Post-Operative Drop in Hemoglobin and Need of Blood Transfusion in Cesarean Section at Dhulikhel Hospital, Kathmandu University Hospital

Background Cesarean section has been identified as one of the commonest indication for blood transfusion in obstetric practice because it involves risk of major intra-operative blood loss. Different figures varying from less than 500 ml to more than 1000 ml have been quoted as estimated blood loss associated with caesarean section. There is also a wide variation in blood ordering practices for this surgery. Objective The objective of this study is to evaluate the blood ordering practice and transfusion for cesarean sections at our institute, to see post-operative drop in hemoglobin and hematocrit and to correlate those parameters with the duration between uterine incision and repair. Methods In this prospective observational study, non-randomised purposive sample was taken from 121 ladies who underwent elective and emergency cesarean section at the department of obstetrics of Dhulikhel Hospital-Kathmandu University Hospital. Post-cesarean drop in hemoglobin and hematocrit and their relation with duration of uterine manipulation was calculated. Cross-match to transfusion (C/T ratio) ratio, transfusion probability (%T) and transfusion index (Ti) were also calculated. Results Most frequent blood group was found to be O positive (38%) among those ladies. Average post-cesarean drop in hemoglobin was 1.52±1.27 gm/dl and drop in haematocrit was 5.49±4.1%. Post-operative drop in hemoglobin and haematocrit had weak and positive linear relation with duration between uterine incision and repair. Cross-match to transfusion ratio was 1, transfusion probability 100% and transfusion index was 2. Conclusion There is no need of routine cross-matching of blood for cesarean section. Only grouping with confirmation of availability should be done for emergency situation. DOI: http://dx.doi.org/10.3126/kumj.v11i2.12490 Kathmandu University Medical Journal Vol.11(2) 2013: 144-146

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Timing of oxytocin administration to prevent post-partum hemorrhage in women delivered by cesarean section: A systematic review and metanalysis

PLoS ONE ◽

10.1371/journal.pone.0252491 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0252491

Author(s):

Maria Regina Torloni ◽

Monica Siaulys ◽

Rachel Riera ◽

Ana Luiza Cabrera Martimbianco ◽

Rafael Leite Pacheco ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Loss ◽

Cesarean Section ◽

Post Partum ◽

Average Risk ◽

Limited Evidence ◽

Post Partum Hemorrhage ◽

Uterine Incision ◽

Mean Differences ◽

Calculated Average

Background There is no consensus on the best timing for prophylactic oxytocin administration during cesarean section (CS) to prevent post-partum hemorrhage (PPH). Objectives Assess the effects of administrating prophylactic oxytocin at different times during CS. Methods We searched nine databases to identify relevant randomized controlled trials (RCT). We pooled results and calculated average risk ratios (RR), mean differences (MD), and 95% confidence intervals (CI). We used GRADE to assess the overall evidence certainty. Results We screened 13,389 references and included four trials. We found no statistically significant differences between oxytocin given before versus after fetal delivery on PPH (RR 0.60, 95%CI 0.15–2.47; 1 RCT, N = 300) or nausea/vomiting (RR 1.21, 95%CI 0.69–2.13; 1 RCT, N = 300). There was a significant reduction in the need for additional uterotonics when oxytocin was given immediately before uterine incision versus after fetal delivery (RR 0.37, 95%CI 0.18–0.73; I2 = 0%; 2 RCTs; N = 301). Oxytocin given before fetal delivery significantly reduced intra-operative blood loss (MD -146.77mL, 95%CI -168.10 to -125.43; I2 = 0%; 3 RCTs, N = 601) but did not change the incidence of blood transfusion (RR 0.50, 95%CI 0.13–1.95; I2 = 0%; 2 RCTs, N = 301) or hysterectomy (RR 3.00; 95%CI 0.12–72.77; I2 = 0%; 2 RCTs, N = 301). One trial (N = 100) compared prophylactic oxytocin before versus after placental separation and found no significant differences on PPH, additional uterotonics, or nausea/vomiting. Conclusions In women having pre-labor CS, there is limited evidence indicating no significant differences between prophylactic oxytocin given before versus after fetal delivery on PPH, nausea/vomiting, blood transfusion, or hysterectomy. Earlier oxytocin administration may reduce the volume of blood loss and need for additional uterotonics. There is very limited evidence suggesting no significant differences between prophylactic oxytocin given before versus after placental separation on PPH, need for additional uterotonic, or nausea/vomiting. The overall certainty of the evidence was mostly low or very low due to imprecision. Protocol: CRD42020186797.

