Reply on Recommendations for postpartum hemorrhage in women who decline blood transfusion

Lee and colleagues call attention to an important topic 1. Increasing evidence that bleeding and allogeneic blood transfusion are associated with adverse effects on clinical and economic outcomes 2 has prompted the development of blood conservation and patient blood management strategies by leading institutions 3. Lee and colleagues refer to bloodless surgery, which is the optimal and rigorous use of appropriate hemostatic, hematopoietic, and uterotonic pharmaceuticals, devices, and blood-conserving techniques to minimize blood loss, support perfusion and oxygenation, stimulate erythropoiesis, and optimize tolerance of anemia. Additionally, in the obstetric setting, thorough patient assessment, planning, and well-rehearsed team protocols are vital, especially for women who decline blood transfusion. It is also essential for the obstetrician to be able to identify the cause of postpartum bleeding and to initiate appropriate intervention without delay according to a well-planned and rehearsed course of action. Advance discussion of a woman's wishes should include the subject of potential hysterectomy, if postpartum hemorrhage cannot be controlled rapidly. The approach to the management of these women by Lee and colleagues is generally accepted by physicians with experience in managing such cases. Regarding the use of recombinant erythropoietin, Breymann et al. reported that in a randomized trial, recombinant erythropoietin at a dose of 300 units/kg/day for four consecutive days plus iron sucrose was more effective in ameliorating postpartum anemia than intravenous iron alone 4. An article on the worldwide need for education in nonblood management in obstetrics and gynecology was published in 1994 5. In the same year, the same author presented a poster at the XIV FIGO World Congress in Montreal, Canada, summarizing various available strategies for the prevention and management of hemorrhage and anemia in obstetrics 6. The reason for my recent letter to the AOGS 7 was to highlight recent developments and the ongoing worldwide need for education, especially for emergencies in limited resource settings, where there may be increasing numbers of women who decline blood transfusions for any one of a variety of reasons, and to stimulate further discussion of this subject. Lessons learned in the care of patients who have refused blood (such as cardiac surgery, orthopedics, critical care) have benefited many other patients 3. The surgical proposal in my letter to the AOGS is founded on the well-recognized first-aid principle, “Stop the bleeding as soon as possible,” 8 and the important but not always appreciated work of AbdRabbo 9.

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