RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10006-2352
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Incidence and Indications of Transfusion of Blood and Blood Products among Women Admitted for Obstetric Care in a Tertiary Care Hospital: A Cross-sectional Study
1Department of Orthopaedics, Smt. B.K. Shah Medical Institute & Research Centre, Vadodara, Gujarat, India
2Department of Obstetrics and Gynaecology, Divisional Railway Hospital, Vadodara, Gujarat, India
3Department of Obstetrics and Gynecology, Southern Railway Headquarters Hospital, Chennai, Tamil Nadu, India
Corresponding Author: Divya Ramalingam, Department of Obstetrics and Gynaecology, Divisional Railway Hospital, Vadodara, Gujarat, India, Phone: +91 9597744707, e-mail: pimsdivya@gmail.com
How to cite this article: Kumar VC, Ramalingam D, Kalyani S. Incidence and Indications of Transfusion of Blood and Blood Products among Women Admitted for Obstetric Care in a Tertiary Care Hospital: A Cross-sectional Study. J South Asian Feder Obst Gynae 2023;15(6):713–716.
Source of support: Nil
Conflict of interest: None
Received on: 19 January 2023; Accepted on: 19 May 2023; Published on: 04 December 2023
ABSTRACT
Background: The three main scourges which account for a majority of MMR are postpartum hemorrhage (PPH), preeclampsia, and sepsis. Postpartum hemorrhage remains most common direct cause for maternal mortality and the most common indirect causes are anemia, preeclampsia, and sepsis in India. The main objective of our study is to determine the incidence and indications of blood and blood products transfusion in women admitted for obstetric care and to assess the timing and type of transfusion.
Materials and methods: Type of study: Cross-sectional Study
The study was conducted in the Department of Obstetrics and Gynecology, Southern Railway Headquarters Hospital, Ayanavaram, Chennai, over 18 months between December 2017 and May 2019. The study area includes all the women admitted in antenatal, labor, postnatal wards, ICU, those seeking an abortion, and emergency inpatient services of obstetrics.
Results: The incidence of blood and blood products transfusion was 2.4%. Postpartum hemorrhage followed by anemia complicating pregnancy is the commonest cause for the need for transfusion.
Conclusions: Vigilant monitoring during the fourth stage of labor for early identification of signs and symptoms of ongoing acute bleeding in the diagnosis of obstetric hemorrhage is recommended. All pregnant women should be counseled regarding the intake of an iron-rich diet and factors affecting iron absorption, and compliance to oral iron supplementations so that hemoglobin could be optimized well in advance, thus avoiding a situation requiring blood transfusion. Each institute should have its transfusion protocol and audits which will aid in identifying triggers for transfusion, to ensure quality transfusion practices.
Keywords: Anemia, Blood transfusion, Obstetric care, Postpartum hemorrhage.
INTRODUCTION
Among comprehensive emergency obstetric care module, blood transfusion is one of the essential components which helps in reducing the maternal mortality rates.1 The other components are the continuous ability of the medical institute to administer parenteral antibiotics for the sepsis-related complication, parenteral oxytocic drugs in managing third-stage labor and postpartum hemorrhage (PPH), anticonvulsants for severe preeclampsia and eclampsia, well-equipped setup for assisted vaginal delivery, manual removal of placenta and retained products, and complete facility for cesarean section with round the clock availability of theater, staff nurse, anesthetists, and neonatologist. These are essential as they function to save the lives of mothers. According to WHO, national system, volunteer donations, blood testing, and avoidance of unnecessary transfusion remain the main cornerstones of safe and effective blood donor services. By saving lives in obstetric emergencies, blood bank services play a very important role.1 Obstetric hemorrhage is one of the most common causes of maternal morbidity and mortality in the world. Obstetric hemorrhage remains an important cause of “near miss” events. Approximately, 140,000 women die of PPH annually worldwide, and of these, more than 50% occur in the first 24 hours of postpartum period. WHO has estimated that per year approximately 20 million mothers suffer significant morbidity from PPH.2
Shock index (SI) has also been used in intensive care units and trauma centers as a guide to estimate the amount of blood loss. Heart rate (HR) is divided by systolic blood pressure (SBP), Normal SI = 0.5–0.7. At times of significant hemorrhage, as there occurs an increase in HR and a fall in SBP, it increases the SI. Studies have determined obstetric shock index (OSI) with normal value in pregnancy as 0.7–0.8 by considering the physiological changes and if OSI >1 it indicates a massive obstetric hemorrhage, which requires blood transfusion in 80% of cases.3
Confidential inquiries into maternal deaths have repeatedly highlighted “too little being done too late” as an important contributor to maternal deaths due to PPH. So treatment should focus on prompt recognition and management of the underlying cause of PPH, effective communication, assessment, and involvement of a wider multi-disciplinary team in the management and monitoring of a woman who has suffered a massive blood loss.4
As per 10 commandments for the transfusion practice in medicine, blood transfusion should be given only when the benefits outweigh the risks and when no appropriate alternatives are available. The main deciding factor for transfusion should not be the lab hemoglobin value. If required, restrictive transfusion policy and component therapy are to be given as the need of the day, after considering various factors like a comprehensive assessment of the patient’s medical condition, clinical profile, hemodynamic stability, the possibility of re-bleed or ongoing bleeding.5