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A randomized controlled trial of sublingual Misoprostol - 600µg versus intravenous Oxytocin - 10IU in prevention of post partum hemorrhage during cesarean section

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20194206 ◽

2019 ◽

Vol 8 (10) ◽

pp. 3865 ◽

Cited By ~ 1

Author(s):

Rajasri G. Yaliwal ◽

Shailaja R. Bidri ◽

Ashwini S. Navani

Keyword(s):

Blood Loss ◽

Cesarean Section ◽

Late Onset ◽

Post Partum ◽

Common Side Effect ◽

Suitable Alternative ◽

Post Partum Hemorrhage ◽

Emergency Cesarean ◽

Estimated Blood Loss ◽

Sublingual Misoprostol

Background: Mortality related to pregnancy and childbirth causes half a million women around the world to die annually. About 35% of these deaths are from postpartum hemorrhage (PPH). Prevention of PPH has been advised by the WHO by the use of Oxytocin 10 IU IM or IV and Misoprostol 600 µg in low resource settings in vaginal delivery. However there have been only a few reports on the use of Misoprostol during cesarean section. The best route and dose of Misoprostol is still being debated.Methods: One hundred women with term singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive either Misoprostol 600µg sublingually or intravenous oxytocin 10 IU soon after delivery of the baby. Estimated blood loss and comparative change in preoperative hemoglobin to post operative hemoglobin levels and side effects were evaluated.Results: Blood loss was found to be more in Misoprostol than Oxytocin. Eight patients of the Misoprostol group required additional oxytocics. Oxytocin group did not receive any additional drugs. No surgical intervention was made in either of the groups. The most common side effect with Misoprostol was shivering (46%) and in Oxytocin group fever (4%).Conclusions: Sublingual Misoprostol of 600µg works to prevent postpartum bleeding. In our study Oxytocin was more effective than Misoprostol in preventing PPH during cesarean section. Late onset of action of Misoprostol in comparison to Oxytocin may render suturing of the uterus difficult due to pooling of blood. In settings in which use of Oxytocin is not feasible, Misoprostol might be a suitable alternative for post-partum hemorrhage.

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Extra-abdominal removal of placenta during cesarean section: a prospective randomized controlled trial of a novel technique

Journal of Perinatal Medicine ◽

10.1515/jpm-2015-0330 ◽

2016 ◽

Vol 44 (5) ◽

Cited By ~ 1

Author(s):

Baris Kaya ◽

Onur Guralp ◽

Korkut Daglar ◽

Abdullah Tuten ◽

Aygul Demirol ◽

...

Keyword(s):

Postoperative Pain ◽

Blood Loss ◽

Cesarean Section ◽

Controlled Trial ◽

Abdominal Cavity ◽

Length Of Hospital Stay ◽

University Hospital ◽

Estimated Blood Loss ◽

Delivery Technique ◽

The Mean

AbstractTo evaluate intraoperative and early postoperative outcomes of a novel placenta delivery technique; extra-abdominal removal vs. intra-abdominal removal of the placenta during cesarean section (CS).A total of 210 women delivering by CS at term in a tertiary university hospital between March 2014 and January 2015 were randomized to extra-abdominal removal vs. intra-abdominal removal of the placenta. The women were randomly allocated to the extra- (group 1) or intra-abdominal removal group (group 2) according to random sampling method, where women with even and odd numbers were allocated to intra- and extra-abdominal groups, respectively. The amount of intra-abdominal hemorrhagic fluid accumulation, the duration of operation and estimated blood loss during operation were the primary outcomes. The secondary outcomes included the mean difference between pre- and post-operative hemoglobin and hematocrit levels, the mean postoperative pain score, any additional need of analgesia, postoperative bowel function, postoperative endometritis and wound infections.The amount of aspirated hemorrhagic fluid was significantly higher in the intra-abdominal group compared to the extra-abdominal group (34.6±22.2 mL vs. 9.4±4.8 mL, P<0.001). Mean duration of the operation, intraoperative blood loss, postoperative requirement of additional analgesia, postoperative pain scores, postoperative endometritis or wound infection, and length of hospital stay were not significantly different between the intra- and extra-abdominal placental removal groups.By extra-abdominal removal of the placenta, the accumulation of bloody fluid in the abdominal cavity is significantly less compared to the intra-abdominal removal method, which, in turn, provides avoidance of excessive mounted-gauze use, intra-abdominal manipulations, or iatrogenic trauma.

