The Appropriateness of Red Blood Cell Transfusions in the Peripartum Patient

The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle

BACKGROUND

With blood products being a limited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use.

AIMS

To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign.

METHODS

An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken.

RESULTS

The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001).

CONCLUSIONS

The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.

Changing red blood cell transfusion practice in obstetrics and gynaecology: A before and after study of hospital-wide education

OBJECTIVES

To assess transfusion practices at a Canadian tertiary care center before and after a hospital-wide blood management educational campaign based on the Choosing Wisely toolkit.

BACKGROUND

Red blood cell (RBC) transfusions are an essential intervention in obstetrics and gynaec ology (O&G). However, with limited guidelines outlining the appropriate use of RBC transfusions, clinicians routinely transfuse based on haemoglobin values and habits.

METHODS/MATERIALS

We conducted a retrospective chart review of all patients who received a RBC transfusion while admitted under an O&G provider in two 12-month periods-before and after the intervention. The campaign consisted of Grand Rounds, formal and informal teaching, and posters placed within the hospital. We judged appropriateness from a set of criteria guided by the status of ongoing bleeding, pre-transfusion haemoglobin, and the number of units ordered simultaneously.

RESULTS

Transfusion appropriateness was poor in pre- and post-intervention periods (46% vs. 51%, p = 0.59). The overall rate of RBC transfusion was reduced from 1.8% to 1.2% (83/4610 vs. 55/4618, p = 0.02) after the intervention. There was a 52% reduction in the total number of RBC units of transfused (229 vs. 111, p < 0.001), a 33% reduction in the number of patients transfused (83 vs. 55, p = 0.016), and fewer multiple-unit transfusions without reassessment (39 vs. 13, p = 0.005).

CONCLUSION

RBC transfusion appropriateness remained low after a hospital-wide educational campaign. However, there was a marked decrease in overall transfusion use, reflecting the adoption of more restrictive transfusion practices. The low rate of transfusion appropriateness represents an opportunity for further improvement.

Improving patient blood management in obstetrics: snapshots of a practice improvement partnership

Iron deficiency and anaemia are common in pregnancy. Audit data from our tertiary obstetrics unit demonstrated 22% of maternity patients experiencing a postpartum haemorrhage received a transfusion; a third of whom were anaemic on admission intrapartum. Australian Patient Blood Management (PBM) Module 5 Obstetrics guidelines focuses on maximising red cell mass at the time of delivery and reducing the reliance on transfusion as a salvage therapy to treat blood loss. A clinical practice improvement partnership began in February 2015 and completed in April 2016; which aimed to implement systems to improve antenatal identification and management of iron deficiency, and improve postpartum anaemia management. In order to develop change strategies, reasons for poor detection and correction of iron deficiency in the antenatal period were identified following a quality improvement methodology. Education was delivered to maternity healthcare providers. Standardised algorithms and an oral iron prescription handout were developed and piloted. Follow-up audit, staff and patient feedback, and other hospital data were collected to measure outcomes. The rate of anaemia on admission intrapartum fell from 12.2% in 2013 to 3.6% in 2016 following the introduction of unselective ferritin screening and other antenatal interventions. Sixty to 70% of maternity patients screened each month had iron deficiency. The algorithms aided staff to become confident in blood test interpretation and management of iron deficiency and anaemia. Patients found the oral iron prescription handout helpful. Additionally, single unit transfusions significantly increased from 35.4% to 50% (p=0.037) over the project timeframe. This project demonstrated the potential to improve patient blood management in obstetrics, reduce anaemia and transfusions by active antenatal interventions.

Risks and trends of red blood cell transfusion in obstetric patients: a retrospective study of 45,213 deliveries using administrative data

BACKGROUND

Transfusion data for obstetric patients are scarce. Identifying characteristics associated with red blood cell transfusion (RBCT) is of importance to better identify patients who would benefit from blood conservation strategies as the risk of alloimmunization from RBCT has the potential to affect the fetus and newborn.

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study using hospital administrative data to identify trends and risk factors of RBCT in obstetric patients. Data were analyzed according to the mode of delivery.

RESULTS

A total of 45,213 deliveries were captured between January 1, 2007, and December 31, 2013. A higher proportion of patients undergoing cesarean sections (C/Ss) received an RBCT (2.3%) compared to other modes of delivery (0.7% for spontaneous vaginal delivery, 1.5% for instrumental delivery; p < 0.001). In addition, the risk of RBCT increased over the 7-year period for those patients undergoing C/S (relative risk [RR], 1.56; 95% confidence interval [CI], 1.14-2.15). An unavailable hemoglobin (Hb) level (RR, 12.94; 95% CI, 7.39-22.66) and Hb level of 70 to 80 g/L (RR, 7.78; 95% CI = 5.21-11.60) were strongly associated with RBCT among women undergoing C/S. Earlier gestational age at induction increased the risk of RBCT across all modes of delivery.

