International Journal of Obstetric Anesthesia (2007) 16, 241–249

 2007 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijoa.2007.01.014

REVIEW ARTICLE

Blood conservation techniques in obstetrics: a UK

perspective
S. Catling
Department Anaesthesia, Singleton Hospital, Swansea, Wales, UK

SUMMARY. In the UK, maternal mortality due to haemorrhage appears to be rising, with obstetric haemorrhage
accounting for 3-4% of the red cells transfused. Allogeneic blood transfusion carries risks such as administration
errors, transmitted infections and immunological reactions. The supply of blood is decreasing, partly due to the exclu-
sion of donors who have themselves received a blood transfusion since 1980, in order to stop transmission of variant-
Creutzfeldt-Jakob disease. The cost of blood is significantly increasing, partly because it is now leucocyte-depleted to
minimize viral transmission. Various blood conservation techniques can reduce exposure to allogeneic blood thereby
reducing risk and conserving the blood supply. These include preoperative autologous donation, acute normovolaemic
haemodilution and intra-operative cell salvage. Preoperative autologous donation may produce anaemia, does not
eliminate transfusion risk, cannot be used in an emergency and is not acceptable to Jehovah’s Witnesses. It should
be reserved for exceptional circumstances (rare blood type or unusual antibodies). Acute normovolaemic haemodilu-
tion may induce anaemia and cardiac failure and cannot be used in an emergency. It may have a limited role in com-
bination with other techniques. Intra-operative cell salvage is more effective and useful in obstetrics than the other
techniques, overcomes their shortcomings and is endorsed by CEMACH, OAA/AAGBI Guidelines, the National
Blood Service and NICE.
 2007 Elsevier Ltd. All rights reserved.

Keywords: Blood conservation; Obstetrics; Preoperative autologous donation; Acute normovolaemic haemodilution; Intra-
operative cell salvage

Contents

Introduction
Why should we consider blood conservation?
Blood conservation techniques
Pre-operative autologous donation
PAD in obstetrics?
Acute normovolaemic haemodilution
Intra-operative cell salvage
Is it safe in obstetrics?
Cell salvage in practice
Conclusion

INTRODUCTION

Accepted January 2007 There were 17 maternal deaths from haemorrhage (8.5
deaths per million maternities) in the three years 2000-
This article was presented at the Joint OAA/SOAP Meeting in Dublin,
August 2006. 2002 in the UK Confidential Enquiry into Maternal
and Child Health (CEMACH) report.1 In the previous
Correspondence to: S. Catling, Consultant in Obstetric Anaesthesia,
Singleton Hospital, Swansea, Wales, UK. triennium the rate was 3.3 per million maternities while
E-mail: sue.catling@btopenworld.com. 25 years ago it was 4.4 per million maternities. Maternal

241
242 International Journal of Obstetric Anesthesia

haemorrhage is the second commonest cause of direct
maternal death in the UK, and despite all efforts, the
number is not declining but appears to be rising. This
is a cause for concern. At the same time, fears about
the safety and the supply of blood in the UK have
prompted efforts to encourage evidence-based blood
transfusion and to consider ways in which allogeneic
transfusion can be minimised. Obstetrics accounted for
3.1% of red cell transfusions in the North of England
in 1999-20002. This figure is probably representative
for the UK as a whole, therefore, approximately
71 000 units of red cells are transfused to obstetric
patients per annum.2
WHY SHOULD WE CONSIDER BLOOD
CONSERVATION?
Blood is a scarce, expensive and potentially infected re-
source, hence the importance of methods for blood
conservation.
Since 1998 the price that a National Health Service
(NHS) hospital pays to the National Blood Service
(NBS) for one unit of red cells in the UK has risen from
£40 to £140 (Fig. 1), largely because all blood is now
leucodepleted to reduce the risk of infection. This has
been mainly driven in the UK by three reports of prob-
able transmission of variant-Creutzfeldt-Jakob disease
(vCJD) through transfused blood3,4 and the subsequent
realisation that new emerging infections (possible un-
known prions) may be in the blood supply and as yet
undetectable. This has led to exclusion from the donor
pool of anyone who received donor blood since 1980.
Further, it is estimated that only 3% of the UK and
US populations are active blood donors (Fig. 2).5 It
has been estimated that demand for red cells will in-
crease by 4.9% by 2008 in the UK, and that if a test
for vCJD is introduced it could reduce the donor pool
by up to 50%.2 This figure has been estimated by the
UK NBS using the results of unpublished donor surveys,
and reflects the fact that many current donors would re-
fuse such a test and withdraw from the donor pool if
testing became mandatory for UK donors. The actual
incidence of vCJD in the donor pool is not known
(Dr Stuart Penny, NBS, Personal Communication). In
1995 the European Union Resolution on Blood safety
and self-sufficiency in the Community (EUR-Lex-
31995Y0630(01)-EN) recommended that all EC coun-
tries audit their complications of blood transfusion,
directly leading to the establishment of the UK haemo-
vigilance system in 1996 (SHOT: serious hazards of
transfusion). This is a UK-wide, confidential, voluntary
anonymised reporting scheme that aims to collect data
on adverse events relating to transfusion of blood and
blood components, and to make recommendations to im-
prove transfusion safety.3 Sixty-seven percent of hospi-
tals in the UK are now reporting to SHOT. The SHOT
database indicates that about 2 500 000 units of red cells
are issued to hospitals from the four UK blood services
per annum. There is no record of the number of red cell
units actually administered, but wastage is thought to be
around 5% annually, which would suggest about
2 375 000 units of red cells are transfused annually in
the UK. A study from the North of England examined
the indications for red cell transfusion between 1999
and 2000 and ascertained that 6.3% were given to
“obstetrics and gynaecology” patients, with 3.1% being
“purely obstetric.”2
A large epidemiological study currently being ana-
lysed in the UK, but as yet unpublished, indicates that
from a sample of 29 hospitals supplied by the NBS,
2.7% of the supplied red cell units were given to patients

