Better systems to identify and treat anaemia in pregnant women can have significant benefits for the mother and baby, including less need for red cell transfusion in cases of postpartum haemorrhage, HAA delegates have been told.
Dr Cindy Flores, a Clinical Practice Improvement Coordinator at the Australian Red Cross Blood Service, said an audit of a Canberra tertiary obstetrics unit found that 23% of women with postpartum haemorrhage received a transfusion, and half of those were anaemic on intrapartum admission.
“There are risks to the mother and the baby from anaemia during pregnancy, and to the mother from postpartum haemorrhage and transfusion,” Dr Flores said. “The missed opportunity for antenatal intervention to address anaemia is a problem worth solving.”
In March 2015 the National Blood Authority released comprehensive evidence-based guidelines on patient blood management in pregnancy and obstetrics.
“One focus of the guidelines is the need to maximise red cell mass at the time of delivery and reduce the reliance on transfusion as a salvage therapy to treat blood loss,” Dr Flores told the meeting.
With her colleagues, she developed and implemented a clinical practice improvement project to improve antenatal detection and management of iron deficiency and subsequent iron-deficiency anaemia.
The first step was an education program in all maternity healthcare services in Canberra. The initiatives included a template for assessing and optimising antenatal, intrapartum and postpartum haemoglobin levels (including routine screening of ferritin levels), patient handouts on oral iron preparations, and a guide on red cell transfusion for postnatal patients who are not actively bleeding. The materials also included a reminder of the definition of anaemia in each trimester.
“Following implementation of the program the rate of intrapartum anaemia fell from 12.2% to 3.6%,” Dr Flores said.
“We found that 60%-70% of women screened each month had iron deficiency. The algorithms helped staff to become confident in interpreting blood tests and managing iron deficiency and anaemia.
“Women found the patient handout helpful, and they said it encouraged them to persist with iron supplementation despite its side effects. IV iron use also increased, with 89 women receiving an infusion. Ferritin screening detected more women who were iron deficient in all three trimesters of pregnancy than detection by haemoglobin alone.”
Fewer blood transfusions were needed despite a similar rate of postpartum haemorrhage.
Haematologist Dr Zoe McQuilten, from Monash Health in Melbourne, presented data from the Australasian Maternity Outcomes Surveillance System (AMOSS) showing that about one in every 2,600 women giving birth have a major obstetric haemorrhage requiring transfusion with five or more units of red cells.
“Postpartum haemorrhage is the most common cause of direct maternal mortality,” she said.
AMOSS includes all facilities in Australia and New Zealand managing at least 50 obstetric cases annually. A prospective case-control study conducted from July 2014 to June 2015 compared 139 cases with the immediately preceding birth at the same maternity unit.
“The incidence of major obstetric haemorrhage was 38.2 per 100,000,” Dr McQuilten said.
“Compared to controls, cases were more likely to be older than 35 years, to have had labour induced, and to have become pregnant as a result of assisted reproductive technology. Other risk factors for haemorrhage, including BMI, parity, prior caesarean section and multiple pregnancy, were not significantly different between cases and controls.”
The most common causes of bleeding were uterine atony (36%), placenta accrete/increta/percreta (17%), retained placenta or membranes (10%) and genital tract trauma (9%).
There were no maternal deaths associated with major bleeding but higher rates of preterm birth, neonatal ICU admission and Apgar score <7 compared to controls.