CONCLUSIONS

The higher frequency of RBCT for unknown and low Hb supports the need for predelivery patient blood management at the time of delivery. The additional risk factors associated with RBCT identified may be used to develop risk stratification tools by mode of delivery to assist in the identification of patients at the highest risk of requiring RBCT.

Single-dose intravenous iron infusion versus red blood cell transfusion for the treatment of severe postpartum anaemia: a randomized controlled pilot study

BACKGROUND AND OBJECTIVES

There are no randomized trials comparing intravenous iron to RBC transfusion for the treatment of severe postpartum anaemia. The objectives of this study were to evaluate the feasibility of randomizing women with severe postpartum anaemia secondary to postpartum haemorrhage to RBC transfusion or intravenous iron, and to describe patient-reported outcomes, and haematological and iron parameters.

MATERIALS AND METHODS

Women with a postpartum haemorrhage exceeding 1000 ml and an Hb between 5·6 and 8·1 g/dl were randomized to 1500 mg of intravenous iron (n = 7) isomaltoside or RBC transfusion (n = 6). Participants completed the Multidimensional Fatigue Inventory and Edinburgh Postnatal Depression Scale, and blood samples were drawn at inclusion, daily during the first week and at weeks 3, 8 and 12.

RESULTS

We screened 162 women and included 13 (8%). There was no significant difference between groups in fatigue or depression scores. RBC transfusion was associated with a higher Hb on day 1, inhibition of reticulocytosis during the first week and low iron levels. Intravenous iron was associated with increased reticulocytosis during the first week, repleted iron stores and a higher Hb in weeks 3-12.

CONCLUSION

This pilot study shows that intravenous iron could be an attractive alternative to RBC transfusion in severe postpartum anaemia, and that a larger trial is needed and feasible.

A Systematic Review and Meta-Analysis of the Clinical Appropriateness of Blood Transfusion in China

The issue of the clinical appropriateness of blood transfusion has become a focus of transfusion medicine worldwide. In China, irrational uses of blood have often been reported in recent years. However, to date there lacks a systematic review of the rational uses of blood. This study aimed to determine the clinical appropriateness of blood transfusion in China. We searched PubMed, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, WanFang Database, and Chinese BioMedical Literature Database, and the retrieval cut-off date was June 31, 2015. SPSS 17.0 and MetaAnalyst 3.13 were employed as the statistics tools in this review. A pooled rate of clinical inappropriateness of transfusion was analyzed by DerSimonian-Laird method. In this study, a total of 39 observational studies were included, which related to 75,132 cases of blood transfusion. According to the meta-analysis results, the overall incidence of clinical inappropriateness of transfusion in China was estimated to be 37.3% (95% confidence interval [CI] [32.1, 42.8]). The subgroup analyses revealed that the pooled rates of clinical inappropriateness of transfusion of plasma, red blood cells (RBCs), cryoprecipitate, and platelets were 56.3% (95% CI [45.8, 66.2]), 30.9% (95% CI [27.1, 35.0]), 25.2% (95% CI [13.2, 42.7]), and 14.1% (95% CI [8.8, 21.9]), respectively. However, the pooled incidence of inappropriateness of transfusion in operative departments was 47.5% (95% CI [36.8, 58.3]), which was significantly higher than that in nonoperative departments, 25.8% (95% CI [18.7, 34.4], P < 0.05). The overall rates of inappropriate use were 36.7% (95% CI [30.2, 43.6]) in major cities and 37.5% (95% CI [31.2, 44.3]) in other cities, respectively; there was no statistically significant difference (P > 0.05). In conclusion, China has suffered from a disadvantage in the clinical appropriateness of blood transfusion, especially in plasma and RBC use. In future, comprehensive measures should be implemented in order to improve the clinical appropriateness of blood transfusion.