140
Red cell prices from the NBS (£)

120

100

80

60

40

20

0
9

6
02
/9

/0

/0

/0

/0

/0

/0
/
98

99

00

02

03

04

05
01
19

20

20
19

20

20

20

20

Fig. 1 Cost of one unit of red blood cells from the UK National Blood Service (NBS) 1998-2006. (Courtesy of Dr Stuart Penny, Head of Hospital
Liaison, NBS, UK).
 Blood conservation techniques in obstetrics 243

1.85

Number of donors (millions)

1.8

1.75

1.7

1.65

1.6

1.55
2001 2002 2003 2004 2005
Year

Fig. 2 Number of blood donors in the UK in millions: April 2001 – March 2005. (Courtesy of Dr Stuart Penny, Head of Hospital Liaison, NBS,
UK).

with the ICD10 coding “pregnancy and childbirth” and a
further 1.3% into patients coded “obstetric and gynaeco-
logical surgery.” (Personal Communication via UK NBS:
with kind permission, Epidemiology and survival of
transfusion recipients: EASTR Group Data). Such cod-
ing complexities make precise figures difficult to ascer-
tain, but it seems likely that the true figure for red cell
transfusion for obstetric haemorrhage annually in the
UK is 3-4% of the total red cells transfused. In actual
numbers, this would translate into approximately
71 250 obstetric transfusions from a total of 2 375 000
red cell units used.
In the five-year period mid-1996 to mid-2001,
17 million blood component units were issued in total
and 1148 incidents were reported to SHOT, of which
60% were incorrect transfusions mainly due to clerical
error.3 Three percent were transfusion-transmitted infec-
tions, including bacterial infections and Hepatitis B,
while 37% were immunological complications including
transfusion related lung injury (TRALI) and both acute
and delayed transfusion reactions (Fig. 3).
In this five-year period, there were 38 deaths due to
transfusion (with a further 24 deaths that were possibly
or probably due to transfusion), in addition to 165 major
morbidities (e.g. renal failure). This led the UK Depart-
ment of Health in 2002 to issue guidelines for better
blood transfusion, which stated, amongst many other
recommendations, that autologous transfusion and cell
salvage systems were to be encouraged.6 Unfortunately,
the latest data from SHOT3 show that for 2004 there
were 439 incorrect blood transfusions, which is a 26%
increase since the previous year. Of these, 23 were

800
699
700

600
Number of incidents

500

400

300

200 146 141

100 70
40 32 13 7
0
IBCT ATR DTR TRALI PTP TTI GVH UNCL

Fig. 3 Incidents reported to the UK Serious Hazards of Blood Transfusion (SHOT) reporting scheme 1996-2001. IBCT: incorrect blood
component transfused; ATR; acute transfusion reaction, DTR: delayed transfusion reaction; PTP: post transfusion purpura; TRALI: transfusion
related acute lung injury; TA-GVHR: transfusion associated graft vs. host reaction; TTI: transfusion transmitted infection; UNCL: unclassified.
244 International Journal of Obstetric Anesthesia

