Guía para Uso de Componentes Sanguíneos

Atención de las Pacientes en las que la Transfusión no es una Opción

I Instituto de Evaluación Tecnológica en Salud

9.8

Temas del Artículo ocultar

9.8
9.8.1 Atención prenatal
9.8.2 Manejo en el trabajo de parto
9.8.3 Manejo de la hemorragia
9.8.4 Manejo de la anemia postparto
9.8.5 Aspectos jurídicos y éticos

Pregunta de antecedentes 4

¿Qué orientación se puede proporcionar para ayudar en la atención de las pacientes obstétricas en las que la transfusión no es una opción?

Evidencia

La transfusión de sangre puede no ser una opción de manejo en algunas situaciones (ej. debido a elección personal, creencias religiosas y/o culturales, presencia de grupos sanguíneos poco frecuentes o anticuerpos complejos, o falta de disponibilidad de componentes sanguíneos).

Los estudios observacionales sugieren un mayor riesgo de morbilidad y mortalidad maternas en tales circunstancias, con una atención deficiente (incluida la demora en la toma de decisiones) contribuyendo así a peores desenlaces (115-116).

9.8.1 Atención prenatal

A principios del período prenatal, identifique las mujeres para las que la provisión de sangre es probable que sea difícil (ej. grupos sanguíneos poco frecuentes).
Un equipo multidisciplinario debe brindar cuidados obstétricos y asesorar a la mujer sobre el mayor riesgo de morbilidad y mortalidad materna asociado a no recibir una transfusión cuando está indicado. La discusión debe ser individualizada, para determinar los componentes sanguíneos específicos y las alternativas a estos, que sean aceptables para la mujer. Documente el asesoramiento proporcionado y las preferencias de la mujer en el registro de control prenatal y en un formato legalmente válido.
Identificar y manejar la anemia y la deficiencia de hierro de acuerdo con las pautas establecidas.
Evaluar a las mujeres con respecto al riesgo de hemorragia, incluidos los factores de riesgo obstétrico establecidos para el sangrado, el uso de anticoagulantes, antecedentes personales de trastornos hemorrágicos hereditarios o adquiridos y antecedentes familiares de trastornos hemorrágicos.
Asesorar a las mujeres con alto riesgo de hemorragia para dar a luz en un sitio que tenga acceso a procedimientos quirúrgicos, radiología intervencionista y rescate celular si esta es una opción aceptable.
Prescribir la terapia prenatal de hierro para las mujeres en las que se espera una pérdida de sangre sustancial y que tienen depósitos de hierro subóptimos (ej. ferritina <100 μg/L) (1).
Considerar los AEE en mujeres seleccionadas con alto riesgo de pérdida importante de sangre. Cuando se utiliza un AEE, debe combinarse con una terapia con hierro.

9.8.2 Manejo en el trabajo de parto

Informar al servicio de obstetricia y a los especialistas (ginecólogo) cuando la mujer sea admitida en el parto.
Se aconseja el manejo activo de la tercera etapa del trabajo de parto con oxitócicos.
Se recomienda la observación cuidadosa y el control de la mujer, incluyendo el registro de la pérdida de sangre y la evaluación fundamental en las primeras horas después del parto, para asegurar la detección temprana y el manejo adecuado del sangrado anormal.

9.8.3 Manejo de la hemorragia

El manejo definitivo temprano puede salvar la vida cuando no se dispone de hemocomponentes para ayudar a optimizar el suministro de oxígeno, el rendimiento cardíaco y la hemostasia.

Involucrar al personal y activar los protocolos de sangrado postparto con una progresión rápida a la próxima intervención si la hemorragia no se controla rápidamente.
Considerar el manejo quirúrgico (incluyendo el taponamiento con balón) y radiología intervencionista antes de lo habitual.
Considerar el rescate celular si está disponible y es aceptable para la mujer.
De igual manera tambien,, Considerar los agentes farmacológicos, incluidos los agentes hemostáticos tópicos, para ayudar en la hemostasia.
También, Considerar el crioprecipitado, concentrado de fibrinógeno o concentrado de complejo de protrombina cuando esté disponible y aceptable para la mujer.

