The practical utility of routine postpartum hemoglobin assessment

Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study)

Changes between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study's principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

The definition, screening, and treatment of postpartum anemia: A systematic review of guidelines

BACKGROUND

Postpartum anemia can negatively affect maternal health and interfere with early parenting. Thus, it is important to have clear, evidence-informed recommendations on its diagnosis and treatment.

OBJECTIVE

To compare global recommendations regarding the appropriate management of postpartum anemia and to highlight similarities and differences.

METHODS

Systematic searches were conducted in the databases PubMed, CINAHL, LILACS, TRIP database, and Scopus, and in the websites of health institutions and scientific societies. Search terms were related to anemia and the postpartum period. Two hundred and eighty papers were identified; the full texts of 30 sets of guidelines were reviewed, with seven being included in the final analysis. Recommendations were extracted through an evaluation of the evidence on the definition, screening, and diagnosis of anemia. The quality of the guidelines was assessed using the AGREE II instrument.

RESULTS

Two sets of guidelines have been elaborated by international organizations, and the rest were produced by professional associations within high-resource countries. The discrepancies found in the guidelines are important and affect the definition of anemia, the criteria for screening asymptomatic women, or the criteria guiding treatment. The quality of the guidelines commonly scored between 4 and 6 on a scale of 0 to 7. Recommendations with poor-quality evidence predominated over recommendations with high-quality evidence.

CONCLUSIONS

This review highlights the need to reach a consensus on the definition of postpartum anemia, to agree on what constitutes a problem for maternal health, and to provide recommendations that reach greater consensus on its diagnosis and treatment.

Is Routine Hemoglobin Monitoring Necessary after Elective Hip and Knee Arthroplasty?

Background

Many orthopaedic units measure hemoglobin (Hb) levels after primary joint arthroplasty to identify patients with postoperative anemia. With the refinement of surgical techniques, blood loss in primary arthroplasty has decreased. The aim of this study was to investigate the postoperative Hb monitoring and transfusion practices in our own institution after elective hip or knee arthroplasty.

Methods

We conducted a retrospective audit of all patients who underwent elective total hip or knee arthroplasty in Galway University Hospital between March 1 and June 1, 2019. We recorded when they underwent postoperative Hb testing, whether or not they had a drop of Hb, which would indicate transfusion (<8 g/dL), and whether or not they were transfused. In patients who underwent transfusion, a chart review was performed to establish the presence of factors that would have triggered repeat Hb testing.

Results

One hundred thirty-six patients underwent elective primary hip or knee arthroplasty in the period. All had a full blood count sent on the first postoperative day. None (0%) had a clinically significant (to < 8g/dL) postoperative Hb drop on day 1. Eighteen (13.2%) patients underwent repeat testing on day 2 or subsequently. Eight (5.9%) exhibited a drop in Hb to less than 8 g/dL, with a mean Hb drop of 4.26 (standard error of the mean ± 0.862, standard deviation ± 0.98), and 5 (3.7%) proceeded to undergo allogenic blood product transfusion. All 5 underwent documented indications for repeat Hb testing.

Conclusions

There is no evidence for performing routine Hb testing on day 1 after elective hip or knee arthroplasty. We recommend that postoperative Hb testing should only be carried out on patients with additional indications.

Anemia and Cost-Effectiveness of Complete Blood Count Testing Among Pregnant Women at King Abdulaziz University Hospital: A Single Tertiary Center Experience

