The haemoglobin level alone can never be the sole criterion for a donor blood transfusion

In modern obstetrics bold transfusions should be the exception rather than the rule. Avoid Blood transfusion as far as possible. The haemoglobin level alone can never be the sole criterion for a donor blood transfusion .How best we, at 2019, can prevent or at least minimize pregnancy associated bood transfusion  over phone to residents on emergency basis?

 The main principle (mantra) are as follows which every obstetrician have to follow:-1) “Ask yourself “Is blood transfusion is absolutely essential” ??  Or else some alternative form fluid therapy will suffice?? The non selective and indiscriminate administration of blood products must be avoided at all times and 2) the indications of Blood Transfusions are a) Severe anaemia during pregnancy and b) in the postpartum period can necessitate the use of blood transfusions / plasma products and volume expanders in cases of traumatic or atonic PPH .3) If no alternative fluid do not work:-. the administration of donor blood and /or plasma products is indicted ONLY if it is proven that the products in questions have been safely manufactured and tested and if their use can avert a life threatening situation for the patient and the condition is so grave that there needs to be a sufficiently high likelihood that maternal death and morbidity cannot be averted through the use of equivalent alternatives. The non selective and indiscriminate administration of blood products must be avoided at all times. According to the literature the rate of donor blood transfusions at specialist treatment centres is 1-2%.. In our experience the critical haemoglobin level provided that the circulation is stable is approximately 6.0 g/dL . We must remember that in case of acute blood loss start giving oxygen and volume expanders immediately and let us all believe that blood transfusions represent only one of many options .The use of blood products is that they represent only one of many options in the management of the patient.

How to manage then without Blood ?? . In our experience the critical haemoglobin level provided that the circulation is stable is approximately 6.0g/dL .In case of acute blood loss start giving oxygen and volume expanders immediately. In the postpartum period can necessitate the use of blood transfusions plasma products and volume expanders.  The primary principle in managing an acute severe hemorrhage is the replacement of fluids to maintain organ perfusion. Other measures include keeping to a minimum the number of blood samples taken for testing and use of the best surgical and anaesthesiological techniques to minimise blood loss.

Other obstetric Measures.

With the advent of alternative measures to control PPH by catheter balloon Tapmonade, now it must be our dedicated approach to control bleeding (PPH) by some other methods rather than blood Transfusions. There it is conveyed to the audience that in deciding for or against a blood transfusion or

Summary of the key principles for the use of blood transfusions in obstetrics.

Pregancy  anaemia (including mild forms) &in gynecological cases preoperatively should be treated promptly to avoid the need for later donor blood transfusions .In general blood losses should be minimized and we must remember that the haemoglobin level alone can never be the sole criterion for a donor blood transfusion . Key factors include clinical finding the haemorrhage situation and the probability of averting significant morbidity or even death.

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The decision to give a bold transfusion should be made according to the relevant guidelines.

Transfusion risks should be weighed up when making the decision

The patient’s wishes must be taken into account if at all possible

Trained staff should carry out and monitor the transfusion

The indications for and circumstances of a blood transfusion must be recorded as must any complication

Effects of iron deficiency on pregnancy

Iron deficiency adversely affects iron dependent enzymes in each cell and has profound effects on muscles and neurotransmitter activity

Iron deficiency is associated with low birthweight and preterm delivery and there is also an association with increased bold loss at delivery

Management

ABC of Oral Fe therapy in Pregnancy:-The rationale for routine supplementation with oral iron is that the increased iron demand during pregnancy cannot be met by increased absorption alone and that a high proportion of women in their reproductive years lack storage iron. Iron supplements prevent iron deficiency anaemia. Many argue that the best approach to iron deficiency in pregnancy is prevention .The world Health organization in conjunction with the International Nutritional Anemia Consultative Group and the United Nations Children’s Fund have issued guidelines recommending routine supplements

