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The Journal of Obstetrics and Gynecology of India (September–October 2014) 64(5):358–361 DOI 10.1007/s13224-014-0534-3

ORIGINAL ARTICLE

Intraoperative Autologous Blood Transfusion of Peritoneal Blood During Laparotomy for Ectopic Pregnancy: Prospective Study
Shukla Padma ? Dwivedi Sudhakar ? Bhargava Meena ? Singh Reeti ? Singh Shipra

Received: 22 April 2013 / Accepted: 8 March 2014 / Published online: 30 March 2014 ? Federation of Obstetric & Gynecological Societies of India 2014

Abstract Objective The purpose of this study was to evaluate the ef?cacy and safety of intraoperative autologous blood transfusion during laparotomy for hemoperitoneum in ectopic pregnancy and also safety of homologous blood transfusion along with autologous blood transfusion. Method Fresh blood, from peritoneal cavity, was collected for autotransfusion in sterile dish, ?ltered through eight layers of sterile gauze pieces, and collected in a sterile bowl. The collected blood was transferred into blood infusion bag containing citrate phosphate dextrose adenine solution in the proportion of ?ve parts of blood to one part of citrate solution. Results Mean volume of autologous blood transfused in patients without homologous transfusion was 573 ± 328. Mean preoperative hemoglobin was 4.95 ± 1.5, and postoperative hemoglobin was 6.85 ± 1.3. Hence, rise in hemoglobin was 1.9 g%. Autologous blood volume transfused in 29 patients (who required homologous blood transfusion) was 488 ± 216. Preoperative hemoglobin was 4.35 ± 1.94. The result was compared with other studies. Conclusion Intraoperative autologous blood transfusion enabled the performance of laparotomy in hemodynamically unstable ectopic pregnancy patients without availability of
Shukla P. (&), Assistant Professor ? Dwivedi S., Associate Professor ? Bhargava M., Professor & Head of the Department ? Singh R., P.G. Student ? Singh S., P.G. Student Shyam Shah Medical College, 12/145 Khutehi, Rewa, MP 486001, India e-mail: shukladrpadma@gmail.com

homologous blood transfusion. Homologous blood transfusion is compatible with autologous blood transfusion. Keywords Autologous ? Homologous ? Blood transfusion ? Laparotomy

Introduction In the peripheral resource-poor hospitals where availability of donor blood is scarce and blood transfusion services are limited, women with ruptured ectopic pregnancy frequently present in poor clinical condition. Intraoperative autologous blood transfusion is the technique of salvaging and subsequently reinstituting the blood which was collected as hemoperitoneum. It is already used for ectopic pregnancies [1] or ovarian bleeding with hemoperitoneum. Developed countries have used blood salvage devices, such as cell saver, to process and retransfuse the salvaged blood [2]. Several simple manual systems have been used in developing countries. In this article, we report the ef?cacy and safety of the intraoperative autologous blood transfusion technique using a manual system.

Subjects and Methods The subjects included in the study were 42 patients with clinically suspected large hemoperitoneum as a result of disturbed ectopic pregnancy, who underwent emergency

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The Journal of Obstetrics and Gynecology of India (September–October 2014) 64(5):358–361

Intraoperative Autologous Blood Transfusion of Peritoneal Blood

Fig. 1 Collection of blood from peritoneal cavity

Fig. 3 Filtered blood kept ready for transfusion

hemostatic clamp applied on mesosalpinx. The collected blood was ?ltered through a sieve composed of eight layers of sterile gauze to be collected into a sterile bowl (Fig. 2). Reinfusion The ?ltered blood was transferred from the bowl to infusion bags, which was then reinfused into the patient (Fig. 3). Calcium gluconate was given to patients who received transfusion of three bags of blood.

Result
Fig. 2 Filtration of blood through 8 layers of gauze pieces

laparotomy in the Obstetrics and Gynaecology unit of Gandhi Memorial Hospital during a 30-month period. Informed consent for the procedure and possible ill effects thereafter was obtained from relatives. Urine pregnancy test was performed on admission which was found to be positive in 39 patients, weakly positive in two, and negative in one patient. Prophylactic antibiotic treatment was administered after scrutiny of patients. Hypovolemic patients were rapidly infused with sodium chloride solution/ringer lactate, while the patients were being rushed to operation theater. All patients were induced with spinal anesthesia. The sterilized equipment for autotransfusion was kept ready for use, comprising two small bowls to take out blood from peritoneal cavity; one bowl to sieve the blood; and one large bowl or kidney tray to collect the ?ltered blood. Eight layers of gauze were put one on another to be used as ?lter. Upon opening the abdomen, a small initial peritoneal incision was made (Fig. 1). Intraperitoneal blood appearing fresh was collected in the small bowl. After removing most of the fresh blood, the peritoneal incision was enlarged, and the

Out of these 42 patients, 9 were nulliparous (one unmarried), 11 were primiparous, and 22 patients were multiparous. History of laparoscopic tubal ligation was present in two, dilatation and curettage in one, and self-abortifacient intake in one patient. All patients included in this study were in a state of hypovolemic shock. Cervical excitation tenderness was absent in collapsed patients with massive hemoperitoneum. Mean age of the patients was 27 ± 8.7. Site of ectopic was ampullary in 24, isthmic in 13, tubal abortion in two, ovarian ectopic in one, and heterotopic pregnancy in two patients. Autologous transfusion was done in all patients, 29 required homologous transfusion along with autologous transfusion. Hemoglobin levels of all the patients were checked preoperatively and 48 h postoperatively. Mean volume of autologous blood transfused in 13 patients (without homologous transfusion) was 573 ± 328. Their mean preoperative hemoglobin was 4.95 ± 1.5, and postoperative hemoglobin was 6.85 ± 1.3. Mean rise of hemoglobin was 1.9 g%. Later, all the anemic patients received total dose infusion of iron. Mean autologous blood volume transfused in 29 patients (who received homologous blood transfusion) was 488 ± 216. Mean preoperative Hb was 4.35 ± 1.94. Mean