General Principles of Transfusion in Obstetrics: There is no single test to measure the rate or degree of appropriateness. Though the guidelines are being accepted, the clinical transfusion practice is with great variation.6 The goals of obstetric transfusion are to achieve >8 gm/dL of Hb, >75 × 109/L of platelet count, <1.5 × mean control of prothrombin time, <1.5 × mean control of Activated PT and >1.0 gm/L of Fibrinogen.7
MATERIALS AND METHODS
A cross-sectional study was carried out from December 1, 2017 to May 31, 2019, for 18 months, in the Department of Obstetrics and Gynecology, Southern Railway Headquarters Hospital, a tertiary care hospital, Ayanavaram, Chennai. The study population includes all the women admitted and underwent transfusion of blood and blood components in the antenatal, labor, postnatal ward, ICU, and those seeking abortion and emergency inpatient services of obstetrics during this period. The patient who required a transfusion was explained about its necessity and the possible risk associated with it. They were also provided with a patient information sheet. Informed consent was obtained from all the patients before transfusion, as per our hospital protocol and guideline. Clinical details and the indications for ordering a blood or blood product were noted in the patient’s case sheet and the blood requisition orders were processed and cross-matched as per the hospital transfusion guidelines. The hospital has a well-equipped blood bank facility under the Department of Pathology, which functions 24 hours a day.
Sample size
The sample size was calculated assuming the expected incidence of transfusion of blood and blood products as 5.3% according to the study done by Bangal VB et al.8 The other parameters considered were 1% absolute precision and 95% confidence level.
where n = Sample size
Z = Z statistic for a level of confidence = 1.96
P = Expected prevalence of proportion
(If the expected prevalence is 5.3%, then P = 0.053), and
d = Precision (If the precision is 1%, then d = 0.01)9
According to the calculation, the required sample size was 1,929 women. Assuming 5% of non-participation rate, another 96 women were added. Hence, we planned to include not less than 2,115 women in the final study. A total of 2,381 women underwent obstetric care during our study period and same were included in the final analysis. The final study included a total of 57 subjects.
Statistical Methods
The incidence of transfusion of blood was considered the primary outcome variable. Demographic parameters, such as obstetric score, type of pregnancy, type of delivery, and indications of transfusion were considered primary explanatory variables. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, and frequency and proportion for categorical variable. Since the study is only descriptive, no inferential statistical analysis has been done. Hence no p-values have been reported. IBM SPSS statistical software was used for data analysis.10
RESULTS
Out of 2,375 obstetric admissions, the incidence of transfusion of blood was 57 (2.4%). And 95% CI (1.85–3.10) (Table 1).
95% CI | ||||
---|---|---|---|---|
Blood transfusion | Frequency | Percentage | Lower | Upper |
Yes | 57 | 2.4% | 1.85 | 3.10 |
No | 2,318 | 97.6% | * | * |
Study included, primigravida of 24 (42.10%) and multigravida of 33 (57.90%) participants.
Among the study population, 21 (36.84%) patients underwent transfusion in antepartum period, 6 (10.52%) in intrapartum period, and 30 (52.64%) in their postpartum period.
Among the study population, 48 (83.93%) participants carried viable pregnancy, 6 (10.71%) participants had ruptured ectopic pregnancy and 3 (5.3%) participants had incomplete miscarriage.
Among the study population, 15 (40.5%) participants had a normal vaginal delivery, 3 (8.15%) participants had an operative vaginal delivery and 18 (51.35%) participants had a cesarean section.
Among the study population of 57 participants, few patients had more than one indication for transfusion, and all the indications for such patients were considered for analysis. The most common indication was PPH followed by anemia complicating pregnancy. Indications of blood transfusion in our study are listed in (Table 2).
Indication of transfusion | Frequency | Percentages |
---|---|---|
Postpartum hemorrhage | 23 | 40.35% |
Anemia | 21 | 36.84% |
Antepartum hemorrhage | 7 | 12.3% |
Ectopic pregnancies | 5 | 8.77% |
Abortions | 3 | 5.26% |
Hypertensive disorders of pregnancy | 8 | 14.04% |
Obstetric hysterectomy | 1 | 1.75% |
DIC | 1 | 1.75% |
Gestational thrombocytopenia | 2 | 3.51% |
Medical disorders complicating pregnancy | 5 | 9.43% |
DISCUSSION
General information regarding obstetric admissions and events in our study period are listed in Table 3.
General data | Numbers |
---|---|
Obstetric admissions | 2,375 |
Total deliveries | 2,097 |
Cesarean deliveries | 872 |
First trimester bleeding | 176 |
Patients requiring transfusion | 57 |
The current study shows the incidence of transfusion rate of 2.4% (Table 4), which is closer to the incidence given by Chawla et al.5 and Bangal et al.8 Any incidence between 1 and 5% may be considered as low and between 6 and 20% as a high rate for discussion purpose. In the current study thought the transfusion rate is low, but a little higher as per the study by Chawla et al. 5 The possible explanation with its comparison is that their study was conducted in a closed group of educated people involving families of armed forces.
