What you can do to optimize blood conservation in ObGyn practice

Transfusion is the last resort

Blood transfusion must also be considered as prophylaxis for blood loss in patients who have critically low hemoglobin levels, with due consideration of the procedure’s risks and benefits. Because the definition of “critically low” varies from patient to patient, other variables should be taken into consideration, including blood pressure; heart rate; urine output; tolerance for performing activities of daily living without dizziness, chest discomfort, or shortness of breath; and medical history. Potential drawbacks are considerable.

The multiple risks associated with transfusion include:

• immunosuppression
• fever
• chills
• urticaria
• hemolytic transfusion reaction
• septic transfusion reaction
• bacterial contamination
• anaphylaxis
• graft-versus-host reactions
• transfer of viral diseases, including hepatitis B and C and human immunodeficiency virus (HIV).

The risk of immunosuppression, in particular, should be weighed heavily for pregnant patients and those who are planning an elective surgical procedure. The possibility of viral transmission is also a deterrent. According to the Red Cross, the transmission rate is one in every 205,000 transfusions for hepatitis B, one in 2 million for hepatitis C, and one in 2,135,000 for HIV. These considerations, as well as the blood shortages that sometimes occur in practice, are sufficient reason to seek safer alternatives, when possible.

When a patient refuses transfusion

Caring for a patient who has an elevated risk of major blood loss can be particularly difficult when she is a member of a religious group such as Jehovah’s Witnesses. These patients generally decline the transfusion of plasma, packed red blood cells, white blood cells, platelets, and whole blood products.

In the Geisinger Health System, consultation with the Blood Conservation Program has been particularly helpful in these circumstances, offering clinicians alternative ways to correct anemia and prepare for the possibility of major blood loss. Patients who will not allow blood transfusion are often willing to accept plasma volume expanders that are not derived from blood, such as perfluorocarbon solutions, hydroxyethyl starch, crystalloid, or dextran.¹³ ESA therapy may be acceptable to some patients who refuse transfusion. Most are willing to go along with oral or IV iron supplementation to reduce their need for transfusion.

Postpartum patients may need special consideration

Iron supplementation is safe for breastfeeding mothers

Anemia in a breastfeeding woman is not uncommon and should be identified and treated. Iron supplementation with oral or IV compounds is considered safe for pregnant and breastfeeding women.

ESA therapy is a riskier strategy, whose benefits must clearly outweigh risks for all patients.

Anemia and postpartum depression

Studies have demonstrated a correlation between anemia and postpartum depression. Beard and colleagues showed a 25% improvement in cognition and improved scores on stress and depression scales in postpartum women who had iron-deficiency anemia when they were treated with daily iron and vitamin C.¹⁴ Other studies have addressed an increased risk of anemia in low-income postpartum women and the deleterious impact of iron-deficiency anemia on the quality of mother–child interactions and subsequent child development. Correcting maternal iron deficiency could prevent adverse outcomes in these mothers and their offspring.^15,16