Intraoperative Cell Salvage for Women at High Risk of Postpartum Hemorrhage During Cesarean Section: a Systematic Review and Meta-analysis
Obore N, Liuxiao Z, Haomin Y, Yuchen T, Wang L, Hong Y
Reproductive sciences (Thousand Oaks, Calif.). 2022
Postpartum hemorrhage (PPH) can lead to substantial blood loss that compromises maternal hemodynamic stability and consequently cause severe maternal complications such as organ dysfunction or death. Intraoperative cell salvage (IOCS), an effective method of blood conservation used in other surgical specialties, can be an alternative intervention for managing PPH. Thus, our aim was to evaluate the efficacy and safety of IOCS for women at high risk of PPH undergoing cesarean sections. We conducted a systematic search of electronic databases from inception to February 25, 2021 for randomized controlled studies and observational studies published in English or Mandarin about IOCS use in cesarean sections. Primary outcomes of interest were changes in postoperative hematologic parameters and any adverse events reported among patients that had IOCS and controls that had an allogeneic blood transfusion. The certainty of the evidence of the outcomes was evaluated using the GRADE approach. A total of 24 studies with 5872 patients were included in the meta-analysis. Eleven randomized controlled trials (RCTs), and 13 observational studies were analyzed. Postoperative hemoglobin levels were higher among patients with IOCS SMD 0.39 (95% CI; 0.20, 0.60; P < 0.001, high certainty). Allogeneic blood transfusion increased adverse events RR = 1.81(95% CI; 1.24, 2.62; P = 0.002, low certainty). IOCS shortened hospital stay SMD - 0.59 (95% CI: - 0.98, - 0.19; P = 0.004, low certainty) and shortened prothrombin time SMD - 0.67 (95% CI; - 1.31, - 0.04), P = 0.037, low certainty). The lower incidence of transfusion-related adverse events and shorter hospital stay among other findings demonstrate that IOCS use in obstetrics is an effective and safe alternative for the management of PPH; however, high-quality randomized control studies are required to confirm this evidence.
The safty profile of blood salvage applied for collected blood with amniotic fluid during cesarean section
Rong X, Guo X, Zeng H, Wang J, Li M, Wang Y
BMC pregnancy and childbirth. 2022;22(1):160
BACKGROUND The guidelines of National Health Service(NHS, the United Kingdom) recommended for use in obstetrics at increased risk of bleeding, requiring two suction devices to reduce amniotic fluid contamination, however, when comes to massive hemorrhage, it is may difficult to operate because the complex operation may delay time. The aim of the study was to detect the effect of amniotic fluid recovery on intraoperative cell salvage in obstetrics and provide evidence for clinical applications. METHOD Thirty-four patients undergoing elective cesarean section were randomly divided into two groups. In group 1, the cumulative blood from the operation field, including the amniotic fluid, was collected using a single suction device for processing. In group 2, after suctioning away the amniotic fluid using another suction device for the cumulative blood from the operation field. From each group, four samples were taken, including maternal venous blood (sample I), blood before washing (sample II), blood after washing (sample III) and blood after filtration with a leukocyte filter (sample IV), to detect serum potassium (K +), hemoglobin (Hb), white blood cell (WBC), fetal hemoglobin (HbF), alpha fetoprotein (AFP) and squamous cell (SC) levels. RESULTS The AFP, K + and WBC levels of sample III and sample IV were significantly lower than sample I in group 1 and group 2 (P < 0.05). Significantly more SCs were found in sample III than in sample I in group 1 and group 2 (P < 0.05), but SCs of sample IV had no statistical difference compared to sample I in group 1 and group 2 (P > 0.05). There was no significant difference in the K + , Hb, WBC, AFP and SC levels of sample IV between group 1 and group 2 (P > 0.05). The HbF levels of sample III and sample IV were significantly higher in group 1 than in group 2 (P < 0.05). CONCLUSION There is little or no possibility for AF contamination to enter the re-infusion system when used in conjunction with a leucodepletion filter. For maternal with Rh-negative blood, we recommend two suction devices to reduce HbF pollution. TRIAL REGISTRATION ChiCTR1800015684 , 2018.4.15.