ABO incompatibilities, with two associated deaths. In as 665 824 per year. For obstetric anaesthetists, perhaps
addition, there were 100 immunological complications a more useful way of viewing these figures is to appre-
with two deaths (one TRALI and one acute transfusion ciate that major obstetric haemorrhage occurs in about
reaction) and two cases of transfusion-transmitted infec- 6.7/1000 deliveries in the UK,7 which means that we
tion including one case of Hepatitis E and one proven are encountering about 4 500 cases per year, from which
vCJD. The case for avoiding allogeneic transfusion there are five to six deaths (0.12%). These cases of ma-
wherever possible has never been stronger. jor haemorrhage represent a large potential target for
From November 2005, it became a legal requirement blood conservation techniques.
for transfusion-related “Serious Adverse Events and Although clearly involving very different patient
Serious Adverse Reactions” in the European Union to groups and very different denominator numbers, it is sal-
be reported to the “competent authority” in the relevant utary to compare the CEMACH (1997-2002) and SHOT
country (http://www.mhra.gov.uk). The UK govern- (1996-2001) mortality figures in terms of absolute
ment has designated the Medical Healthcare Products numbers:
and Devices Regulatory Agency (MHRA) to be the rel-  Deaths due to massive obstetric haemorrhage over six
evant Ôcompetent authority’, and an on-line reporting years:{CEMACH 1997-2002} = 24 (4/year)
system for serious adverse blood reactions and events  Deaths due to blood transfusion over five years:
(SABRE: sabre@mhra.gsi.gov.uk) is the mechanism {SHOT 1996-2001} = 38 (7.6/year) or 62 (12.4/year)
by which such events and reactions are reported to if “probable and possible” cases are included in
MHRA. This differs from SHOT in that it is a legal mortality.
requirement, whereas SHOT continues to be voluntary, At a time when obstetricians and obstetric anaesthe-
and differs also in that “near-misses” and “non-harm- tists are focusing on novel techniques to reduce obstetric
events” do not have to be reported to MHRA, thereby haemorrhage, such as B-Lynch sutures, recombinant fac-
losing valuable denominator data about transfusion tor VIIa and interventional radiology, it is startling to rea-
standards in the UK. Hospitals and clinicians are there- lise that between 1996 and 2002 allogeneic blood
fore encouraged to continue reporting to SHOT, which transfusion killed more people in the UK than obstetric
is a professionally affiliated organisation, and the haemorrhage. We should therefore logically be devoting
SABRE system accordingly allows for reporting to both as much thought and effort into reducing these deaths as
or either. to addressing obstetric haemorrhage. The baseline trans-
The most recent UK CEMACH Report1 (2000-2002) fusion rate for the unselected pregnant population is 0.57%,
identifies 17 deaths due to obstetric haemorrhage, which ranging from 0.4% in low risk groups with no identifiable
is a large increase on the seven deaths in the previous risk factors, to 1.6% when risk factors are included.8 So
triennium, and is depressingly similar to the numbers far there have been no reports to SHOT identifying
dying of haemorrhage 20 years ago. The report calcu- blood transfusion as a cause of death in the obstetric
lates the number of maternities (pregnancies resulting population, although the role of TRALI and severe immu-
in live birth at any gestation or stillbirths occurring at nological reactions to massive allogeneic blood transfu-
or after 24 week’s completed gestation) for this period sion has not been investigated in this population.

2.3
Red cell demand (millions)

2.2

2.1

2.0

1.9

1.8

1.7
20 03

20 04

20 05

6
1

20 02
3

-0
00
-9

-9

-9

-9

-9

-9

-9

00

-
0
02

03

04

05
-2

-2
92

93

94

95

96

97

98

-2
00

01
19

19

19

19

19

19

19

99
20

20
19

Fig. 4 Number of red cell units issued by the four UK Blood Services 1992-2006. (Courtesy of Dr Stuart Penny, Head of Hospital Liaison, NBS,
UK).

