Enhancing Patient Blood Management in Pregnancy at [INSERT LOCAL HOSPITAL NAME]

 
Disclaimer: This presentation has been designed for UK Healthcare Trusts using
guidelines available by February 2018. If you wish to use this presentation for your
own trust, please make any changes necessary to comply with your local guidelines,
and ensure the references used are still valid at the date you are training.
 
Please note, this presentation follows the local guidance in the Trust it was first
designed for, which involved taking a haematinic screen in the first instance of
anaemia in pregnancy.
 
Current national guidance states that iron deficiency anaemia in pregnancy can be
confirmed by administering a trial of oral iron in microcytic or normocytic anaemia
(unless the woman is know to have a haemoglobinopathy).If this is your local policy
you will need to edit the slides accordingly.
 
 
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Bringing Patient Blood Management to Maternity at
[INSERT LOCAL HOSPITAL NAME HERE]
 
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PBM is an evidence
based, multi-disciplinary
approach to optimising
the care of patients who
may need a transfusion
 
https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-
committee/patient-blood-management
 
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Patient Benefit
 
Blood Supply Sustainability
 
Cost to the NHS
 
https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-
committee/patient-blood-management
 
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Anaemia in pregnancy affects more than 56 million women globally
 
 
Iron deficiency in pregnancy is a well known risk for adverse maternal and foetal outcome
 
 
Correction of anaemia, even late in pregnancy, may reduce these adverse events
 
 
 
 
Other options to use PBM include the appropriate use of cell salvage for caesarean sections
 
 
 
 
 
Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005, Mc Lean et al, Public Health Nutrition: page 1-11
 
 
 
 
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?
% of women were anaemic at booking
 
?
% of women were anaemic at 28 weeks
 
?
% of women were anaemic pre delivery
 
?
% of women were anaemic post delivery
 
?
% of women had a transfusion
 
?
% of women were prescribed oral iron post delivery
 
?
% of women who had a caesarean section had a EBL of 500 ml or more
 
 
? = replace with local hospital data
 
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Review Hb and thalasaemia screen
at booking
 
If Hb result of <110g/l add on a
haematinics screen
 
Check patient history to find out if
they’ve ever had oral iron before and
if it was effective
 
 
 
Offer empirical trial of oral iron –
ferrous sulphate 200mg tds
 
Educate the women about the most
effective way of taking oral iron, and
encourage them to seek further
advice if they suffer from side effects
 
Check Hb 4 weeks after they start
oral iron, an increase  of 20g/L can
be expected.
 
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
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Women with multiple pregnancy
should have an additional FBC at 20-
24 weeks
Check patient history to find out if
they’ve ever had oral iron before and if
it was effective
Offer empirical trial of oral iron –
ferrous sulphate 200mg tds
If Hb <105g/L, schedule haematinics
screen to confirm iron deficiency
 
 
 
Educate the women about the most
effective way of taking oral iron, and
encourage them to seek further advice if
they suffer from side effects
 
Check Hb 4 weeks after they start oral
iron, an increase  of 20g/L can be
expected.
 
If Hb doesn’t improve after 4 weeks,
discuss with women. If there is
compliance with taking oral iron, or
compliance can’t be improved, refer for
IV iron
 
 
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
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If Hb <105g/dl, schedule haematinics screen to confirm iron deficiency
 
If iron deficiency is confirmed, refer directly for IV iron
 
 
 
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
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RCOG Green-top guidelines state that oral iron should be the preferred
first line treatment for iron deficiency
 
However,  parental iron is indicated if the women is approaching term
and there if insufficient time for oral supplementation to be effective
 
 
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
 
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As well as if the patient has iron deficiency anaemia and is >34 weeks, IV
iron may also be considered if:
 
There are significant symptoms of anaemia
Oral iron is not showing a response
Anaemia is severe (Hb <70g/L)
 
In these cases, the woman should be referred to secondary care.
 
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The first trimester
During cases of sepsis (but can be given post sepsis)
Chronic liver disease
Iron overload or haemochromatosis
 Known serious hypersensitivity to any parenteral iron products
Non iron deficiency anaemia
 
 
 
 
The risk is enhanced for patients with
known allergies including drug
allergies, including patients with a
history of severe asthma, eczema or
other atopic allergy
 
There is  an increased risk of
hypersensitivity reactions to parenteral
iron complexes in patients with
immune or inflammatory conditions
(e.g. systemic lupus erythematosus,
rheumatoid arthritis).
 
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Contact the woman’s obstetrician for advice
 
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Patient Blood Management (PBM) plays a crucial role in optimizing care for pregnant women, particularly in addressing iron deficiency anaemia. This presentation highlights the importance of PBM, the impact of anaemia in pregnancy, and relevant audit results to guide healthcare trusts in improving maternal outcomes. Recommendations for implementing PBM strategies tailored to the local setting are emphasized.


