Research advances in the application of autologous blood transfusion technology in maternal perioperative period

Author: Wu Bin, Zeng Hong, Department of Anesthesiology, Peking University Third Hospital

Autologous blood transfusion technology is not used in obstetrics is not a lot, mainly considering maternal safety issues, such as amniotic fluid embolism, immune hemolysis, etc.

1.

Perioperative hemorrhage is a leading cause of maternal mortality, especially in developing countries, where the most common causes are placental abnormalities, including placenta accreta spectrum disorders (PAS), and placental abruption

Garmi et al.

Abnormal placenta due to the possibility of incision of the placenta abnormally attached or implanted, poor postpartum uterine contraction, resulting in a significant increase

Since the 1970s, intraoperative cell salvage (IOCS) technology has been widely used in vascular surgery, orthopedics, urology, cardiac surgery, neurosurgery and other specialties

Intraoperative autologous blood transfusion is also a method of blood protection that reduces the need for allogeneic transfusions by collecting a patient's blood and circulating it

2.

With advances in technology, such as the use of immunoglobulins to prevent maternal allogeneic immune responses, and the development of pathophysiological understanding of amniotic fluid embolism, the acceptability of obstetric autologous blood transfusion has increased

Sullivan et al.

This study showed that in combination with leukocyte filters, there was little or no chance of amniotic fluid contamination entering the reinfusion system, however the study did not return treated autologous blood into patients

Waters et al.

Amniotic fluid embolism is anaphylactoid syndrome

Neither group had abnormal levels of amniotic fluid embolic markers or DIC during the perioperative period, and there were no serious complications

3.

With the increase of gestational circumference, pregnant women are in a relatively high coagulant state, if perioperative bleeding occurs, DIC is prone to occur, and the blood products and plasma products transfused during the rescue process of hemorrhage will also affect the coagulation system to a certain extent, and the impact of IOCS on the coagulation system is also a matter of

Wang et al.
reported 157 cases of caesarean section, including 101 cases in the IOCS group (average IOCS transfusion volume of 432.
65 ml), 56 cases in the control group without IOCS, and the intraoperative blood loss in the 2 groups were similar, and the prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and thrombin time (TT)
were determined in 12-24 h before and 6-12 h after surgery 。 The results showed that IOCS was correlated with the decrease in allogeneic transfusion requirements (P<0.
001), PT and APTT were significantly higher than before surgery, and Fib was significantly decreased (both P<0.
01), while the difference between the two groups was not statistically significant (P>0.
05); there was no correlation between PT, APTT, and TT with recovered blood transfusion after surgery (P>0.
05), while Fib levels were negatively correlated with blood transfusion (P<0.
01).
<b13>

IOCS is thought to reduce the need for allogeneic transfusions and has no significant effect
on coagulation function after caesarean section.
Maternal coagulation abnormalities seriously threaten the safety of the mother and fetus, IOCS will not affect the maternal coagulation function, but IOCS infusion is all red blood cells, and the plasma layer rich in platelets is completely removed, so if IOCS is used during maternal bleeding, it is still necessary to supplement plasma and clotting factors
.

4.
Fetal red blood cell contamination

Another concern of the IOCS is that women trigger an immune response due to the return of blood that has been washed and filtered to still have fetal red blood cells, and it is unclear how much this response will be triggered
.
Ralph et al.
reported 70 cases of IOCS during caesarean section, the median amount of back transfusion was 324ml (118~1690ml), the median fetal erythrocyte contamination was 0.
8ml (0.
2~12.
9ml), 48 cases were followed up for detection of antibodies for 3 to 6 months after surgery, and only 1 case was positive for anti-S antibody (the clinical significance of this antibody was unclear), and the study believed that it was impossible to determine the immune response
of fetal red blood cells to the mother.
When the mother-fetal Rh blood group does not match, the biggest risk is that it may stimulate the mother to produce antibodies, resulting in a severe hemolytic reaction
in the next fetus.

Sullivan et al.
used Kleihauer-Betke method to detect fetal red blood cells in maternal blood before and after childbirth, 37% of fetal red blood cells were positive before and after delivery, and 53% were postpartum, and in 53 cases of postpartum fetal red blood cell positive, the median fetal red blood cells were 0.
66ml (quartile spacing 0.
22~2.
20, maximum 21.
20ml).

From 8 weeks of pregnancy to delivery, fetal red blood cells may be present in the maternal blood circulation, but it is unclear how much can trigger an immune response
.

The multicenter randomized controlled trial of Khan et al.
included pregnant women with fetal RhD-positive RhD, compared with the control group (no IOCS group, n=119), the fetal-mother transfusion rate in the intervention group (using IOCS group, n=133) was 25.
6% in the fetal transfusion rate and 10.
5% in the non-IOCS group (OR=5.
63, 95% CI: 1.
43-22.
14, P=0.
013), but the study did not provide long-term follow-up data for RhD-negative mothers, It is not known whether increased maternal fetal red blood cell exposure affects the next pregnancy and the effectiveness
of anti-D prophylaxis.