Diagnosis and treatment of iron deficiency anemia during pregnancy and the postpartum period: Iron deficiency anemia working group consensus report

According to the World Health Organization (WHO), anemia is the most common disease, affecting >1.5 billion people worldwide. Furthermore, iron deficiency anemia (IDA) accounts for 50% of cases of anemia. IDA is common during pregnancy and the postpartum period, and can lead to serious maternal and fetal complications. The aim of this report was to present the experiences of a multidisciplinary expert group, and to establish reference guidelines for the optimal diagnosis and treatment of IDA during pregnancy and the postpartum period. Studies and guidelines on the diagnosis and treatment of IDA published in Turkish and international journals were reviewed. Conclusive recommendations were made by an expert panel aiming for a scientific consensus. Measurement of serum ferritin has the highest sensitivity and specificity for diagnosis of IDA unless there is a concurrent inflammatory condition. The lower threshold value for hemoglobin (Hb) in pregnant women is <11 g/dL during the 1^st and 3^rd trimesters, and <10.5 g/dL during the 2^nd trimester. In postpartum period a Hb concentration <10 g/dL indicates clinically significant anemia. Oral iron therapy is given as the first-line treatment for IDA. Although current data are limited, intravenous (IV) iron therapy is an alternative therapeutic option in patients who do not respond to oral iron therapy, have adverse reactions, do not comply with oral iron treatment, have a very low Hb concentration, and require rapid iron repletion. IV iron preparations can be safely used for the treatment of IDA during pregnancy and the postpartum period, and are more beneficial than oral iron preparations in specific indications.

What factors contribute to hospital variation in obstetric transfusion rates?

Background and Objectives

To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity.

Materials and Methods

Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed.

Results

Overall, the transfusion rate was 1·4% (hospital range 0·6–2·9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1·1–2·0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0·59, P = 0·01), but not with low Apgar scores (0·39, P = 0·08), or readmission rates (0·18, P = 0·29).

Conclusion

Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.

Risk factors for blood transfusion at delivery in Finland

OBJECTIVE

To examine the prevalence and risk factors for blood transfusion during delivery.

DESIGN

Register-based retrospective cohort study from Finland.

SETTING

National Medical Birth Register data during 2006-2008.

SAMPLE

A total of 171 731 women having singleton deliveries, of whom 3394 (1.98%) received blood transfusion.

METHODS

We calculated odds ratios (ORs) with 95% confidence intervals (CIs) by multivariate logistic regression to adjust for confounders related to maternal background and mode of delivery.

MAIN OUTCOME MEASURES

Blood transfusion rates by risk factors.

RESULTS

Blood transfusion rate during labor increased slightly, from 1.83% in 2006 to 2.27% in 2008 (p < 0.001), during the study period. The highest rate, almost 4%, was reported in central hospitals. Advanced maternal age and primiparity predisposed to blood transfusion. A previous cesarean section increased these rates also in subsequent vaginal delivery (2.64%) compared with women who had vaginal deliveries only (0.86%, OR 3.14, 95% CI 2.65-3.72). Induction of labor almost doubled the risk for blood transfusion (adjusted OR 1.74, 95% CI 1.60-1.89). All instrumental vaginal deliveries (adjusted OR 2.46, 95% CI 2.25-2.69) and any cesarean sections (adjusted OR 1.80, 95% CI 1.66-1.96) increased this risk. Delivery of a large-for-gestational age newborn increased the blood transfusion risk over twofold.

CONCLUSIONS

As previous cesarean section includes an increased risk for blood transfusion, even in subsequent deliveries, it is essential to consider the mode of labor carefully. The blood transfusion rate was the highest in central hospitals, suggesting differences in blood transfusion practice.

Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study

OBJECTIVE

To examine the association between intended mode of delivery and severe postpartum haemorrhage.

DESIGN

A retrospective cohort study.

SETTING

Material from a nationwide study in Denmark.

POPULATION

Danish women giving birth in 2001-08.

METHODS

We compared use of red blood cell transfusion by intended mode of delivery in the total population (n = 382 266), in low-risk nulliparous women (n = 147 132) and in women with a previous caesarean delivery (n = 25 156).

MAIN OUTCOME MEASURE

Red blood cell transfusion within 7 days of delivery.

RESULTS

In the total population the crude transfusion rates for women with planned caesarean delivery and intended vaginal delivery were 2.24 and 1.75%. After adjustment for maternal age, body mass index, birthweight, smoking, parity, number of infants and previous caesarean delivery, the risk of red blood cell transfusion was significantly lower in women with planned caesarean delivery compared with intended vaginal delivery (odds ratio 0.82; 95% CI 0.73-0.92; P < 0.01). In low-risk nulliparous women and in women with a previous caesarean delivery the transfusion rates were lower for planned caesarean delivery compared with intended vaginal delivery before and after adjustment.