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  1. Disclaimer: This presentation has been designed for UK Healthcare Trusts using guidelines available by February 2018. If you wish to use this presentation for your own trust, please make any changes necessary to comply with your local guidelines, and ensure the references used are still valid at the date you are training. Please note, this presentation follows the local guidance in the Trust it was first designed for, which involved taking a haematinic screen in the first instance of anaemia in pregnancy. Current national guidance states that iron deficiency anaemia in pregnancy can be confirmed by administering a trial of oral iron in microcytic or normocytic anaemia (unless the woman is know to have a haemoglobinopathy).If this is your local policy you will need to edit the slides accordingly.

  2. IRON DEFICIENCY TREATMENT IN PREGNANCY Bringing Patient Blood Management to Maternity at [INSERT LOCAL HOSPITAL NAME HERE]

  3. WHAT IS PATIENT BLOOD MANAGEMENT? PBM is an evidence based, multi-disciplinary approach to optimising the care of patients who may need a transfusion https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion- committee/patient-blood-management

  4. WHY DOES PBM MATTER? Patient Benefit Blood Supply Sustainability Cost to the NHS https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion- committee/patient-blood-management

  5. HOW CAN PBM HELP OUR WOMEN? Anaemia in pregnancy affects more than 56 million women globally Iron deficiency in pregnancy is a well known risk for adverse maternal and foetal outcome Correction of anaemia, even late in pregnancy, may reduce these adverse events Other options to use PBM include the appropriate use of cell salvage for caesarean sections Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993 2005, Mc Lean et al, Public Health Nutrition: page 1-11

  6. AUDIT RESULTS FOR Local Hospital ?% of women were anaemic at booking ?% of women were anaemic at 28 weeks ?% of women were anaemic pre delivery ?% of women were anaemic post delivery ?% of women had a transfusion ?% of women were prescribed oral iron post delivery ?% of women who had a caesarean section had a EBL of 500 ml or more ? = replace with local hospital data

  7. FIRST TRIMESTER Offer empirical trial of oral iron ferrous sulphate 200mg tds Review Hb and thalasaemia screen at booking Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects If Hb result of <110g/l add on a haematinics screen Check patient history to find out if they ve ever had oral iron before and if it was effective Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected. RCOG Greentop Guidelines Blood Transfusion in Obstetrics May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

  8. WEEKS 13-34 Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects Women with multiple pregnancy should have an additional FBC at 20- 24 weeks Check patient history to find out if they ve ever had oral iron before and if it was effective Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected. Offer empirical trial of oral iron ferrous sulphate 200mg tds If Hb <105g/L, schedule haematinics screen to confirm iron deficiency If Hb doesn t improve after 4 weeks, discuss with women. If there is compliance with taking oral iron, or compliance can t be improved, refer for IV iron RCOG Greentop Guidelines Blood Transfusion in Obstetrics May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

  9. AFTER 34 WEEKS If Hb <105g/dl, schedule haematinics screen to confirm iron deficiency If iron deficiency is confirmed, refer directly for IV iron RCOG Greentop Guidelines Blood Transfusion in Obstetrics May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

  10. STRAIGHT TO IV IRON AFTER 34 WEEKS?! RCOG Green-top guidelines state that oral iron should be the preferred first line treatment for iron deficiency However, parental iron is indicated if the women is approaching term and there if insufficient time for oral supplementation to be effective RCOG Greentop Guidelines Blood Transfusion in Obstetrics May 2018

  11. When else might IV iron be used in pregnancy? As well as if the patient has iron deficiency anaemia and is >34 weeks, IV iron may also be considered if: There are significant symptoms of anaemia Oral iron is not showing a response Anaemia is severe (Hb <70g/L) In these cases, the woman should be referred to secondary care. Pavord et al (2012) UK guidelines on the management of iron deficiency in pregnancy British Journal of Haematology , 158 , 588-600

  12. WHEN IS IV IRON CONTRAINDICATED? The first trimester The risk is enhanced for patients with known allergies including drug allergies, including patients with a history of severe asthma, eczema or other atopic allergy During cases of sepsis (but can be given post sepsis) Chronic liver disease Iron overload or haemochromatosis There is an increased risk of hypersensitivity reactions to parenteral iron complexes in patients with immune or inflammatory conditions (e.g. systemic lupus erythematosus, rheumatoid arthritis). Known serious hypersensitivity to any parenteral iron products Non iron deficiency anaemia

  13. NOT SURE IF IV IRON IS APPROPRIATE? Contact the woman s obstetrician for advice

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