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Step towards Formulating a Maximum Surgical Blood Ordering Schedule in Obstetrics and Gynecology

Journal of Lumbini Medical College ◽

10.22502/jlmc.v4i2.100 ◽

2016 ◽

Vol 4 (2) ◽

pp. 99 ◽

Cited By ~ 1

Author(s):

Shreyashi Aryal ◽

Deepak Shrestha ◽

Brijbala Bharadwaj ◽

Narinder Kaur

Keyword(s):

Blood Transfusion ◽

Cesarean Section ◽

Abdominal Hysterectomy ◽

Obstetrics And Gynecology ◽

Transfusion Rate ◽

Cross Sectional ◽

Emergency Cesarean ◽

Utilization Patterns ◽

Blood Usage ◽

Transfusion Ratio

Introduction: Blood transfusion is an essential part of perioperative care in surgeries in obstetrics and gynecology. A tendency of over ordering of blood imposes additional workload to the blood bank and extra cost to the laboratory and patients. Maximum surgical blood ordering schedule (MSBOS) is a guide which helps in the decision of ordering and transfusing blood which reduces blood wastage. This study was done with the aim of evaluating the blood ordering and utilization patterns in obstetric and gynecologic surgeries and formulation of MSBOS for these procedures for the institute. Methods: This is a cross-sectional, hospital based study conducted for the duration of three months. All patients undergoing major and minor surgeries at the department were included. Crossmatch to transfusion ratio (C/T), transfusion probability (%T), transfusion index (TI) and MSBOS were calculated for each procedure. Results: Total 309 surgeries were performed in the department during the study period of three months. Most common surgery was emergency cesarean section (n=164, 53.1%) followed by abdominal hysterectomy (n=43, 13.9%). Utilization of crossmatched blood was 22.51%. Overall transfusion rate for all surgeries was 3.88%. Overall C/T ratio, %T, and TI were 4.44, 9.83 and 0.27 respectively which elicited indiscriminate ordering of blood. Conclusion: Over ordering and under utilization of blood were seen in this audit. Blood ordering patterns need to change in order to minimize over ordering of blood which may prevent abuse of the system. MSBOS maybe an useful tool in this institute as it allows optimum blood usage for surgeries.

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Anesthetic management in cesarean delivery of women with placenta previa: a retrospective cohort study

BMC Anesthesiology ◽

10.1186/s12871-021-01472-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dazhi Fan ◽

Jiaming Rao ◽

Dongxin Lin ◽

Huishan Zhang ◽

Zixing Zhou ◽

...

Keyword(s):

Cohort Study ◽

Blood Transfusion ◽

Blood Loss ◽

General Anesthesia ◽

Cesarean Delivery ◽

Retrospective Cohort ◽

Placenta Previa ◽

Neuraxial Anesthesia ◽

Estimated Blood Loss ◽

Maternal And Neonatal Outcomes

Abstract Background The incidence of placenta preiva is rising. Cesarean delivery is identified as the only safe and appropriate mode of delivery for pregnancies with placenta previa. Anesthesia is important during the cesarean delivery. The aim of this study is to assess maternal and neonatal outcomes of patients with placenta previa managed with neuraxial anesthesia as compared to those who underwent general anesthesia during cesarean delivery. Methods A retrospective cohort study was performed of all patients with placenta preiva at our large academic institution from January 1, 2014 to June 30, 2019. Patients were managed neuraxial anesthesia and general anesthesia during cesarean delivery. Results We identified 1234 patients with placenta previa who underwent cesarean delivery at our institution. Neuraxial anesthesia was performed in 737 (59.7%), and general anesthesia was completed in 497 (40.3%) patients. The mean estimated blood loss at neuraxial anesthesia of 558.96 ± 42.77 ml were significantly lower than the estimated blood loss at general anesthesia of 1952.51 ± 180 ml (p < 0.001). One hundred and forty-six of 737 (19.8%) patients required blood transfusion at neuraxial anesthesia, whereas 381 out of 497 (76.7%) patients required blood transfusion at general anesthesia. The rate neonatal asphyxia and admission to NICU at neuraxial anesthesia was significantly lower than general anesthesia (2.7% vs. 19.5 and 18.2% vs. 44.1%, respectively). After adjusting confounding factors, blood loss was less, Apgar score at 1- and 5-min were higher, and the rate of blood transfusion, neonatal asphyxia, and admission to NICU were lower in the neuraxial group. Conclusions Our data demonstrated that neuraxial anesthesia is associated with better maternal and neonatal outcomes during cesarean delivery in women with placenta previa.