CONCLUSION

Compared with intended vaginal delivery, planned caesarean delivery was associated with a reduced risk of severe postpartum haemorrhage indicated by use of red blood cell transfusion.

Non-invasive measurement of hemoglobin during cesarean hysterectomy: a case series

Obstetric patients diagnosed with abnormal placentation (placenta accreta, increta or percreta) are at increased risk of major postpartum hemorrhage and cesarean hysterectomy. Obstetric anesthesiologists are primarily involved in intraoperative transfusion management in these cases. Hemoglobin assessment is invaluable for assisting transfusion decision-making during the acute period of obstetric hemorrhage. However, laboratory and point-of-care tests of hemoglobin concentration are time-dependent and intermittent, and do not provide a real-time assessment of change during the acute phase of blood loss. A new non-invasive hemoglobin monitor has been introduced recently, which provides real-time measurement of hemoglobin values (SpHb) using multi-wavelength pulse co-oximetry. We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution. We discuss the potential clinical utility of non-invasive hemoglobin monitoring for pregnant patients at high risk of obstetric hemorrhage, and the potential role of SpHb in guiding transfusion therapy.

Measures of blood loss and red cell transfusion targets for caesarean delivery complicated by placenta praevia

OBJECTIVE

The objective of this study was to assess the association between transfusion, per cent drop in haemoglobin (Hb), and estimated blood loss during the delivery and the first postoperative week following caesarean delivery for placenta praevia. Clinical data predictive of an objective laboratory test for risk of haemorrhage and the need for transfusion were investigated. Transfusions outside national Guidelines were noted.

DESIGN

Retrospective observational study of patients with placenta praevia, who were delivered consecutively by caesarean section at Royal Brisbane and Women's Hospital from 1999 to 2005.

SETTING

University-affiliated tertiary hospital. All caesareans were performed by one or more consultant obstetricians, gynaecology oncology surgeons and registrar assistants.

RESULTS

Seventy-one (28.9%) of 246 patients with placenta praevia were transfused, with 45 of these receiving three or more red cell units. The antenatal Hb fell by a mean of 20.2% (SD 13.5). The average operative haemorrhage was estimated as 1225 mL (SD 996). No patient or surgical factors were significantly associated with changes in Hb. There was a significant association between per cent fall in antenatal Hb and both transfusion P < 0.001 and estimated loss P = 0.002. After transfusion, the Hb of 19 patients was higher than that recommended by Guidelines.

CONCLUSIONS

Whether transfusion is necessary, but not the number of red cell units, can be planned by the effect of haemorrhage on antenatal Hb during delivery by caesarean section complicated by placenta praevia.

Anti-hepatitis C virus-positive blood donors: are women any different?

We sought to assess clinical, epidemiological, biochemical, serological and histological characteristics of anti-hepatitis C virus (HCV)-positive female blood donors and compare them with men. As women are frequently the minority among blood donors, studies evaluating this population usually reflect characteristics of male gender. This retrospective study included 380 blood donors with confirmed positive anti-HCV. The mean age was 36.9 +/- 11.3 years and 33.2% were women. Compared with men, female donors showed higher prevalence of prior transfusion of blood products (P = 0.031) and lower prevalence of intravenous drug use (P = 0.001) and alcohol abuse (P < 0.001). Women exhibited lower medians of alanine aminotransferase (P < 0.001) and gamma-glutamyltransferase (P < 0.001). They also showed higher platelet count (P < 0.001) and prothrombin activity (P = 0.049), and a lower frequency of antibody against core antigen of hepatitis B virus (anti-HBc) positivity (P = 0.032). A higher proportion of spontaneous viral clearance (P = 0.001) and a lower frequency of viraemia (P < 0.001) were observed among women. On liver biopsy, women had lower prevalence of fibrosis stage > or = 2. Multivariate analysis identified age (OR = 1.050, 95% CI: 1.019-1.081, P = 0.001) and anti-HBc positivity (OR = 2.184, 95% CI: 1.010-4.722, P = 0.047) as independent predictors of significant fibrosis. Female blood donors presented higher prevalence of spontaneous viral clearance as well as biochemical and histological evidence of less advanced liver disease. These findings could be because of intrinsic characteristics of female gender or secondary to associated factors such as younger age or anti-HBc positivity.

Transfusion of red blood cells: no impact on length of hospital stay in moderately anaemic parturients

BACKGROUND

In a search for information to improve decision making on red blood cell (RBC) transfusion, we examined the impact of RBC transfusion on the length of hospital stay for delivery in moderately anaemic women (haemoglobin, 7-10 g/dl).

