Hanyang Med Rev.  2018 Mar;38(1):62-66. 10.7599/hmr.2018.38.1.62.

Patient Blood Management: Obstetrician, Gynecologist's Perspectives

• Lee WM

• KMID: 2407803
• DOI: http://doi.org/10.7599/hmr.2018.38.1.62

Abstract

Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patient blood management (PBM). We will review to summarize the alternative measures and interventions used in bloodless surgery in the field of obstetrics and gynecology. In the obstetric field, PBM has been developed as an evolving evidence-based approach with a number of key goals: (i) to identify, evaluate, and manage anemia; (ii) reduce iatrogenic blood loss; (iii) optimize hemostasis; and (iv) establish decision thresholds for transfusion. Transfusion, mechanical method including balloon tamponade and uterine artery embolization, and intraoperative cell salvage were introduced for PBM. In the gynecologic field, PBM is not significantly different from that in the obstetric field. Preoperative managements include iron supplement, erythropoietin administration, autologous blood donation, and uterine artery embolization. Meticulous hemostasis, short operative time, hypotensive anesthetic techniques, hemodilution during operation, blood salvage and pharmacological agents were introduced to intraoperative management. Postoperative measures include meticulous postoperative monitoring of the patient, early detection of blood loss, reduction of blood sampling, appropriate use of hemopoiesis, normalization of cardio-pulmonary function and minimization of oxygen consumption. In conclusion, each obstetrician and gynecologist should be aware about the appropriate method for blood conservation and use in practice. A comprehensive approach to coordinating all members of the bloodless agent and surgical team is essential.

Keyword

Patient blood management; Obstetrics and gynecology; Transfusion; Cell salvage; Uterine artery embolization

MeSH Terms

Anemia
Balloon Occlusion
Blood Donors
Bloodless Medical and Surgical Procedures
Erythropoietin
Gynecology
Hemodilution
Hemorrhage
Hemostasis
Humans
Iron
Methods
Obstetrics
Operative Time
Oxygen Consumption
Uterine Artery Embolization
Erythropoietin
Iron

Reference

1. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012; 120:1029–1036.

2. Santoso JT, Lin DW, Miller DS. Transfusion medicine in obstetrics and gynecology. Obstet Gynecol Surv. 1995; 50:470–481.

3. Brittingham TE, Chaplin H Jr. Febrile transfusion reactions caused by sensitivity to donor leucocytes and platelets. J Am Med Assoc. 1957; 165:819–825.

4. Heddle NM, Klama LN, Griffith L, Roberts R, Shukla G, Kelton JG. A prospective study to identify the risk factors associated with acute reactions to platelet and red cell transfusions. Transfusion. 1993; 33:794–797.

5. Dodd RY. Current safety of the blood supply in the United States. Int J Hematol. 2004; 80:301–305.

6. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. First of two parts--blood transfusion. N Engl J Med. 1999; 340:438–447.

7. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion. 1992; 32:601–606.

8. Nicholls MD. Transfusion: morbidity and mortality. Anaesth Intensive Care. 1993; 21:15–19.

9. Santoso JT, Saunders BA, Grosshart K. Massive blood loss and transfusion in obstetrics and gynecology. Obstet Gynecol Surv. 2005; 60:827–837.

10. Gutierrez MC, Goodnough LT, Druzin M, Butwick AJ. Postpartum hemorrhage treated with a massive transfusion protocol at a tertiary obstetric center: a retrospective study. Int J Obstet Anesth. 2012; 21:230–235.

11. Duchesne JC, Hunt JP, Wahl G, Marr AB, Wang YZ, Weintraub SE, et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years. J Trauma. 2008; 65:272–276. discussion 276-8.

12. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG. 2009; 116:748–757.

13. Royal College of Obstetricians and Gynaecologists. The role of emergency and elective interventional radiology in postpartum haemorrhage. Royal College of Obstetricians and Gynaecologists Good Practice Guideline No. 6. London: Royal College of Obstetricians and Gynaecologists;http://www.rcog.org.uk/womens-health/clinical-guidance/role-emergency-and-electiveinterventionalradiology-postpartum-haem. Published 2007.