Encouragingly, since 2000 there has been a fall in
the UK demand for red cells (Fig. 4). This has been
achieved through more rational use of blood, including
lower transfusion triggers and blood conservation
techniques.
BLOOD CONSERVATION TECHNIQUES
Probably the most effective single blood conservation
technique is the rational decision not to transfuse a
patient if the haemoglobin is 8 g/dL or above. A system-
atic review of clinical trials comparing liberal or conser-
vative transfusion regimes in a heterogeneous group of
surgical and critical care patients has confirmed a trend
towards better outcomes when less blood is used.9
Within that review, the best evidence comes from a sin-
gle, large, randomised trial in critically ill patients in
intensive care, which failed to demonstrate clear benefit
from maintaining haemoglobin levels above 7 g/dL.10
There is evidence that elderly critical care patients with
ischaemic heart disease benefit from a higher haemo-
globin, in that their prognosis after myocardial infarc-
tion is better if a low admission haemoglobin is raised
to 10 g/dL by red-cell transfusion.11 With this single
exception, there is no other evidence supporting the pol-
icy of transfusion to raise haemoglobin above 8 g/dL in
any clinical situation.
In obstetrics this simple policy is often confounded
by the rapidly changing clinical situation and the need
to stay ahead of, or at least up with, continuing blood
loss in the parturient. As McClelland from the Scottish
National Blood Transfusion Service in Edinburgh so
eloquently puts it: “Transfusion has risks, but bleeding
to death is fatal.”12
Techniques for blood conservation include:
a) Pre-operative autologous donation (PAD)
b) Acute normovolaemic haemodilution (ANH)
c) Intra-operative cell salvage (IOCS)
Pre-operative autologous donation
In this technique, the patient donates up to four units of
their own blood in the month before elective surgery,
while taking iron supplementation. Theoretically, the
haemoglobin will recover between donations, so the
patient presents for surgery with a normal haemoglobin
and several units of their own (autologous) blood ready
for transfusion if necessary. This technique was popular
from the early 1980s in the US, Canada and Europe, but
has the same inherent risks in collection, storage, identi-
fication and administrative error as allogeneic blood.
With a 35-day storage limit using routine blood bank
refrigeration techniques, the date for surgery must be
guaranteed.
Blood conservation techniques in obstetrics 245
In practice, the haemoglobin rises little, if at all,
between autologous collections, so a patient with a start-
ing haemoglobin of 13 g/dL will present for surgery with
a haemoglobin of 10 g/dL and three units of autologous
blood in blood bank.13 The 2001 guidelines in Scotland
for non-pregnant women suggested that women with
haemoglobin >13 g/dL were suitable for PAD, while
those with haemoglobin 11-13 g/dL should receive eryth-
ropoietin (EPO) to increase their red cell mass, and those
with haemoglobin <11 g/dL should be excluded.14 Preg-
nant women are usually not defined as anaemic until
their haemoglobin is <10.5 g/dL, and widespread use
of EPO is unrealistic because of its high cost. Potential
thrombotic and hypertensive side effects of EPO have
been noted in long-term use and when the haemoglobin
has been elevated above 13 g/dL,15 but a systematic re-
view found little evidence for this in short-term use.16
There is no evidence specifically relating to these com-
plications in the pregnant population.
In 2004 the Joint Working Parties on Autologous
Transfusion and Alternatives to Transfusion presented
their report A National Blood Conservation Strategy
for the National Blood Transfusion Committee and the
NBS in the UK.17 This report highlights the fact that
PAD is not economically effective and that the main
hazard of transfusion, as identified by SHOT reports3
(i.e. the risk of getting the wrong blood) is no less with
PAD than with allogeneic transfusion. Following this
report, the NBS sent a questionnaire to UK hospitals
previously identified as using PAD, and established that
a negligible number of centres were now offering this
service, mainly in paediatric spinal surgery. The NBS
consequently has withdrawn the routine use of PAD in
adults in the UK, unless the patient has a very rare blood
type or unusual antibodies, which make cross-matching
very difficult.
PAD in obstetrics?
There is very little experience of PAD in obstetrics in
the UK, but several studies from the US in the 1980s
and 1990s demonstrated that the technique is well toler-
ated in all trimesters of pregnancy, despite theoretical
problems of pregnant women having physiologically
lower haemoglobin and increased intravascular
water.18–20
PAD has no role in emergency haemorrhage, and is
not acceptable to Jehovah’s Witnesses, but may have a
very limited role in parturients for elective caesarean
section who are at very high risk of bleeding (e.g.
placenta accreta, massive fibroids) and in whom
there are also exceptional cross-matching difficulties.
Such patients could donate in the first trimester before
significant physiological haemodilution occurs, when
their blood may be frozen and stored. The haemoglobin
246 International Journal of Obstetric Anesthesia
