ROLE OF LABORATORY ROLE OF LABORATORY MEDICINE IN CARE OF MEDICINE IN CARE OF

CRITICALLY ILL CRITICALLY ILL MOTHERS AND INFANTSMOTHERS AND INFANTS

DR ANDREW K. GACHIIDR ANDREW K. GACHII

INTRODUCTION INTRODUCTION

Laboratory tests play a crucial role in Laboratory tests play a crucial role in practice of medicine practice of medicine

Estimated that up to 70% of diagnosis in Estimated that up to 70% of diagnosis in medical practice is made in the lab.medical practice is made in the lab.

Implies that lab. tests are a necessary tool Implies that lab. tests are a necessary tool before treatment is instituted before treatment is instituted

More crucial in Emergencies including More crucial in Emergencies including management of acute obstetric/neonatal management of acute obstetric/neonatal casescases

INTRODUCTIONINTRODUCTION

Pregnancy is considered a normal Pregnancy is considered a normal physiologic process.physiologic process.

However it is associated with significant However it is associated with significant alterations in the ‘normal’ valuesalterations in the ‘normal’ values

‘ ‘Normal’ values are higher or lower in Normal’ values are higher or lower in pregnancy than in non-pregnant statepregnancy than in non-pregnant state

INTRODUCTIONINTRODUCTION

Examples of ‘normal values’ affected in Examples of ‘normal values’ affected in pregnancy include.pregnancy include.

Hb and Haematocrit- reduced by 43% due to Hb and Haematocrit- reduced by 43% due to haemodilution.haemodilution.

Blood urea Nitrogen(BUN) as well as Blood urea Nitrogen(BUN) as well as creatinine tend to reduce from 13 and 1.1 creatinine tend to reduce from 13 and 1.1 to 4-7 and 0.4-0.7 respectively.to 4-7 and 0.4-0.7 respectively.

Due to increased renal clearance.Due to increased renal clearance.

PHYSIOLOGIC CHANGES IN PHYSIOLOGIC CHANGES IN PREGNANCYPREGNANCY

Test Test Effect of Pregnancy Effect of Pregnancy Bilirubin Bilirubin Unchanged Unchanged ALS & AST ALS & AST Unchanged Unchanged Prothrombin time Prothrombin time Unchanged Unchanged Alkaline phosphates Alkaline phosphates Increase 2 4 fold (2 X ULN) (placenta) Increase 2 4 fold (2 X ULN) (placenta)

2-2- Bile acids Bile acids Increase 2 3 fold (glycocholate, taurocholate, Increase 2 3 fold (glycocholate, taurocholate,

chenodeoxycholate) 2-chenodeoxycholate) 2- Fibrinogen Fibrinogen Increases 50% Increases 50% Globulins Globulins Increases alpha & beta; Decreases gamma Increases alpha & beta; Decreases gamma

Alpha fetoprotein Alpha fetoprotein Increases (specially with twins) Increases (specially with twins) Hemoglobin Hemoglobin Decrease in late pregnancy Decrease in late pregnancy

PHYSIOLOGIC CHANGES IN PHYSIOLOGIC CHANGES IN PREGNANCYPREGNANCY

Leukocyte count Leukocyte count Increases Increases Ceruloplasmin Ceruloplasmin Increase Increase Cholesterol Cholesterol Increases 2 fold 2-Increases 2 fold 2- Triglycerides Triglycerides Increase Increase

Recommended laboratory tests Recommended laboratory tests in the initial prenatal care visitin the initial prenatal care visit

1.1. Hct, HbHct, Hb2.2. U/A,U/CU/A,U/C3.3. BG,RhBG,Rh4.4. Pap smearPap smear5.5. Antibody screenAntibody screen6.6. Rubella statusRubella status7.7. Syphilis screenSyphilis screen8.8. Hbs AgHbs Ag9.9. Offer HIV testingOffer HIV testing

CRITICALLY ILL MOTHERS CRITICALLY ILL MOTHERS • • Pre-eclampsiaPre-eclampsia • • HELLP SyndromeHELLP Syndrome • • Amniotic fluid embolismAmniotic fluid embolism EclampsiaEclampsia • • Septic pelvicSeptic pelvic • • Acute Fatty Liver of pregnancyAcute Fatty Liver of pregnancy • • PeripartumCardiomyopathyPeripartumCardiomyopathy • • Peripartum HemorrhagePeripartum Hemorrhage • • Sheehan’s syndromeSheehan’s syndrome thrombophlebitisthrombophlebitis • • Supine hypotension syndromeSupine hypotension syndrome

• • Ectopic pregnancyEctopic pregnancy • • DIC after fetal demiseDIC after fetal demise

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Obstetric emergencies are almost Obstetric emergencies are almost always associated with blood always associated with blood transfusiontransfusion

A life saving procedure but is not A life saving procedure but is not without risks without risks

Recipient may develop transfusion –Recipient may develop transfusion –transmitted infection as well as suffer transmitted infection as well as suffer from immunological sequel e.g. red from immunological sequel e.g. red call alloimmunisation. call alloimmunisation.

