Transfusion and Apheresis Science 58 (2019) 412–415

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Transfusion and Apheresis Science

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Review

Patient blood management in obstetrics – Review T

⁎
Jarmila A. Zdanowicz, Daniel Surbek
Department of Obstetrics and Gynecology, Bern University Hospital, University of Bern, Bern, Switzerland

A R T I C LE I N FO A B S T R A C T

Keywords: Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia,
Obstetrics reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia.
Patient blood management Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower
Postpartum hemorrhage hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several
Red blood cell transfusion
medical specialties, such as cardiac, trauma and orthopedic surgery.
In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the
potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge
to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the
clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited.
In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its chal-
lenges in the clinical routine.

1. Definition of patient blood management (PBM)
While allogenic blood transfusion has been viewed as a valid
treatment for blood loss for a long time, adequate and prepared pre-,
peri- and postoperative management is now emerging for un-
complicated elective surgeries in several medical specialties, summar-
ized as patient blood management [1]. In general, PBM aims to mini-
mize blood loss by maintaining adequate hemoglobin levels, reduce
allogenic blood transfusion while at the same time optimizing patient
care and outcome [1]. To this end, PBM is based on a so-called three
pillar matrix for successful implementation: First, identification and
treatment of anemia and low hemoglobin levels, furthermore, reducing
(perioperative) blood loss and optimizing hemostasis, and finally,
avoiding red blood cell (RBC) transfusions by tolerating individual
anemia to a certain justifiable extent [1,2].
Successful PBM has been shown to reduce perioperative blood loss,
lower transfusion rates, reduce perioperative morbidity and mortality,
and cut hospital length of stay and costs [3–5].
A trigger for PBM has been the realization that RBC transfusions are
associated with an increased morbidity and mortality, longer hospital
length of stay as well as higher risk for admission to the intensive care
unit [1]. In addition, transfusion risks include but are not limited to
transmission of infections, hemolytic transfusion reactions, transfusion-
associated circulatory overload, transfusion associated acute lung
injury and transfusion-related immunomodulation [6,7]. Furthermore,
studies have shown that patients with restrictive RBC administration,
such as Jehovah’s witnesses, have better clinical outcomes [1].
In other medical specialties, where elective surgeries are common,
PBM has been already successfully established, including in cardiac
surgery, trauma surgery and orthopedic surgery [5,8,9].
2. Current approach to PBM in obstetrics
In obstetrics, postpartum hemorrhage (PPH) is defined as a blood
loss of 500 ml or more after vaginal birth, and 1000 ml or more after
cesarean section within 24 h postpartum [10]. PPH is one of the main
causes for 75% of maternal mortality according to the World Health
Organization (WHO) [11,12]. Hence, implementing PBM in obstetrics
potentially benefits mother and child. However, data on PBM in ob-
stetrics has not been researched as well as in other medical specialties.
Risk factors that lead to PPH have been studied extensively, the
most common ones being uterine atony, anemia, trauma, placental
pathologies and coagulopathies [13]. Yet, most women experiencing a
PPH have no known risk factors. Risk factors and causes for PPH are
summarized in Table 1. Guidelines have been established in several
countries dealing with prevention and treatment of PPH, yet these re-
commendations across national guidelines are not always consistent
[14]. To date, Australia has been one of the few countries that has

⁎
Corresponding author at: Department of Obstetrics and Gynecology, Bern University Hospital, Theodor-Kocher-Haus, Friedbühlstrasse 19, 3010 Bern,
Switzerland.
E-mail address: daniel.surbek@insel.ch (D. Surbek).

https://doi.org/10.1016/j.transci.2019.06.017

1473-0502/ © 2019 Elsevier Ltd. All rights reserved.

