Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis
Obstetrics and gynecology. 2023;141(1):49-58
OBJECTIVE To evaluate red blood cell use during delivery in patients with placenta accreta spectrum. DATA SOURCES We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies. METHODS OF STUDY SELECTION Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype. TABULATION, INTEGRATION, AND RESULTS Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes. CONCLUSION Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021240993.
Hemoglobin Change after Red Blood Cell Transfusion for Postpartum Anemia: Secondary Analysis of a Randomized, Controlled Trial
American journal of perinatology. 2023
OBJECTIVE We aimed to describe hemoglobin (Hb) change after transfusion in the nonacute postpartum anemic population in order to provide clinicians with appropriate expectations regarding Hb rise posttransfusion. STUDY DESIGN We performed a secondary analysis of a randomized controlled trial comparing initial transfusion with 1 unit of packed red blood cells (pRBCs) to 2 units pRBCs for postpartum women requiring nonacute transfusion (n = 66). Inclusion criteria were: age 18 years and older, Hb level either <7 g/dL or >7 g/dL with signs or symptoms of anemia, and > 6 hours postpartum without contraindication to transfusion. Hb assessment was performed 4 to 6 hours after initial transfusion. Hb change (ΔHb) was calculated as posttransfusion Hb minus randomization Hb. Our primary goal was to describe mean ΔHb per pRBC transfused at the 4- to 6-hour posttransfusion blood count. We also compared ΔHb per pRBC transfused by number of units transfused, body mass index (BMI), and symptoms (dizziness and/or fatigue) at time of posttransfusion assessment. RESULTS Participants were mean age 29, mean BMI of 27, and over 70% self-identified as black, 12% identified as white, and 9% as Asian race. Mean Hb prior to transfusion was 6.9 ± 0.6 g/dL. Mean ΔHb per pRBC transfused was 0.9 ± 0.4g/dL. There was no difference in ΔHb per pRBC by BMI category (normal weight < 25 kg/m(2): 1.1 ± 0.2 g/dL; overweight 25-29.9 kg/m(2): 0.9 ± 0.5 g/dL; obese ≥ 30 kg/m(2): 0.9 ± 0.5 g/dL; p = 0.12). Finally, there was also no significant difference in ΔHb per pRBC by whether or not symptoms of anemia persisted after initial transfusion (1.0 ± 0.7 vs. 0.9 ± 0.4 g/dL, p = 0.39). CONCLUSION Our data supports the classically accepted rise in Hb after pRBC of approximately 1 g/dL, regardless of BMI category or anemia symptomatology. The study population includes patients at highest risk of postpartum anemia. The results of our study provide important information for clinicians caring for postpartum patients with nonacute anemia. KEY POINTS · Postpartum anemia is a significant public health issue.. · Providers use hemoglobin change to assess response to blood transfusion.. · The established 1 g/dL change in Hb after transfusion is based on historic surgical populations.. · Our data suggests the 1 g/dL Hb change is applicable to postpartum patients..
Race/Ethnicity as a Risk Factor in the Development of Postpartum Hemorrhage: A Thorough Systematic Review of Disparity in the Relationship Between Pregnancy and the Rate of Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is a major cause of maternal death and morbidity worldwide. Throughout the years, there have not been many studies looking into the association of race and ethnicity with the occurrence of PPH. The goal of this study was to assess race and ethnicity as risk factors in the development of PPH in pregnant women. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) standards, we conducted the analysis and conducted a literature search using Google Scholar and PubMed. After applying our inclusion and exclusion criteria, the search technique yielded a total of eight articles. The analysis included seven observational studies and one randomized controlled trial. The incidence of PPH was chosen as the major outcome measure. An evaluation of eight studies revealed that although Hispanics, Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have a higher chance of developing PPH caused by uterine atony, Caucasians had a greater rate of transfusion than the other groups. In addition, compared to Caucasians, African Americans or African descendants had a lower risk of atonic PPH but increased odds of atonic PPH requiring interventions. On the other hand, compared to non-native groups, Native Americans had increased odds of uterine atony. The results showed that, in contrast to other races/ethnicities, Caucasians had the lowest risk of PPH. Additionally, it was shown that African Americans or those descended from Africans had a higher chance of PPH but a lower risk of atonic PPH.
