H & H

Specialties Ob/Gyn

Published

I am five weeks into my orientation in labor and delivery. I have an ER background as well as cardiac stress testing and occupational health. I was able to witness a spontaneous lady partsl delivery yesterday with a hemorrhage afterwards the patient's hemoglobin was 11.6 prior to delivery. The next hemoglobin that was drawn around five hours after delivery was a nine. Today the patient passed the baseball size clot and her hemoglobin is 7.6. The patient denies dizziness but she is very pale she is very tachycardic at about 118 to 140. I feel like this patient should be receiving blood products. How old below does your obstetrical floor let the H&H get before transfusing!?

You know, I was just thinking too- the mom is a primip and trying to diligently breast feed. They were talking about the baby losing weight and them having to stay longer---ahhhh!!! I can feel the critical thinking chains tightening :)

Specializes in Pedi.
Dizziness, lethargy, inability to get out of bed. That kind of thing. It's been my experience that OB docs have a much higher threshold for allowing low H&H, where in another department, they'd be freaking out. You have to remember that in most cases, you're seeing healthy young women who can easily bounce back from blood loss and/or low H&H. Plus, in most cases, you're already dealing with some dilutional anemia (which is why "anemia" is defined differently in pregnant women than in the rest of the population).

Even in oncology where patients aren't going to bounce back much on their own, we don't transfuse until the Hgb is

With the patient continuing to pass baseball sized clots and her H &H continually dropping, I was concerned (especially coupled with the HR). BUT-- I see that a bedside ultrasound, vigilant monitoring of her symptoms and understanding that young healthy women are more apt to bounce back quicker are important things to consider. If after receiving all of the medications she did, she had not passed anymore clots and her H&H was stabilizing, I wouldn't have been as concerned.....the bedside ultrasound seems most important to determine if there is indeed retained placenta.

[h=1]Guidelines Define Hemoglobin Levels for Transfusion[/h] Free Medscape registration required to read article--excellent professional site. Karen

I am truly grateful for all of this discussion- it's really helping me to get a good idea about these kinds of situations....has anyone ever had to transfuse for hemorrhage? What was the situation?

The link won't let you guys read- so the above link is the resource and here's the article:

March 26, 2012 — Red blood cell (RBC) transfusions in most hospitalized patients should be performed based on "restrictive," rather than "liberal," hemoglobin levels (7 - 8 g/dL), according to new clinical guidelines from the American Association of Blood Banks (AABB).

The new guidelines are based on a systematic literature review and were formulated by a multinstitutional panel of 20 experts led by Jeffrey L. Carson, MD, from the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School in New Brunswick, and were published online March 26 in the Annals of Internal Medicine.

"Many small trials have addressed the question of optimal use of RBC transfusions," Dr. Carson and colleagues write. "Recently, 2 additional trials were published that expanded by 30% the number of patients included in the evidence base of transfusion trials. Thus, it is timely to reexamine the data and provide guidance to the medical community," the authors write.

The new guidelines outline 4 major recommendations based on various levels of evidence. The authors conducted a systematic review of 19 randomized clinical trials (including 6264 patients) evaluating transfusion thresholds. Trials were published from 1950 to February 2011.

The first recommendation is adherence to a restrictive transfusion strategy (7 - 8 g/dL) in hospitalized, stable patients. This is classified as a "strong" recommendation based on high-quality evidence.

The second recommendation is that a restrictive strategy be used in hospitalized patients with preexisting cardiovascular disease with consideration of transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less. The authors describe this recommendation as "weak," with moderate-quality evidence.

The third recommendation is that the AABB cannot recommend either for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with acute coronary syndrome. The panel classified this as an uncertain recommendation, with very low-quality evidence.

The fourth recommendation is that transfusion decisions should be influenced by symptoms as well as hemoglobin concentration, although again, this was a weak recommendation with low-quality evidence.