J.A. Zdanowicz and D. Surbek Transfusion and Apheresis Science 58 (2019) 412–415

Table 1 the UK National Institute for Health Care and Excellence (NICE) re-
Risk factors for postpartum hemorrhage (PPH) [13,52]. commend a cutoff hemoglobin value below 110 g/l in the first trimester
Uterine Atony (Tone) Coagulopathy (Thrombin) and below 105 g/l in in the second trimester to define anemia [19–22].
- Multiparity - Congenital bleeding disorders The main cause for anemia in pregnancy is iron deficiency [23]. Due
- Multiple pregnancy - Acquired coagulopathies to the changes in blood circulation, the iron need for pregnant women is
- Previous postpartum - Anticoagulants also different from that of non-pregnant women, while a majority of
hemorrhage - Placental abruption
- Age > 40 years, BMI> 35 kg/ - Pre-eclampsia
women already have an iron deficiency going into the pregnancy [24].
m2 - Sepsis It has been estimated that the additional iron need of a pregnant
- Asian ethnicity - Amniotic fluid embolism woman is approximately 1 g [24].
- Placenta previa NICE guidelines recommend hemoglobin screening in early preg-
- Prolonged labor
nancy as well as at 28 weeks of gestation [22]. Current guidelines in
Trauma/Surgery (Trauma) Placenta (Tissue)
- Perineal or vaginal trauma - Retained placenta Switzerland recommend testing the hemoglobin level at least once per
- Cesarean delivery - Morbidly adherent placenta accreta, trimester, while additionally analyzing the ferritin level in the first
- Instrumental vaginal delivery increta, percreta trimester [19]. Here, a cutoff level below 30 ng/ml for serum ferritin
- Uterine rupture - Placental abruption has been recommended in pregnancy for diagnosis of iron deficiency
- Placenta previa
[21]. As ferritin is an acute phase protein, CRP (C-reactive protein)
Other
- Anemia should always be analyzed at the same time to exclude an elevated
- Antepartum bleeding ferritin level due to infection. It is important to diagnose if an existing
- Chorioamnionitis anemia is caused by iron deficiency and can be treated as such. Iron
- Nicotine and cocaine abuse
deficiency anemia can lead to preterm birth, reduce neonatal birth
- Macrosomia
- Laceration of birth canal weight, and lead to neonatal iron deficiency as well [7,19]. In women at
- Preexisting chronic disease risk for hemoglobinopathies (such as thalassemia or sickle cell anemia),
- Dead fetus further blood tests should be performed [7]. This might include a full
- Uterine fibroma blood count, mean red cell volume (MCV) as well as additional para-
- Medically induced abortion
meters to detect vitamin B12 or folate deficiency or reticulocyte count
[7].
To prevent anemia, treatment with 30–60 mg of elemental iron per
Table 2
Specific patient blood management in obstetrics. day is advised. Oral iron substitution is recommended for anemia with a
hemoglobin level above 80 g/l, with a dose of 80–100 mg per day [7].
PBM
In case of normal hemoglobin with ferritin levels below 30 ng/ml
Antepartum - Periodic check of hemoglobin and ferritin levels treatment is also recommended, with a dose of 30–60 mg per day
- Anemia and iron deficiency treatment [19,21]. As oral substitution can have some unwanted side effects, most
- Identification of risk factors for postpartum hemorrhage commonly gastrointestinal toxicity, intravenous iron administration is a
- Planned birth for women at risk
valid alternative [7]. Further indications for intravenous iron admin-
Peripartum - Evaluation of hemostasis
- Administration of oxytocin and tranexamic acid
istration might be inadequate increase in hemoglobin after oral sub-
- Mechanical and surgical treatment stitution, advanced gestational age combined with low hemoglobin
- Uterine artery embolization levels as well advanced anemia with a hemoglobin level below 80 g/l
- Use of cell saver [18,19].
- Transfusion of blood and blood products
In addition to RBC and blood volume, there are several changes in
Postpartum - Individual evaluation
- Hemoglobin levels after acute phase clotting mechanisms during pregnancy. Levels of clotting factors VII,
- Iron administration VIII, IX, X and XII are increased, as well as fibrinogen levels and von
- Restrictive transfusion of blood products Willebrand factor, leading to a hypercoagulability in pregnancy [17].
At the same time, factor XI and protein S decreases, while prothrombin,
protein C and factor V levels stay the same. With plasminogen activator
successfully and extensively implemented a program for PBM in ob- inhibitor levels of PAI-1 and PAI-2 increased, overall fibrinolysis is
stetrics, while elsewhere new guidelines are slowly being established decreased in pregnancy. While this provides the advantage of mini-
[7,15]. In obstetrics, a three pillar matrix for PBM includes identifica- mizing blood loss during delivery, it also leads to a higher risk for
tion of women at risk during pregnancy, minimizing acute peripartal thromboembolic events during pregnancy and in the puerperal period
blood loss and tolerating postpartum anemia. [25].