The standard oral preparations are combined with folic acid and are suitable for both prevention and treatment of iron deficiency in pregnancy, .Iron absorption from the small intestine is enhanced by ascorbic acid meat and alcohol Inhibitors to absorption include physic  acid and tannins present in tea coffee and chocolate. The incidence of gastrointestinal side effects is directly related to the dose of iron taken. A dose of 60mg/day of iron may be sufficient for prophylaxis. Therefore women who have troublesome side effects may be advised to take alternate day twice weekly or weekly supplements rather than to discontinue them. For those women who are unable to tolerate oral preparations parenteral therapy with intravenous iron preparations is an alternative. This is safe in pregnancy and does not have the gastrointestinal side effects. Parenteral iron may provide a more rapid and complete correction of iron deficiency.

What is the possible maximum rise in Hb % if other conditions are optimal?? Iron deficiency diagnosed late in pregnancy may necessitate blood transfusion as the maximum rise in haemoglobin achievable with either oral or parenteral iron is 0.8g/ dL/wk. 

Similar arguments apply to routine folate supplementation in pregnancy . Since a normal diet is not sufficient to meet the increased requirement for folate in pregnancy.

Prophylaxis of Fe def anemia: How & when to initiate Fe suppl??  ?? All women planning a pregnancy are advised to take 400 ug/day folate for 12 weeks pre pregnancy and or the first trimester to reduce the risk of neural tube defects and other fetal abnormalities.

Anemia  in Pregnancy:-What are the indications when we should seriously consider higher dose of Folic Acid?? What are rational indications for higher dose of Folic acid? Preconception supplementation as is recommended internationally  is usably 0.4 mg OD but in our country 0.4 mg(400 mcg) is not available. As we all prescribe L-M foliate  .But earlier say 8 yrs back   Folic  acid 5 mg was the convention (three times the usual dose);with a higher dose of 5mg/day dose include women 1) Who themselves have spina bifida 2)  With a previous fetus with a neural tube defect 3) Taking AEDs or sulfasalazine 4)  With diabetes or obesity 5)With haemolytic SCD and other anaemias 6) Known malabsorption syndrome 7) Proven folate deficiency

Vitamin B 12 injections may be safely continued in pregnancy

Anaemia –points to remember in Exam at least :-Changes in hemodynamic:-

The plasma volume increased by 50% in pregnancy and 2) so there is a fall in haemoglobin concentration 3) Pregnancy causes a two to threefold increase in the requirement for iron and a 10to 20 fold increase in folic acid requirements. 4) Many women develop iron deficiency anaemia because they enter pregnancy with depleted iron stores. 5) may have low Ferritin:-as there are many A woman may be iron deficient despite having a normal haemoglobin level and MCV . 6) those who are planning for preg-it is better and prudent to initiate replacement by suppl of iron and folic  ACID  deficiency in pregnancy is prevention with oral iron and folate supplements at least in those at high risk of becoming anaemic . The maximum rise in haemoglobin achievable with either oral or parenteral iron is 0.8g/dL/wk.All women planning a pregnancy should be advised to take 0.4 mg/day folate preconception as prophylaxis against neural tube defects and other fetal abnormalities.

Flow chart if pt can’t afford too much money at a time: Or has happens at Ante OPD when too many ANC reports daily and Govt can’t afford for such reagents & Pathologists too. :-Phase wise tests of anemia :- MCV<80FL
Check Ferritin and exclude haemoglobinopathies

B) If MCV>100 Low B 12: Br careful to treat for  B 12 deficinecy : recheck at post natal follow up
Check B 1 2 and folate consider LFT s+TFT Folate 5mg od FBC monthly
Iron supplements if indicated
Check reticulocytes and direct Coombs Hematology referral if abnormal
normal B 12

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Anaemic blood test : Hb<11g/dL at 12 weeks Hb<10.5 g/dL at 28 weeks