can be maintained with iron or EPO as needed, even in
the third trimester.18 This procedure would now require
the involvement of a designated UK blood processing
centre rather than a hospital blood bank, and is very
rarely indicated, but in the UK NBS, frozen blood can
be stored for up to 10 years.
Acute normovolaemic haemodilution
This is the immediate pre-operative collection of whole
blood from the patient, with simultaneous volume
replacement with crystalloid/colloid to maintain normo-
volaemia. This reduces the number of red cells lost at
surgery, and autologous fresh whole blood, with the
starting haematocrit, containing active clotting factors
and functioning platelets, can be transfused when hae-
mostasis is secured.
The precise volume of blood to be withdrawn can be
calculated using the equation published by Gross:21
ðHi; HfÞ
Volume to be removed ¼ EBV 
Hav
where: EBV = estimated blood volume, Hi = initial hae-
matocrit, Hf = final haematocrit, and Hav = average of
Hi and Hf.
In practice, 2-3 units of blood are removed in the
immediate pre-operative period (in the UK this would
be done in the anaesthetic room) and replaced with
colloid/crystalloid on a 1:1 and 3:1 ratio respectively.
The blood remains in theatre in citrated bags, where it
can be stored at room temperature for 6 h (maintaining
normal platelet function) or in a refrigerator for 12 h,
and is re-transfused before the patient leaves theatre.
This reduces the potential for both administrative error
and infection. Current UK guidelines suggest that the
technique may be useful where the starting haemoglobin
is >10 g/dL, there is no myocardial disease and the
anticipated blood loss is at least 20% of the blood
volume.22 The acute reduction in haemoglobin and
consequent reduction in oxygen-carrying capacity is
compensated for by a rise in cardiac output to maintain
oxygen delivery. In pregnancy there is already a large
rise in cardiac output, and there was concern over
whether ANH in pregnancy would precipitate cardiac
failure or cause placental insufficiency. Work from
Canada has shown that, in practice, ANH involving
the immediate pre-operative removal of 750-1000 mL
of blood is well tolerated in the healthy, term parturient
undergoing elective caesarean section where major
haemorrhage was predicted.23
Mathematical modelling shows that ANH is effective
for only a minority of patients, i.e. healthy adults with a
high initial haemoglobin in whom a low target haemo-
globin is acceptable, who are expected to lose >50%
blood volume, and who can withstand withdrawal of
1000 mL of blood pre-operatively.24 Using the model,
one unit of allogeneic blood could be saved if ANH
was used in a blood loss of 2000 mL with a target hae-
moglobin of 9 g/dL. There is, however, little grade 1
evidence to suggest that ANH alone spares significant
quantities of allogeneic blood. The NBS Working Party
and a recent meta-analysis17,25 both concluded that the
quality of published studies was not good enough to
make firm conclusions on efficacy or safety, and that
ANH should be considered only in conjunction with
other techniques as part of an integrated approach to
minimise exposure to homologous blood.
Of course, efficacy in these studies is invariably de-
fined as the demonstrable saving of allogeneic red cell
transfusion. No study has yet considered ANH as a pri-
mary means of conserving and re-transfusing platelets/
coagulation factors. Each unit of ANH blood is equiva-
lent to one unit of red cells plus one unit of fresh plasma
and contains approximately 55-225 · 109 platelets. In
Swansea we have successfully used this technique at
caesarean section for platelet/coagulation conservation
in some Jehovah’s Witnesses to whom this was accept-
able. In this scenario, the blood can be taken via a triple-
lumen central venous line into three citrated blood bags
and the tubing to each can be left in continuity with the
circulation throughout the surgery.
Intra-operative cell salvage
This is a technique for re-cycling operative blood loss.
Blood is aspirated from the surgical site through heparin-
ised tubing and a filter into a collecting reservoir.26 The
cells are separated by haemoconcentration and differen-
tial centrifugation in 0.9% saline, and washed in 1-2 L of
0.9% saline, which removes circulating fibrin, debris,
plasma, microaggregates, complement, platelets, free
haemoglobin, circulating pro-coagulants and most of
the heparin. Up to 250 mL of packed red cells with a hae-
matocrit of 55-80 can be returned to the patient within
three minutes of aspiration. Salvaged red cells are at least
equal and usually superior to banked blood in terms of
red cell survival, morphological changes, 2,3 DPG activ-
ity and potassium content. The NBS Working Party on
Autologous Transfusion17 concludes that IOCS is the
most valuable form of autologous transfusion and that
UK hospital trust managers should be encouraged to
establish its use. If all hospitals in England used IOCS
where a blood loss of >1000 mL was anticipated, more
than 160 000 units of red cells would be saved annually.13
This would represent a significant improvement in
patient safety and would make an enormous contribution
to conservation of blood stocks in the UK.
In obstetrics, with an estimated incidence of major
haemorrhage in the UK of 6.7/1000 deliveries7 and

