Blood antibodies

[Dinkyconductor]

Patient shows up for 14th baby, 5th c-section, known previa. She's in labor, surgeon wants to go for c-section ASAP.

She's gotten blood before, so she has a variety of antibodies (not anti-d, we're talking Lewis, Kell, Kidd, etc.) Blood bank tells me it will be hours before they can match her to acceptable PRBC units.

Yeah, yeah, I know, I agree with you, I wish she had had the tubes tied ten babies ago, but she's here now, and very very likely to bleed/have an accreta. I plan to do it under general (I have good IV access, I placed an a-line, airway is not a problem, the only controversy here is with the blood)

If I had my way, we would have seen her last week in preop and arranged to have blood available, but she's just shown up now for the first time at this hospital.

What would you do if you have to go before the blood bank can provide you with acceptable blood? Now we have late decels, can we proceed knowing we'll have to give her type matched but uncrossed blood in a pt with antibodies?

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[rsgillmd]

She's in labor -- so try to see if you can convince the obstetrician to tocolyze -- Mag, terb, nitro. Whatever your flavor is. It may work.

Late decels by themselves are not going to prompt a C-section. Usually it's the overall strip. See if the obstetrician can manage medically -- O2, tilt to the side, etc.

Doesn't sound like a case you want to rush into. Rather sounds like one where you need to have a very thorough discussion with the obstetrician about your concerns. Don't forget, that the obstetrician is a physician who also cares about doing the right thing for his/her patient. If it is a resident approaching you, go over their head and talk to the attending directly.

Other questions to consider: How good is your surgeon? What were the previous operations like? If she had extensive scar tissue on her previous repeat C/S, then you are more likely to run into trouble.

Your scenario is too vague to say anything more than general statements.

 

[jwk]

Great advice already. If they just have to go, the patient needs to know up front the problems you're facing, and that there is an excellent chance her uterus may have to come out to save her life. I'd let your OB's know they need to be extremely aggressive with hemostasis (yeah, I know, good luck with that) and have a pretty low threshold for considering clamping the uterine arteries if they get into trouble. If they're pushing that hard, they may not want to wait for UA balloons placed by IR, but that's a possibility time permitting.

I would think the blood bank can still attempt to crossmatch whatever they have available, even in the presence of antibodies. You may get lucky.

 

[IlDestriero]

Cell saver.

 

[cchoukal]

I was about to post that transfusion reactions to the minor antibodies are not typically the severe hemolytic reactions associated w/ RBCs mismatched on the major antibodies, but w brief lit search on pubmed turns up a couple case reports.

Still, I think if you have to go, then O blood or even cross-matched RBCs (the first two steps, ruling out major antibody reactivity) should be available. As others have said, this would be a great time to:

1) Work it out w/ the attending OB that the case actually has to go
2) Have a 2nd experienced OB if possible
3) Develop a plan for a c-hysterectomy
4) alert IR

 

[jwk]

Cell saver.

Cellsaver is contra-indicated in the presence of amniotic fluid. However, I've seen it used after washing out the abdomen with a bunch of saline.

 

[pgg]

I think previous posters already hit everything I was going to say. Tocolytic and wait, or if they can't/won't wait then O or xmatched blood is OK for immediate use as the hemolysis will very likely be days-to-a-week delayed.

I'd use the partially matched blood before I'd go for cellsaver.

 

[IlDestriero]

Cellsaver is contra-indicated in the presence of amniotic fluid. However, I've seen it used after washing out the abdomen with a bunch of saline.

That's correct. I've done it for a similar scenario twice, though neither patient ultimately needed the blood. We delivered the baby after careful suctioning of the amniotic fluid and a quick rinse with a liter or 2 of warm saline, than changed to the cell saver suction. There are a number of case reports.

 

[Idiopathic]

.

 

[pgg]

That's correct. I've done it for a similar scenario twice, though neither patient ultimately needed the blood. We delivered the baby after careful suctioning of the amniotic fluid and a quick rinse with a liter or 2 of warm saline, than changed to the cell saver suction. There are a number of case reports.

I wonder, in the event of a bad outcome, which would be easier to defend. Cell saver use after cleaning up the amniotic fluid as best you can, or giving blood that may cause a delayed reaction. I lean toward giving the partially matched blood (as the risk is deferred to a later, presumably more controlled environment), but I suppose once the lawyers come to feed, you're screwed either way.

 

[IlDestriero]

I wonder, in the event of a bad outcome, which would be easier to defend. Cell saver use after cleaning up the amniotic fluid as best you can, or giving blood that may cause a delayed reaction. I lean toward giving the partially matched blood (as the risk is deferred to a later, presumably more controlled environment), but I suppose once the lawyers come to feed, you're screwed either way.

One was a JW, so blood was not an option. She was OK with cell saver though. The other pt had antibodies, but we had one unit available, which she got. There is literature supporting it's safe use. At trial, I'm sure their experts would disagree. What's new.