MCV<80FL				MCV80-100
	Check Ferritin and exclude haemoglobinopathies

MCV>100	LowB12
	Alert GP for B12 recheck at post natal follow up

Check B12 and folate consider LFT s+TFT Folate 5mg od FBC monthly Iron supplements if indicated Check reticulocytes and direct coombs Haematology referral if abnormal  normalB12

B) Macrocytes:-- High MCV:-If MCV>100 and Low B 12
Investigate for for B 12 recheck at post natal follow up
Check B 1 2 and folate consider LFT s+TFT Folate 5 mg od FBC monthly, Iron supplements if indicated
Check reticulocytes and direct Coombs Hematology referral if abnormal
normal B 12

A)    MCV>100 Low B 12::
Be alert for B 12 recheck at post natal follow up
Check B 1 2 and folate consider LFT +TFT, Folate 5mg od, FBC monthly
Iron supplements if indicated
Check reticulocytes and direct Coombs Hematology referral if abnormal
normal B 12

Physiology of haemopoietic system in pregancy:- 1) Physiological Increase in plasma volume is relatively greater than of red cell mass and this dilution effect increases with advancing gestation

But one should not be taken granted that all anemia’s are delusional anemias . There can be already preexisting pathological anaemia and this should not be overlooked . A significant anaemia particularly at booking is less likely to be physiological and other causes should be sought.

Erythrocyte size should be checked (microcytic, Macrocytic  or Normocytic).

Thalassaemia/sickle cell disease should be managed jointly with a hematologist and offered prenatal diagnostic testing and if husband too is a trait then prenatal diagnostic is most important .

Chronic disease or malnutrition may lead to an iron deficiency and is often missed.

. Effective antenatal treatment also reduces the need for peripartum blood transfusion .

Antenatal management

Other points to remember while in practice: A) it is  true that -Pregnant women obtain virtually all necessary vitamins and minerals from a healthy balanced diet- except folic acid and for some iron but hunger burden in India is too high to accept this philosophy that all is well.. B) A caveat; Anaemia in Pregnancy period quite often remain undiagnosed (Idiopathic anemia) :-Science till date is in dark about   why some women develop iron deficiency even with good diet.

C ) Oral iron can be unpleasant to take with GI side effects try different formulation such as syrups It can take weeks or months to correct iron deficiency therefore treatment should be started as soon as the diagnosis is made. Appropriate iron supplementation reduces the incidence of anaemia in pregnancy by about 40%but not all. We should communicate that there are iron absorption inhibitors / Iron absorption promoters in the duodenum,. & how many of  us  request the concerned woman request 1) not to take PPI ( which decreases HCL) & how many clinicians ask for chewing Vit C tab prior to principal meals food. How mangos we ask them to consume iron Prepn 2 hrs before food to ensure high acid

Parenteral irons are effective when oral preparations are not tolerated advises facilities for cardiopulmonary resuscitation should be available when giving IV treatment –small incidence of anaphylaxis

Per partum management

Women giving birth with significant iron deficient anaemia are at increased risk of adverse obstetric outcomes

The non selective and indiscriminate administration of blood products must be avoided at all times. According to the literature the rate of donor blood transfusions at specialist treatment centres is 1-2%. At the Zurich University Hospital‘s obstetrics clinic the current rate is 0.5-1%

Situation that can lead to a donor blood transfusion

Postpartum anaemia with signs of shock

Severe acute blood loss following spontaneous delivery or caesarean section

Severe anaemia during pregnancy associated with maternal decompensation .Obstetric clinics and specialists should  therefore be prepared for emergency blood transfusion. The availability of refrigerated blood and plasma products is essential.

But we must be aware that it is important to have strict criteria for or against the administration of blood replacement products and to be aware of the potentials and risks of these substances.

In the absence of haemoglobinopathies B12 and folate deficiencies should be excluded and iron deficiency assessed

Treat anaemia in pregnancy it is associated with an increase in adverse obstetric events including PPH and infection