obstetrics consuming about 70 000 red cell units annu-
ally,2 there is an opportunity to reduce allogeneic blood
transfusions and conserve the national supply by using
IOCS in caesarean sections where major blood loss is
anticipated. In massive unexpected obstetric haemor-
rhage where the immediate supply of allogeneic blood
may be exceeded, cell salvage has been successfully
used as a life-saving procedure to recirculate ongoing
losses and maintain tissue oxygenation until bank blood
became available.27
Is it safe in obstetrics?
Obstetrics was originally cited as a theoretical contrain-
dication to the use of cell salvage because of the possible
risks of amniotic fluid embolism and Rhesus immunisa-
tion. The former has never been documented and re-
mains entirely theoretical, and the latter is preventable
with adequate anti-D immunisation.28
The cell saver has been safely used in over 400 pub-
lished obstetric cases without causing harm,29–35 and in
many unpublished cases (see below) although it is
impossible to prove complete safety.
A brief letter published in 2000 refers to a Jehovah’s
Witness with severe preeclampsia and classic haemo-
lysis, elevated liver enzymes, low platelets (HELLP)
syndrome who died following caesarean delivery in
which cell salvage was used without the use of a leuco-
depletion filter.36 Her pre-operative haemoglobin
was 7.1 g/dL, platelet count 48 · 109/L and the esti-
mated intra-operative blood loss 600 mL. Following
extubation she became restless and dyspnoeic with oxy-
gen saturations of 85%, rapidly progressing to cardiac
arrest, which occurred during the transfusion of
200 mL of cell-saved blood. Unfortunately, no other
physiological, anaesthetic or post-mortem details were
given, and other causes of postoperative hypoxia were
not considered. It is therefore impossible to say whether
this death was related to cell salvage. Further, it must be
remembered that the cell saver only replaces red cells,
and will not correct coagulopathy.
A randomised controlled trial with a power of 80% to
exclude a five-fold increase in amniotic fluid embolism
would require 265 000 patients, so is unlikely ever to be
performed.35 Fortunately there is evidence for reassur-
ance. The cell salvage process effectively removes
amniotic fluid from aspirated blood. After initial simple
filtration through a 150-l primary filter, the Haemonet-
ics Cell Saver 5 (Haemonetics Corporation, Braintree,
Massachusetts USA)37–39 removes small plasma-phase
molecules such as a fetoprotein and tissue factor by cen-
trifugal separation. The final leukocyte-depletion filter
step further removes particulate elements using a com-
plex “active, biological” filtration process involving a
40-l mesh (Leuco Guard RS, Pall Biomedical Products
Blood conservation techniques in obstetrics 247
Co., East Hills, NY). Using the Haemonetics Cell Saver
5 in combination with a the new generation Pall RS leu-
cocyte depletion filter, virtually all fetal squames and
phospholipid lamellar bodies are removed.40
Secondly, even if small quantities of amniotic fluid
escaped the filter they would not necessarily cause dam-
age, since amniotic fluid embolism is no longer regarded
an embolic disease. The presence of fetal squames in
maternal blood was regarded as a marker of amniotic
fluid embolism until pulmonary artery flotation cathe-
ters showed that many otherwise healthy parturients
apparently had abundant fetal squames in their circula-
tion.41 For a time the significance of this was debated
because fetal squames cannot be distinguished from
adult squames arising from catheter contamination at
insertion. However, lamellar bodies composed of phos-
pholipids from the developing fetal lung have been dem-
onstrated in all of 15 caesarean section patients at the
time of placental separation.40 Since they can have no
other possible source apart from amniotic fluid, all
recently delivered women must have amniotic fluid in
their blood, and the vast majority remain healthy. It
therefore follows that the retransfusion of cell-salvaged
blood, even if contaminated with traces of amniotic
fluid, would not present an increased risk to the patient
from whom that blood came, as she has already been
exposed to it.
The term amniotic fluid embolism is a historical mis-
nomer and the syndrome is today regarded as a type of
anaphylactic reaction,42–44 the precise trigger element of
which remains unknown. It nevertheless seems intui-
tively reasonable to remove amniotic fluid and placental
tissue as far as possible with conventional suction before
aspirating to the cell saver after delivery of the pla-
centa,38 in order to minimise the initial load presented
to the cell salvage and filter system.
Fetal red-cell contamination of cell saved blood re-
mains a real risk. The cell saver cannot distinguish fetal
from maternal red cells, so any aspirated fetal red
cells will be retransfused. This will increase the dose of
anti-D immunoglobulin required to prevent Rhesus
immunisation of Rhesus-negative mothers. In practice
2-19 mL of fetal blood may be retransfused38 requiring
500-2500 units of anti-D, so Kleihauer testing should be
