Review Article

Rationale use of blood and its components

in obstetric-gynecological practice
Shakuntala Chhabra, Anu Namgyal

Abstract
Appropriate and rational use of blood/components is essential for ensuring availability for the needy as well as
preventing risks of transfusion-transmitted diseases and saving resources. Rational use means providing the right
blood or products, in the right quantity, to the right patient and at the right time, bridging demand, and supply
gap. The safety, adequacy, and effectiveness can only be achieved if unnecessary transfusions can be prevented.
Further, risk can be reduced, but cannot be eliminated completely. Alternative to banked blood, autologous blood
donation, normovolemic hemodilution, and intraoperative cell salvage should be considered as possible options.
Recombinant factor VIIa is a new adjunct for treatment of massive hemorrhage and should be considered, if
available.

Keywords: Blood transfusion, obstetric gynecologic practice, rationale use

Introduction highest in India with half of the global maternal deaths

Every day many lives are saved through blood
transfusion (BT), which maintains the circulating
oxygen-carrying capacity in various disorders, which
include disorders of pregnancy, birth, postbirth, or
gynecological diseases. However, statistics reveal
that 74% of transfusions in adults are inappropriate[1,2]
and critical appraisal is essential. The objective of
this review is to understand the usage of blood and
its products with maximum benefits and minimum
side-effects to patients in hospital settings decreasing
the indiscriminate use.
One common indication in women is severe anemia,
prevalence of which in South Asian countries is high,
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due to anemia.[3] It may be either due to gynecological
disease or obstetric cause, nutritional or other reasons.
Whatever the cause severe anemia in women is
frequently treated with BT, however blood should
only be used if there is cardiopulmonary dysfunction,
not as a cure for anemia. Furthermore, these patients
have normal blood volume and whole BT may cause
circulatory overload, so packed red blood cells
(PRBCs) should be given and the underlying disorder
investigated and treated.
Normally, blood loss during birth is well-tolerated
because of changes during pregnancy. In general,
<15% loss results in minimal symptoms; 15-30%
causes tachycardia; 30-40% shock; >40% loss leads
to severe shock. With underlying diseases, even with
<30-40% loss, blood is required.[4] The risk of mortality
increases significantly in otherwise stable patients
when the hemoglobin (Hb) falls to 3.5-4 g/dL, but in
cases with ischemic heart disease with 7 g/dL.[5] So,
obstetric hemorrhage is a major cause of perinatal and
maternal mortality,[6] about 25-30% maternal deaths due
to hemorrhage. Author has found obstetric hemorrhage

Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India

Address for correspondence:

Prof. S. Chhabra, Department of Obstetrics Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha,
Maharashtra, India. E-mail: chhabra_s@rediff mail.com

September 2014 | Vol 19 | Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
94 Chhabra and Namgyal: Blood, its components in obstetric gynecologic practice