3. Blood circulation and anemia in pregnancy 4. Peripartum management

In pregnancy, blood circulation is adapted for mother and fetus in
order to provide an optimized uteroplacental circulation and aims to
minimize the effects of blood loss during delivery. The circulating blood
volume is increased by 40–45%, while erythropoiesis is enhanced as
well [16]. Consequently, plasma volume and red blood cell mass are
increased, effectively leading to a hemodilution and physiological an-
emia. An anemia plateau is reached around 30–32 weeks of gestation
[17]. Hence, classification of anemia during pregnancy differs from
non-pregnant women, however, a consensus on an exact definition is
lacking. According to the WHO, anemia during pregnancy is defined as
a hemoglobin level below 110 g/l [18], irrespective of how advanced
the pregnancy is. Anemia is further classified into mild (100–109 g/l),
moderate (70–99 g/l) and severe (< 70 g/l) [18]. Swiss guidelines, the
American College of Obstetricians and Gynecologists (ACOG) as well as
During excessive active bleeding (as defined above) within 24 h of
giving birth, several strategies exist to deal with PPH and its underlying
causes. Actual blood loss during delivery is often underestimated,
particular in vaginal delivery. Treatment is based on birth mode as well
on bleeding causes, categorized into “four T’s”: tone (uterine atony),
trauma (vaginal laceration, uterine rupture or inversion), tissue (re-
tained placental tissue, clots) and thrombin (coagulopathy).
Guidelines for peripartum management vary across national socie-
ties [14,26–29]. There is a general agreement that women with pla-
cental pathologies such as placenta previa or placenta increta are at a
much higher risk for PPH and should be advised to deliver in a tertiary
center.
First-line treatment includes all mechanical and medicinal treat-
ment. Mechanical interventions include uterine massages to stimulate