 

[lushmd]

There is some data indicating that by using a leukocyte depletion filter, one can safely use cell salvage in C-sections.

 

[Dinkyconductor]

Thanks, everyone.

Ultimately, i had a few type-matched units available and proceeded under general, there (miraculously) was no accreta and blood loss was typical.

But this scenario could happen anytime, for any emergency surgery, wanted to get some opinions for the next time it happens.

Good advice all around.

 

[Boujee]

would acute normovolemic hemodilution be an option?

 

[THP]

Ob resident here.

We had a similar situation the other week. Luckily she was not in active labor and just latently laboring. We were able to do the c-hyst under general anesthesia in a controlled environment, with the cell saver. We did not have the antibody issue however.

On more than one occasion I have used the cell saver at the time of c/s. We have both sets of suction hooked up. We use cell saver prior to myotomy. Switch to regular suction during delivery until the placenta is gone, then switch back to cell saver. This is saved for situations where we expect a massive blood loss.

In this situation if she was truly laboring with a previa and likely accreta, and she was near term there is no way tocolytics would work. I would go with the O- blood and the cell saver and get the situation under control rather than wait until after the bleeding starts.

 

[pgg]

In this situation if she was truly laboring with a previa and likely accreta, and she was near term there is no way tocolytics would work.

Why is that?

Thanks for posting.

 

[THP]

Why is that?

Thanks for posting.

Tocolytics don't seem to work well if the patient is in active labor. I think they are effective in the setting of contractions which are not overly painful with 1-3cm of dilation. Its pretty uncommon that we can make someone who changes her cervix from 2-->3-->4cm in a short period of time (2-3 hours) while painfully contracting stop.

You also have to ask why is she contracting? If there is an abruption or infection we wouldn't want to tocolyze her.

In the setting described it might be reasonable to try a tocolytic for an hour or two if she is not bleeding to ensure a controlled environment. If it is going to take 6 plus hours to do the cross matching and she was truly laboring I don't think it would be worth the risk to wait.

 

[rsgillmd]

Tocolytics don't seem to work well if the patient is in active labor. I think they are effective in the setting of contractions which are not overly painful with 1-3cm of dilation. Its pretty uncommon that we can make someone who changes her cervix from 2-->3-->4cm in a short period of time (2-3 hours) while painfully contracting stop.

You also have to ask why is she contracting? If there is an abruption or infection we wouldn't want to tocolyze her.

In the setting described it might be reasonable to try a tocolytic for an hour or two if she is not bleeding to ensure a controlled environment. If it is going to take 6 plus hours to do the cross matching and she was truly laboring I don't think it would be worth the risk to wait.

True, but the original post didn't give much detail about the "labor" or other things.

And as you said, tocolysis may buy you time to have a more thorough assessment of the situation and try to do this in a little more controlled manner.

 

[rsgillmd]

Tocolytics don't seem to work well if the patient is in active labor. I think they are effective in the setting of contractions which are not overly painful with 1-3cm of dilation. Its pretty uncommon that we can make someone who changes her cervix from 2-->3-->4cm in a short period of time (2-3 hours) while painfully contracting stop.

You also have to ask why is she contracting? If there is an abruption or infection we wouldn't want to tocolyze her.

In the setting described it might be reasonable to try a tocolytic for an hour or two if she is not bleeding to ensure a controlled environment. If it is going to take 6 plus hours to do the cross matching and she was truly laboring I don't think it would be worth the risk to wait.

True, but the original post didn't give much detail about the "labor" or other things (hemodynamic stability, fetal status, bleeding, etc.)

And as you said, tocolysis may buy you time to let everyone's adrenaline levels drop and little and have a more thorough assessment of the situation, all with the goal of possibly doing this C/S in a little more controlled manner.

 

[cchoukal]

Ob resident here.

We had a similar situation the other week. Luckily she was not in active labor and just latently laboring. We were able to do the c-hyst under general anesthesia in a controlled environment, with the cell saver. We did not have the antibody issue however.

On more than one occasion I have used the cell saver at the time of c/s. We have both sets of suction hooked up. We use cell saver prior to myotomy. Switch to regular suction during delivery until the placenta is gone, then switch back to cell saver. This is saved for situations where we expect a massive blood loss.

In this situation if she was truly laboring with a previa and likely accreta, and she was near term there is no way tocolytics would work. I would go with the O- blood and the cell saver and get the situation under control rather than wait until after the bleeding starts.

Thanks for posting. I would only add that in the presence of one of the minor antibodies, I don't think O- has any advantage over type-specific vis-a-vis transfusion reactions. I would probably save the O- for the next patient and use type-specific.

 

[THP]

Thanks for posting. I would only add that in the presence of one of the minor antibodies, I don't think O- has any advantage over type-specific vis-a-vis transfusion reactions. I would probably save the O- for the next patient and use type-specific.

fair enough. I don't know much about minor antibodies and the risk of transfusion reaction.