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1.
Effective management of foetal anaemia in Rh(D) alloimmunised pregnant women with intrauterine transfusion: a Systematic Review
Prescott, B., Jackson, D. E.
Hematology, transfusion and cell therapy. 2023
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Free full text
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Editor's Choice
Abstract
BACKGROUND Foetal anaemia is caused by a severe pregnancy complication, haemolytic disease of the foetus and newborn. Intrauterine transfusions (IUTs) are performed to treat foetal anaemia in alloimmunised pregnant women. If left untreated hydrops can develop thereby reducing the chance of survival. Survival rates have improved but the procedure is not without complications. Procedure-related complications can be associated with early gestational age, hence delaying IUT could improve outcomes. This review aims to determine the effectiveness and safety of IUTs by examining survival and mortality rates, procedure-related complications with associated foetal mortality and the influence of hydrops. STUDY DESIGN AND METHOD A systematic review was conducted by searching keywords in four scientific databases from January 2000 to April 2022. A meta-analysis was performed with the OpenMeta-Analyst software using an arcsine transformed proportion with the binary random-effects model and maximum likelihood method. RESULTS Fifteen studies were identified as eligible and used in the meta-analysis. The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present. CONCLUSION The findings of this systematic review and meta-analysis provide evidence that IUT is a safe and effective treatment for foetal anaemia in the absence of hydrops when experienced personnel perform the procedure to minimise the risk of procedure-related complications.
PICO Summary
Population
Rh(D) alloimmunised pregnant women (15 studies).
Intervention
Systematic review and meta-analysis to determine the effectiveness and safety of intrauterine transfusions (IUTs).
Comparison
Outcome
The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present.
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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
Okunlola O, Raza S, Osasan S, Sethia S, Batool T, Bambhroliya Z, Sandrugu J, Lowe M, Hamid P
Cureus. 2022;14(6):e26460
Abstract
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.
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3.
Pure red-cell aplasia secondary to pregnancy: Case report and review of the literature
Herrera-Quintana JF, Rojas-Figueroa AC, Aragón-Mendoza RL, Gallo-Roa R, Castillo-Zamora MF
Revista colombiana de obstetricia y ginecologia. 2020;71(4):365-373
Abstract
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.
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4.
Intraoperative cell salvage for obstetrics: a prospective randomized controlled clinical trial
Liu Y, Li X, Che X, Zhao G, Xu M
BMC pregnancy and childbirth. 2020;20(1):452
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Free full text
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Editor's Choice
Abstract
BACKGROUND The latest basic studies and clinical evidence have confirmed the safety and efficacy of intraoperative autologous blood cell transfusion in cardiac surgery and orthopaedics. However, in caesarean section, there are still concerns about the contamination of amniotic fluid and foetal components, and consequently the application of intraoperative autologous blood cell transfusion is not universal. Therefore, this study aimed to evaluate the clinical value of intraoperative autologous blood cell transfusion in obstetric surgery. METHODS A prospective, randomized, controlled, feasibility study was performed in women undergoing caesarean section. One hundred sixteen participants were randomly assigned at a 1:1 ratio into either the intraoperative cell salvage group or the control group. Allogeneic blood cells were transfused into patients with haemoglobin concentrations < 80 g/dL in both the intraoperative cell salvage group and the control group. RESULTS No significant differences were found between the two groups in age, weight, maternal parity, history of previous caesarean section, gestational weeks of delivery, etc. However, compared with the control group, patients in the intraoperative cell salvage group had a significantly lower amount of allogeneic blood cell transfusion, lower incidence of postoperative incision infection, delayed wound healing, perioperative allergy, adverse cardiovascular events, hypoproteinaemia and shorter hospital stay. CONCLUSION The results of this study suggest that the use of autologous blood cell transfusion is safe and effective for patients with obstetric haemorrhage. TRIAL REGISTRATION All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional and/or National Research Committee of Beijing Obstetrics and Gynecology Hospital, Capital Medical University (2016-XJS-003-01) as well as the 1964 Helsinki Declaration and its later amendments or other comparable ethical standards. The clinical trials were registered (ChiCTR-ICC-15,007,096) on September 28, 2015.
PICO Summary
Population
Women undergoing caesarean section (n= 116).
Intervention
Intraoperative cell salvage (n= 58).
Comparison
Control group, allogeneic red blood cell infusion when the haemoglobin concentration was < 80 g/L (n= 58).
Outcome
Patients in the intraoperative cell salvage group had a significantly lower amount of allogeneic blood cell transfusion, lower incidence of postoperative incision infection, delayed wound healing, perioperative allergy, adverse cardiovascular events, hypoproteinaemia and shorter hospital stay.
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Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion
Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hosli I
Archives of gynecology and obstetrics. 2019
Abstract
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.
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6.
Efficacy and safety of blood transfusion in obstetric patients: systematic review of the literature
Modolo C, Agarwal A, Piva MFL, Botan AG, Camargo SEA, Gawish N, Modolo NSP, El Dib R
Ginekologia Polska. 2017;88((8)):446-452.