contributing to 20% maternal deaths.[7] More than 4000
cases of severe hemorrhage are reported each year in the
United Kingdom.[8] RCOG[9] also reports that hemorrhage
is the leading cause of intensive care unit admissions. The
occurrence of massive obstetric hemorrhage in developed
and developing countries differs greatly, with the risk of
death in developed countries 1:100,000, in developing
countries 1:1000 births [10] Hemorrhagic shock produces
a reduction in tissue perfusion, hypoxic metabolism,
acidosis and deterioration in organ function, dyspnea,
aggression or drowsiness and myocardial depression and
accordingly it is classified and management planned with
the clear need of BT [Table 1].
In obstetric practice, bleeding could be antepartum,
intrapartum or postpartum. Gynecological disorders like
abnormal uterine bleeding, leiomyoma or cancers also
lead to heavy hemorrhage. Disseminated intravascular
coagulation (DIC) which causes profuse bleeding
occurs in cases of retained products of conception,
eclampsia, amniotic fluid embolism, postpartum
hemorrhage and abortion. The need for transfusion can
be reduced by, preventing/treating anemia and blood
loss; however, there are limitations to prevention and
BT becomes essential.
Blood Transfusion Services
The challenge for BT services (BTS) is to provide
quality services, containing costs and inappropriate
use of blood squanders limited resources, creates an
artificial shortage. A crossmatch:transfusion ratio (CTR)
of 2.5:1 is generally accepted as efficient utilization of
blood.[11] A study had revealed over crossmatching of
varying degrees in various procedures, over transfusion
45.5% and case postponement rate of 18.1% indicating
inefficient utilization of resources. Another study
revealed the rate of inefficient utilization 9.0%.[12]
The maximum number of units transfused for each
surgical procedure indicates the potential of severity of
bleeding in that procedure, a useful guide for the need
of crossmatched blood. The transfusion index of each
surgical procedure, an index of blood requirement for
that particular procedure helps in planning.[13]
When to Transfuse
Historically, patients are transfused to keep the
Hb concentration 10 g/dL or more, but this needs a
relook. A study has demonstrated decreased mortality
in critically ill patients who were transfused at lower
Hb thresholds.[14] Karpati et al.[15] have reported
around  50% incidence of myocardial ischemia with
Hb of 6.0 g/dL or lower, systolic blood pressure of
88 mm Hg or lower, diastolic blood pressure of 50 mm
Hg or lower, and a heart rate >115 beats/min. Blood is
needed for immediate transfusion in cases of excessive
hemorrhage at birth with Hb <7 g/dL. Kalaivani et al.[16]
advocates BT for pregnant women with Hb <5 g/dL
who are symptomatic or have orthostatic hypotension
irrespective of any other issue, however in practice,
there is advocacy for transfusion with this Hb level,
irrespective of symptoms, especially nearing date of
birth. Determining the point, at which BT is essential,
can be difficult. Many factors, including vital signs,
ongoing blood loss, and coexisting disease need to
be considered. In acute hemorrhage, BT should be
initiated as soon as possible to offset the deficit. But
blood should be transfused only when required to save
a life and effective transfusion requires a minimum of
two units for an adult. The decision to transfuse should
be based on the risk for developing complications of
inadequate tissue-oxygen delivery. With massive
hemorrhage (blood loss >40%), it is essential to
restore volume and oxygen-carrying capacity, by
massive transfusion, (10 units of RBCs within 24 h, or
4-5 RBC transfusions within 1 h, replacement of one-
half the patient’s blood volume within 3 h).[17] Earlier
Cosgriff et al.[18] had defined massive transfusion
as “administration of >10 units of PRBCs.” The
massively bleeding patient must be assessed

Table 1: Signs symptoms with hemorrhage

Severity of shock ACS class Signs symptoms Blood loss (ml) % blood volume lost Remarks
None Class I None Up to 750 10-15
Mild Class II Tachycardia (<100 bpm); mild hypotension; normal 750-1500 15-25 Volume replacement with
or pulse pressure (peripheral vasoconstriction) crystalloid and/or colloid
Moderate Class III Tachycardia (100-120 bpm); hypotension (systolic 1500-2000 25-40 Transfusion probable
blood pressure 80-100 mm Hg); pulse pressure;
anxiety, confusion; oliguria
Severe Class IV Tachycardia (>120-140 bpm; hypotension (systolic >2000 >40 Transfusion probable
blood pressure <80 mm Hg); pulse pressure;
confusion, lethargy; anuria
ACS = American College of Surgeons, bpm = Beats per minute. (ACOS 2004; Santoso 2009)