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Blood Transfusion Practice before and after Implementation of Type and Screen Protocol in Emergency Department of a University Affiliated Hospital in Iran

Emergency Medicine International ◽

10.1155/2014/316463 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 5

Author(s):

Mostafa Alavi-Moghaddam ◽

Mahmoud Bardeh ◽

Hossein Alimohammadi ◽

Habib Emami ◽

Seyed-Mostafa Hosseini-Zijoud

Keyword(s):

Emergency Department ◽

Blood Transfusion ◽

Transfusion Practice ◽

Time Interval ◽

Blood Transfusions ◽

Common Diseases ◽

Before And After ◽

Transfusion Ratio ◽

Cross Match

Background. Blood transfusion is the cornerstone of therapy for many serious and common diseases. This study was performed to assess blood transfusion practice before and after implementation of type and screen protocol in emergency department of a university affiliated hospital in Iran, 2012-2013.Methods. An audit was studied before and after the implementation of type and screen protocol. The number of blood transfusions, time interval between blood order and transfusion, cross-match to transfusion ratio (C/Tratio), and transfusion index (TI) were checked.C/Tratio was used as a measure of the efficiency of blood ordering practice. We compared our results before and after implementation of type and screen protocol.Results. In present study after implementation of type and screen protocol, the time interval between requesting blood transfusion and transfusion of blood has decreased significantly (P<0.001). The number of blood transfusions required by actual patients increased significantly from 1/2 to 2 (P<0.001). The average cross-match to transfusion (C/T) ratio got near 1.13 from 1.41 and TI got near 0.91 from 0.58 (P<0.001).Conclusion. The implementation of T&S protocol has been proven to be safe, efficient, and beneficial to the transfusion practice of our hospital from the current study.

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Bloodless surgery and gynecological patients among Jehovah’s Witnesses

Česká gynekologie ◽

10.48095/cccg2021110 ◽

2021 ◽

Vol 86 (2) ◽

pp. 110-113

Author(s):

Milan Kudela ◽

◽

Radovan Pilka ◽

Petr Dzvinčuk ◽

Radim Marek ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Loss ◽

Gynecologic Surgery ◽

Jehovah’S Witnesses ◽

Ethical Problems ◽

Jehovah's Witnesses ◽

Estimated Blood Loss ◽

Risk Patients ◽

Bloodless Surgery ◽

Excessive Blood Loss

Overview Objective: The aim of this research is to present our experiences with the surgical treatment of gynecological patients among Jehovah’s Witnesses. Moreover, the medical, moral, and ethical problems in this regard have been highlighted. Methods: 75 Jehovah’s Witnesses patients were operated on for various benign and malignant gynecological diseases between 2007 and 2018. All of these patients were operated on according to the rules of blood-sparing surgery. Results: The operations were assessed according to the diagnosis, mode of surgery, estimated blood loss, and disease outcome. Excessive blood loss did not occur during any of these operations, and the estimated blood loss for the same procedure was 10 to 550 mL. Conclusion: Jehovah’s Witnesses gynecological patients is a group of high-risk patients because they refuse to undergo blood transfusion. Nevertheless, the principles of blood-sparing surgery should be applied to not only Jehovah’s Witnesses patients but also to all patients in general. Even if a blood transfusion is the last resort to solve issues pertaining to excessive blood loss during complicated operations, the said procedure always carries certain risks. Therefore, blood transfusion should be performed only on rare occasions. Jehovah’s Witnesses patients categorically refuse blood transfusion even if it is the only way to save one’s life. Even though the legislation of the Czech Republic deals with this problem, there are other moral and ethical aspects that need to be addressed in this regard. Keywords: bloodless surgery – Gynecologic surgery – Jehovah’s Witnesses – legislation – moral and ethical problems

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Tranexamic acid in prevention of postpartum hemorrhage in elective cesarean section

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20190017 ◽

2019 ◽

Vol 8 (2) ◽

pp. 372

Author(s):

Pravin Shah ◽

Ajay Agrawal ◽

Shailaja Chhetri ◽

Pappu Rijal ◽

Nisha K. Bhatta

Keyword(s):

