Obstetrics and Maternity Patient Blood Management

How do you manage your obstetric and maternity patients with anaemia? Here are some scenarios to consider.

Nancy Chan, age 32 is 4 months pregnant. She had a history of iron deficiency anaemia in her last pregnancy. Her Hb is 123 g/L and her ferritin is <5 µg/L.

What treatment, if any would you recommend?

Sally Johnson, age 29, is in her third trimester of pregnancy. She has iron deficiency anaemia. She was not able to tolerate the oral iron you prescribed, despite decreasing the dose and frequency, so stopped taking it. Her Hb has dropped further and she is scheduled for a LUSC in two weeks due to placenta praevia.

Do you prescribe more steak dinners?

Tell her to persist with oral iron?

Give her a shot of intramuscular iron?

Or schedule some intravenous iron ASAP?

Kaylee Jones, age 31, is 7 months pregnant with her third child. She is feeling short of breath walking down the street. Her haemoglobin is 61 g/L. She is pale and tachycardic.

Do you transfuse her? How many units?

Find out the answers and learn more in our latest Transfusion Q&A topic Obstetrics and Maternity Patient Blood Management Guidelines part 1: Anaemia

All cases are based on the National Blood Authority Patient Blood Management Guidelines and the explanations provide links to the guidelines and other resources.

Dr Sandy Minck, the author of this post, is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Obstetrics and Maternity Patient Blood Management Guidelines released

The fifth in a series of six evidence-based patient blood management (PBM) guidelines, the Obstetrics and Maternity module was approved by the National Health and Medical Research Council (NHMRC) in December 2014, and released on 23 March 2015.

The module contains a series of recommendations based on evidence from the systematic review; practice points developed through consensus decision making by the Clinical/Consumer Reference Group (CRG) where there was insufficient high quality data; and thirdly, unique so far to the fifth module, expert opinion points to guide practice in areas outside the scope of the systematic review.

Evidence from the systematic review led to four recommendations. Firstly, routine administration of iron supplementation to all pregnant women is not recommended. The administration of iron to pregnant women with iron deficiency is recommended, but not the routine addition of folic acid. Finally, ESAs should not be routinely used in maternity patients. Further guidance regarding anaemia and iron therapy is provided in the form of practice points.

The module also covers blood group and screen during pregnancy; planning for when transfusion is not an option; transfusion in women who are not actively bleeding, and when there is critical bleeding including the use of massive transfusion protocol. The use of modified blood components (CMV negative and phenotyped); transfusion support for maternity care/services; guidance for coagulopathic patients at risk of bleeding; and the use of recombinant activated factor VIIa, cell salvage, interventional radiology also feature.

To learn more about obstetric and maternal patient blood management and the PBM guidelines, why not register to attend Transfusion Update: Obstetric and Maternal Patient Blood Management either in person or by webinar. This session will cover PBM in maternity care including iron deficiency anaemia, indications for blood product support during pregnancy, the needs of the growing fetus and critical bleeding.

Wednesday 13 May, 1.30pm – 3.00pm (Sydney time), at The Royal Women’s Hospital, 20 Flemington Rd, Parkville, or by webinar.
Presented by Dr Helen Savoia, Head of Haematology, The Royal Children’s Hospital, Dr Wendy Pollock, Critical Care Nurse and Midwife, Mercy Hospital for Women, and Dr Shelley Rowlands, Obstetrician and Fetal Maternal Specialist, Royal Women’s Hospital. The session is Chaired by Mr Leigh McJames, General Manager, National Blood Authority.

Dr Sandy Minck, the author of this post, is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Demand for red cells is falling. What’s going on?

Demand for red cells is declining in Australia and internationally. In Australia, demand for red cell units dropped by 4.8 percent from 2011/12 to 2012/13, 7.9% in 2013/14, and is expected to decline by a further 3% in 2014/15. In the UK demand started to decline sharply in October 2012, with a reduction of 2.7% in 2012/13, a further 4.8% in 2013/14, and the trend forecast to continue over the medium term. Sanquin Blood Services in the Netherlands saw a greater than 20% reduction in demand from 2009 to 2013. In New Zealand the clinical use of red cell components has reduced significantly over the last decade with transfusion rates falling by almost 25% from 29.6 red cells per 1000 population in 2006 to a projected 22.3 per 1000 by the end of 2014. The US estimates 8.2% fewer transfusions in 2011 compared to 2008, with transfusion rates falling from 48.4 units per 1000 to 44.0/1000.

