What Is the Main Idea?

When a person undergoes non-emergency major surgery, existing or new blood problems such as unusual clotting or too much bleeding can be life-threatening. However, blood problems can usually be detected before surgery, and the medical team can plan treatment to prevent or counteract a complication. This process is known as “patient blood management” (PBM). The PBM process has been successfully used for surgery and is now being applied to other areas of medical care, such as pregnancy and birth. The authors of the open-access review article “Patient Blood Management in Pregnancy”, published in the journal Transfusion Medicine and Hemotherapy, aimed to review and describe treatment protocols for blood problems during pregnancy, birth and the post-birth period.

What Else Can You Learn?

The authors write within the context of pregnancy, birth and the post-birth period. However, their descriptions can help you understand blood problems outside of this context, as the causes and treatments can be similar.

Why Is Patient Blood Management Relevant to Pregnancy and Birth?

Up to 40% of pregnant woman experience the blood problem of anemia and iron deficiency. This can lead to the mother feeling unwell and to serious pregnancy complications. It is also connected to poor post-birth health for both mothers and babies.

Severe bleeding during and after childbirth is called postpartum hemorrhage (PPH). This life-threatening emergency accounts for up to one-third of birth-related deaths in both developing and developed countries. Women who survive can have permanent reproductive disability. Furthermore, the number of at-risk mothers continues to rise (due to reasons such as increased use of Caesarean delivery, effects of fertility treatment and increased age of mothers).

What Are the Stages of Patient Blood Management during Pregnancy and Birth?

PBM is a multidisciplinary and individualized treatment approach:

  • Firstly, during early pregnancy for at-risk mothers, early screening and treatment of anemia and iron deficiency occurs.
  • Secondly, during delivery, steps to minimize blood loss are taken.
  • Thirdly, in the event of anticipated or unexpected high blood loss, a blood transfusion of either donor or the mother’s salvaged blood can be used.

What Is Iron Deficiency Anemia and How Is a Pregnant Woman Treated?

Anemia in pregnancy is a blood condition where there are not enough red blood cells, or not enough hemoglobin inside the red blood cells. Hemoglobin is a protein inside red blood cells that helps them work properly. The leading cause of anemia during and after pregnancy is iron deficiency.

A pregnant woman with iron deficiency anemia may experience fatigue, weakness or dizziness. It also affects thermoregulation, immune function, neurologic function, and enzymatic function, which is why it can place a woman at-risk of complications during pregnancy and birth. Additionally, it can affect the unborn baby’s growth and development.

Iron levels can be tested with a blood test. The authors discussed expected test results for pregnant women (different to non-pregnant women). They also reported the following treatment options that are safe for pregnancy:

  • Iron tablets are the gold standard for mild to moderate iron deficiency anemia but take a few weeks for full results. Unfortunately, there can be gastrointestinal side effects. However, these can be helped by taking tablets on alternate days.
  • If tablets do not help, then after the second trimester iron can be given with an intravenous drip. This is also an option for anemia that requires rapid normalization.
  • A third option is to give recombinant erythropoietin (rhEPO). This medication stimulates the production of red blood cells. However, it requires the presence of enough iron in the blood before it can work; therefore is often given alongside an iron drip (see above). This combination can be the best treatment for severe anemia or when a woman does not want to receive a blood transfusion.

How Can Blood Loss during Pregnancy and Birth Be Minimized?

Some bleeding and blood loss during and after birth is normal. However, too much (more than 500 ml) is classified as post-partum hemorrhage (PPH) and can be life-threatening. There are four leading causes of PPH: uterine atony, trauma, placental disorders and blood clotting defects. These are known as the four Ts: tone, trauma, tissue and thrombin. More than one cause can happen together, and treatment also addresses several causes simultaneously.

The authors list medications, delivery techniques, surgical options and diagnostic tests to reduce bleeding. Although they cannot describe everything in detail, they stress the importance of professionals working together, following a sequence of treatment protocols. The authors highlight a high-quality research trial where the medication tranexamic acid (TXA) was identified as significantly reducing the number of women who die from PPH. This is given as soon as bleeding starts and at further time stages according to a planned protocol. They also report on how the use of some quick-result blood tests is connected with better outcomes, because they enable individualized treatment.

What Is a Blood Transfusion?

If a person loses too much blood, they may need their blood replacing. An allogenic blood transfusion uses blood from a donor. An autologous blood transfusion uses the patient’s own blood and is known as cell salvage. The authors report on the use of cell salvage within the context of birth and specifically Caesarean delivery. They describe safety reviews that identified cell salvage as a safe option so long as steps such as filtering the blood from amniotic fluid were carried out. Cell salvage also results in healthier mothers post-birth and shorter hospital stay.

Take-Home Message

Pregnancy and birth result in normal changes to the blood. Iron deficiency anemia, although potentially serious, can often be easily treated with tablets. However, sometimes the blood changes can put a mother or baby at high risk of complications. If a woman is assessed as high-risk in early pregnancy, then her healthcare providers can follow a protocol of prevention and treatment. There are many treatment options that can be individualized to the mother and baby, including medication, birth techniques, surgical techniques and blood tests. Using all of these preventative and treatment options together, in a collaborative and individualized way, gives mothers and babies the best chance of survival and optimal post-birth health.

Note: The authors of this paper make a declaration about grants, research support, consulting fees, lecture fees, etc. received from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest.

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