Pure red-cell aplasia secondary to pregnancy: Case report and review of the literature
Revista colombiana de obstetricia y ginecologia. 2020;71(4):365-373
OBJECTIVE To report a case of pure red-cell aplasia secondary to pregnancy and to conduct a review of the literature regarding diagnosis and treatment, as well as maternal and perinatal prognosis. METHODS This is the case of a 24-year-old patient at 34 weeks of gestation, referred to a regional public referral hospital due to anemia. Bone marrow biopsy was performed, leading to the diagnosis of pregnancy-related pure red-cell aplasia. The patient received serial red blood cell transfusions. Delivery by Cesarean section at term resulted in a healthy newborn. Hemoglobin values remained stable during the postoperative period. A literature search was conducted in Medline via PubMed, LILACS, SciELO and ScienceDirect using the terms "pregnancy" and "pure red-cell aplasia". Case reports, case series and literature reviews in English and Spanish published between January 1999 and January 2020 that report pregnant women with pure red-cell aplasia were included. Information on diagnosis, treatment and maternal and perinatal prognosis was collected. Three of the authors selected the studies by title and abstract; A descriptive synthesis is provided. RESULTS Overall, 828 titles were identified; of these,818 were discarded after reviewing the inclusions criteria. Ten articles were included: six case reports, three case reports with literature review, and one case report in the poster modality, for a total number of 10 reported cases. Diagnosis was based on low hemoglobin levels and compromised erythroid cell line in bone marrow biopsy. Treatment consists of red blood cell transfusions, with good maternal and fetal prognosis. CONCLUSIONS Diagnosis of pure red-cell aplasia during pregnancy requires bone marrow biopsy. With transfusion support, maternal perinatal prognosis is good. Further studies are required to assess the safety and efficacy of steroid use in this pregnancy-related condition.
Single- versus multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized, controlled trial
Am J Obstet Gynecol. 2020
BACKGROUND The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and use of a scarce resource. There is minimal data regarding single-unit protocols within obstetrics. OBJECTIVE We aimed to compare a single- vs. multiple-unit transfusion protocol for treatment of hemodynamically stable postpartum anemia. STUDY DESIGN We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells [pRBCs] (single-unit protocol) to 2 units of pRBCs (multiple-unit protocol) from 3/2018-7/2019. Postpartum women >6 hours from delivery who required transfusion were approached for consent. Unstable vital signs, hemoglobin(Hb)< 5g/dL, hemoglobinopathy, and cardiomyopathy were enrollment exclusions. Hemoglobin assessment and standardized clinical evaluation were performed 4-6 hours post-transfusion; additional pRBCs were given if indicated. The primary outcome was total units transfused. Secondary outcomes include length of stay, endometritis, wound separation/infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4-9 weeks postpartum. 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; alpha=0.05). RESULTS 66 women were randomized (33/arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization Hb. Mean number of units transfused was lower in the single- compared to the multiple-unit protocol (1.2u vs. 2.1u, p< 0.001). Only 18.2% of women in the single-unit arm required additional pRBCs. At post-transfusion assessment, women in the single-unit arm had lower Hb (7.8g/dL vs. 8.7g/dL, p< 0.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4-9 week postpartum outcomes. CONCLUSION In women with hemodynamically stable postpartum anemia, a single-unit protocol avoids a second unit of pRBCs in >80% of women without significant impact on morbidity. Our work supports use of single-unit initial transfusion in this population.
Haemodynamically stable postpartum women requiring blood transfusion in a single US centre (n= 66).
1 unit of packed red blood cells (pRBCs), (single-unit protocol, n= 33).
2 units of pRBCs (multiple-unit protocol, n= 33).
There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization Hb. Mean number of units transfused was lower in the single- compared to the multiple-unit protocol (1.2u vs. 2.1u). Only 18.2% of women in the single-unit arm required additional pRBCs. At post-transfusion assessment, women in the single-unit arm had lower Hb (7.8g/dL vs. 8.7g/dL), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4-9 week postpartum outcomes.
A Regression Model for Prediction of Cesarean-Associated Blood Transfusion
American journal of perinatology. 2019
OBJECTIVE To develop a model to predict cesarean-associated red blood cell transfusion. STUDY DESIGN Secondary analysis of all cesarean deliveries in the Maternal-Fetal Medicine Units Network Cesarean Registry. Using a split-sample technique, the derivation group was used to identify associated factors and build predictive models, and the validation group was used to estimate classification errors and determine test characteristics. Using factors available at the time of cesarean, we developed a multivariable logistic regression prediction model. RESULTS A total of 59,468 women were split evenly and randomly into the derivation and validation groups. The overall rate of transfusion was 2.7%. The area under the receiver operating characteristic curve for the derivation and validation groups were 0.82 (95% confidence interval [CI]: 0.80-0.84) and 0.84 (95% CI: 0.82-0.85), respectively (p = 0.16). The strongest predictors of transfusion were placenta previa (odds ratio [OR]: 7.06, 95% CI: 5.19-9.61) and eclampsia/Hemolysis Elevated Liver Enzymes Low Platelets syndrome (OR: 5.67, 95% CI: 3.77-8.51). In the validation group, the model had a sensitivity, specificity, positive, and negative predictive values of 55.8, 91.5, 16.2, and 98.6%, respectively. Overall, 90.5% of patients were correctly classified. CONCLUSION A regression model incorporating variables available at the time of cesarean accurately predicts the need for intra- or postoperative transfusion.
Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion
Archives of gynecology and obstetrics. 2019
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
Intrauterine administration of autologous peripheral blood mononuclear cells in patients with recurrent implantation failure: A systematic review and meta-analysis
Journal of reproductive immunology. 2019;131:50-56
Intrauterine administration of autologous peripheral blood mononuclear cells (PBMC) has been proposed to improve implantation rates in women with recurrent implantation failure (RIF). The objective of this study was to evaluate whether intrauterine administration of PBMC improves clinical pregnancy and live birth in couples with RIF. Various databases were searched including Medline, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials up to April 2018. This review included all studies that compared intervention of PBMC in infertile women undergoing any form of assisted reproductive technology (ART). Two independent reviewers assessed eligibility; methodological quality; and extracted data. Meta-analysis using a random-effects model was performed to calculate the pooled estimates. Eight studies involving 886 patients were included. The probability of clinical pregnancy was significantly higher in women who received PBMC compared with control (RR: 1.92, 95% CI: 1.48-2.49; P < 0.001). No difference was observed in the studies that transmitted the embryo at blastocyst (RR: 2.44, 95% CI: 1.42-4.20; P = 0.001), or cleavage stage (RR: 2.01, 95% CI: 1.36-2.96; P < 0.001). There was no difference between studies that transmitted the embryo in fresh (RR: 2.14, 95% CI: 1.38-3.32; P < 0.001), or frozen condition (RR: 1.79, 95% CI: 1.32-2.43; P < 0.001). The probability of live birth was significantly higher in women who received PBMC compared with control (RR: 1.93, 95% CI: 1.35-2.76; P < 0.001). Administration of PBMC, irrespective of embryo stage and cycle type, increases clinical pregnancy and live birth in patients experienced RIF. However, these overall estimates should be considered with caution due to the small number, quasi-experimental design and poor quality of most included studies.
Effect of withholding feeds on transfusion related acute gut injury in preterm infants - a pilot randomized controlled trial
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2019;:1-161
BACKGROUND Several retrospective studies have reported an increase in necrotizing enterocolitis (NEC) during the 48 hours following red blood cell (RBC) transfusion. Whether withholding enteral feeding during transfusion decreases the risk of transfusion-associated acute gut injury (TRAGI) in preterm infants is unclear. STUDY DESIGN AND METHODS In this pilot study, 112 preterm infants with gestational age ≤ 32 weeks and/or birth weight ≤ 1500 grams were randomly assigned to withholding (NPO) or continuance of feeding (FED) during RBC transfusion. Primary outcome measure was development of NEC (stage ≥ 2) within 72 hours of a transfusion and the change in abdominal circumference. RESULTS One hundred fifty-four transfusion episodes (74 NPO and 80 FED) were analyzed. Demographic characteristics were found to be similar in both groups. There was no difference in rates of NEC (0 versus 3.4%; p = 0.49) between the NPO and FED groups. The incidence of feeding intolerance was higher in the FED group however it was statistically insignificant (1.9 versus 6.8%, p = 0.36). Abdominal circumference remained similar in both groups in all three consecutive days following transfusion (p > 0.05). CONCLUSION This pilot study does not support withholding feedings during transfusion but is not adequately powered to test the hypothesis that NPO decreases NEC rates. Adequately powered well designed multicenter trials are still required.
Blood adiponectin concentration at birth in small for gestational age neonates: A meta-analysis
Diabetes & metabolic syndrome. 2019;13(1):183-188
AIMS: Small for gestational age (SGA) is associated with increased rates of neonatal mortality and morbidity. Adiponectin secreted from adipose tissue is implicated in the etiology of death and illness during infancy. SGA is also a likely risk factor for the development of metabolic and clinical complications in adulthood. The present study was performed to determine whether SGA neonates and healthy controls show differences in blood adiponectin concentration at birth. METHODS Databases were searched to identify English-language studies providing the numbers of SGA neonates, the numbers of healthy controls, and the means and standard deviations (SDs) of blood adiponectin concentrations at birth in both groups. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). A meta-analysis was performed to summarize the standardized mean differences (SMDs) in blood adiponectin concentration between SGA neonates and healthy controls. RESULTS The results summarized from five good quality (i.e., NOS score≥5) studies involving 253 neonates showed that blood adiponectin concentration was significantly lower in SGA neonates than in healthy controls (P=0.016), and the effect was moderate (i.e., SMD=0.4-0.7). CONCLUSIONS Synthetic evidence indicated that blood adiponectin concentration at birth is lower in SGA neonates than in healthy controls.