Patient blood management and transfusion in gynaecology

It is 04:15 on labour ward. A grand multip has just had a precipitate vaginal birth and the uterus is atonic. The drape is filling, the EBL is already 1500 mL, and the anaesthetist is calling for help. You are the registrar. The next ten minutes decide whether you activate the massive transfusion protocol and the WOMAN window, or whether you fall behind the curve. This topic is the rehearsal for both: the elective preop optimisation that prevents the crisis, and the crisis response that gets the patient home alive.^[13][14][18]

Overview and definition

Patient blood management is the evidence-based, multidisciplinary approach to optimising the management of patients who may need transfusion. The three-pillar framework, internationally endorsed by WHO (2010), is the basic science. ^[1]

• Pillar 1 — Optimise erythropoiesis. Detect and treat anaemia preoperatively (iron deficiency, renal disease, anaemia of chronic disease); iron infusion and EPO; nutritional optimisation. ^[1]
• Pillar 2 — Minimise blood loss. Surgical technique, antifibrinolytics (tranexamic acid), intraoperative cell salvage, anaesthetic technique (normothermia, controlled hypotension where indicated), meticulous haemostasis. ^[1][6]
• Pillar 3 — Optimise tolerance of anaemia. Restrictive transfusion threshold; optimise cardiac output, oxygen delivery, 2,3-DPG shift; minimise iatrogenic blood loss (phlebotomy). ^[1][2]

Anaemia definitions (WHO):

• Non-pregnant women: Hb under 120 g/L.
• Pregnant women: Hb under 110 g/L.
• Severity: mild 100–119 g/L, moderate 70–99 g/L, severe under 70 g/L.^[17]

The clinical picture is graded on the same volume and physiology basis as postpartum haemorrhage; the silent same thing: the decompensation trails the worsening by hours, and the eyeball and the pulse predict the outcome before the number does. ^[1][13]

^{[12] [17] [12] [17]}

References21ShowHide

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