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J.A. Zdanowicz and D. Surbek
uterine contractions in cases of uterine atony, which is the most fre-
quent cause of PPH [30]. Medicinal treatment includes uterotonics
(such as oxytocin and prostaglandins) and pro-coagulants (like fi-
brinogen, tranexamic acid or fresh frozen plasma).
4.1. Oxytocin and prostaglandins
Oxytocin, or alternatively carbetocin, is recommended across
guidelines as the first-line medication of choice to prevent PPH. It can
be administered intravenously (usually 5–10 IU) as well as in-
tramuscularly, with the effect setting in after only a few minutes [30].
Additionally, a continuous intravenous infusion (20–40 IU in
500–1000 L at a rate of 125–150 ml/h) can be applied [14,30]. If
bleeding persists, further treatment with prostaglandins or its deriva-
tives are recommended, for example, misoprostol administered at
800 μg vaginally or rectally [26,30]. If this fails, sulprostone in-
travenously (a maximum of 1500 μg/24 h) can be given [26].
4.2. Tranexamic acid
Tranexamic acid is an anti-fibrinolytic drug that has been shown to
prevent blood loss in surgery by approximately one third. When ad-
ministered within three hours after onset of bleeding, it also reduces
death from bleeding [31,32]. Currently, in obstetrics, the administra-
tion of tranexamic acid has not been among the first-line treatment
options [26]. However, recently, the early and prophylactic use of
tranexamic acid (1–2 g) along with administration of uterotonics has
been shown to benefit women with PPH as soon as more than a normal
peripartum bleeding occurs [33,34].
4.3. RBC administration
Administration of RBC should be carried out cautiously and re-
strictively and there is no clear hemoglobin cut-off value as to when
RBC transfusion is required. A hemoglobin level below 60 g/l seems a
reasonable cutoff below which RBC administration should be per-
formed, provided that there is no active bleeding [35]. However, in the
case of active and severe bleeding, a hemodynamically instable patient
will clearly benefit from a RBC transfusion, irrespective of hemoglobin
level [36].
4.4. Cell saver
Cell saver, that is intraoperative blood salvage or homologous blood
transfusion, has been described as an alternative treatment to RBC
administration. However, it is not routinely used in obstetrics and few
studies exist, although no major complications have been described to
date [37].
4.5. Fibrinogen
Fibrinogen is crucial for coagulation and its level is the most sen-
sitive indicator for hemostasis imbalance and severity of PPH.
Hypofibrinogenemia (< 1 g/L) can be treated with administration of
fresh frozen platelets (FFP) as well as fibrinogen concentrate [34].
Administration of fibrinogen has been shown to reduce bleeding and
the need for RBC transfusions [38].
4.6. Fresh frozen plasma (FFP)
The Royal College of Obstetricians and Gynaecologists (RCOG) re-
commends administration of FFP for persistent PPH combined with
prolonged prothrombin time or activated partial thromboplastin time.
Four units of FFP are recommended for every four units of RBC [35].
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Transfusion and Apheresis Science 58 (2019) 412–415
4.7. Recombinant activated factor VIII (rhFVIIa)
RhFVIIa (Novo Seven®) should only be administered in cases of
severe bleeding if surgical treatment fails and is not considered routine
use in PPH [34].
5. Surgical management
Especially for PPH caused by an atony of the lower uterine segment,
balloon tamponades are available as a second-line therapy [13]. There
are several different balloon systems available, including Bakri balloon,
Foley catheter, or Sengstaken tube [39]. For example, the Bakri balloon
is slowly filled with liquid, hence applying pressure to the uterine wall
to stop bleeding [40,41].
Further surgical interventions include uterine compression sutures
that are placed throughout the uterus for compression of the atony site.
The most commonly used are B-Lynch sutures, as well as suture tech-
niques by Hayman and Cho [42–44]. Possible complications include
uterine adhesions (synechiae), necrosis and pyometra [45]. Vascular
ligation of arteries, usually of uterine, ovarian, or internal iliac arteries,
aims to reduce blood flow to the uterus and can be also used as a
supporting measure when bleeding persists following a hysterectomy
[46].
In addition, pelvic artery embolization of uterine or internal iliac
arteries can be performed, which is usually done in the interventional
radiology unit and can also effectively stop PPH [47]. If all previously
described measures fail, peripartum hysterectomy is the last resort for
treatment [46]. As it is associated with a high morbidity and mortality,
it should only be performed by an experienced surgeon [48].
6. Postpartum management
After delivery, detection and treatment of anemia is equally im-
portant. Swiss guidelines recommend determination of hemoglobin le-
vels at 48 h postpartum, unless other reasons for an earlier blood ana-
lysis are present. Postpartum anemia is defined as a hemoglobin
level < 120 g/l, while a significant anemia is defined at a level below
110 g/l [19]. Another definition is a hemoglobin level below 110 g/l
one week after delivery and below 120 g/l at eight weeks after delivery
[7].
Postpartum anemia might lead to several health constraints, such as
an increased risk for infections, reduced lactation, reduced cognitive
ability and emotional stability as well as fatigue and dyspnea [49]. Low
iron concentration in the postpartum period seems to be associated with
an increased risk for postpartum depression and fatigue [50,51].
Treatment for postpartum anemia with a hemoglobin level of
90–110 g/l should occur with oral elemental iron at 80–100 mg per day
for at least three months. Intravenous iron should be administered with
severe anemia below 90 g/l with relevant clinical symptoms [36]. The
threshold for RBC transfusion is between 65–70 g/l, however, this also
depends on the clinical outcome of the patient and should be ad-
ministered restrictively [36].
7. Conclusion
PPH is one of the leading causes for maternal mortality. There are
several strategies and different national guidelines for dealing with PPH
in the obstetric field. However, successful PBM strategies aimed at
systematically reducing peripartum blood loss are still lacking. In order
to reach this goal, a multidisciplinary approach is needed involving
obstetricians, anesthesiologists, transfusion medicine specialists and
radiologists.
As pregnancy is a physiologically different entity regarding he-
mostasis and its management, particular attention should be paid to this
patient cohort. Furthermore, since pregnant women are consistently
cared for throughout their pregnancy, this provides an unique
J.A. Zdanowicz and D. Surbek Transfusion and Apheresis Science 58 (2019) 412–415

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