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Hence strict adherence to correct Hence strict adherence to correct sampling, cross-match and administration sampling, cross-match and administration procedures is of paramount importance procedures is of paramount importance even in emergency.even in emergency.

Careful evaluation in utilization of blood Careful evaluation in utilization of blood and blood products necessary. and blood products necessary.

At KNH we are able to provide, Whole At KNH we are able to provide, Whole blood (ideally should not be used unless in blood (ideally should not be used unless in dire emergency), red cell concentrates, dire emergency), red cell concentrates, fresh frozen plasma, platelet concentrates. fresh frozen plasma, platelet concentrates.

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Lab is able to do initial blood grouping and Lab is able to do initial blood grouping and cross-matching, antibody screening and cross-matching, antibody screening and identification.identification.

Investigate blood transfusion reactionsInvestigate blood transfusion reactions Main challenges in blood transfusion is the Main challenges in blood transfusion is the

availability of blood and blood products, availability of blood and blood products, manual procedures with associated delay in manual procedures with associated delay in release of blood and delays in supplies of release of blood and delays in supplies of reagents.reagents.

Minimized when the new-blood transfusion Minimized when the new-blood transfusion centre is opened.centre is opened.

Host state of the art lab. And transfusion Host state of the art lab. And transfusion centre. centre.

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Plasma fractionsPlasma fractions Blood componentsBlood componentsWhole bloodWhole blood

• CryoprecipitateCryoprecipitate Fresh Frozrn PlasmaFresh Frozrn Plasma plateletsplatelets Packed red cellsPacked red cellsFreshFresh

- oldold• Clotting factor concentratesClotting factor concentrates• Immunoglobulin preparationsImmunoglobulin preparations• Saline albumin solutionSaline albumin solution• Salt-poor albuminSalt-poor albumin when fibrinogen level is less than 80-100mg/dlwhen fibrinogen level is less than 80-100mg/dl

Initially a tx for VW Dz, HemophiliaInitially a tx for VW Dz, Hemophilia

Now a source of fibrinogen in obstetric emergenciesNow a source of fibrinogen in obstetric emergencies when PT & PTT are higher than 1.5 times control levels when PT & PTT are higher than 1.5 times control levels All clotting factors; no plateletsAll clotting factors; no platelets

Can supplement RBC’s when whole blood not available for exchange transfusionCan supplement RBC’s when whole blood not available for exchange transfusion when platelet. count less than 50000/cmm when platelet. count less than 50000/cmm

or when massive blood loss or replacement has occurredor when massive blood loss or replacement has occurred -Washed RBC’s-Washed RBC’sPts with allergic reactions to plasma proteinsPts with allergic reactions to plasma proteins

-Leuko-poor RBC’s-Leuko-poor RBC’sPts with febrile, non-hemolytic reactions to plasma WBC’sPts with febrile, non-hemolytic reactions to plasma WBC’s DIVCDIVC

Massive haemorrhageMassive haemorrhageMajor liver traumaMajor liver trauma

Bleeding associated with liver diseaseBleeding associated with liver disease

Clotting disorders Clotting disorders HaemophiliaHaemophilia

Liver disease Liver disease dose: 1- 1.5 -2 packs/ 10 kg dose: 1- 1.5 -2 packs/ 10 kg

(8-10 packs)(8-10 packs) normal dose: 12 - 15ml/ kg normal dose: 12 - 15ml/ kg (4-5packs)(4-5packs) Platelet concentrates Platelet concentrates

(1 pack/10kg) (1 pack/10kg) dose : 6units RDP or 1 unit SDPdose : 6units RDP or 1 unit SDP

OTHER HAEMATOLOGICAL OTHER HAEMATOLOGICAL INVESTIGATIONS INVESTIGATIONS

Total white cell counts especially in Total white cell counts especially in patients with sepsis patients with sepsis

Platelet counts in cases of Platelet counts in cases of thrombocytopenia and DICthrombocytopenia and DIC

Coagulation factors including Coagulation factors including monitoring of fibrinogen and d-monitoring of fibrinogen and d-dimers level in cases of DIC. dimers level in cases of DIC.