Journal of Mahatma Gandhi Institute of Medical Sciences September 2014 | Vol 19 | Issue 2
Chhabra and Namgyal: Blood, its components in obstetric gynecologic practice
frequently to determine the efficacy of treatment as
well as to identify correctable complications, bleeding
or hemolysis.
Pretransfusion
Efforts should first be made to stabilize the patient
without blood through prompt and appropriate
supportive care, intravenous crystalloid or colloid
solutions, and oxygen. The first treatment for
hypotension, shock, and acute blood loss is volume
expansion with normal saline (without dextrose),
infused in a volume at least 3 times the volume lost[19]
or 50 ml/kg followed by colloid solution, 6% dextran
or 6% hydroxyethyl starch, given in equal volume to
the blood lost, 6% dextran should not exceed 50 ml/
kg body weight, and 6% hydroxyethyl starch 20 ml/kg
body weight in 24 h. In acute cases, an early Hb will
not reflect the severity of loss accurately until there
has been adequate plasma volume replacement. Serial
levels are required to determine the need for red cell
transfusion.
Preparing for Transfusion
In an obstetric emergency where type-specific or
crossmatched blood is not available, Rh-negative O
group blood can be administered to prevent the risk
of Rh sensitization. Crossmatched blood should be
administered as soon as available because the estimated
risk of a hemolytic reaction has been reported to be as
high as 5%, although trauma patient’s reports reveal
lower complication rates.[20]
Response to massive hemorrhage needs a coordinated
effort between clinicians and the blood bank. So,
a massive hemorrhage protocol outlined before
an emergency occurs, clinical drills on obstetric
hemorrhage scenario etc are essential.[21]
Perioperative transfusion
In anesthetized patients, vital signs alone may be
inadequate. Signs, symptoms, if possible and prior
medical history, cardiopulmonary reserve, amount
of anticipated blood loss, oxygen consumption and
presence of atherosclerotic heart disease are all
important. Prior to elective surgery, all efforts should
be made to correct anemia, except for emergency, all
patients getting anesthesia need to have minimum Hb
of 8 g/dL. Cherian et al.[22] report that transfusion may
be necessary with Hb <8 g/dL and blood loss of >1 L.
Transfusion is not indicated as treatment of anemia
September 2014 | Vol 19 | Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
95
postoperatively or postpartum in stable cases with no
active bleeding.
Procedure and Monitoring
Both whole blood and PRBCs contain a small amount
of citrate anticoagulant and an additional preservative.
Blood collected in citrate phosphate dextrose (CPD)
adenine-1 anticoagulant can be stored for up to 35 days
and it is essential to start transfusion and return unused
blood within 30 min of leaving the laboratory.
All transfusions should be given and monitored
by clinician closely for the first 15 min for serious
hemolytic reactions, with monitoring of the vital signs
every 30 min and infuse for a maximum of 4 h.
Components
Red blood cells can be transfused either as whole
blood or PRBC. A unit of whole blood is 400-500 ml,
with a hematocrit of 45-55%, each unit of PRBCs, has
180-200 ml of RBCs, 50-70 ml of plasma and hematocrit
of 60-70%. PRBCs are indicated in decreased oxygen
carrying capacity or hypoxia due to inadequate red
cell mass. RBC must be ABO-compatible. RBC
transfusions should not be initiated in response to Hb
estimation alone, or to an increase in heart rate and/or
respiratory rate, as these may be normal compensatory
mechanisms.
Platelets or fresh frozen plasma (FFP) should be given
according to need. FFP is indicated for correction of
coagulation abnormalities, micro vascular bleeding
when prothrombin time (PT) and partial thromboplastin
time are >1.5 times the mid-range normal reference
value. ABO-compatible FFP is indicated for treatment
of bleeding with multiple coagulation-factors
deficiencies, massive transfusion with coagulation
abnormalities, and bleeding due to warfarin therapy in
a dose of 15 ml/kg if the PT is prolonged, and platelet
concentrates (4-6 donor units for an adult) when the
platelet counts fall below 20,000/mm3. If the platelet
counts or coagulation profile are not available, two
units of FFP and six units of platelet concentrate may
be given for every six units of blood transfused within
24 h.[23]
Each unit of blood contains >5.5 × 1010 platelets,
approximately 50 ml of plasma, so four to eight
units of concentrated platelets are needed for
profound thrombocytopenia. Obstetrical patients
96 Chhabra and Namgyal: Blood, its components in obstetric gynecologic practice

