Transfusion of Whole Blood and Cesarean Delivery
| Status: | Recruiting |
|---|---|
| Healthy: | No |
| Age Range: | 18 - 50 |
| Updated: | 2/3/2019 |
| Start Date: | August 10, 2017 |
| End Date: | June 30, 2019 |
| Contact: | Nwamaka H Nnamani, MD |
| Email: | Nwamaka.Nnamani@UTSouthwestern.edu |
| Phone: | 2147867973 |
Is the Transfusion of Whole Blood Better for Resuscitation in Cesarean Delivery? A Retrospective Analysis of the Transfusion of Whole Blood Versus Component Therapy During Cesarean Delivery.
The rate of postpartum hemorrhage (PPH) has risen dramatically in the developed world, along
with a rise in blood transfusion rates. The rate of cesarean delivery has increased
dramatically in the past decade and is well over 30% in the United States. With an increase
in primary and repeat cesarean delivery, comes the added risk of abnormal placentation, which
can contribute to maternal and fetal morbidity and mortality via placenta accreta, increta,
and percreta. The incidence of accreta has increased 10-fold over the past 50 years, becoming
the most common reason for cesarean hysterectomy in highly industrialized countries. These
conditions have tremendous impact on maternal outcomes.
Although whole blood (WB) contains all of the individual blood components, there are concerns
for the use of WB due to the potential limitations such as the hemostatic efficacy of
platelet after cold storage, the risk of hemolytic transfusion reaction following the
transfusion of un-cross matched WB and the logistical issues in providing WB. Traditional
obstetric transfusion protocols involve blood component therapy. Whole blood contains all
components and could be more efficient for massive transfusion in obstetric hemorrhage.
Trauma resuscitation protocols mimic whole blood in the 1:1:1 transfusion protocols of packed
red blood cells to plasma to platelet ratio. It is difficult to compare trauma resuscitation
to obstetric hemorrhage, but both can involve significant resuscitation and serious sequelae
from unnecessary transfusion.
The use of WB instead of component therapy may reduce the multiple organ dysfunction rates
due to the rapid resolution of shock and coagulopathy. Additionally, the number of donor
exposure is important factor for the transfusion-related allergic reactions including severe
systemic reactions such as anaphylaxis. Use of WB may decrease number of donor exposure. The
secondary aim is to compare the incidence of 3 common adverse outcomes associated with the
transfusion of blood products in subjects who receive whole blood versus component therapy.
Investigators hypothesize that the patients receiving WB will have fewer incidences of a)
acute renal failure, b) acute heart failure and c) transfusion-related lung disease compared
to those receiving component therapy.
with a rise in blood transfusion rates. The rate of cesarean delivery has increased
dramatically in the past decade and is well over 30% in the United States. With an increase
in primary and repeat cesarean delivery, comes the added risk of abnormal placentation, which
can contribute to maternal and fetal morbidity and mortality via placenta accreta, increta,
and percreta. The incidence of accreta has increased 10-fold over the past 50 years, becoming
the most common reason for cesarean hysterectomy in highly industrialized countries. These
conditions have tremendous impact on maternal outcomes.
Although whole blood (WB) contains all of the individual blood components, there are concerns
for the use of WB due to the potential limitations such as the hemostatic efficacy of
platelet after cold storage, the risk of hemolytic transfusion reaction following the
transfusion of un-cross matched WB and the logistical issues in providing WB. Traditional
obstetric transfusion protocols involve blood component therapy. Whole blood contains all
components and could be more efficient for massive transfusion in obstetric hemorrhage.
Trauma resuscitation protocols mimic whole blood in the 1:1:1 transfusion protocols of packed
red blood cells to plasma to platelet ratio. It is difficult to compare trauma resuscitation
to obstetric hemorrhage, but both can involve significant resuscitation and serious sequelae
from unnecessary transfusion.
The use of WB instead of component therapy may reduce the multiple organ dysfunction rates
due to the rapid resolution of shock and coagulopathy. Additionally, the number of donor
exposure is important factor for the transfusion-related allergic reactions including severe
systemic reactions such as anaphylaxis. Use of WB may decrease number of donor exposure. The
secondary aim is to compare the incidence of 3 common adverse outcomes associated with the
transfusion of blood products in subjects who receive whole blood versus component therapy.