Blood Loss ◽

Cesarean Section ◽

Tranexamic Acid ◽

Postpartum Hemorrhage ◽

Elective Cesarean Section ◽

Controlled Study ◽

Control Group ◽

Estimated Blood Loss ◽

Elective Cesarean ◽

The Mean

Background: Postpartum hemorrhage is a common and occasionally life-threatening complication of labor. Cesarean section is associated with more blood loss in compared to vaginal delivery. Despite, there is a trend for increasing cesarean section rates in both developed and developing countries thereby increasing the risk of morbidity and mortality, especially among anemic women. The objective of this study was to evaluate the effect of preoperative administration of intravenous Tranexamic acid on blood loss during and after elective cesarean section.Methods: This was a prospective, randomized controlled study with 160 eligible pregnant women of 37 or more period of gestation. They were all planned for elective cesarean section and were randomized into two groups either to receive 10ml (1gm) of Tranexamic acid intravenously or 10ml of normal saline. Blood loss was measured during and for 24 hours after operation.Results: The mean estimated blood loss was significantly lower in women treated with Tranexamic acid compared with women in the placebo group (392.13 ml±10.06 vs 498.69 ml±15.87, respectively; p<0.001). The mean difference in pre-operative and post-operative hemoglobin levels was statistically significant in the Tranexamic acid group than in the control group (0.31±0.18 vs 0.79±0.23, respectively; p<0.001).Conclusions: Pre-operative use of Tranexamic acid is associated with reduced blood loss during and after elective cesarean section. In a developing country like ours where postpartum hemorrhage is a major threat to the life of the mothers, it seems to be a promising option.

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The Use of Tranexamic Acid in Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00283 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0028

Author(s):

Laura Luick ◽

Vytas Ringus ◽

Garrett Steinmetz ◽

Spencer Falcon ◽

Shaun Tkach ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Loss ◽

Tranexamic Acid ◽

Total Ankle Arthroplasty ◽

Wound Complications ◽

P Value ◽

Ankle Arthroplasty ◽

Estimated Blood Loss ◽

Number Of Patients ◽

Significant Difference

Category: Ankle Arthritis Introduction/Purpose: The number of total ankle arthroplasties (TAA) is on the rise. Complications associated with TAA include need for blood transfusion, deep vein thrombosis, hematoma, infection, and wound complications. Tranexamic acid (TXA) use in the total knee and total hip population has been found to decrease the rate of blood transfusion. The rate of infections and blood transfusions in TAA was reported to be 3.2% and 1.3%, respectively. In calcaneal fractures TXA was found to decrease wound complications. Our goal was to evaluate the use of TXA in the TAA population to see if its use decreases blood loss or wound complications. Methods: This is a retrospective review of two patient cohorts operated on by a single surgeon from 2010 to 2016. We compared a group of TAA patients that did not receive TXA versus a subsequent group that received TXA. Patients received 1 g IV TXA before tourniquet was inflated and another 1 g following the release of the tourniquet. Pre-operative hemoglobin and hematocrit levels were compared to postoperative levels. Post-operative complications were compared between the two groups. Results: 87 patients were included in the study. 35 patients (40%) received TXA. In patients that received TXA, 18 had postoperative hemoglobin levels available. These patients were compared to a control cohort of 52 patients that did not receive TXA. No significant difference existed between the two groups in gender or age (p=0.9; p=0.7 respectively). Mean estimated blood loss was the same between the two groups. Overall postoperative complications, including wound complications, were higher in the TXA group at 26% vs 12% but this was not statistically significant (p-value = 0.086). The preoperative to postoperative change in hemoglobin/hematocrit levels was not statistically significant between groups (p-value = 0.78). There was one transfusion required in the non-TXA group and no transfusions required in the TXA group (p=0.9). Conclusion: The use of TXA was not found to provide a beneficial effect in total ankle arthroplasty in either decreasing wound complications or blood loss. Given these results, TXA use might not be cost effective in total ankle arthroplasty as opposed to other total joint arthroplasties. Further higher levels studies with increased number of patients are required to further evaluate TXA effectiveness in TAA.

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Total abnormal invasive placenta in a woman with a history of placental abruption and severe hemorrhage

Case Reports in Perinatal Medicine ◽

10.1515/crpm-2017-0037 ◽

2017 ◽

Vol 7 (1) ◽

Author(s):

Haruka Imai ◽

Junichi Hasegawa ◽

Yuki Suzuki ◽

Haruhiro Kondo ◽

Nao Suzuki

Keyword(s):

Blood Transfusion ◽

Cesarean Section ◽

Placental Abruption ◽

Massive Hemorrhage ◽

Uterine Atony ◽

Emergency Cesarean ◽

Ischemic Change ◽

Severe Hemorrhage ◽

Invasive Placenta ◽

History Of

Abstract Abnormal invasive placenta (AIP) is subdivided into total, partial and focal types. A diagnosis of total AIP is made when the entire placenta adheres to the uterine myometrium. We experienced a patient with total AIP who had a history of an emergency cesarean section at 36 weeks of gestation due to placental abruption, and massive hemorrhage due to severe uterine atony treated conservatively with blood transfusion. From our experience with the present case, we hypothesize that total AIP resulted from thinning of the entire endometrium, as can occur with an ischemic change of the entire uterus after disruption of Nitabuch’s layer in severe placental abruption and intramuscular extravasation with uterine atony. This situation might adversely affect placental implantation in the current pregnancy.

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