Potential LSCS (patient trying for VBAC).

Background 

• Previous Emergency LSCS for failure to progress
• Anaemia

Issues

• Declining blood products
  • Concern over receiving blood from someone who has had COVID Vaccine. 
  • Will only accept if ‘going to die’ or would like re-discussion if blood transfusion indicated a less emergent setting
  • Patient asking for cell salvage currently low stock of disposable products

Discussion

• Ensure all sources of anaemia have been optimized prior to OT (B12/folate/Fe)
• Important to establish exact beliefs behind product refusal and individual products
• Cell saver only gives RBCs, but not clotting factors/ fibrinogen which are important in all massive transfusion settings
• Intra-operative blood transfusion in obstetrics is only really used when there is a real threat of significant morbidity or mortality
• Patient low risk of PPH
• Cell salvage may be a distraction in this setting, where early clotting factor replacement would likely be essential and the patient would accept blood products in a life threatening situation
• Cell salvage in pregnancy
  • Potential risk of amniotic fluid embolism and rhesus isoimmunization (no serious adverse events yet reported)
  • RANZCOG recommends cell salvage when >1000ml blood loss is expected, unclear benefit if <1000ml blood loss. 
  • Contraindications
    • Contaminants such as faeces, haemostatic agents (e.g. gelfoam)
    • History of HITS (ACD anticoagulant may be used instead of heparin)
    • Homozygous Sick cell disease 

• Benefits No risk of allogenic transfusion reactions/ blood born infectionsCan be useful when antibodies present/ crossmatching problematicSafely administered along with uterotonics and TXASalvaged RBCs more physiologic than stored blood (temp, 2,3DPG, pH and K)

• DisadvantagesRed cells only returned, nil clotting factorsCost of device and disposable, training costsDedicated staff member used (and must be available)Setup time may limit utility during an E0 caesareanAvailability of resources

• https://resources.wfsahq.org/atotw/intraoperative-cell-salvage-in-obstetrics/#:~:text=Cell%20salvage%20is%20a%20safe,risk%20factors%20for%20postpartum%20haemorrhage.
• https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03138-w

Plan

• Discuss with patient and document thoroughly, treat patient as normal as we only give RBCs if absolutely necessary anyway
• Not for cell salvage