Bleeding during child birth can be a dramatic and life-threatening event.1 Post-partum haemorrhage (PPH) and obstetric haemorrhage remain common causes of maternal mortality worldwide.2 PPH is a particular problem in resource-poor countries, where it has remained in the top three causes of maternal death for over 20 years.2 Industrialised nations also face this problem, with increased rates of blood transfusion reported following PPH.3
Blood loss during uneventful childbirth varies with the type of delivery and ranges normally between 200 and 400 ml. However, significant blood loss resulting in PPH can occur rapidly. PPH is defined in Australia as blood loss of 750 ml or more after caesarean delivery or 500 ml or more after vaginal birth. Risk factors for PPH are increasing worldwide and include advanced maternal age and obesity, as well as caesarean section; with rates exceeding 30%, this is the most commonly performed major surgical procedure in the United States.4 Worldwide PPH rates show geographical variation and are on average estimated to affect 11% of all women, with 4.2% suffering severe PPH.5
In well defined scenarios, such as bleeding disorders, grand multiparity and abnormal placentation, a higher risk of bleeding is generally flagged and management often carefully planned. However, it is imperative to be vigilant and keep in mind that every woman can bleed during childbirth. Identification of factors that can minimise the impact of potential blood loss and/or reduce the rate of PPH should be considered in the antenatal period. One such factor is anaemia.
Anaemia is a demonstrated risk in any perioperative setting, including obstetrics. Anaemia increases the risk of morbidity, mortality and blood transfusion. In the presence of anaemia, any nonemergency surgical procedure potentially associated with blood loss should be delayed to allow enough time to optimise the patient's own red blood cell mass and improve outcome.6,7
Pillar one of patient blood management (PBM) includes steps to assure timely identification and management of conditions such as iron deficiency and anaemia, which have been shown to be effective for transfusion reduction, enhanced patient safety, faster recovery, shorter hospital stays and economic benefits7,8 Defined risk groups, such as patients requiring colorectal, orthopaedic or cardiac surgery, are already benefitting from the attention and appropriate treatment modalities brought to them by PBM.8–10 Anaesthesiologists are often involved in the preoperative management and optimisation of patients scheduled for elective major surgery. However, the implementation of PBM strategies remains extremely variable, particularly in the preoperative setting.11,12 Obstetric patients may benefit from the introduction of clear PBM strategies, particularly those patients with iron deficiency and/or anaemia.
Although morbidity and mortality from severe PPH is high, women entering labour in an anaemic state and/or with iron deficiency are exposed to an even higher risk.13 Iron repletion and haemoglobin (Hb) optimisation prior to delivery are of pivotal importance, can easily be achieved and offer an important and protective strategy to reduce the need for peri-partum transfusion.14 Antenatal screening for iron deficiency, reflecting pillar one of the PBM concept, should be routine for women at risk of anaemia or iron depletion.15 If detected, iron deficiency should be treated early to benefit the mother and the unborn.13 Oral iron remains the first-line treatment, but adequate response needs to be assured. In the non-responsive, non-tolerant or non-compliant pregnant woman, or if iron deficiency anaemia is detected late in pregnancy, intravenous iron offers a well tolerated and effective approach.16
Improving Hb, even at a late stage of the third trimester, may shield some mothers from the risks of an allogeneic transfusion.16,17 This not only spares resources, but also optimises the health of women throughout and beyond their pregnancy into the challenging post-partum period. Further, transfusion risks and associated adverse outcomes are well described18,19 and emphasise the clinician's responsibility to protect women from exposure to allogeneic transfusion.
To minimise the rate of excessive post-partum transfusion (and therefore exposure of patients to the risks associated with transfusion), both patients and clinicians can choose to adopt a more restrictive transfusion threshold by accepting lower Hb values. This is because anaemia tolerance is generally high in post-partum women, particularly in those who are younger and are generally healthy, due to optimal physiological compensatory mechanisms. A recent publication underpinned the safety of a restrictive Red Blood Cell transfusion approach in this setting.20 A slight increase in ‘short-lived’ physical fatigue should be explained to women as an acceptable alternative and highlight the potential for transfusion reduction and avoidance with associated long-term gains. Postoperative intravenous iron can serve as a valuable adjunct to enhance erythropoiesis and speed up the recovery process.17
Cooperation and communication among anaesthesiologists and obstetricians play a vital role in optimising pregnancy outcomes. PPH is a challenging scenario for all involved, as the speed and extent of blood loss can be striking. Estimation of blood loss is difficult and unreliable, with the severity often masked by compensatory mechanisms of young, generally healthy women. To minimise risk for the parturient, all measures should ideally be in place before delivery.
Standard protocols, including those for high-risk pregnancies, should be in place at every institution, and individual cases should be discussed at a multidisciplinary meeting. Women with a known risk of major haemorrhage should be referred to dedicated tertiary centres. Women in labour, particularly with anaemia and/or bleeding risks, should be known to the anaesthesiologist on duty. A specific obstetric haemorrhage bleeding protocol combining the appropriate medical and surgical management with important PBM tools such as cell salvage, point-of-care coagulation monitoring, tranexamic acid and fibrinogen is essential and should become an integrated modality in the treatment approach.9,14
Obstetric PBM goes beyond managing the acute haemodynamic and haemostatic compromise. The cycle from persistent iron deficiency in pregnancy to residual post-partum iron deficiency occurs in many women and is compounded by obstetric haemorrhage and breastfeeding. If overlooked or inadequately addressed, long-standing iron deficiency will remain in the post-partum period and often in the next pregnancy. Fatigue is one of the most common presentations in the post-partum period, associated with low concentration, low mood and irritability. All impact on maternal ability to function and to care for the newborn,21 which may also impact longer term child health.22 Extending PBM into the post-partum period may have significant health benefits for both the mother and her child.
Women deserve optimal antenatal and peri-partum care. Obstetricians and anaesthetists share the responsibility to facilitate best practice. PBM, with emphasis on managing antenatal iron deficiency and/or anaemia, offers valuable interventions to make childbirth a memorable event, with the best possible short-term and long-term outcomes for both mother and child.
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