Abstract
OBJECTIVES To evaluate the efficacy of blood transfusion compared to no intervention in obstetric patients. MATERIAL AND METHODS A systematic review was performed with Cochrane Database of Clinical Trials, PubMed, EMBASE and LILACS databases searched as of September, 2016. Two authors independently selected relevant clinical trials, assessed their methodological quality and extracted data, using the GRADE approach. RESULTS Five studies within a total of 6,297 met the inclusion criteria, with women generally aged 20-40 years. Three included studies allocated women to receive blood transfusion or no intervention. Two other studies allocated women with either restricted or full blood supplies. The major issue regarding risk of bias was the extent of concealment of randomization and blinding. There was no statistically significant difference between blood transfusion versus no transfusion or restricted blood supply on mortality (relative risk 0.82 [95% confidential interval 0.32 to 2.09], p = 0.68; two studies; I2 = not applicable). CONCLUSIONS Very low-quality evidence suggests no significant difference between blood transfusion and no intervention in obstetric patients, underlining the need for more robust clinical trials evaluating this area.
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7.
Fetal MCA Doppler to time intrauterine transfusions in red cell alloimmunisation: a randomised trial
Dodd JM, Andersen C, Dickinson JE, Louise J, Deussen A, Grivell RM, Voto L, Kilby MD, Windrim R, Ryan G
Ultrasound in Obstetrics & Gynecology : the Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2017;51((3):):306-312
Abstract
OBJECTIVES Red cell alloimmunisation affects up to 0.6% of all live births, and can be successfully treated with intrauterine fetal blood transfusion. Fetal middle cerebral artery (MCA) Doppler peak systolic velocity (PSV) is a non-invasive test, to identify fetal anaemia and requiring intrauterine transfusion (IUT). Traditionally, timing of subsequent IUTs has involved estimating a fall in fetal haematocrit of 1% per day, or a fall in fetal haemoglobin of 0.3 g/dL per day. The aim of this pragmatic multi-centre randomised trial was to evaluate whether Doppler MCA-PSV in the fetus that has undergone one IUT for anaemia secondary to red cell alloimmunisation was non-inferior to timing IUT by timing based on predicting the fall in fetal haematocrit or fetal haemoglobin, without compromising infant haemoglobin at birth. METHODS We conducted an international, multi-centre randomised trial. Women with pregnancies complicated by fetal anaemia secondary to red cell alloimmunisation (due to any antibody alone or in combination) as indicated by the need to undergo a single IUT were eligible for inclusion. Women were randomised to the Timing of Transfusion by MCA-PSV Group (ultrasound determination of the fetal MCA-PSV, with a serial upward trend with values >1.5MoM considered indicative of the need for another IUT), or to the Timing of Transfusion by Prediction of the Fall in Fetal Haematocrit (Hct) Group (subsequent IUT's timed according an estimated fall in fetal Hct of 1% per day or fetal haemoglobin of 0.3 g/dL per day, to maintain the fetal haemoglobin between 7-10 g/dL). The primary study outcome was infant haemoglobin measured at birth. The trial was registered on the Australian and New Zealand Clinical Trials Register (ACTRN12608000643370). RESULTS We randomised 71 women (36 to the MCA-PSV Group; and 35 to the Fall in Fetal Hct. Group) from 13 centres in Australia, New Zealand, Canada, United Kingdom, Ireland, Belgium, and Argentina. The median gestational age at randomisation was 30.3 weeks, and the majority of women were Caucasian and non-smokers; 9.9% of women had Kell alloimmunisation, and 14% of fetuses were hydropic at their first IUT. There were no statistically significant differences between the two treatment groups with regards to mean haemoglobin at birth (MCA-PSV Group 103.6 +/- 38.2 g/dL versus Fall in Fetal Hct Group 120.3 +/- 31.4 g/dL; adjusted mean difference -15.6; 95% CI -32.4 to 1.3; p = 0.070)), or the number of IUTs performed after randomisation (MCA-PSV Group 1.75 (+/-1.79) versus Fall in Fetal Hct Group 1.80 (+/-1.32); adjusted relative risk aRR 0.88; 95% confidence interval (CI) 0.61 to 1.26; p = 0.474). There were no statistically significant differences between the two groups in the risk of adverse infant outcomes related to alloimmunisation, or procedure related complications. CONCLUSIONS Both Doppler MCA-PSV measurement and estimating the fall in fetal haematocrit or haemoglobin can be used to time second and subsequent IUTs.
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8.
Prophylactic versus selective blood transfusion for sickle cell disease in pregnancy
Okusanya BO, Oladapo OT
The Cochrane Database of Systematic Reviews. 2016;((12)):CD010378.