with microvascular bleeding often require platelet
transfusions when the platelet count is <50,000/mm3.
Platelet transfusion is generally not indicated for
patients with extrinsic platelet dysfunction (e.g.,
uremia), since platelets will also function inadequately.
Prophylactic platelet transfusion is not effective for
thrombocytopenia due to increased platelet destruction;
the cause should be investigated and treated. One unit
of platelets increases the platelet count by 5000-10,000
cells/µL in the absence of platelet destruction.[24] It is
essential to know which component is needed, when
and how much quantity and the precaution needed
[Table 2]. While, it is possible to transfuse ABO-
incompatible platelets, they may have a shorter life
span.[23] Rh compatibility needs to be seen in obstetric
population and Rh immune globulin is needed if Rh-
positive platelets are administered to Rh-negative
mother.[25]
Cryoprecipitate extracted from thawing FFP slowly,
rich in factor VIII (FVIII) and fibrinogen is used
to treat microvascular bleeding in the presence of
fibrinogen deficiency, 150 mg/dL due to DIC or
massive transfusion, with fibrinogen concentration
less than 80-100 mg/dL essential for treatment of
congenital fibrinogen deficiency or bleeding with
von Willebrand’s disease when factor concentrates
are unavailable. Because cryoprecipitate has only a
small amount of plasma, ABO-compatibility is not
necessary.[23]
Activated recombinant FVII (rFVII), is a promising
new alternative to blood component identical in
structure and function to human FVIIa, originally
developed to prevent or control bleeding in patients
with hemophilia A or B with inhibitors to FVIII or
FIX to augment the intrinsic clotting pathway by
binding with tissue factor directly activating FIX and
FX, and effective dose is 50-100 µg/kg intravenously
every 2 h until hemostasis is achieved, majority of
patients require only one dose.[21] However, we must
ensure adequate platelets and clotting factors because
rFVIIa increases clotting by acting on these substrates.
Because rFVIIa is derived from recombinant
technology and not from human proteins, so there is
no risk of viral transmission, but thrombosis, including
cerebrovascular accidents, myocardial infarction,
pulmonary embolism, and clotting of indwelling
devices are reported, most occur within 3 h of the last
dose.[26]
Autologous blood donation
Two to four units of blood may be collected prior at least
7 days apart, and last at least 4 days before surgery, in
case of elective surgery with Hb 10 g/dL or greater for
her own use during surgery, autologous transfusion.[27]
No single-unit autologous transfusion is advocated,
and unused autologous units can be released into the
general pool.[28]
Preoperative isovolemic hemodilution may be
performed by removal of two or more units of blood
and replaced with an equal volume of crystalloid to
improve tissue perfusion during surgery and make
blood available during and after surgery. It is a viable
option for peripartum hemorrhage risk, especially
for those with rare antibodies difficult to transfuse
with compatible homologous blood. It has minimal
hemodynamic effects with maintenance of fetal
umbilical artery systolic/diastolic ratio,[29] but cost
discourages routine use.[30]
Yamada et al.[31] report that women with placenta
previa who did not donate blood prepartum had a
4 times greater rate (12% vs. 3.1%) of peripartum
homologous BT and recommend donation at 32 weeks’
gestation with removal of 400 ml/week for storing
volume of 1200-1500 ml Fuller and Bucklin,[32] report
higher overall rate of BT, highest with autologous
blood donor 71% receiving blood peripartum