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The Journal of Obstetrics and Gynecology of India (September–October 2014) 64(5):358–361

volume of autologous transfusion was 85 cc more in patients who did not receive homologous transfusion. No adverse reaction occured due to autotransfusion during intraoperative period, except one patient who had shivering. No adverse reaction was seen in autologous along with homologous blood transfusion in postoperative period too. None of the patients developed postoperative fever or wound sepsis. All patients were discharged on the

seventh postoperative day. There was no mortality in this series. Other adverse outcomes, such as bleeding tendency or embolism, were not found in any subject. The above results were compared with other studies (Tables 1, 2, 3). Discussion Autotransfusion is useful alternative for blood replacement and augmentation of blood oxygen-carrying capacity. In the literature, various complications with autotransfusion are noted, such as infection, pulmonary edema, coagulopathy, and air embolism, but reports of complications are uncommon [2]. There is no risk of reaction caused by mismatched and massive homologous blood transfusion. Blood retrieval and ?ltering is simple, without any need for typing and crossmatching; hence, blood is readily available to transfuse, while a waiting for arrangement of homologous blood transfusion is eliminated. Developed countries have used blood-salvaging devices which do not appear to offer advantages over manual devices, although no comparisons have been made so far in randomized trials [6]. Conclusion

Table 1 Autologous blood transfused in different studies Simple Salvage Method Pathak et al. [3] Maleki et al. [4] Price et al. [5] Ansaloni et al. [6] Jongen et al. [7] Awojobi et al. [8] Present Study Autologous blood transfused (ml) 915
a

(250–3,000)
a

1,800 2,000 1,014 1,252 573
b

(1,500–2,500) (348) (500–3,000)

b

1,239 (500–1,500)
a

(328)

Mean volume transfused in the present study was less than the other studies
a b

Mean (range) Mean standard deviation

Table 2 Comparison of pre and post transfusion hemoglobin Study Pathak et al. [3] Maleki et al. [4] Price et al. [5] Ansaloni et al. [6] Present Study Presurgery Hb 8.1 7.5 5.0 7.5 a (3.3) 4.95
a

3–7 days postsurgery Hb 9.5 12.4 9.0 8.6
a

(2.8)
a

(1.5)

6.85

(1.3)

Mean postsurgery hemoglobin was higher in all studies in comparison with presurgery hemoglobin
a

Mean ± standard deviation

Autologous transfusion in ectopic pregnancy is a safe, simple, instantly available, and well-accepted method of blood transfusion. It enables performance of laparotomy for large hemoperitoneum in hemodynamically unstable patients. Homologous blood transfusion is compatible with autologous transfusion whenever required in postoperative period. Hence, autologous transfusion is a life-saving infusion method compatible with RBCs’ platelets and other blood components too, but to what extent remains yet to be explored.

Table 3 Complications of autologous blood transfusion Simple salvage autotransfusion study No. and type of transfusion SABT Pathak et al. [3] Laskey et al. [9] Jongen [7] Obiechina [10] Awojobi [8] Present Study 168 58 48 64 107 42 SABT ? DBT 362 – – 38 – 29 Transient hyperpyrexia transient oliguria Pulmonary edema Death 9 12 pulmonary embolism None None Shivering Complication related to SABT

SABT Salvage autologous blood transfusion, DBT donor blood transfusion

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The Journal of Obstetrics and Gynecology of India (September–October 2014) 64(5):358–361

Intraoperative Autologous Blood Transfusion of Peritoneal Blood

References
1. Takashi Y, Yukiko O, Hajime Ku, et al. Intraoperative autologous blood transfusion for hemoperitoneum resulting from ectopic pregnancy or ovarian bleeding during laparoscopic surgery. JSLS. 2003;7(2):97–100. 2. Selo-Ojeme DO, Onwude JL, Onwndiegwu U. Autotransfusion for ruptured ectopic pregnancy. Int J Gynaecol Obstet. 2003;80:103–10. 3. Pathak UN, Stewart DB. Autotransfusion in ruptured ectopic pregnancy. Lancet. 1970;1:961–4. 4. Maleki H, Bordbar A, Fateh N. Twenty two cases of autotransfusion. Anaesthesia. 1975;30:227–9.

5. Price ME, Kembey TY. Collecting blood for autotransfusion in ectopic pregnancy. Trop Doct. 1985;15:67–8. 6. Ansaloni L, Gaines C, Tocalli E. ‘Soup Laddle autotransfusion. Br J Surg. 1996;83:104. 7. Jongen VHW. Autotransfusion and ectopic pregnancy: an experience from Tanzania. Trop Doct. 1997;27:78–9. 8. Awojobi OA, Ogunsina S, Adekola F. Ectopic pregnancy in a rural population with high twinning rate. Trop Doct. 2002;32:37–8. 9. Laskey T, Wood PB. Ectopic pregnancies and intraoperative autotransfusion. Trop Doct. 1991;21:116–8. 10. Obiechina N, Emelife EC, Ezcasur E. The place of autotransfusion in the management of ectopic pregnancy: 10 years experience. J Obstet Gynaecol. 2001;21:513–5.

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