Rh-negative women will produce specific D antibodies due to fetal Rh positive, if IOCS, in the case of fetal umbilical cord blood test result is Rh positive (or unknown), inject anti-D human immunoglobulin within 72 h after the return infusion at least 1500 U, and can also be used Kleihauer-Betke method to detect the fetal red blood cell concentration in the mother, thereby determining the need for maternal injection of anti-D human immunoglobulin
.

In summary, the use of IOCS in obstetrics is safe, but Rh-negative patients should be cautious, and ABO blood group mismatch is a small problem, because ABO blood group antigen is not fully developed at birth, and the newborn produces ABO antibodies
3 to 6 months after birth.
The use of IOCS in obstetrics has its own special place, to understand the maternal and fetal blood type, to increase the safety
of use.

5.
Application of autologous blood transfusion technology in clinical practice

The prospective randomized controlled study of Liu et al.
included 58 cases of IOCS and allogeneic transfusion cesarean section, all of which were transfusions of hemoglobin < 80g/L, and if the IOCS group could not meet this standard, allogeneic transfusions were supplemented, and the targets of both groups were hemoglobin >80g/L
。 The intraoperative blood loss in the 2 groups was similar [(2350.
68±600.
52)mlvs.
(2520.
12±610.
77)ml, P=0.
986], the intraoperative differences in crystal fluid, colloidal fluid, fibrinogen and platelet transfusion were not significant, and the autologous blood retransfusion volume (735.
67±37.
58) ml in the IOCS group was significantly reduced compared with the IOCS group [(820.
76±185.
93)mlvs.
(1370.
53± 200.
65) ml, P=0.
000], there was no significant difference in perioperative coagulation function index in the 2 groups, and the postoperative incision infection, delayed incision healing, allergic reactions, adverse cardiovascular events, low incidence of hypoproteinemia in the IOCS group, and short
hospital stay time.

The use of IOCS for obstetric haemorrhage has been found to be safe and effective
.
Wu et al.
retrospectively analyzed the data of 361 cases of central placenta previa caesarean section, 137 cases of IOCS and allogeneic transfusion were each matched by tendency scores, the median autologous blood transfusion in the IOCS group was 300ml (100-1800ml), of which 37 cases (27%) required combined allogeneic transfusion, the IOCS group was infused with allogeneic erythrocytes and fresh frozen plasma The amount was significantly less than that of the control group, the postoperative C-reactive protein in the IOCS group was lower, the hospital stay was shorter, and no amniotic fluid embolism and DIC occurred in the 2 groups , respiratory distress syndrome and other complications
.

Zeng et al.
have also shown that IOCS can reduce the allogeneic transfusion rate (OR = 0.
179, 95% CI: 0.
098 to 0.
328).

When bleeding ≤ 3000ml, 93% of IOCS groups (80/86) did not require allogeneic transfusions, and 50% (49/98) of the control group; When the bleeding > 3000 ml, 29% (6/21) of the IOCS group did not require allogeneic transfusion, and 100% (17/17) of the control group required allogeneic transfusion
.
There were no complications or adverse reactions
in both groups.
The study suggests that IOCS can reduce the rate of allogeneic transfusion in placental implant patients and is safe
for obstetrics.

A study of 1,170 obstetric IOCS cases including Sullivan came to similar conclusions
.
IOCS treatment of high-risk obstetric haemorrhage has been recognized by
a number of obstetric organizations.
From August 2016 to January 2019, Lv Bin et al.
collected a total of 1265 cases of IOCS technology transfusion in caesarean section in 11 tertiary hospitals across the country, with no amniotic fluid embolism, serious adverse effects of blood transfusion, shock, and death, and believed that IOCS technology transfusion was relatively safe and effective in caesarean section, saving medical resources, but it was necessary to strictly regulate its application indications, mainly maternal hemorrhage rescue, disagreement to transfuse of allogeneic blood, Autologous blood transfusion device with leukocyte filter and experienced to perform
.

Obstetric IOCS technology is becoming more and more mature and may be widely used in qualified hospitals, but it still needs more perfect scientific research clinical data and basic research to verify
.

6.
Summary

Clinical studies have shown that IOCS can be safely used in pregnant women, especially in placental abnormalities, maternal hemorrhage rescue, etc.
, has basically reached a consensus
.
2 suction devices and autologous blood return transfusion devices
with leukocyte filters should be used.

Source: Wu Bin,Zeng Hong.
Research progress on the application of autologous blood transfusion technology in maternal perioperative period[J].
Chinese Journal of Minimally Invasive Surgery,2022,22(03):251-254.