Clinical Review

What you can do to optimize blood conservation in ObGyn practice

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This institution’s protocol is worth considering for identifying and correcting iron-deficiency anemia before delivery and elective gyn surgery. The goals? To avert complications and avoid transfusion.


 

References

The authors report no financial relationships relevant to this article.

Obstetric hemorrhage is responsible for approximately 17% to 25% of all pregnancy-related deaths.1 Excessive blood loss also is a risk during gynecologic surgery. Iron-deficiency anemia increases the risk of complication and the need for transfusion in both settings. By identifying and treating anemia before childbirth and elective surgery, you can optimize the patient’s condition and usually avert the need for emergency transfusion.

The Geisinger Health System has developed a unique Blood Conservation Program that focuses on the prevention of major blood loss by identifying and treating anemia in antepartum, postpartum, and gynecologic patients. The program’s protocols for treating anemia in antepartum and surgical patients are illustrated in FIGURES 1 AND 2. Geisinger practitioners have found that adherence to these protocols reduces the need for transfusion in many patients and improves their quality of life.

Here, we 1) look at the key data that will help you identify and then treat anemia in gynecologic, obstetric, and postpartum patients and 2) describe a variety of treatment options.


FIGURE 1 The gynecologic surgical patient: Preop diagnosis and treatment of anemia

* If anemia is refractory to iron therapy, consider erythropoietin therapy if benefits outweigh risks.


FIGURE 2 For the antepartum patient: Diagnosis and treatment of anemia

* If anemia is refractory to iron therapy, consider erythropoietin therapy if benefits outweigh risks.

Focus on the baseline hemoglobin level

The key to prevention of emergency transfusion—as well as postpartum anemia—is optimization of the patient’s hemoglobin level before delivery. It also is prudent when elective surgery is planned. In our institution, clinicians whose patients are at risk for hemorrhage or significant blood loss have the option of consulting with the Blood Conservation Program.

When the program began in November 2004, its primary purpose was to reduce the need for blood transfusion in elective surgery, including gynecologic procedures. It later expanded to include obstetric patients who have a hemoglobin level below 11 g/dL and patients who are considered to be at risk of major blood loss.

In addition to obstetric and surgical patients, the Geisinger Blood Conservation Program provides support for patients who will not accept blood or blood products for religious or personal reasons, even in life-threatening situations. The program has provided more than 8,000 consultations to date.

When to evaluate patients for anemia

Anemia in women is most often defined as a hemoglobin level below 12 g/dL or a hematocrit below 36%. In pregnant patients, the cutoff points are lower: 11 g/dL and 33%, respectively. During pregnancy, hemoglobin and hematocrit levels reach their nadir during the second trimester and then begin to rise until term.

Symptoms of anemia include fatigue, depression, shortness of breath, hypotension, and heart palpitations. However, some patients at risk of major blood loss during delivery or surgery do not display typical symptoms associated with anemia, and the condition can be confirmed only by laboratory testing.

At Geisinger, we recommend consultation with the Blood Conservation Program for any patient who exhibits symptoms of anemia or who is at risk of major blood loss. For example, the risk of blood loss during childbirth varies with the method of delivery.1 On average, obstetric patients lose 500 mL of blood during vaginal delivery; 1,000 mL during cesarean delivery; and 1,500 mL when cesarean delivery is followed by hysterectomy.1,2 Hemorrhage is classified as follows:

  • Class 1 – Blood loss as high as 750 mL, or 15% of blood volume
  • Class 2 – 750 to 1,500 mL, or 15% to 30% of blood volume
  • Class 3 – 1,500 to 2,400 mL, or 30% to 40% of blood volume
  • Class 4 – more than 2,400 mL, or more than 40% of blood volume.1

Abnormal placentation, such as placenta accreta, percreta, increta, and previa, which can often be diagnosed antepartum, may lead to significant blood loss during and after delivery. Obstetric emergencies, including abruption, trauma, and uterine rupture, may also be associated with major blood loss.

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