Table 2: Blood product information

Product Contents Indications for administration Notes
Packed red Red blood cells Improve oxygen-carrying Type-specific and crossmatched blood
blood cells Almost always for hemoglobin <6 g/dL
Rarely for hemoglobin >10 g/dL
Platelets Platelets Microvascular bleeding with platelet counts <50,000 cells/µL Blood product most often associated with bacterial
contamination
Fresh frozen All plasma Microvascular bleeding due to clotting factor (20-30 min) deficiency Must be thawed before administration
plasma proteins and International normalized ratio >2 × normal
clotting factors Activated partial thromboplastin time >1.5 × normal
Cryoprecipitate Factor VIII and Microvascular bleeding due to fibrinogen deficiency Can also be used to treat congenital deficiencies or
fibrinogen Fibrinogen <80-100 mg/dL von deficiencies or von Willebrand’s disease when
clotting factors are unavailable

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Chhabra and Namgyal: Blood, its components in obstetric gynecologic practice
compared to 12% who received homologous blood.
Autologous blood has smaller incidence of bacterial
contamination.[33]
Acute normovolemic hemodilution
It involves the collection of autologous blood
immediately before surgery or delivery, maintained
by intravenous fluid administration with colloids
or crystalloids, colloid equal to blood withdrawn,
crystalloid, 3 times of blood removed.[34] When blood
is subsequently lost, it has less RBC mass and the
blood removed can be returned. Monk[34] reported
that because the blood is collected and stored at the
bedside for immediate reinfusion, the risks of bacterial
contamination and administrative error associated with
autologous blood storage are significantly reduced
and no patients had nausea, vomiting, dizziness, or
lightheadedness, abnormalities in vital signs or fetal
heart rate in his series.
Intra-operative Cell Salvage
Blood shed within the surgical field retrieved by an
anticoagulated suction apparatus and collected within
a reservoir from where it is centrifuged, washed, and
pumped into an infusion bag and returned to the patient
later, is effective in reducing the need for allogenic red
cell transfusion.[35,36] Cell salvage is recommended
where an intraoperative blood loss of more than 1500
ml is anticipated. Cell salvage should only be used by
the teams with expertise and experience. Contamination
by amniotic fluid, risks of amniotic fluid embolism, and
anti-D formation are genuine concerns.[37] However, in a
multicenter historical cohort study with 139 autologous
BTs during cesarean delivery through intraoperative
cell salvage technique, no acute febrile illness or adult
respiratory distress syndrome was reported.[38]
Errors
While patients are often highly concerned
about the infectious risks, there is more risk of
ABO-incompatibility and similar mix ups, unrelated
to infections. In many cases, multiple errors are
involved, phlebotomy, patient misidentification,
sample mislabeling, and laboratory errors.[39] Vigilance
is imperative.
Risks of Blood/Component Transfusion
Transfusion may be a lifesaving procedure but is not
without risk. 1% of all transfusions lead to some adverse
reaction. Although many measures are taken to reduce
September 2014 | Vol 19 | Issue 2 Journal of Mahatma Gandhi Institute of Medical Sciences
97
risks, donor risk screening, laboratory testing, it is not
possible to have zero risk, because of immunological
or nonimmunological mechanisms, immediate, and
delayed.
Recipients may develop transfusion-transmitted
infection, immunological complications. Massive
transfusion is associated with the vicious cycle of
metabolic acidosis, abnormalities of coagulation,
biochemistry, and hypothermia. The treatment of the
hemorrhage with red cell transfusion can worsen the
coagulopathy by diluting platelets and clotting factors
as well as contributing to hypothermia and acidosis.[40]
Hemolytic reactions
It is most serious complication arising from erroneous
transfusion due to recipient’s circulating antibodies
destroying the donor’s RBCs characterized by fever,
urticaria, nausea, chest and flank pain, hyperkalemia,
hypotension, DIC, hemoglobinemia, and acute renal
failure.[24,41]
Petrovich[41] reported that a delayed hemolytic reaction
occurs because of extravascular hemolysis of donor