Investigators hypothesize that the patients receiving WB will have fewer incidences of a)
acute renal failure, b) acute heart failure and c) transfusion-related lung disease compared
to those receiving component therapy.
Rates of obstetric blood product transfusion have increased by 33% since 2001, with the
majority of this phenomenon associated with hemorrhage. While transfusion in obstetrics
represents a very small proportion of overall blood use, it is a limited, costly resource,
and not without risk. The current trend is to reduce unnecessary transfusion and utilize
goal-directed therapy.
Unfortunately, obstetric transfusions tend to be urgent, unpredictable, and occur in
otherwise healthy women. The maternal population has changed dramatically with older
first-time mothers, women with multiple repeat cesarean deliveries, and the presence of
significant co-morbidity. Clinical practice may also have changed in slightly less
restrictive criteria for transfusion practices all resulting in higher transfusion rates in
the obstetric population.
Identified risk factors that predispose a woman to obstetric hemorrhage include abnormal
placentation in the form of placenta previa or a low-lying placenta, placenta
accrete/percreta/increta, hematocrit level of less than 30 in conjunction with other risk
factors, platelet (PLT) count of less than 100 X 109/L, active bleeding on admission, and
known coagulopathy. Other risk factors during and after labor include prolonged second stage
of labor, prolonged oxytocin use, active bleeding, chorioamnionitis, magnesium sulfate use,
use of vacuum or forceps-assisted delivery, cesarean delivery, and retained placenta.
The presence and easy access to component therapy can pose a problem at smaller institutions.
Many smaller hospitals for example, may thaw plasma only on receipt of an order to transfuse
the plasma, which can cause a significant delay. Similarly, many community hospitals may not
routinely stock platelets. While these smaller facilities are crucial to taking care of
routine patients, the more severe hemorrhaging patient could potentially benefit from whole
blood.
The aim of this study is to compare overall transfusion rates in subjects who receive whole
blood to those who receive component therapy to see if there is any benefit to whole blood
transfusion.
majority of this phenomenon associated with hemorrhage. While transfusion in obstetrics
represents a very small proportion of overall blood use, it is a limited, costly resource,
and not without risk. The current trend is to reduce unnecessary transfusion and utilize
goal-directed therapy.
Unfortunately, obstetric transfusions tend to be urgent, unpredictable, and occur in
otherwise healthy women. The maternal population has changed dramatically with older
first-time mothers, women with multiple repeat cesarean deliveries, and the presence of
significant co-morbidity. Clinical practice may also have changed in slightly less
restrictive criteria for transfusion practices all resulting in higher transfusion rates in
the obstetric population.
Identified risk factors that predispose a woman to obstetric hemorrhage include abnormal
placentation in the form of placenta previa or a low-lying placenta, placenta
accrete/percreta/increta, hematocrit level of less than 30 in conjunction with other risk
factors, platelet (PLT) count of less than 100 X 109/L, active bleeding on admission, and
known coagulopathy. Other risk factors during and after labor include prolonged second stage
of labor, prolonged oxytocin use, active bleeding, chorioamnionitis, magnesium sulfate use,
use of vacuum or forceps-assisted delivery, cesarean delivery, and retained placenta.
The presence and easy access to component therapy can pose a problem at smaller institutions.
Many smaller hospitals for example, may thaw plasma only on receipt of an order to transfuse
the plasma, which can cause a significant delay. Similarly, many community hospitals may not
routinely stock platelets. While these smaller facilities are crucial to taking care of
routine patients, the more severe hemorrhaging patient could potentially benefit from whole
blood.
The aim of this study is to compare overall transfusion rates in subjects who receive whole
blood to those who receive component therapy to see if there is any benefit to whole blood
transfusion.
Inclusion Criteria:
- Subjects who underwent cesarean delivery
- Received a blood transfusion or blood component therapy
Exclusion Criteria:
- If sufficient information from the electronic record cannot be collected, those
patients will be excluded.
- Subjects with pre-existing coagulation abnormalities such as hemophilia A, Von
Willebrand's disease or any history of hereditary coagulopathies
- The utilization of the Massive Transfusion Protocol (MTP) intraoperatively
- Subjects with pre-existing renal failure, preexisting peripartum cardiomyopathy, or
acute lung injury.
- Subjects who has transfusion of blood group O as non O recipient or received emergent
uncross-matched blood in hospital admission or wrong blood transfusion.
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