performed as soon as practicable. In this context it is worth
remembering that all Rhesus-negative women having
caesarean sections will receive anti-D prophylaxis.
There is now extensive but largely unpublished expe-
rience of the use of cell salvage in obstetrics in the UK
(in preparation). For example, in Wales there is now a
structured programme for cell salvage under the direc-
tion of a national co-ordinator at the Welsh Blood Ser-
vice. An All-Wales cell-salvage database has been
established, which shows that between April and June
2006, 309 cell-salvage procedures were carried out in
248 International Journal of Obstetric Anesthesia
Wales, of which 28 (9%) were in obstetric cases. This is
the same rate as for cell salvage in vascular surgery in
Wales during this period. (Welsh Blood Service Cell
Salvage Co-ordinator: Ms Hannah Grainger, Personal
Communication). It is routinely used in many UK cen-
tres for emergency and elective cases where significant
obstetric haemorrhage is expected, or where it occurs
unexpectedly. Routine indications for its use include
major degrees of placenta praevia, placenta accreta
and massive fibroids, particularly among Jehovah’s
Witnesses. Theoretical fears of contamination of the
re-transfused blood with amniotic fluid leading to
coagulopathy or even iatrogenic amniotic fluid embolus
have not been borne out in practice.
Within the past year, IOCS in obstetrics in the UK has
been endorsed by CEMACH,1 NICE45 and the 2005 Re-
vised Guidelines for Anaesthetic Obstetric Services
issued by the OAA/AAGBI. In the US, the American
Society of Anesthesiologists 2006 Practice Guidelines
for Obstetric Anesthesia46 recommended: “In cases of
intractable hemorrhage when banked blood is not avail-
able or the patient refuses banked blood, intraoperative
cell salvage should be considered if available.”
Although there is a mechanism for clinicians to report
any complications to the MHRA (the UK Government
body with legal responsibility for blood safety), so far
there have been no reports of any adverse events.
Cell salvage in practice
Cell salvage machines are simple to set up; an experi-
enced operator can prepare one for use within five min-
utes. In the UK the machine is normally defined as a
piece of anaesthetic equipment and as such is set up
and run by the anaesthetic nurse or operating department
practitioner (ODP) and supervised by the anaesthetist.
Most hospitals have local protocols and training pro-
grammes for cell salvage, with national and local
e-learning guides now available. In elective cases, cell
salvage can be connected and ready from the start of
Table 1. Summary of blood conservation techniques in obstetrics
PAD
Proven effective no
Transfusion risk eliminated no
Theoretical risks anaemia
Actual problems none recorded
Value in emergency no
Acceptable to Jehovah’s Witnesses no
Recommended by NBS no
Recommended in NICE guidelines no
PAD: pre-operative autologous donation; ANH: acute normovolaemic haemodilution; IOCS: intra-operative cell salvage; NBS: National Blood
Service.
the procedure, and in emergencies it can be rapidly set
up once major haemorrhage is identified. It is important
to realise that once set up, the machine operates auto-
matically and requires minimal intervention either from
ODP or anaesthetist, so, unlike a bypass machine for
example, it does not require an extra dedicated team
member. Some UK centres are incorporating compe-
tency in cell salvage into the training programmes for
junior anaesthetic trainees. Whereas not all UK obstetric
units have a dedicated cell saver, an increasing number
have immediate access to one from other theatres. It can
be set up electively for predictable major haemorrhage
(placenta accreta, major fibroids, etc.), and rapidly
brought on-line for unexpected haemorrhage. The anti-
coagulation/aspiration tubing can be very rapidly set
up and connected to the collecting reservoir without
opening any of the other kit, if “predictable” bleeding
does not occur. This partial set-up reduces the cost of
disposables from about £100 for the full kit, to about
£35 for the aspiration + reservoir kit only. In emergency
unexpected haemorrhage, this partial set-up will enable
blood loss to be salvaged within minutes, and the rest
of the kit can be opened and connected as time allows.
Once the blood is aspirated into the reservoir, it is anti-
coagulated and there is no urgency to process it. In tor-
rential bleeding, the centrifuge should be connected as
soon as possible, and the machine will automatically
process as much blood as is aspirated and have it ready
for re-transfusion within a few minutes.
CONCLUSION
The characteristics of the three blood conservation tech-
niques are summarised in Table 1. Of the three, intra-
operative cell salvage is the most practicable, effective
and useful. It is now regarded as a safe and acceptable
technique in obstetric haemorrhage in the UK and is
slowly gaining acceptance in the US. Pre-operative
autologous donation and acute normovolaemic haemo-
ANH IOCS
no yes
yes yes
anaemia amniotic fluid embolus
cardiac failure Rhesus immunisation
placental insufficiency
none recorded none recorded
no yes
yes yes
no yes
no yes