All organisations report that the decline in red cell demand is likely due to the growing adoption of programs to reduce wastage and improve appropriate use. In Australia, the National Blood Authority (NBA) has implemented the National Blood and Blood Product Wastage Reduction Strategy 2013-17 to facilitate improved inventory management and logistics. The NBA and other blood sector stakeholders have also been focussed on practice improvement, including improving appropriate use through the publication and implementation of Patient Blood Management Guidelines. The Australian Red Cross Blood Service has developed a transfusion education curriculum and numerous resources to promote patient blood management principles including appropriate and safe transfusion practices.

New Zealand specifically attribute the initial decrease in demand as being driven by blood conservation programs such as “Why use two when one will do?” emanating from Canterbury District Health Board and increasingly rolled out across the country. Australia is encouraging a similar theme with the single unit transfusion guide. Increasing awareness of the importance of maximising patient’s haemoglobins prior to surgery has also contributed to the fall in clinical use. Pre-operative assessment identifies many patients who are iron deficient, treatment of which improves haemoglobin levels prior to surgery with a consequent reduction in the need for transfusion. Additionally, improved surgical techniques and other patient blood management (PBM) strategies – such as cell salvage – have contributed.

What does the decline in red cell demand mean? The upside is the benefit to patients and healthcare facilities – reduced transfusion rates results in decreased adverse outcomes, such as decreased morbidity, mortality and length of stay; and decreased cost.

The downside is the impact on the blood services – the costs of the blood supply chain are relatively fixed in nature and it is challenging to reduce costs at the same rate as volume reduction. As capacity is reduced in line with longer term trends in demand, blood services remain dependent on their donors to be able to respond to short term demand pressures. In addition, there is the need to increase the proportion of rare blood group donors, especially of O negative. In managing this environment we can sometimes be seen as presenting conflicting messages to our donors.

If you would like to find out more about how the Blood Service aligns supply and demand, You can head along to the Melbourne Processing Centre, 100 – 154 Batman Street, West Melbourne on Wednesday 8 April at 1.30pm. You can also join this session by webinar, or catch up with a recorded version after the event. Register at Transfusion Online Learning on transfusion.com.au.

Some other useful resources:

Understanding red cell decline: a global challenge for blood services.
National Blood Authority Australia Annual report 2013-14.
The 2011 National Blood Collection and Utilization Survey Report. Department of Health and Human Services, USA.
NHS Blood and Transplant Annual Report and Accounts 2013/14.
New Zealand Blood Service Annual Report 2013/2014.
Sanquin Blood Supply Annual Report 2013.

Dr Sandy Minck is a Medical Officer at the Australian Red Cross Blood Service and a member of the Transfusion Practice and Education team.

Quick transfusion quiz for busy health professionals

Transfusion Q&A is a database of questions, grouped by topic, designed to test your knowledge of safe transfusion practices and patient blood management. We made it specifically for the time poor (that would be all of us, then).

You can access Transfusion Q&A at qanda.transfusion.com.au. Alternatively you can access individual topics on Transfusion Online Learning on transfusion.com.au.

You choose how you complete a topic: all in one hit as a “quick quiz”; or enrol to get sent questions over time. You choose the device on which you access the education – PC, laptop, mobile phone, or tablet.

If you enrol, the system sends notifications when questions are due to be answered. During enrolment you choose to receive these via email or SMS. You can also choose to customise delivery notifications, indicating how many questions you want to receive with each notification and how often you get the notifications.

But don’t worry if you can’t be bothered with the customisation – we have pre-set a delivery schedule for you.

Every time you answer a question you get feedback on your response and an explanation with links to the relevant information about the topic.

If you want to receive a certificate for CPD purposes, enrol in a topic. You’ll need to get each question correct twice to be awarded a certificate – there are no rewards for random guessing in this game.

If you think you already know your stuff, but just want to confirm this, do a quick quiz. You’ll still get instant feedback on the answers to your questions and a score at the end, but no certificate.

Once you log into Transfusion Q&A, your dashboard will list the topics you are currently enrolled in and those you have completed, with links to your certificate.

 

– Dr Sandy Minck