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Patient Blood Management in obstetrics

Background. Patient blood management (PBM) in obstetrics is the timely application of evidence-based therapeutic and surgical concepts, aimed at maintaining hemoglobin concentration, optimizing hemostasis, and minimizing blood loss to improve clinical outcomes for the patient. 
Objective. To describe PBM in obstetrics. 
Materials and methods. Analysis of literature data on this issue. 
Results and discussion. Risk factors for increased blood loss include the history peculiarities (cesarean section, postpartum hemorrhage, rapid delivery), placenta previa, placenta accreta, multiple pregnancy, polyhydramnios, large fetus, comorbid conditions of the mother. The prevalence of postpartum anemia in 48 hours after delivery is about 50 % in Europe and up to 80 % in developing countries. The reasons for insufficient detection and correction of anemia and iron deficiency in the antenatal period include the lack of standardized examinations for iron deficiency and algorithms for its treatment, incomplete history, and misinterpretation of examination results. Most obstetric guidelines recommend screening for anemia in pregnant women only with a comprehensive blood test without ferritin. Early identification of anemia allows to eliminate it before entering the labor process. Ways to solve the problem of anemia in pregnant women and women in labor include the detection of iron deficiency before pregnancy or in its early stages, correction of iron deficiency with oral (first trimester) or intravenous (third trimester) drugs. In case of the increased blood loss during childbirth or abdominal delivery, rapid correction of iron deficiency with iron saccharate may be required. The consensus of the Network for the Advancement of PBM, Hemostasis and Thrombosis Prevention (NATA) recommends that maximum efforts must be made to treat iron deficiency anemia before delivery. Severe cases may require hospital settings. To eliminate individually calculated postpartum iron deficiency, it is recommended to use intravenous drugs (Sufer, “Yuria-Pharm”). After cesarean section, the aministration of uterotonics (oxytocin) is recommended. In women at increased risk of postpartum hemorrhage, the administration of tranexamic acid (Sangera, “Yuria-Pharm”) should also be considered. The WOMAN project (The World Maternal Antifibrynolytic) aimed to determine the effect of early administration of tranexamic acid on mortality, hysterectomy and other adverse effects of bleeding. About 20,000 women who received tranexamic acid or placebo were examined. Significantly lower bleeding mortality was observed with tranexamic acid (1.5 % vs. 1.9 % in the placebo group; p<0.045). It is recommended to enter the first dose of this drug as soon as possible (within the first 3 hours) from the beginning of bleeding, the second – in case of the effect absence of effect in 30 minutes. 
Conclusions. 1. PBM in obstetrics is the timely application of evidence-based therapeutic and surgical concepts aimed at maintaining hemoglobin concentration, optimizing hemostasis and minimizing blood loss. 2. Early identification of anemia allows to eliminate it before entering the labor process. 3. Ways to solve the problem of anemia in pregnant women and women in labor are the detection of iron deficiency before pregnancy or in its early stages, correction of iron deficiency with oral (first trimester) or intravenous (third trimester) drugs. 4. To eliminate postpartum iron deficiency, it is recommended to use intravenous drugs (Sufer). 5. In women at increased risk of postpartum hemorrhage, the administration of tranexamic acid (Sangerа) should also be considered.