3. James Blundell
NM 3

4. NM 4

5. RED BLOOD CELLS
NM 5

6. NM 6
What they do…………....?

7. NM 7
………….make the blood carry more oxygen

8. RED BLOOD CELLS
• Approved name: Red Blood Cells
• Also referred to as Packed Cells, Red Cells,
Packed Red Blood Cells, RBCs
• Erythrocytes concentrated from whole blood
donations by centrifugation or collected by
apheresis
• Anticoagulated with CPDA
NM 8American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007

9. RED BLOOD CELLS
• Hematocrit ranges from about 50-65% to about
65-80% ( depends on preservative-anticoagulant
used)
• 50-65% in case AS, 65-80% in case CPDA,
CPD
• One pack contains ~ 50 mL of donor plasma
• Increase of Hb in an adult (who is not bleeding
or hemolyzing) by ~ 1 g/dL or Hct by 3%
NM 9
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007

10. RBC:
Transfusion Trigger
• Historically, transfused to keep Hb > 10 g/dL 1
• Hb > 10 g/dL: NO 2
• Hb < 6 g/dL: TRANSFUSE 2
• Hb 6-10 g/dL: CONSIDER 2
- Any indication of organ ischemia
- Rate and magnitude of any potential or actual bleeding
- Patient’s intravascular volume status and risk of complications due to
inadequate oxygenation
NM 10
1. Goodnough et al. Transfusion medicine: first of two parts N Engl J Med 1999;340(6):438–47
2. Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the
ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105:

11. RBC:
Transfusion Trigger
• 50% incidence of silent MI in patients admitted
in ICU with PPH & hypovolemic shock [1]
• Risk factors:
Hb < 6.0 g/dL
SBP < 88 mm Hg or DBP < 50 mm Hg
HR > 115 bpm
• Obstetricians trigger: 8 g/dl [2]
NM
1. Karpati et al. High incidence of MI during PPH Anesthesiology 2004;100(1): 30-6
2. Matot et al. A survey of physicians’ attitudes toward blood transfusion in patients undergoing cesarean
section. Am J Obstet Gynecol 2004;190(2):462–7
11

12. RBC Transfusion:
Take care !!!
• Follow electrolytes, esp potassium levels
• Give calcium after every 4-5 packs of
PRBCs
NM
Foley: Obstetric Intensive care manual; 2nd
Ed
13

13. NM 14
PLATELETS

14. PLATELETS
• Approved names: Platelets; Platelets Pheresis
• Platelets: RDPs, whole blood derived platelets,
randoms, platelet concentrates
• Platelets Pheresis: SDPs.
NM 15

15. PLATELETS: RDPs
• Derived from Whole Blood
• Contains ≥5.5 x 1010
platelets in ~ 50 mL of plasma
• Stored at 220
C for 5 days / 7 days, continuous agitation
• No viable platelets in stored blood at 40
C after 48 hrs
• Platelet viability (pH< 6.0) & bacterial contamination
NM 16
Hoffbrand: Postgraduate Haematology 5th
Ed 2005, Clinical blood transfusion

16. PLATELETS: SDPs
• Obtained using automated instrumentation by
Plateletpheresis
• Contains ≥3.0 x 1011
platelets in about 250 mL of
plasma
• Reduce donor exposure, HLA compatability
• Leukoreduced because of apheresis collection
NM
Hoffbrand: Postgraduate Haematology 5th
Ed 2005, Clinical blood transfusion
17

17. PLATELETS:
Transfusion Trigger
Surgical and obstetric patients with microvascular bleeding
◦ Usually require transfusion if the platelet count is <50 x 109
/l
◦ Rarely require therapy if it is >100 x 109
/l
◦ With intermediate platelet counts (50-100 x 109
/l)-based on the patient's risk for
more significant bleeding
◦ Massive transfusions
Vaginal deliveries may be undertaken with platelet counts less
than 50 x 109
/l
Platelet transfusion may be indicated despite an apparently
adequate platelet count if there is known platelet dysfunction
and microvascular bleeding
NM Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the
ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105:
18