Background Iron deficiency is the most common etiology of anemia among pregnant women. Many studies showed that anemia during pregnancy had been associated with adverse outcomes such as intrauterine growth retardation, preterm delivery, and maternal mortality. However, screening for those pregnant remains controversial.  Objectives To find the prevalence of anemia among pregnant women and pregnancy outcomes. Also, to find the cost-effectiveness of running complete blood count (CBC) tests among them. Methods This is a retrospective record review done on pregnant women who delivered at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between January 1, 2018, and December 31, 2018. They were screened for eligibility, with the exclusion of those with hemoglobinopathies such as sickle cell anemia and thalassemia. Data were collected from their electronic medical records. Results A total of 5,120 pregnant women had delivered from January 1, 2017, to August 31, 2018, and 2,845 (55.6%) developed anemia during pregnancy. Out of 2,822, 2,301 were mild, 471 moderate, 50 severe, and 2,185 were normal. A total of 3,656 (71.4%) women were Saudis, and 1,464 (28.6%) were non-Saudis. The mean age was 29.85±6 years, and their first hemoglobin reading mean was 10.6±1.3g/dl. Out of 2,822, 546 developed undesired pregnancy outcomes. History of anemia, blood transfusion, intrauterine fetal demise, and stillbirth was significantly associated with abnormal hemoglobin levels (p<0.05). Complete blood count (CBC) testing for these pregnant women cost 422,990.92 US dollars. Conclusion Although the cut-off point of diagnosing anemia level during pregnancy isn't fully understood, pregnant women with mild to moderate levels appeared to have lesser adverse pregnancy outcomes in comparison to women with severe level. Therefore, screening during prenatal visits or antenatal for anemia should be tailored to each pregnant based on her condition and the overall clinical judgment.

Undiagnosed abnormal postpartum blood loss: Incidence and risk factors

BACKGROUND

We aimed to evaluate the incidence of undiagnosed abnormal postpartum blood loss (UPPBL) after vaginal delivery, identify the risk factors and compare them to those of postpartum haemorrhage (PPH).

METHOD

The study population included women who participated in a randomized controlled trial of women with singleton low-risk pregnancy who delivered vaginally after 35 weeks' gestation (n = 3917). Clinical PPH was defined as postpartum blood loss ≥ 500 mL measured by using a collector bag and UPPBL was defined by a peripartum change in haemoglobin ≥ 2 g/dL in the absence of clinical PPH. Risk factors were assessed by multivariate multinomial logistic regression.

RESULTS

The incidence of UPPBL and PPH was 11.2% and 11.0% of vaginal deliveries, respectively. The median peripartum change in Hb level was comparable between UPPBL and PPH groups (2.5 g/dL interquartile range [2.2-3.0] and 2.4 g/dL IQR [1.5-3.3]). Risk factors specifically associated with UPPBL were Asian geographical origin (adjusted OR [aOR] 2.3, 95% confidence interval [CI] 1.2-4.2; p = 0.009), previous caesarean section (aOR 3.4, 2.1-5.5; p<0.001) and episiotomy (aOR 2.6, 1.8-3.6; p<0.001). Risk factors for both UPPBL and PPH were primiparity, long duration of labour, instrumental delivery and retained placenta.

CONCLUSION

Undiagnosed abnormal postpartum blood loss is frequent among women giving birth vaginally and has specific risk factors. The clinical importance of this entity needs further confirmation, and the benefit of systematic or targeted prevention strategies needs to be assessed.

Maternal anaemia after delivery: prevalence and risk factors

The purpose of this study was to assess the prevalence of postpartum anaemia and determine the clinical risk factors for this condition to provide a viable alternative to postpartum haemoglobin measurement. In total, 1415 patients at Hospital Universitario del Tajo, Madrid, who underwent postpartum haemoglobin testing were included, and risk factors for having an Hb level <10 g/dl were determined. We found that 29% of the mothers were anaemic, and birth canal lacerations, caesarean delivery, episiotomy and South American origin were identified as the main risk factors for this condition. When we examined the performance of each risk factor alone in the prediction of postpartum anaemia, none of them achieved a sensitivity of 30%. Selective screening of women who had any of these five risk factors resulted in 23% of cases remaining unidentified. Despite the high incidence and disease burden of this condition, the management of puerperal anaemia is not standardised, and this condition is not easy to predict. Universal screening should be considered in high-prevalence settings. Impact statement The World Health Organisation (WHO) describes the postnatal period as the most critical and yet most neglected phase in the lives of mothers and infants. It is a common knowledge that a woman's adjustment to life with her new infant is very difficult. This period, known as the puerperium, often involves poor sleep quality, pain and fatigue, if not other major complications. In this context, we must face the challenge of increasing breastfeeding rates, which is why health care providers should be aware of the medical and psychological needs of the new mother. This work reports that postpartum anaemia, a potentially preventable or treatable condition that can make it more difficult to resume everyday activities, is highly prevalent. It remains to be seen whether ensuring the appropriate diagnosis and treatment of anaemia after delivery will result in improvements in the physical and psychological well-being of obstetric patients.