Effect of intraoperative cell rescue on bleeding related indexes after cesarean section
Yu YF, Cao YD
World journal of clinical cases. 2022;10(8):2439-2446
BACKGROUND Obstetric hemorrhage is the leading cause of maternal mortality globally, especially in China. The key to a successful rescue is immediate and rapid blood transfusion. Autotransfusion has become an integral part of clinical blood transfusion, with intraoperative cell salvage (IOCS) being the most widely used. AIM: To investigate the application of IOCS in cesarean section. METHODS A total of 87 patients who underwent cesarean section and blood transfusion in our hospital from March 2015 to June 2020 were included in this prospective controlled study. They were divided into the observation (43 cases) and control (44 cases) groups using the random number table method. The patients in both groups underwent lower-segment cesarean section. The patients in the control group were treated with traditional allogeneic blood transfusion, whereas those in the observation group were treated with IOCS. Hemorheology [Red blood cell count, platelet volume, and fibrinogen (FIB)] and coagulation function (partial prothrombin time, prothrombin time (PT), platelet count, and activated coagula-tion time) were measured before and 24 h after transfusion. In the two groups, adverse reactions, such as choking and dyspnea, within 2 h after cesarean section were observed. RESULTS Before and after transfusion, no significant differences in hemorheology and coagulation function indices between the two groups were observed (P > 0.05). About 24 h after transfusion, the erythrocyte count, platelet ratio, and FIB value significantly decreased in the two groups (P < 0.05); the PLT value significantly decreased in the two groups; the activated partial thromboplastin time, PT, and activated clotting time significantly increased in the two groups (P < 0.05); and no statistical differences were observed in hemorheology and coagulation function indices between the two groups (P > 0.05). Furthermore, there was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05). CONCLUSION In patients undergoing cesarean section, intraoperative cell salvage has a minimum effect on hemorheology and coagulation function and does not increase the risk of amniotic fluid embolism.
A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial
Khan KS, Moore P, Wilson M, Hooper R, Allard S, Wrench I, Roberts T, McLoughlin C, Beresford L, Geoghegan J, et al
Health Technology Assessment (Winchester, England). 2018;22((2)):1-88.
BACKGROUND Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking. OBJECTIVES To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use. DESIGN Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded. SETTING A total of 26 UK obstetric units. PARTICIPANTS Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated. INTERVENTIONS Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed. MAIN OUTCOME MEASURES Primary - donor blood transfusion. Secondary - units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer-Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes - costs of resources and service provision taking the UK NHS perspective. RESULTS We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at pound8110 per donor blood transfusion avoided. CONCLUSIONS The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective. FUTURE WORK Research into risk of alloimmunisation among women exposed to cell salvage is needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN66118656. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 2. See the NIHR Journals Library website for further project information.
Cell salvage and donor blood transfusion during cesarean section: a pragmatic, multicentre randomised controlled trial (SALVO)
Khan KS, Moore PAS, Wilson MJ, Hooper R, Allard S, Wrench I, Beresford L, Roberts TE, McLoughlin C, Geoghegan J, et al
Plos Medicine. 2017;14((12)):e1002471.
BACKGROUND Excessive haemorrhage at cesarean section requires donor (allogeneic) blood transfusion. Cell salvage may reduce this requirement. METHODS AND FINDINGS We conducted a pragmatic randomised controlled trial (at 26 obstetric units; participants recruited from 4 June 2013 to 17 April 2016) of routine cell salvage use (intervention) versus current standard of care without routine salvage use (control) in cesarean section among women at risk of haemorrhage. Randomisation was stratified, using random permuted blocks of variable sizes. In an intention-to-treat analysis, we used multivariable models, adjusting for stratification variables and prognostic factors identified a priori, to compare rates of donor blood transfusion (primary outcome) and fetomaternal haemorrhage ≥2 ml in RhD-negative women with RhD-positive babies (a secondary outcome) between groups. Among 3,028 women randomised (2,990 analysed), 95.6% of 1,498 assigned to intervention had cell salvage deployed (50.8% had salvaged blood returned; mean 259.9 ml) versus 3.9% of 1,492 assigned to control. Donor blood transfusion rate was 3.5% in the control group versus 2.5% in the intervention group (adjusted odds ratio [OR] 0.65, 95% confidence interval [CI] 0.42 to 1.01, p = 0.056; adjusted risk difference -1.03, 95% CI -2.13 to 0.06). In a planned subgroup analysis, the transfusion rate was 4.6% in women assigned to control versus 3.0% in the intervention group among emergency cesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 2.2% versus 1.8% among elective cesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46). No case of amniotic fluid embolism was observed. The rate of fetomaternal haemorrhage was higher with the intervention (10.5% in the control group versus 25.6% in the intervention group, adjusted OR 5.63, 95% CI 1.43 to 22.14, p = 0.013). We are unable to comment on long-term antibody sensitisation effects. CONCLUSIONS The overall reduction observed in donor blood transfusion associated with the routine use of cell salvage during cesarean section was not statistically significant. TRIAL REGISTRATION This trial was prospectively registered on ISRCTN as trial number 66118656 and can be viewed on http://www.isrctn.com/ISRCTN66118656.