According to the panelists, other guidelines have proposed that transfusion is generally not indicated when the hemoglobin concentration is above 10 g/dL, but is indicated when it is less than 6 to 7 g/dL. "However, none of these guidelines recommended a specific transfusion trigger," they write.

"n the current guidelines we explicitly used an evidence-based process that employed the [Grading of Recommendations Assessment, Development, and Evaluation (GRADE)] method," the authors note. "Although individual clinical factors are important, hemoglobin level is one of the critical elements used daily by physicians in the decision to transfuse. Thus, specific evidence-based recommendations on use of hemoglobin levels will help standardize transfusion practice," they conclude.

Transfusing Based on Hemoglobin Levels Alone "Insufficient"

In a related editorial, Jean-Louis Vincent, MD, from the Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Belgium, points out that "basing the decision to transfuse only on hemoglobin levels is insufficient."

He adds that he does "not believe that available evidence supports a fixed transfusion trigger. Rather, transfusion decisions need to consider individual patient characteristics, including age and the presence of [coronary artery disease], to estimate a specific patient's likelihood of benefit from transfusion."

He concludes, "The decision to transfuse is too complex and important to be based guided by a single number."

Support for the development of the guidelines was provided by the AABB in Bethesda, Maryland. Dr. Carson reports having a grant or grants pending from Amgen. Conflict-of-interest information for all authors is available on the journal's Web site. Dr. Vincent has disclosed no relevant financial relationships.

Specializes in Pedi.

I could open and read the article from the link just fine.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I am truly grateful for all of this discussion- it's really helping me to get a good idea about these kinds of situations....has anyone ever had to transfuse for hemorrhage? What was the situation?

Yes, there have definitely been times when we've had to transfuse. Generally they're in emergent code white situations with acute blood loss, rather than due to a low H&H. Situations where a woman has an EBL of 2000 and we had to place a Bakri (tamponade) or in the OR where a hyst is necessary to stop the bleeding. I do remember once when a woman came in 3-4 days PP with continued bleeding, and it turns out she still had the POC from a 12-week twin loss that didn't pass during the delivery. She went back for a D&C and then we gave her a unit of PRBCs.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I know I personally appreciate very conservative use of transfusing. I would not want blood unless it was necessary to save my life. It should generally be used as a last resort.

I could open and read the article from the link just fine.

When I clicked that link it only took me to a login page, not the article.

Yes there have definitely been times when we've had to transfuse. Generally they're in emergent code white situations with acute blood loss, rather than due to a low H&H. Situations where a woman has an EBL of 2000 and we had to place a Bakri (tamponade) or in the OR where a hyst is necessary to stop the bleeding. I do remember once when a woman came in 3-4 days PP with continued bleeding, and it turns out she still had the POC from a 12-week twin loss that didn't pass during the delivery. She went back for a D&C and then we gave her a unit of PRBCs.[/quote']

Ahhhhhh~ the most EBL I've seen in OB so far has been 900....your story puts everything into perspective. We do circulate and baby catch our own csections (of which I have seen two and they both did not have unusual EBLs), and both were routine according to the staff. I feel way better knowing all of this....it's good to hear the case scenarios and what is emergent and what isn't. I've been working through basic FHR monitoring and working on my NRP while orientating, so there has been lots of info to soak in. It's really great to talk things out....I just want to do the very best by all of these moms and babies...

Specializes in labor & delivery.

We recently had a pp patient with h/h below 7/20. Her only symptoms were slight dizziness and elevated heart rate. She looked good, was able to get up and walk around. All they did was giver her iron. No excessive bleeding was noted. I agree with Klone about being conservative about transfusing. I would not take blood except to save my life, either.

We recently had a pp patient with h/h below 7/20. Her only symptoms were slight dizziness and elevated heart rate. She looked good was able to get up and walk around. All they did was giver her iron. No excessive bleeding was noted. I agree with Klone about being conservative about transfusing. I would not take blood except to save my life, either.[/quote']

I'm glad to hear that this is common treatment and will not be so worried now :)

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