Patient blood management in obstetrics: management of anaemia and haematinic deficiencies in pregnancy and in the post‐partum period: NATA consensus statement (2017)

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, policymaking and epidemiology was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO) and the European Board and College of Obstetrics and Gynaecology (EBCOG). Members of the task force assessed the quantity, quality and consistency of the published evidence and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing the perinatal care of women in all settings and by policymakers in charge of decision making for the update of clinical practice in health-care establishments. They need to be tailored for application in individual patients or any population after consideration of the values and preferences of both health-care providers and patients, as well as equity issues; explicit assessment of harms and benefits of each recommendation; feasibility including resources, capacity and equipment; and implementability. PBM has become the buzzword in transfusion medicine. A few years ago, clinicians who spoke about PBM at meetings were considered abstruse visionaries. With time, their vision has evolved and come into focus. This has allowed the health-care community to better understand the concept and, most importantly, to apply it in everyday clinical practice. PBM or, more precisely, patient-centred blood management “is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcomes” (Shander et al., 2016). By definition, the approach is multidisciplinary and focuses on the treatment of each individual patient in whom significant blood losses are likely to occur and where transfusion of blood products is part of the established treatment (Gombotz, 2012). PBM involves – but is not restricted to – the appropriate use of blood products, defined by the World Health Organisation (WHO) as “the transfusion of safe blood products to treat a condition leading to significant morbidity or mortality that cannot be prevented or managed effectively by other means.” (WHO, 2001a). Although PBM is known best in the management of elective surgical procedures, it can (and should) also be applied to any procedure likely to result in excessive bleeding, post-procedural anaemia and the use of blood products. The “three pillars” of PBM require that (i) perioperative erythropoiesis be optimised, (ii) blood losses be minimised and (iii) tolerance to anaemia be harnessed appropriately (Isbister, 2013). PBM is a continuous process, initiated early in the preoperative period and continued intra- and post-operatively. The whole concept of PBM has been elegantly summarised by Hofmann et al. (Hofmann et al., 2007) (Figure S1, Supporting Information). At present, preoperative anaemia is often ignored, surgery proceeds as planned, and RBCs are transfused when deemed necessary (Muñoz et al., 2015; Meier et al., 2016) Yet, cohort studies (in cardiac, non-cardiac and vascular surgery) have shown that preoperative anaemia is associated with an increased incidence of post-operative adverse events, including mortality (Wu et al., 2007; Ranucci et al., 2012; Gupta et al., 2013) In addition, preoperative anaemia and low intraoperative haemoglobin (Hb) concentration are important predictors of perioperative allogeneic RBC transfusions (Muñoz et al., 2015). Blood transfusions entail a number of known risks (e.g. transmission of infectious agents, transfusion reactions, ABO mismatch, transfusion-related acute lung injury, transfusion-associated circulatory overload, etc.) and other less well-known ones. The latter are related, in essence, to emergent pathogens and to immunomodulation (increased incidence of infections and cancer recurrence) (Goodnough & Shander, 2012). At present, it remains difficult to determine whether the observed adverse events and mortality are related to preoperative anaemia per se or to the increase in allogeneic transfusions secondary to anaemia (Figure S2). Notwithstanding, the overall outcome is negative, so preoperative anaemia must be managed in a timely fashion (Muñoz et al., 2015). PBM implementation remains inadequate, even in centres where audits are conducted on a regular basis (Gombotz et al., 2014; Van der Linden & Hardy, 2016). That being said, it has not been unequivocally demonstrated that correction of preoperative anaemia is associated with improved outcomes (Muñoz et al., 2015). High-quality evidence in that direction would definitely improve adherence to PBM principles. This consensus statement reflects the position of the NATA, the FIGO and the EBCOG. It includes recommendations on the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period as part of PBM in obstetrics. The prevention and treatment of post-partum haemorrhage (PPH) will be addressed in a separate consensus statement. The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings and by policymakers in charge of decision making for the update of clinical practice in health-care establishments. It is important to note that these recommendations need to be tailored for application in individual patients or any population after consideration of the values and preferences of both health-care providers and patients, as well as equity issues; explicit assessment of harms and benefits of each recommendation; feasibility including resources, capacity and equipment; and implementability. Further involvement of relevant stakeholders at the local level is advised. Members of the task force assessed the quantity, quality and consistency of the published evidence and formulated recommendations using the system developed by the GRADE working group (Guyatt et al., 2008) (Figure S3). A preliminary version of the consensus statement was drafted by M. M. and circulated among the members of the panel for additional input and editing. The document was further reviewed by two experts in the field (F. G. and N. M.) who were not previously involved in the process. The document was then submitted for publication and underwent the journal's regular peer-review process. The recommendations in this statement are expected to remain valid for an estimated standard period of 10 years. This statement will be disseminated to all members of NATA, FIGO and EBCOG, and open access will be provided. Additionally, the recommendations will be presented at international forums and specialised events targeting clinicians in charge of the management of anaemia and haematinic deficiencies in pregnant and post-partum women. Anaemia occurs frequently during pregnancy. Anaemia can be aggravated by childbirth and is associated with adverse events. In most cases, it is possible to identify and correct the situation prior to childbirth, thereby improving patient outcomes. During pregnancy, there is a considerable increase (40–45%) in plasma volume (Sanghavi & Rutherford, 2014). The maternal plasma erythropoietin level also increases during pregnancy, with a peak in the third trimester, to accelerate erythropoiesis and help compensate for the dilution effect. These changes, resulting in an increase in total blood volume, are important to meet the increased demands of blood flow for the uterus and foetus, and may protect pregnant woman against the adverse effects of blood loss during labour. However, the disproportion in volume expansion between the plasma and RBC volumes results in haemodilution, and therefore, cut-off values for the definition of anaemia during pregnancy should be lower than those for non-pregnant women (Milman, 2008). The definition of a normal concentration in pregnancy is and consistency the cut-off values for anaemia should be studies of well as and women who a normal pregnancy and et al., et al., The has defined anaemia in pregnancy as an and anaemia as or (WHO, are recommendations on the use of cut-off by trimester, but it is that during the of pregnancy, concentration by Additionally, the that anaemia is a as is by the anaemia is has even when anaemia is The College of and and for in anaemia in pregnancy as an in the and in the and third et al., 2012). It is estimated that in of pregnant women were with between et al., 2013). 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