MICROBIOLOGY MICROBIOLOGY Of major importance in cases of sepsis both in Of major importance in cases of sepsis both in

mothers and neonates.mothers and neonates. Tests include direct staining of micro-organisms Tests include direct staining of micro-organisms

e.g. gram stain- may provide quick diagnosise.g. gram stain- may provide quick diagnosis Cultures are the hall-mark- include urine, csf, and Cultures are the hall-mark- include urine, csf, and

most important blood cultures. most important blood cultures. Main challenge is the cost of reagents and in Main challenge is the cost of reagents and in

particular the bottles particular the bottles Cost cannot be sustained by the KNH charges.Cost cannot be sustained by the KNH charges. Ideal is to automate cultures and sensitivity Ideal is to automate cultures and sensitivity

testings.testings.

•Blood culture --

IMMUNOLOGY IMMUNOLOGY

Rapid tests for pregnancy especially Rapid tests for pregnancy especially in cases of suspected ectopic in cases of suspected ectopic pregnancy.pregnancy.

Testing for viral infections including Testing for viral infections including Hepatitis B as C as well as HIV.Hepatitis B as C as well as HIV.

Especially crucial in in acutely ill Especially crucial in in acutely ill mothers who may require dialysis.mothers who may require dialysis.

Main challenge is the supply of Main challenge is the supply of reagents and outdated equipment. reagents and outdated equipment.

CLINICAL CHEMISTRYCLINICAL CHEMISTRY

Forms backbone of laboratory support in Forms backbone of laboratory support in diagnosis and management of critically ill diagnosis and management of critically ill mothers and neonates.mothers and neonates.

Ranges from liver function tests, renal function Ranges from liver function tests, renal function tests to endocrinology.tests to endocrinology.

At KNH we have been able to place Clinical At KNH we have been able to place Clinical Chemistry Equipment at no cost. Chemistry Equipment at no cost.

The supply of reagents is through contract with The supply of reagents is through contract with the owner’s of the equipment. the owner’s of the equipment.

Through these equipment we are able to do Through these equipment we are able to do liver function tests within minutes.liver function tests within minutes.

CLINICAL CHEMISTRYCLINICAL CHEMISTRY

We are able to reduce the turn-around time from We are able to reduce the turn-around time from two day to one hour or lesstwo day to one hour or less

Main advantage is the back-up whereby several Main advantage is the back-up whereby several equipments are available in various labs that equipments are available in various labs that utilize the same reagentsutilize the same reagents

Main challenge is reagent supply.Main challenge is reagent supply.

Maintaining the Internal and external quality Maintaining the Internal and external quality control (IQA and EQA) due to cost.control (IQA and EQA) due to cost.

CLINICAL CHEMISTRY-CTCLINICAL CHEMISTRY-CT

Of importance in neonatal jaundice Of importance in neonatal jaundice and sepsisand sepsis

Levels of bilirubin can be availed Levels of bilirubin can be availed within 5-10 minuteswithin 5-10 minutes

We have developed an SOP on We have developed an SOP on communicating on critical valuescommunicating on critical values

Clinician should be informed Clinician should be informed immediately such values are detected. immediately such values are detected.

CLINICAL CHEMISTRYCLINICAL CHEMISTRY

Main challenge is the delay in Main challenge is the delay in communicating the results.communicating the results.

We are in the process of automating We are in the process of automating at least six of its key laboratories at least six of its key laboratories including chemistry and including chemistry and microbiology.microbiology.

Clinicians will be able to receive and Clinicians will be able to receive and retrieve the results from their retrieve the results from their workstations. workstations.

CLINICAL CHEMISTRYCLINICAL CHEMISTRY

Complete automation likely to be Complete automation likely to be complete this financial year.complete this financial year.

Delayed reports can be avoided through Delayed reports can be avoided through introduction of more POINT OF CARE introduction of more POINT OF CARE testing.testing.

Already familiar with use of Hb meters Already familiar with use of Hb meters glucometers-can more tests e.g bilirubin glucometers-can more tests e.g bilirubin be introduced.be introduced.

Main challenge is calibration and quality Main challenge is calibration and quality control.control.

THE ENDTHE END

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