Effects of autologous blood injection at Zusanli (ST 36) on ovarian function in patients with primary ovarian insufficiency
Jiang R, Zou Y
Zhongguo Zhen Jiu = Chinese Acupuncture & Moxibustion. 2017;37((11)):1169-72.
OBJECTIVE To observe the effects of autologous blood injection and 0.9% NaCl at Zusanli (ST 36) on ovarian function in patients with primary ovarian insufficiency. METHODS Sixty patients with primary ovarian insufficiency were randomly divided into an observation group and a control group, 30 cases in each one. The patients in the observation group were treated with injection of autologous blood at Zusanli (ST 36); the patients in the control group were treated with 0.9% NaCl with identical volume at Zusanli (ST 36). Both the treatments were given once a week for 3 months. The ovarian function, including follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) were tested before treatment, 1 month, 2 months and 3 months after first acupoint injection; the endometrial thickness before and after treatment and clinical efficacy were compared in the two groups. RESULTS Compared before treatment, FSH was lowered in the observation group after 1-month treatment (P<0.05), while FSH and LH were lowered and E2 was increased after 2-month treatment and 3-month treatment (all P<0.05). Compared with 1-month treatment, FSH and LH were lowered and E2 was increased in the observation group after 2-month treatment and 3-month treatment (all P<0.05). Compared with 2-month treatment, FSH was lowered and E2 was increased in the observation group after 3-month treatment (both P<0.05). The differences of all serum tests before and after treatment were insignificant in the control group (all P>0.05). The FSH after 1-month treatment, and FSH, LH and E2 after 2-month treatment and 3-month treatment in the observation group were significantly different from those in the control group (all P<0.05). The endometrial thickness after treatment in the observation group was higher than that before treatment (P<0.05), while the endometrial thickness after treatment in the control group was similar to that before treatment (P>0.05); the difference of endometrial thickness before and after treatment in the observation group was higher than that in the control group (P<0.05). The clinical effective rate was 83.3% (25/30) in the observation group, which was superior to 46.7% (14/30) in the control group (P<0.05). CONCLUSION The autologous blood injection at Zusanli (ST 36) can significantly improve ovarian function, promote endometrial growth in patients with primary ovarian insufficiency.
Routine cell salvage during elective caesarean section: a pilot randomised trial
Geoghegan J, Middleton L, Moore P, Subseson G, Khan K, Daniels J
International Journal of Obstetric Anesthesia. 2015;24((1):):86-7.
Does current evidence support the use of intraoperative cell salvage in reducing the need for blood transfusion in caesarean section?
Dhariwal SK, Khan KS, Allard S, Wilson M, Moore P, SALVO study group
Current Opinion in Obstetrics & Gynecology. 2014;26((6):):425-430.