9.8.4 Manejo de la anemia postparto

Use hierro intravenoso en mujeres con anemia postparto moderada, y considere la posibilidad de agregar AEE cuando la anemia sea grave.
En el caso de la anemia grave postparto, el manejo debe guiarse por un asesoramiento temprano y continuo por parte de un experto.

9.8.5 Aspectos jurídicos y éticos

En cualquier situación en que el rechazo de la transfusión pueda afectar la salud del feto (ej. anemia prenatal materna profunda, transfusión intrauterina), obtenga asesoramiento legal y complete la documentación pertinente, de acuerdo con los requisitos jurídicos.

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98. James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. (2009). Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. American Journal of Obstetrics and Gynecology 201(1):12.e11-12.e18.
99. Australia and New Zealand Society of Blood Transfusion (ANZSBT) (2007). Guidelines for pretransfusion laboratory practice. 5th Edition. http://www.anzsbt.org.au/publications/documents/plp_guidelines_mar07.pdf
100. (2009). Coronial inquest into the death of Rebecca Murray. File No 615/2007, Coronial Jurisdiction of New South Wales.
101. Stock O and Beckman M (2014). Why group and save? Blood transfusion at low risk elective caesarean section. Australian and New Zealand Journal of Obstetrics and Gynaecology 54(3):279-282
102. Lombardi G, Garofoli F and Stronati M (2010). Congenital cytomegalovirus infection: treatment, sequelae and follow-up. The Journal of Maternal-Fetal & Neonatal Medicine 23(S3):45-48.
103. Johnson J, Anderson B and Pass RF (2012). Prevention of maternal and congenital cytomegalovirus infection. Clinical Obstetrics and Gynecology 55(2):521-530.
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106. Department of Health NSW (2010). Maternity – prevention, early recognition & management of postpartum haemorrhage (PPH). Policy Directive, Department of Health NSW. http://www0.health.nsw.gov.au/policies/pd/2010/PD2010_064.html
107. Allard S, Green L and Hunt BJ (2014). How we manage the haematological aspects of major obstetric haemorrhage. British Journal of Haematology 164(2):177–188.
108. Solomon C, Collis RE and Collins PW (2012). Haemostatic monitoring during postpartum haemorrhage and implications for management. British Journal of Anaesthesia 109(6):851–863.
109. Wikkelsoe AJ, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, Ekelund K, et al. (2012). The FIB-PPH trial: Fibrinogen concentrate as initial treatment for postpartum haemorrhage: study protocol for a randomised controlled trial. Trials 13:110.
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Instituto de Evaluación Tecnológica en Salud

IETS Colombia - Instituto de Evaluación Tecnológica en Salud. Instituto de Evaluación Tecnológica en Salud. Fue creado en el 2011 según lo estipulado en la Ley 1438, como una corporación sin ánimo de lucro, con participación de entidades públicas y privadas. De acuerdo con el Departamento Administrativo de la Función Pública, nuestro Instituto es una entidad descentralizada del sector de la salud. Es la Agencia Nacional de Evaluación de Tecnología Sanitaria de Colombia, que genera evidencia con rigor científico para soportar la toma de decisiones, promueve el desarrollo de mejores políticas públicas y prácticas asistenciales en salud con el fin de contribuir al mejoramiento de la salud de los colombianos, y a la sostenibilidad del sistema con legitimidad, innovación, calidad, equidad y eficiencia.

Anterior Siguiente

9.8

Pregunta de antecedentes 4

Evidencia

Los estudios observacionales sugieren un mayor riesgo de morbilidad y mortalidad maternas en tales circunstancias, con una atención deficiente (incluida la demora en la toma de decisiones) contribuyendo así a peores desenlaces (115-116).

9.8.1 Atención prenatal

9.8.2 Manejo en el trabajo de parto

9.8.3 Manejo de la hemorragia

9.8.4 Manejo de la anemia postparto

9.8.5 Aspectos jurídicos y éticos

Referencias

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