18. PLATELETS:
Response to therapy
• Measure platelet count from 10 minutes to 3 hours after
transfusion.
• Expect an adult platelet count increment of:
~ 5-10,000/ mm3
for each RDP
~ 30-60,000/ mm3
for each SDP
• ~ 7.1 x 109
platelets/L (~1 RDP) are consumed daily in
endothelial support functions
NM Slichter et al. Factors affecting post transfusion platelet increments, platelet refractoriness, and
platelet transfusion intervals in thrombocytopenic patients. Blood 2005;105:4106-14.
19

19. PLATELETS:
Response to therapy
• Response to platelet transfusion is adversely
affected by
Fever
Sepsis
Splenomegaly
Severe bleeding
Consumptive coagulopathy
HLA alloimmunization
Certain drugs e.g. amphotericin
NM Slichter et al. Factors affecting post transfusion platelet increments, platelet refractoriness, and
platelet transfusion intervals in thrombocytopenic patients. Blood 2005;105:4106-14.
20

20. PLATELETS:
Response to therapy
• ABO-incompatible platelets may be transfused,
but have a shorter life span 1
• Rh compatibility should be considered in the
obstetric population
• Rh immune globulin should be administered if
Rh-positive platelets are administered to an Rh-
negative individual 2
NM 1. Yazer MH. The blood bank ‘‘black box’’ debunked: pretransfusion testing explained.CMAJ
2006;174(1)
2. Menitove JE. Immunoprophylaxis for D- patients receiving platelet transfusions from D+ donors?
21

21. NM 22

22. NM 23FROZEN PLASMA

23. FROZEN PLASMA
• Approved name: Fresh frozen plasma (FFP)
• Noncellular portion of blood, prepared from whole blood
or collected by apheresis
• Volume of the unit ~ 250 mL but variations expected
• FFP when frozen at -180
C to - 300
C within 6-8 h of
collection, contains all coagulation factors
• Plasma frozen within 24 hours (FP24) and thawed
plasma may contain variably reduced levels of Factor V
and Factor VIII
NM 24

24. FROZEN PLASMA
• Must be ABO-compatible with the recipient’s red cells 1
• Group AB Plasma is suitable for all blood types
• Frozen Plasma must be thawed (20-30 min); infused
immediately or stored at 1-6o
C for up to 24 hours 2
• FFP and FP24 may be relabeled as Thawed Plasma &
used as a source of stable coagulation factors for up to 5
days 2
NM 1. Yazer MH. The blood bank ‘‘black box’’ debunked: pretransfusion testing explained.CMAJ 2006;174(1)
2. American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
25

25. FROZEN PLASMA:
Transfusion Trigger
• Correct multiple coagulation factor deficiencies
• Plasma transfusion should be guided by coagulation
testing
• INR > 2 (some > 1.5) or aPTT > 1.5
• Clinical evidence of bleeding, if assays not available
• Dosage ~ 10-20 mL/kg
NM
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
26

26. NM 27

27. NM 28

28. NM 29

29. Learning from the
wars……….
NM
Shaz et.al. Transfusion management of trauma patients. Anesth Analg. 2009; 108:219-22
30
RBC to FFP ratio close to 1

30. FROZEN PLASMA:
Indications
• Active bleeding or risk of the same due to deficiency of
multiple coagulation factors
• Severe bleeding due to warfarin therapy, or urgent
reversal of warfarin effect
• Massive transfusion with coagulopathic bleeding
• Bleeding or prophylaxis of bleeding for a known single
coagulation factor deficiency for which no concentrate is
available
NM
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
31

31. FROZEN PLASMA:
Contraindications
• Increasing blood volume or albumin
concentration
• Coagulopathy that can be corrected with
administration of Vitamin K
• Normalizing abnormal coagulation screen
results, in the absence of bleeding
NM 32