14. Penney G, Brace V. Near miss audit in obstetrics. Curr Opin Obstet Gynecol. 2007; 19:145–150.

15. Allam J, Cox M, Yentis SM. Cell salvage in obstetrics. Int J Obstet Anesth. 2008; 17:37–45.

16. Glaspy J, Cavill I. Role of iron in optimizing responses of anemic cancer patients to erythropoietin. Oncology (Williston Park). 1999; 13:461–473. discussion 477-8, 483-8.

17. Fried W. Erythropoietin. Annu Rev Nutr. 1995; 15:353–377.

18. FDA Alert: Information for healthcare professionals: erythropoiesis stimulating agents (ESA) [Aranesp (darbepoietin), Epogen (epoetin alfa), and Procrit (epoetin alfa)]. Rockville, MD: Food and Drug Administration;2007. Accessed May 25, 2007. http://www.fda.gov/cder/drug/infoSheets/HCP/RHE2007HCP.htm.

19. Steinbrook R. Erythropoietin, the FDA, and oncology. N Engl J Med. 2007; 356:2448–2451.

20. Shander A. Surgery without blood. Crit Care Med. 2003; 31:S708–S714.

21. Nagarsheth NP, Shander A, Malovany R, Tzeng J, Ibrahim I. Bloodless surgery in a Jehovah's Witness patient with a 12.7-kg uterine leiomyosarcoma. J Surg Educ. 2007; 64:212–219.

22. Takemura M, Yamasaki M, Tanaka F, Shimizu H, Okamoto E, Hisamatu K, et al. Transcatheter arterial embolization in the management of gynecological neoplasms. Gynecol Oncol. 1989; 34:38–42.

23. Butori N, Tixier H, Filipuzzi L, Mutamba W, Guiu B, Cercueil JP, et al. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids. Eur J Radiol. 2011; 79:1–6.

24. Powell JL, Mogelnicki SR, Franklin EW 3rd, Chambers DA, Burrell MO. A deliberate hypotensive technique for decreasing blood loss during radical hysterectomy and pelvic lymphadenectomy. Am J Obstet Gynecol. 1983; 147:196–202.

25. Mirhashemi R, Averette HE, Deepika K, Estape R, Angioli R, Martin J, et al. The impact of intraoperative autologous blood transfusion during type III radical hysterectomy for early-stage cervical cancer. Am J Obstet Gynecol. 1999; 181:1310–1315. discussion 1315-6.

26. Hansen E, Knuechel R, Altmeppen J, Taeger K. Blood irradiation for intraoperative autotransfusion in cancer surgery: demonstration of efficient elimination of contaminating tumor cells. Transfusion. 1999; 39:608–615.

27. Nagarsheth NP, Sharma T, Shander A, Awan A. Blood salvage use in gynecologic oncology. Transfusion. 2009; 49:2048–2053.

28. Hardy JF. Pharmacological strategies for blood conservation in cardiac surgery: erythropoietin and antifibrinolytics. Can J Anaesth. 2001; 48:S24–S31.

29. Yamada T, Yamashita Y, Terai Y, Ueki M. Intraoperative blood salvage in abdominal uterine myomectomy. Int J Gynaecol Obstet. 1997; 56:141–145.

30. Connor JP, Morris PC, Alagoz T, Anderson B, Bottles K, Buller RE. Intraoperative autologous blood collection and autotransfusion in the surgical management of early cancers of the uterine cervix. Obstet Gynecol. 1995; 86:373–378.

31. Despotis G, Avidan M, Lublin DM. Off-label use of recombinant factor VIIA concentrates after cardiac surgery. Ann Thorac Surg. 2005; 80:3–5.

32. Habler O, Voss B. [Perioperative management of Jehovah's Witness patients. Special consideration of religiously motivated refusal of allogeneic blood transfusion]. Anaesthesist. 2010; 59:297–311.

33. deCastro RM. Bloodless surgery: establishment of a program for the special medical needs of the Jehovah's witness community--the gynecologic surgery experience at a community hospital. Am J Obstet Gynecol. 1999; 180:1491–1498.

34. Fiorica JV, Roberts WS, Hoffman MS, Barton DP, Finan MA, Lyman G, et al. Concentrated albumin infusion as an aid to postoperative recovery after pelvic exenteration. Gynecol Oncol. 1991; 43:265–269.

35. Goodnough LT. The role of recombinant growth factors in transfusion medicine. Br J Anaesth. 1993; 70:80–86.