Study | Incidence of transfusion rate (%) |
---|---|
Current study | 2.4% |
Chawla et al.5 | 1.3% |
Bangal et al.8 | 5.33% |
RI Anorlu et al.11 | 14.1% |
The current study shows a lesser rate of transfusion compared with the study by Bangal et al.8 and RI Anorlu et al.11 The possible explanation would be that our study area involves a closed urban railway population with easy availability of health services and antenatal care. Good counseling given during their antenatal visit and good doctor–patient relationships make them approach early for any obstetric problem and so high-risk obstetric condition is diagnosed well in time.
In the study done by Bangal et al.8 at a Rural Medical College in Maharashtra, most patients required blood transfusion for emergency indications like obstetric hemorrhage and many patients had severe nutritional anemia coming from a rural setup. During their study period, they also had study participants who suffered excessive blood loss intraoperative, which needed an emergency blood transfusion and by which they were able to save many lives. These could be the probable reason for their study having a higher transfusion rate compared with ours.
In the study done by RI Anorlu et al. 11 an appreciable number (54%) could have been avoided, as they had many preventable determinants for their transfusion. Provision of hematinics, effective malaria chemoprophylaxis, and treatment for helminthic infections at antenatal clinics would have reduced the prevalence of anemia in pregnancy which in turn would have reduced the transfusion rate for anemia as an indication. Also, their relative higher cesarean rate is found to be the most common determinant for higher blood transfusion in their study.
Primigravida vs multigravida: The incidence was more common among multiparous women, especially in the last trimester, which was similar to the study done by Chawla et al.5
Vaginal delivery vs cesarean section: The incidence was higher (51.35%) among those delivered through cesarean section which was similar to the study done by RI Anorlu et al.11 (68.8%). This can be explained on the basis that cesarean section by itself increases the risk of excessive loss of blood. Other confounding factors include preoperative anemia, a previous cesarean section with adhesions, increasing parity, skills of the surgeon, the indication and type of cesarean section, and the presence of other related comorbidities or medical disorders.
Timing of transfusion: Majority had a transfusion in their postpartum period (59.65%) and intrapartum period (9%), which is similar to the study done by Fazal et al.12 (73%). This is explained based on the most common indication of transfusion, being PPH which occurs in the postpartum period.
INDICATIONS OF TRANSFUSION
From our present study, the most common indication was PPH followed by anemia complicating pregnancy (Table 5) which is similar to the studies done by Chawla et al.5 Patel et al.13 and Anjali et al.14 All or most of the studies conducted have shown PPH especially uterine atony as the main culprit or the scourge followed by anemia complicating pregnancy. The two main factors which contribute to maternal mortality and morbidity in developing countries are major obstetric hemorrhage and anemia in pregnancy, which is similar to the studies done by Patel et al. and Anjali et al.13,14
Indication of transfusion | Present study | Chawla et al.5 | Fazal et al.12 | Bangal et al.8 |
---|---|---|---|---|
Postpartum hemorrhage | 40.35% | 50% | 23% | 10.8% |
Anemia | 36.84% | 25% | 27% | 37.2% |
Antepartum hemorrhage | 12.3% | 15.7% | 48.2% | 25.9% |
Ectopic pregnancies | 8.77% | – | – | 5.03% |
Abortions | 5.26% | – | – | 2.9% |
Hypertensive disorders of pregnancy | 14.04% | – | 9.2% | – |
Obstetric hysterectomy | 1.75% | – | – | 0.79% |
DIC | 1.75% | – | – | – |
Gestational thrombocytopenia | 3.51% | – | 0.9% | – |
Medical disorders complicating pregnancy | 9.43% | – | 4.5% | 1.72% |
HELLP syndrome | – | 9.3% | 6.9% | – |
Uterine inversion | – | – | 6.9% | – |
Amniotic fluid embolism | – | – | 0.4% | – |
In the study done by Fazal et al.,12 the most common indication has been classified based on the timing of transfusion and represented separately. In the antenatal period, anemia was their most common indication. The most common indication for transfusion in the peripartum period was abruption, placenta previa, and atonic PPH in decreasing order. Thus, in contrast, this study has shown a higher rate of transfusion for antepartum hemorrhage, as their study population involved patients with placenta previa and abruption placenta more than those who had PPH.
LIMITATIONS OF THE STUDY
There were no established criteria for initiating transfusion and most of the time decision was taken based on experts opinion and hematological lab parameters. Methods to minimize the requirement of blood transfusion has not been studied.
CONCLUSION
Thus, 2.4% of all patients from our center had blood and blood component transfusions during the study period. Postpartum hemorrhage followed by anemia complicating pregnancy is the commonest cause for the need for transfusion among women admitted for obstetric and postnatal care.
ORCID
Vinod Kumar C https://orcid.org/0000-0001-8186-2304
Divya Ramalingam https://orcid.org/0000-0002-3396-2543
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