Abstract
BACKGROUND Pregnant women with sickle cell disease (HbSS, HbSC and HbSbetaThal) may require blood transfusion to prevent severe anaemia or to manage potential medical complications. Preventive blood transfusion in the absence of complications starting from the early weeks of pregnancy or blood transfusion only for medical or obstetric indications have been used as management policies. There is currently no consensus on the blood transfusion policy that guarantees optimal clinical benefits with minimal risks for such women and their babies. This is an update of a Cochrane review that was published in 2013. OBJECTIVES To assess the benefits and harms of a policy of prophylactic versus selective blood transfusion in pregnant women with sickle cell disease. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies. We did not apply any language or date restrictions. SELECTION CRITERIA Randomised controlled trials evaluating the effects of prophylactic versus selective (emergency) blood transfusion in pregnant women with sickle cell disease (SCD). Quasi-randomised trials and trials using a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors independently assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Out of six relevant reports identified by the search strategy, one trial involving 72 women with sickle cell anaemia (HbSS) met our inclusion criteria. The trial was at unclear risk of bias. Overall, there were few events for most of the reported outcomes and the results were generally imprecise. The included trial reported no maternal mortality occurring in women who received either prophylactic or selective blood transfusion. Very low-quality evidence indicated no clear differences in maternal mortality, perinatal mortality (risk ratio (RR) 2.85, 95% confidence interval (CI) 0.61 to 13.22; very low-quality evidence) or markers of severe maternal morbidity (pulmonary embolism (no events); congestive cardiac failure (RR 1.00, 95% CI 0.07 to 15.38; very low-quality evidence); acute chest syndrome (RR 0.67, 95% CI 0.12 to 3.75)) between the treatment groups (prophylactic blood transfusion versus selective blood transfusion). Low-quality evidence indicated that prophylactic blood transfusion reduced the risk of pain crisis compared with selective blood transfusion (RR 0.28, 95% CI 0.12 to 0.67, one trial, 72 women; low-quality evidence), and no differences in the occurrence of acute splenic sequestration (RR 0.33, 95% CI 0.01 to 7.92; low-quality evidence), haemolytic crises (RR 0.33, 95% CI 0.04 to 3.06) or delayed blood transfusion reaction (RR 2.00, 95% CI 0.54 to 7.39; very low-quality evidence) between the comparison groups.Other relevant maternal outcomes pre-specified for this review such as cumulative duration of hospital stay, postpartum haemorrhage and iron overload, and infant outcomes, admission to neonatal intensive care unit (NICU) and haemolytic disease of the newborn, were not reported by the trial. AUTHORS' CONCLUSIONS Evidence from one small trial of very low quality suggests that prophylactic blood transfusion to pregnant women with sickle cell anaemia (HbSS) confers no clear clinical benefits when compared with selective transfusion. Currently, there is no evidence from randomised or quasi-randomised trials to provide reliable advice on the optimal blood transfusion policy for women with other variants of sickle cell disease (i.e. HbSC and HbSbetaThal). The available data and quality of evidence on this subject are insufficient to advocate for a change in existing clinical practice and policy.
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Well being of obstetric patients on minimal blood transfusions (WOMB trial)
Prick BW, Steegers EA, Jansen AJ, Hop WC, Essink-Bot ML, Peters NC, Uyl-de Groot CA, Papatsonis DN, Akerboom BM, Metz GC, et al
BMC Pregnancy and Childbirth. 2010;10:83
Abstract
BACKGROUND Primary postpartum haemorrhage is an obstetrical emergency often causing acute anaemia that may require immediate red blood cell (RBC) transfusion. This anaemia results in symptoms such as fatigue, which may have major impact on the health-related quality of life. RBC transfusion is generally thought to alleviate these undesirable effects although it may cause transfusion reactions. Moreover, the postpartum haemoglobin level seems to influence fatigue only for a short period of time. At present, there are no strict transfusion criteria for this specific indication, resulting in a wide variation in postpartum policy of RBC transfusion in the Netherlands. METHODS/DESIGN The WOMB trial is a multicentre randomised non-inferiority trial. Women with acute anaemia due to postpartum haemorrhage, 12-24 hours after delivery and not initially treated with RBC transfusion, are eligible for randomisation. Patients with severe physical complaints are excluded. Patients are randomised for either RBC transfusion or expectant management. Health related quality of life (HRQoL) will be assessed at inclusion, at three days and one, three and six weeks postpartum with three validated measures (Multi-dimensional Fatigue Inventory, ShortForm-36, EuroQol-5D). Primary outcome of the study is physical fatigue three days postpartum. Secondary outcome measures are general and mental fatigue scores and generic health related quality of life scores, the number of RBC transfusions, length of hospital stay, complications and health-care costs. The primary analysis will be by intention-to-treat. The various longitudinal scores will be evaluated using Repeated Measurements ANOVA. A costs benefit analysis will also be performed. The power calculation is based on the exclusion of a difference in means of 1. 3 points or greater in favour of RBC transfusion arm regarding physical fatigue subscale. With missing data not exceeding 20%, 250 patients per arm have to be randomised (one-sided alpha = 0. 025, power = 80%). DISCUSSION This study will provide evidence for a guideline regarding RBC transfusion in the postpartum patient suffering from acute anaemia. Equivalence in fatigue score, remaining HRQoL scores and physical complications between both groups is assumed, in which case an expectant management would be preferred to minimise transfusion reactions and costs.