dilution now have extremely limited roles in UK prac-
tice, and should be reserved for exceptional circum-
stances after full discussion with the haematologists.
Intra-operative cell salvage, on the other hand, should
be encouraged and developed as a simple, effective
method of blood conservation.
REFERENCES
1. Confidential Enquiry into Maternal and Child Health. Why
Mothers Die 2000-2002. London: RCOG Press; 2004.
2. Wells A W, Mounter P J, Chapman C E, Stainsby D, Wallis J P.
Where does blood go? Prospective observational study of red cell
transfusion in north England. BMJ 2002; 325: 803–4.
3. SHOT (Serious Hazards of Transfusion). www.shot-uk.org.
4. Pedan A H, Head M W, Ritchie D L, Bell J E, Ironside J W.
Preclinical vCJD after blood transfusion in a PRNP codon 129
heterozygous patient. Lancet 2004; 364: 527–9.
5. Davey R J. Recruiting blood donors: challenges and opportunities.
Transfusion 2004; 44: 597–601.
6. Better Blood Transfusion 2: Health Service Circular; DoH 2002.
7. Waterstone M, Bewely S. Incidence and predictors of severe
obstetric morbidity: a case control study. BMJ 2001; 322:
1089–93.
8. Ekeroma A J, Ansari A, Stirrat G M. Blood transfusion in
obstetrics and gynaecology. Br J Obstet Gynaecol 1997; 104:
278–84.
9. Hill S R, Carless P A, Henry D A, et al. Transfusion thresholds and
other strategies for guiding allogeneic red blood cell transfusion.
Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.:
CD002042. DOI: 10.1002/14651858.CD002042. In: The Cochrane
Library, Oxford: Update Software; 2002: Issue 2.
10. Herbert P C, Wells G F, Blajchman M A, et al. A multicenter,
randomized controlled clinical trial of transfusion requirements in
critical care. Transfusion requirements in Critical Care
Investigators, Canadian Critical Care Trials Group. N Engl J Med
1999; 340: 409–17.
11. Wu W C, Rathore S S, Wang Y, Radford M J, Krumholz H M.
Blood transfusion in elderly patients with acute myocardial
infarction. N Engl J Med 2001; 345: 1253–6.
12. McClelland B. Who needs a transfusion? In: Thomas D,
Thompson J, Ridler B, eds. A Manual for Blood
Conservation. Shrewsbury: tfm Publishing, 2005: 35–44.
13. Blood Matters. Issue 16: 2004. UK National Blood Service.
14. Scottish Intercollegiate Guidelines Network 54: Perioperative
blood transfusion for elective surgery: A National Clinical
Guideline 2001. www.sign.ac.uk.
15. de Andrande J R, Jove M, Landon G, Frei D, Guilfoyle M,
Young D C. Baseline hemoglobin as a predictor of the risk of
transfusion and response to Epoetin alpha in orthopedic surgery
patients. Am J Orthop 1996; 25: 533–42.
16. Faught C, Wells P, Fergusson D, Laupacis A. Adverse effects of
methods for minimizing perioperative allogeneic transfusion: a
critical review of the literature. Transfus Med Rev 1998; 12:
206–25.
17. A National Blood Conservation Strategy for NBTC and NBS.
Report from the Working Party on Autologous Transfusion and the
Working Party on Alternatives to Transfusion to the NBS sub-
group on the appropriate use of blood. Dr Virgie James, Jan 2004.
18. McVay P A, Hoag R W, Hoag M S, Toy P T. Safety and use of
autologous blood donation during the third trimester of pregnancy.
Am J Obstet Gynecol 1989; 160: 1479–86.
19. Herbert W N, Owen H G, Collins M L. Autologous blood storage
in obstetrics. Obstet Gynecol 1988; 72: 166–70.
20. Malynn E R, Kruskall M S, Neeson S L, Leonard S S. Analysis of
autologous donations in pregnant women with placenta previa.
Transfusion 1988; 28(Suppl 6): 34s.
21. Gross J B. Estimating allowable blood loss: correction for dilution.
Anesthesiology 1983; 58: 277–80.
Blood conservation techniques in obstetrics 249
22. Napier J A, Bruce M, Chapman J, et al. Guidelines for autologous
transfusion.II. Perioperative haemodilution and cell salvage. Br J
Anaesth 1997; 78: 768–71.
23. Grange C S, Douglas M J, Adams T J, Wadsworth L D. The
use of acute hemodilution in parturients undergoing cesarean
section. Am J Obstet Gynecol 1998; 178: 156–60.
24. Goodnough L T, Monk T G, Brecher M E. Acute normovolemic
hemodilution should replace the preoperative donation of
autologous blood as a method of autologous-blood procurement.
Transfusion 1998; 38: 473–6.
25. Segal J B, Blasco-Colmenares E, Norris E J, Guallar E.
Preoperative acute normovolemic hemodilution: a meta-analysis.
Transfusion 2004; 44: 632–44.
26. Tawes Jr R L. Clinical applications of autotransfusion. Semin Vas
Surg 1994; 7: 89–90.
27. Catling S J, Freites O, Krishnan S, Gibbs R. Clinical experience
with cell salvage in obstetrics: 4 cases from one UK centre. Int J
Obstet Anesth 2002; 11: 128–34.
28. Catling S, Joels L. Cell Salvage in obstetrics – the time has come.
Br J Obstet Gynaecol 2005; 112: 131–2.
29. Fong J, Gurewitsch E D, Kumip L, Klein R. Clearance of fetal
products and subsequent immunoreactivity of blood salvaged at
cesarean delivery. Obstet Gynecol 1999; 93: 968–72.
30. Potter P S, Waters J H, Burger G A, Mraovi B. Application of cell
salvage during cesarean section. Anesthesiology 1999; 90: 619–21.
31. Rebarber A, Lonser R, Jackson S, Copel J A, Sipes S. The safety of
intraoperative autologous blood collection and autotransfusion
during cesarean section. Am J Obstet Gynecol 1998; 179: 715–20.
32. Rainaldi M P, Tazzari P L, Scagliarini G, Borghi B, Conte R.
Blood salvage during caesarean section. Br J Anaesth 1998; 80:
196–8.
33. Jackson S H, Lonser R E. Safety and effectiveness of intracesarean
blood salvage. Transfusion 1993; 33: 181.
34. Weiskopf R B. Erythrocyte salvage during cesarean section
(Editorial). Anesthesiology 2000; 92: 1519–22.
35. Camann W. Cell salvage during cesarean delivery: is it safe and
valuable? Maybe, maybe not! (Editorial). Int J Obstet Anesth
1999; 8: 75–6.
36. Oei S G, Wingen C B M, Kerkkamp H E M. Cell Salvage: how
safe in obstetrics? Int J Obstet Anesth 2000; 9: 143.
37. Thornhill M L, O’Leary A J, Lusson S A, Rutherford C, Johnson
M D. An in vitro assessment of amniotic fluid removal from
human blood through cell saver processing. Anesthesiology 1991;
75: A830.
38. Catling S J, Williams S, Fielding A M. Cell salvage in obstetrics: an
evaluation of the ability of cell salvage combined with leucocyte
depletion filtration to remove amniotic fluid from operative blood
loss at caesarean section. Int J Obstet Anesth 1999; 8: 79–84.
39. Bernstein H H, Rosenblatt M A, Gettes M, Lockwood C. The
ability of the Haemonetics 4 cell saver system to remove tissue
factor from blood contaminated with amniotic fluid. Anesth Analg
1997; 85: 831–3.
40. Waters J H, Biscotti C, Potter P S, Phillipson E. Amniotic fluid
removal during cell salvage in the cesarean section patient.
Anesthesiology 2000; 92: 1531–6.
41. Clarke S L, Pavlova A, Greenspoon J, Horenstein J, Phelan J P.
Squamous cells in the maternal pulmonary circulation. Am J
Obstet Gynecol 1986; 154: 104–6.
42. Clarke S L, Hankins D V, Dudley D A, Dildy G A, Porter T F.
Amniotic fluid embolism; analysis of the National Registry. Am J
Obstet Gynecol 1995; 172: 1158–69.
43. Fineschi V, Gambassi R, Gherardi M, Turillazzi E. The diagnosis
of amniotic fluid embolism: an immunohistochemical study for the
quantification of pulmonary mast cell tryptase. Int J Legal Med
1998; 111: 238–43.
44. Farrar S C, Gherman R B. Serum tryptase analysis in a woman
with amniotic fluid embolism: A case report. J Reprod Med 2001;
46: 926–8.
45. UK National Institute for Health and Clinical Excellence NHS:
Intraoperative blood cell salvage in obstetrics. Nov 2005.
46. American Society of Anesthesiologists. Practice Guidelines for
Obstetric Anesthesia. http://www.asahq.org/publicationsAnd-
Services/OBguide.pdf.