32. NM 33
CRYOPRECIPITATE

33. CRYOPRECIPITATE
• Approved name: Cryoprecipitated Antihemophilic
Factor (AHF)
• Also referred to as cryoprecipitate, cryo
• Prepared by thawing one unit of FFP between 1-
6o
C and recovering the cold insoluble precipitate
• Cryo is refrozen within 1 hour
NM 34

34. CRYOPRECIPITATE
• Concentrated levels of
Fibrinogen (~150 mg)
Factor VIII:C (~80IU)
Factor VIII:vWF
Factor XIII
Fibronectin
• 5-20mL of plasma
NM 35

35. CRYOPRECIPITATE
• An acellular blood component
• Compatibility testing is unnecessary, & Rh type need not
be considered
• CMV testing and leukoreduction are not required
• Frozen cryoprecipitate has to be thawed
• Thawed cryo to be kept at room temperature and
transfused as soon as possible after thawing (4 h, if units
pooled after thawing; 6 h, if single unit, or pooled before
thawing)
NM 36

36. CRYOPRECIPITATE
• Two units of Cryo (150-250mg/unit) contains as
much fibrinogen as one unit of FFP (2-4mg/ml)
• One unit of cryoprecipitate per 10 kg of body
weight raises plasma fibrinogen concentration by
~ 50 mg/dL in the absence of continued
consumption or massive bleeding
NM Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the
ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105:
37

37. CRYOPRECIPITATE:
Transfusion Trigger
• Fibrinogen <40 mg/dl
• Fibrinogen <100 mg/dl with bleeding or surgery
• DIC in obstetric patient
• Factor XIII deficiency
• vWD with bleeding or surgery
NM 38

38. Know Your
Blood bank
WellNM 39

39. NM 40

40. rFVIIa
• Acts by TF dependent & TF independent
pathway
• 30 to 90 mcg/kg i/v every 2 hours until
hemostasis is achieved
• Adequate levels of platelets and clotting factors
• Risk of thrombosis
NM
Fuller et al. Blood Component Therapy in Obstetrics Obstet Gynecol Clin N Am 34 (2007) 443–458
41

41. NM Magon N, Babu KM. Recombinant factor VIIa in post-partum hemorrhage: A new
weapon in obstetrician's armamentarium. North Am J Med Sci 2012;4:157-62.
42

42. NM Magon N, Babu KM. Recombinant factor VIIa in post-partum hemorrhage: A new
weapon in obstetrician's armamentarium. North Am J Med Sci 2012;4:157-62.
43

43. rFVIIa
• Role?
• How to monitor its clinical effect?
• How safe is it?
• How cost effective?
NM 44

44. Massive Transfusion
Bloody
vicious
cycle
NM Cosgriff N et al. Predicting life-threatening coagulopathy in the massively transfused trauma patient:
hypothermia and acidoses revisited. J Trauma 1997;42(5): 857–62
45

45. Transfusions:
How innocuous are they?
Immunologic Complications: Immediate
• Hemolytic transfusion reaction
• Immune-mediated platelet destruction
• Febrile non-hemolytic reaction
• Allergic reactions
• Anaphylactoid reactions
• TRALI
NM
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
46

46. Transfusions:
How innocuous are they?
Immunologic Complications: Delayed
• Alloimmunization to antigens of red cells, white
cells, platelets, or plasma proteins
• Delayed hemolytic reaction
• Post-transfusion purpura (PTP)
• Graft-vs-host disease (GVHD)
NM
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
47

47. Transfusions:
How innocuous are they?
Non-immunologic Complications
• Transmission of infectious disease
• Bacterial contamination
• Circulatory overload
• Hypothermia
• Metabolic complications
NM
American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
48

48. BLOOD
TO GIVE
OR
NOT TO GIVE
NM 49

49. THANK YOU
NM 50