Pregnancy and blood transfusion

[urge]

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Let's say you are on call and a pregnant lady (pick your trimester)comes for couple of orifs after a motor vehicle accident. Ob is monitoring. You did some regional. Towards the end of the case you check a crit and it comes back 24%. Does the fact that she is pregnant change your transfusion management? Would you transfuse? How about crit of 22%? 20%?

 

[coprolalia]

The principles of rheology and pregnancy-induced changes of maternal physiology would, on the face of it, say "no". You have to have a specific indication to transfuse any patient, which means they have to be symptomatic (hypotensive, tachycardic, end organ compromise, etc.).

-copro

 

[urge]

The principles of rheology and pregnancy-induced changes of maternal physiology would, on the face of it, say "no". You have to have a specific indication to transfuse any patient, which means they have to be symptomatic (hypotensive, tachycardic, end organ compromise, etc.).

-copro

So, you would treat her like every other pt?

 

[coprolalia]

So, you would treat her like every other pt?

No, I believe I said:

The principles of rheology and pregnancy-induced changes of maternal physiology would, on the face of it, say "no".

Remember the physiology of the fetus here, too. They are necessarily living at a lower pH, and they have fetal hemoglobin. Likewise, the mom is going to, by the very nature of her pregnancy, live comfortably around Hb 10-11 and Hct 30-33.

Don't confuse oxygen carrying capacity and oxygen delivery to the fetus.

-copro

 

[urge]

No, I believe I said:

Remember the physiology of the fetus here, too. They are necessarily living at a lower pH, and they have fetal hemoglobin. Likewise, the mom is going to, by the very nature of her pregnancy, live comfortably around Hb 10-11 and Hct 30-33.

Don't confuse oxygen carrying capacity and oxygen delivery to the fetus.

-copro

😕

Your name suits you perfectly.

 

[dfk]

what was her starting crit?

 

[dhb]

what was her starting crit?

Why does it matter?

Treat if symptomatic, avoid blood as much as possible. I would definitely not transfuse at a crit of 24%, heck even 18 isn't too bad if she's not actively bleeding

 

[dfk]

Why does it matter?

Treat if symptomatic, avoid blood as much as possible. I would definitely not transfuse at a crit of 24%, heck even 18 isn't too bad if she's not actively bleeding

it matters b/c i want to know. i do agree no need to transfuse if not symptomatic.

 

[Noyac]

it matters b/c i want to know. i do agree no need to transfuse if not symptomatic.

What kind of response is that "b/c I want to know"?

Seriously, why do you want to know?

 

[dfk]

What kind of response is that "b/c I want to know"?

Seriously, why do you want to know?

why would i want to know the starting crit? serious??

 

[huktonfonix]

yes its a serious question. This is a previously healthy (albeit pregnant) patient who has been bleeding secondary to trauma and surgery. We already know her crit is gonna be low. It doesnt really matter what her starting crit was, its likely to have been slightly lower than normal due to pregnancy and is almost certainly lower now due to bleeding and fluid replacement. The main question now is whether or not you need to transfuse. I would transfuse if there is sign of inadequate end organ oxygen delivery (heart, brain, baby) that isnt due to another reason (hypoxia, inadequate CO, etc...)

 

[dfk]

OP never stated what the initial crit was, as we know. she may have been on the low side from the start. not all preggos are standard numbers. for me to want to know the initial crit to help determine how the baseline function is compared to post surgery is not wrong. this is just ridiculous to question. if the patient is asymptomatic, why transfuse? isn't the whole basis for transfusing PRBCs based on the need for O2 carrying? in any event, i don't care, i want to know the baseline... if she starts out at 27, i'm not too concerned. if she started out at 35, then i might pucker a bit more. hard concept? nah.

 

[urge]

What if during the case she started having a non reassuring fht? Crit is 24. Would you transfuse?

 

[Planktonmd]

OP never stated what the initial crit was, as we know. she may have been on the low side from the start. not all preggos are standard numbers. for me to want to know the initial crit to help determine how the baseline function is compared to post surgery is not wrong. this is just ridiculous to question. if the patient is asymptomatic, why transfuse? isn't the whole basis for transfusing PRBCs based on the need for O2 carrying? in any event, i don't care, i want to know the baseline... if she starts out at 27, i'm not too concerned. if she started out at 35, then i might pucker a bit more. hard concept? nah.

Your are contradicting yourself or maybe I misunderstood your response:
You are saying that you won't transfuse unless she becomes symptomatic but at the same time you are implying that the initial hematocrit would influence your decision to transfuse.
Is that what you are trying to say?

 

[isoman2000]

I think that he is saying knowing the inital crit can help guide decisions just as any pre-op lab can, not that it tells you when to transfuse, I would liketo know the crit, I do not have to know to do the case.

 

[dfk]

What if during the case she started having a non reassuring fht? Crit is 24. Would you transfuse?

non-reassuring fht's b/c of blood loss? or other reason? deliver the baby quickly, then transfuse (especially if mom not symptomatic).

 

[urge]

non-reassuring fht's b/c of blood loss? or other reason? deliver the baby quickly, then transfuse (especially if mom not symptomatic).

"deliver the baby" - Seems like a knee jerk response. Let's say she in her second trimester.

Besides, why not transfuse first, then deliver the baby? Why does the baby need to come out before the transfusion? Why not wait and see if the tracing gets better after the transfusion?

 

[huktonfonix]

What if during the case she started having a non reassuring fht? Crit is 24. Would you transfuse?

All other things being equal and optimized (oxygenation/ventilation ok. normovolemic, LUD in place, normotensive), I would probably transfuse at this point since I would consider this to be end organ dysfunction due to inadequate O2 delivery.

 

[Noyac]

why would i want to know the starting crit? serious??

No Einstein. The question was, "why do you want to know?"

 

[Noyac]

non-reassuring fht's b/c of blood loss? or other reason? deliver the baby quickly, then transfuse (especially if mom not symptomatic).

What other reason? She has lost blood, right?

So mom is losing blood and now the fht's are down. You are going to call in an OB team to deliver the baby? Wait a minute, big picture here. She is bleeding or has bled and delivering the baby is going to cost here around 500-1000 cc of blood. You are going to wait till the baby is out b/4 transfusing?

She is a trauma, we don't know her starting crit b/c she came i bleeding unless some very astute paramedic drew an H/H just before the trauma 😱 then put her back in the car and sent her on her way.

 

[Noyac]

I have another question. Do we need to wait for s/s of end organ dysfunction b/4 transfusing? This may be what the OP is getting at, I don't know.

DFK, you want to sit this one out?

 

[fakin' the funk]

it matters b/c i want to know.

Dogpiling here...
it also costs $200 and takes 5mL of blood from the pt...

 

[toughlife]

DFKs questions and answers are entertaining. Great job, keep it up!

 

[Arch Guillotti]

Theatre-style!

 

[Planktonmd]

I am still waiting for the part where someone is usually accused of discriminating against nurses.

 

[Arch Guillotti]

I am still waiting for the part where someone is usually accused of discriminating against nurses.

I have zero tolerance for any "nurse nonsense".

 

[dhb]

why would i want to know the starting crit? serious??

Because you don't need to: arterial oxygen content is always higher that oxygen consumption. The range of maximal O2 delivery being because of blood rheology +- 24-36% crit, under that you'll need the pump to compensate.

The point at which arterial O2 content will be lower than extraction is not determined by the previous Hb level. This is what you want to anticipate when transfusing.

With this we haven't touched on perfusion, micro circulation and O2 delivery 😀