Dr Catherine FlynnConsultant Haematologist

CWIUH

Patients who Decline Blood Products:-Haematological Aspects of Care

Bloodless Labour and Delivery in CWIUH!

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Total deliveries

8500 deliveries in 2009, 2.5% transfused

2.5%

97.5%

Multidisciplinary Communication

Incidence of JW in Ireland

6.5 million Jehovah’s Witnesses in 235 countries worldwide and about 150 000 in Great Britain and Ireland. Estimated 5,000 Jehovah's Witnesses in Ireland

Maternal Morbidity in JW

Mount Sinai study (Singla et al 2001)Netherlands Study (Van Wolfswinkel et al 2009)

2008 Report of Jehovah's Witnesses Worldwide

Peak Witnesses in in 2007 (>140 000)Brazil

Democratic Republic of CongoGermany

ItalyJapanMexicoNigeria

PhilipinesRussiaUkraineZambia

Co existent Hb Disorders

Van Wolfswinkel et al 2009 BJOGNetherlands study 1 JW patient with sickle cell disease

Whole Blood

Red Cells White Cells Platelets Plasma

Oxygen therapeutics**Products in development

Interferons*

Interleukins**Recombinant Products available

Platelet Substitutes**Products in development

Clotting Factor Concentrate* (*VIIa,VIII,IX available)

Prothrombin Complex Concentrate

Fibrinogen

Albumin ±

Immune Globulins

UNACCEPTABLE

PERSONAL DECISION

‘Meeting the clinical challenge of care for Jehovah’s Witnesses’

Bodnaruk et al Trans Med Revs 2004

Platelets in additive solution

Optimisation of Haematological Status of Mother

INTRAPARTUMANTEPARTUM POSTPARTUM

Ante-partum

Identify the patient early and discuss optionsInvolve senior peopleIdentify and investigate co-existent risk factors for anaemia/bleedingConsider stopping warfarin/aspirin/clopidrogelMinimise phlebotomy and use paediatric blood tubes for laboratory studiesEstimate bleeding risk (placental position/previous pregnancies)

Define Acceptable Treatment for every PatientPharmacological agents that do not contain

blood productsTransexamic acid/ DDAVP/ Recombinant factor concentratesHaematinics and Growth factorsIron/albumin free erythropoietinSynthetic oxygen carriersNon blood volume expanders

Transfusion Treatment PlanTreatment AcceptPrimary Blood ComponentsRed Cells Yes No

Apheresis Platelets Yes No

Minor FractionsSolvent Detergent Plasma/ Octoplas Yes No

Washed Platelets in Platelet Additive Solution Yes No

Blood ProductsFibrinogen Yes No

Fibrin Glue Yes No

Prothrombin Complex Yes No

Immunoglobulin Yes No

Recombinant Clotting FactorsFactor VIIa Yes No

Factor VIII or IX Yes No

Discuss Alternative Treatment Options

Iron (PO or IV)ErythropoietinTranexamic AcidRecombinant Blood Products

Erythropoietin and Blood Conservation

Albumin free erythropoietin (rHuEPO) enhances erythopoiesisNeoRecormon (Roche) epoetin beta Aranesp(Amgen) darbepoetin alfa

Multiple case reports, few trials

Time to start treatmentDosagesRoute of AdministrationTreatment Duration

Most reported cases use adjunctive iron/folic acid/Vit B12

Variable

Erythropoiesis

Copyright restrictions apply.

Price, S. et al. Anesth Analg 2005;101:325-327

Haematological Variables During admission

Intrapartum/Post Partum

Anaesthetic/Surgical optionsKeep warm, normalise pH as platelets and coagulation factors less functionalConsider positionPrompt oxytoxicsAntifibrinolytics (tranexamic acid/aprotonin)Topical Fibrin Glue (contains a blood fraction)

Antifibrinolytic agentsCyklokapron / Tranexamic acidPotent competitive inhibitor of the activation of plasminogen to plasmin. No evidence in animal studies of a teratogenic effect. Use in pregnant woman is limited/ crosses the placenta A synthetic derivative of the amino acid lysine with antifibrinolytic activity. With strong affinity for the five lysine-binding sites of plasminogen, tranexamic acid competitively inhibits the activation of plasminogen to plasmin, resulting in inhibition of fibrinolysisLonger half-life/ ten times more potent and less toxic than aminocaproic acid

Tranexamic acid/ Cyclokapron

Meta-analysis comparing tranexamic acid with no treatment.

3 major trials involving 461 participants

Transexamic acid versus no treatment and blood loss post delivery

No mortality data

A single dose of 1 gram of tranexamic acid given intravenously

Tranexamic acid may reduce blood loss in post partum haemorrhage

Ferrer et al ,BMC Pregnancy and Childbirth 2009

World Maternal Antifibrinolytic Trial

The WOMAN trial is a large, international, randomised, placebo controlled trial. http://www.thewomantrial.Lshtm.ac.uk.

Tranexamic Acid for the Treatment of Postpartum Haemorrhage: An International Randomised, Double Blind, Placebo Controlled Trial

Recombinant Blood Products

BenefixAdvateFactor VIIa

Options

Identification of the case and optimisation of haematological status of the motherOptimisation of 3rd stage of labourPrompt surgical intervention if necessaryOther agents haematinic support/erythropoiesis stimulants/antifibrinolytics/recombinant blood products

VIIa/Novoseven

VIIa/Novoseven

Limited to the site of tissue injury and tissue factor exposure. Useful in the obstetric setting where there is often bleeding from a large raw area of exposed tissue. Action of rFVIIa is dependant on the presence of adequate numbers of circulating platelets and adequate fibrinogen concentration.

rFVIIa in major obstetric HaemorrhagerFVIIa should be considered in major obstetric haemorrhage

A dose of 90 μg/kg is recommended

Use of rFVIIa should not be seen as an alternative to surgical haemostasis or correction of coagulopathy with blood products.

Before administration of rFVIIa, the following laboratory indices are desirable; –Prothrombin time < 1.5 × upper limit of normal –Fibrinogen > 1.0 g/L–Platelet count > 50 × 109/L

A pH > 7.1 is also desirable for optimal effect.Bomken et al Obstet Gynecol Int. 2009: 364843.

Post Haemorrhage

Oxygen and erythropoietin 300IU/kg x3 per weekShortens lag period of erythropoiesis and accelerates haemoglobin recoveryIron supplementation essential

Oral iron is slow and unreliableIV iron (Iron Sucrose) (Venofer) 200mg x3/weekAugment with B12 and folic acid

Hyperbaric Oxygen

Novel Alternatives

Haemoglobin-based oxygen carriersPerfluorocarbons, Hyperbaric oxygen