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PURPOSE OF REVIEW An important cause of maternal morbidity and direct maternal death is obstetric haemorrhage at caesarean section. Concerns regarding allogeneic blood safety, limited blood supplies and rising health costs have collectively generated enthusiasm for the utility of methods intended to reduce the use of allogeneic blood transfusion in cases of haemorrhage at caesarean section. This can be achieved by intraoperative cell salvage (IOCS). The aim of this review is to summarize and examine the evidence for the efficacy of IOCS during caesarean section, in women at risk of haemorrhage, in reducing the need for allogeneic blood transfusion. RECENT FINDINGS The majority of the evidence currently available is from case reports and case series. Although this evidence appears to support the use of IOCS in obstetrics, strong clinical evidence or economic effectiveness from clinical trials are essential to support the routine practice of IOCS in obstetrics. SUMMARY Current evidence is limited to reported case series and two small controlled studies. Overall, IOCS may reduce the need for allogeneic blood transfusions during caesarean section. Future large randomized trials are required to assess effectiveness, cost effectiveness and safety. The results of the current ongoing SALVO (A randomised controlled trial of intra-operative cell salvage during caesarean section in women at risk of haemorrhage) trial will shed light on these aspects.
Salvage autotransfusion versus homologous blood transfusion for ruptured ectopic pregnancy
Selo-Ojeme DO, Feyi-Waboso PA
International Journal of Gynaecology and Obstetrics. 2007;96((2):):108-11.
OBJECTIVE To compare the clinical outcomes of simple salvage autotransfusion and homologous blood transfusion in the management of ruptured ectopic pregnancies. METHODS Standard statistical analysis was done and relative risk (RR) and 95% confidence interval (CI) were calculated for 112 women randomized to salvage autotransfusion or donor blood transfusion following ruptured ectopic pregnancy. RESULTS More women in the autologous group received more than 1000 mL of blood (RR, 6. 41; 95% CI, 2. 75-15. 24) and had a hematocrit greater than 0. 27 at discharge (RR, 3. 62; 95% CI, 1. 41-6. 67). There were no significant differences in the incidence of postoperative fever (RR, 0. 95; 95% CI, 0. 43-2. 01), postoperative wound infection (RR, 0. 73; 95% CI, 0. 17-3. 19) or duration of hospital stay longer than 7 days (RR, 1. 3; 95% CI, 0. 44-4. 31). CONCLUSION In resource-poor countries, women with a ruptured ectopic pregnancy receive more blood with salvage autotransfusion.
Blood salvage during caesarean section
Rainaldi MP, Tazzari PL, Scagliarini G, Borghi B, Conte R
British Journal of Anaesthesia. 1998;80((2):):195-8.
The aim of this study was to assess blood salvage during Caesarean section. In 15 Caesarean sections, red cells lost were collected and washed with a Dideco machine and tested for the presence of fetoplacental material, bacterial contamination, free haemoglobin and fetal blood cells. Successive patients were allocated randomly to one of two groups. In group 1 (n = 34), intraoperative blood was salvaged, while group 2 served as a control. The mean amount of blood salvaged in group 1 was 363 (SD 153) ml. Blood was salvaged following these guidelines: identification of blood group of the mother and fetus; avoidance of aspirating blood from the umbilical cord; commencement of salvage after removing the fetoplacental unit; completely filling the centrifugation bowl with red cells; washing the cells using at least 1000 ml of physiological solution per bowl; and mixing the contents of the bowl, completely eliminating the buffy coat where fetal cells are located. In group 1, the use of homologous blood transfusions was significantly lower (one of 34 (2.9%) patients compared with eight of 34 (23.5%); P = 0.01), haemoglobin concentrations during the first 4 days after operation were significantly higher and postoperative hospital stay was significantly shorter. Duration of hospital stay was significantly shorter in group 1 (5.3 (1.9) vs 7.3 (4) days; P = 0.003). Mean base haemoglobin concentrations were significantly lower in group 1 (10.7 (1.4) vs 11.7 (1.5) g dl-1; P > 0.0001), while after surgery mean haemoglobin concentrations were significantly higher approximately 3 h after operation compared with the control group (10.2 (1.5) vs 8.6 (1.2) g dl-1; P < 0.0001). On the first day, haemoglobin concentrations were 9.8 (1.5) vs 8 (1.4) g dl-1 (P < 0.0001), on the second day 9.8 (1.4) vs 7.7 (1.4) g dl-1 (P < 0.0001), on the third day 10.1 (1.5) vs 7.5 (1.3) g dl-1 (P < 0.0001) and on the fourth day 10.4 (1.5) vs 8.1 (1.4) g dl-1 (P < 0.0001).