METHODS

This was a retrospective, observational study covering 2 years (2002 and 2003), and included major blood-transfusing hospitals from four university and five central hospital districts managing 67.5% of Finnish in-hospital deliveries. The impact of the transfusion of 1-2 RBC units vs. no transfusion on the length of hospital stay was evaluated for three different haemoglobin levels: 7-7.9, 8-8.9 and 9-10 g/dl.

RESULTS

Of the 1954 moderately anaemic mothers in hospital for delivery, 13.3% were transfused with RBC. The mean length of hospital stay was 5.2 days vs. the average Finnish hospital delivery stay of 3.5 days. No differences in stay were found between patients with comparable anaemia transfused with 1-2 RBC units or none (at the three haemoglobin levels: P= 0.50, P= 0.07 and P= 0.54, respectively). The final haemoglobin value was higher (P < 0.001) in transfused patients.

CONCLUSION

The duration of admission for delivery in moderately anaemic parturients was longer than the average length of hospital stay in Finnish parturients. However, 1-2 RBC units had no impact on the length of stay, suggesting that unnecessary RBCs are transfused after delivery. Thus, transfusion practices in obstetrics are not always optimal.

An Analysis of Transfusion Practice and the Role of Intraoperative Red Blood Cell Salvage During Cesarean Delivery

BACKGROUND

We sought to determine to what extent intraoperative salvaged red blood cells (RBC) might theoretically reduce exposure to appropriately transfused allogenic erythrocytes in Cesarean delivery patients.

METHODS

Medical records of Cesarean delivery patients requiring blood transfusions from January 1, 1992 to June 30, 1996 and June 1, 1998 to June 30, 2003 were reviewed. For each patient, we calculated the number of allogenic RBC units that could have theoretically been avoided had intraoperative autotransfusion been performed, based upon estimated blood loss, preoperative hematocrit, and the amount of retrieved blood needed to yield a single RBC unit. RBC transfusion appropriateness was determined using the recommended guideline of transfusing RBCs if the hemoglobin is <7 gm/dL in a patient with continuing bleeding.

RESULTS

A small percentage of Cesarean delivery patients (1.8%) received blood product transfusions. Of 207 patients receiving blood transfusions, salvaged erythrocytes could have theoretically decreased exposure to allogenic RBCs in 115 (55.6%) patients. Only 75.7% of these 115 patients were appropriately transfused with erythrocytes.

CONCLUSION

Theoretically, based on best, average, and worst RBC salvage recovery calculations, 25.1%, 21.2%, or 14.5% of the appropriately transfused patients, respectively, could have completely avoided allogenic RBC transfusion.

Intravenous versus oral iron therapy for postpartum anaemia

OBJECTIVE

Postpartum iron deficiency anaemia (IDA) is common in women. Most women are treated with either oral iron supplementation or blood transfusion. Hence, the aim of our study was to compare the effect of treatment with either oral ferrous sulphate or intravenous ferrous sucrose on postpartum IDA.

DESIGN

A single centre, prospective randomised controlled trial.

SETTING

Women's Centre, John Radcliffe Hospital, Oxford, UK.

POPULATION

Forty-four women with haemoglobin (Hb) of <9 g/dl and ferritin of <15 microgram/l at 24-48 hours postdelivery.

METHODS

Women were randomised to receive either oral ferrous sulphate 200 mg twice daily for 6 weeks (group O) or intravenous ferrous sucrose 200 mg (Venofer; Vifor International Ltd, St Gallen, Switzerland), two doses given on days 2 and 4 following recruitment (group I).

RESULTS

were analysed by the Students t-test, chi-square test and analysis of variance.

MAIN OUTCOME MEASURES

Hb, haematocrit, red cell indices, ferritin and serum iron levels were measured on days 0, 5, 14 and 40. Results By day 5, the Hb level in women treated with intravenous iron had risen from 7.3 +/- 0.9 to 9.9 +/- 0.7 g/dl, while there was no change in those treated with oral iron. Women treated with intravenous iron had significantly higher Hb levels on days 5 and 14 (P < 0.01) than those treated with oral iron; although by day 40, there was no significant difference between the two groups. Throughout the study, ferritin levels rose rapidly in those treated with intravenous iron and remained significantly higher than in those treated with oral iron (P < 0.01).

CONCLUSIONS

Intravenous iron sucrose increases the Hb level more rapidly than oral ferrous sulphate in women with postpartum IDA. It also appears to replenish iron stores more rapidly. However, this study was not large enough to address the safety of this strategy.