erythrocytes in the presence of antibodies from previous
transfusions or pregnancy in recipient serum that were
at levels too low to be detected during the crossmatch.
Clinical manifestations occur approximately 1 week
after a seemingly compatible transfusion and are
characterized by anemia, mild fever, increased
unconjugated bilirubin, jaundice, hemoglobinuria,
decreased haptoglobin, and spherocytosis with
self-limited symptoms.[24]
Transfusion-transmitted infectious disease
The incidence of transfusion-transmitted infectious
diseases has decreased dramatically, because of
improved donor screening for viral pathogens, such as
HIV, hepatitis C, hepatitis B, etc.[17]
Researchers reported West Nile Virus first in 2002
and prompted the nucleic acid testing, specially in
locales with high West Nile Virus activity.[42,43] Variant
Creutzfeldt-Jakob disease is an emerging concern,
with one probable case of transfusion-associated
transmission prompting exclusion of blood donors who
had spent more than 6 months in the United Kingdom.
Researcher also reports that Trypanosoma cruzi, cause
of trypanosomiasis (Chagas’ disease), can also be
transmitted, a growing concern in the United States
because the parasite can survive cryopreservation
of blood products. Bacterial contamination of
98 Chhabra and Namgyal: Blood, its components in obstetric gynecologic practice
blood products is the most common cause of acute
transfusion-associated mortality from an infectious
agent. Goodnough et al.[30] report that bacterial
contamination occurs most often with platelets, with
an estimated incidence of one for every 12,000 units of
blood administrated because platelets must be stored
at room temperature and so have a higher potential
for supporting bacterial growth. The most frequent
contaminating organism is Yersinia entercolitica for
RBCs and Staphylococcos aureus for platelets.[42]
The clinical presentation ranges from mild fever to
acute sepsis leading to death. Bacterial contamination
should be suspected and antibiotic therapy considered
in patients who develop fever within 6 h after platelet
transfusion.
Transfusion-associated acute lung injury
Transfusion-associated acute lung injury, an acute
respiratory distress syndrome which can occur within
2-6 h after transfusion[43-45] is estimated to occur once
in every 2000-5000 transfusions of blood or blood
products,[44] leading cause of death from transfusions
in the United States; pathogenesis is antibody-
mediated.[46]
Miscellaneous complications
Petrovich[41] reported that other complications can
occur due to the CPD, anticoagulant preservative. In
massive transfusion, citrate can bind plasma calcium
and lead to hypocalcemia, causing hypotension,
tetany, and cardiac arrhythmias. Plasma calcium
levels should be measured during massive transfusion
and hypocalcemia treated with intravenous calcium
chloride. Acidosis can occur (pH < 6.9) during storage
because of the metabolism of glucose to lactate.
Hyperkalemia can occur with PRBC administration
because of passive diffusion of potassium out of the
RBCs during storage, however with normal renal
function; the excess potassium is transported back
into the cells or excreted in the urine. Because blood
is stored at 1-6°C, hypothermia can result, especially
during massive transfusion.
Conclusion
The present review reinforces the importance of
justified and appropriate use of blood and its products
in the clinical setting. Judicious implementation of
guidelines for use of various blood products may
help decrease the inappropriate use of blood and its
components.
Journal of Mahatma Gandhi Institute of Medical Sciences September 2014 | Vol 19 | Issue 2
A hospital BT committee of representatives from
service users can formulate steps to improve the quality,
optimize expenditure and blood usage. It could ensure the
replacement of routine compatibility testing by the “type,
screen and hold” procedure for procedures with CTR’s
more than 2.5, low transfusion indices (<0.5)-as well as
a low number of maximum blood units transfused.[47]
Guidelines are essential to assist clinicians in identifying
indications for blood use and triggers for transfusion,
ensure the quality BTS and practices. BTS need to oversee
all policies and procedures relating to blood utilization,
staff education, and training on BT practices.[48]
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