Management of massive bleeding in a Jehovah’s Witness obstetric patient: the overwhelming importance of a pre-established multidisciplinary protocol

Introduction

Life-threatening massive bleeding is doubtlessly one of the biggest challenges in health care, especially in patients who reject allogeneic transfusion, such as Jehovah’s Witnesses. However, according to the principle of patients’ autonomy, our job is to accept their decision and provide them with the best possible assistance. We present a protocol for the management of massive post-operative bleeding successfully applied in a Jehovah’s Witness after a Caesarean section (CS).

Case report with results

A 37-year pregnant patient (39 weeks) presented in labour at our emergency area. Third trimester clinical and analytical data were normal (Hb 12.2 g/dL, platelets 168×10⁹/L), but she had had a previous CS. As she refused blood transfusion, she received verbal and written information about our bloodless surgery protocol during the pre-operative assessment, gave signed consent, and underwent urgent CS with spinal anaesthesia (Bupivacaine 0.5%, 2.2 mL + fentanyl, 10 mg). According to the intra-operative protocol, we administered cefoxitin 2 g and oxytocin 20 IU (5 IU in a bolus plus 15 IU in 100 mL saline). Intra-operatively, using continuous circuitry for cell salvage, 600 mL of shed blood were processed and 189 mL of packed red blood cells (RBC) reinfused through a leucocyte-depletion filter. Birth and delivery occurred uneventfully (neonate’s weight 3,200 g, Apgar score 10/10).

At the end of surgery, the patient was transferred to the post-anaesthesia recovery unit and then discharged to the ward 2 hours later. Eight hours after surgery, abundant vaginal bleeding and signs of hypovolaemic shock were observed, indicating the need for surgical abdominal exploration. The patient was transferred back to the theatre, where significant free fluid was not initially detected by abdominal ultrasound. Two venous lines (16 G and 14 G) were inserted and a first analytical control showed an Hb of 5.9 g/dL (Figure 1). As symptoms worsened, antibiotic prophylaxis and balanced general anaesthesia with sevoflurane 1–2% were established and an intrauterine balloon was implanted, according to our obstetric bleeding protocol (conservative approach)^1–2.

Figure 1.

Time-course of haemoglobin level during hospital stay.

The patient received seven doses of ferric carboxymaltose 1,000 mg iv (white arrows) and eight of epoetin alpha 40,000 IU sc (black arrows), plus folic acid 5 mg/day orally, during her stay in hospital.

PreOP: pre-operative; 2^nd OP: second operation due to post-operative bleeding.

As a new ultrasound examination verified a significant increase of intra-abdominal free fluid, an exploratory laparotomy was performed, with meticulous haemodynamic control (arterial) and administration of vasoactive drugs (central venous catheter). Noradrenaline 0.1–1 mg kg⁻¹ min⁻¹ was infused continuously to maintain a mean arterial pressure of 60 mmHg. Lung protective ventilation was implemented at a tidal volume of 400 mL, respiratory rate 14 breaths min⁻¹, positive end-expiratory pressure (PEEP) 6 mmHg, and fraction of inspired oxygen (FiO₂) 80% to maintain an oxygen saturation of 95%.

During the intervention, 6,000 mL of surgical field fluids (shed blood plus irrigation) were processed and 630 mL of packed red blood cells reinfused (always keeping the continuity of the circuit). Additionally, the patient received 3,000 mL of normal saline, 1,000 mL of lactated Ringer’s solution, and 1,500 mL of 4% succinylated gelatin. Administration of oxytocin 60 IU intravenous (iv), carbetocin 100 mg iv, methylergometrine 0.4 mg intramuscular, and tromethamine 250 mg intramyometrial proved unsuccessful in reversing the uterine atony.

As bleeding persisted, we went onto the next step of our protocol for management of massive bleeding without blood transfusion, administering fibrinogen concentrate 4 g, tranexamic acid 1 g, and desmopressin 20 IU, and replenishing plasma ions with calcium gluconate 0.7 g, magnesium sulphate 1.5 g, and bicarbonate 80 mEq. We continued with the administration of prothrombin complex concentrate 500 IU, and recombinant activated factor VII 5 mg, which also failed to halt the bleeding. Finally, the surgical team performed a subtotal hysterectomy with annexectomy and hypogastric artery ligation, which did, at last, arrest the bleeding.

After the intervention, the patient was transferred to the intensive care unit (ICU) with assisted ventilation, preserved diuresis and no need for vasoactive drugs, despite her Hb being 2.3 g dL⁻¹. During her stay in the ICU (29 days), she received ferric carboxymaltose 6×1,000 mg iv and epoetin alpha 8×40,000 IU sc (Figure 1), as well as folic acid 5 mg daily and goal-directed therapy antibiotics. The patient was discharged without sequelae 36 days after surgery.

Discussion

The favourable outcome of this case demonstrates how a multidisciplinary patient blood management protocol allows treatment of massive bleeding without blood component transfusions (Figures 2 and 3) thus observing the patient’s advance directives. As our hospital is a reference centre for treating patients who reject allogenic blood transfusion, from the very first contact and whenever feasible, the attending physician should refer such patients to the appropriate hospital team. Any professionals’ decision to refuse to be involved in the treatment of these patients should always be respected and accepted, provide assistance for the patient is guaranteed.

Figure 2.

Perioperative management protocol for patients refusing blood transfusion.

PACU: post-anaesthesia care unit; *see Figure 3.

Figure 3.

Algorithm for the classification and treatment of obstetric bleeding.

Thus, during the pre-operative consultation, competent patients receive sufficient verbal and written information about the benefits and risks of the different treatment options, allowing them to make a free choice. In this consultation, the patients also inform us (through a questionnaire) of their own wishes and values, including any advance directives, in the case of bleeding which requires intensive medical care, and sign the informed consent. All patients aged 16 and over are presumed, by law, to have the capacity to consent to treatment unless there is evidence to the contrary. To facilitate the management of regulatory and ethical issues, we have developed action protocols based on the patients’ legal decision-making capacity and type of surgical procedure (Table I). These multimodal protocols have been developed by a multidisciplinary team of anaesthesiologists, critical care specialists, surgeons, internists and haematologists, with the collaboration of the departments of regulatory affairs and quality control (Figure 2). We also recommend that the patients register their advance directives at the regional government office (Generalitat Valenciana)^3,4.

Table I.

Juridical and ethical issues of the management of patients who reject being treated with blood products in elective or urgent procedures 4–5. Manises General Hospital, Valencia.

Patient	Elective procedures	Urgent procedures
Of legal age or emancipated minor	Respect the patient’s wishes expressed at that moment or in advance directives.	Respect the patient’s wishes expressed at that moment or advance directives. If there are no advance directives or written legal document: inform the family, transfuse and inform the judge as soon as possible.
Minor >16 years old	Inform relatives or guardians. Respect the patient’s decision, if it is accepting the transfusion. In the case of rejecting the transfusion, inform the judge on duty. In the case of voluntary discharge, inform the judge and wait for a decision.	Inform relatives or guardians. Respect the patient’s decision, if it is accepting the transfusion. In the case of rejecting the transfusion, inform the judge on duty.
Minor <16 years old	The decision to accept the transfusion is made by the legal guardian. In the case of rejecting the transfusion, inform the judge on duty. In the case of voluntary discharge, inform the judge and wait for a decision.	The decision to accept the transfusion is made by the legal guardian. In the case of rejecting the transfusion, transfuse and inform the judge on duty as soon as possible.
Disability	Respect the patient’s wishes if they had been expressed before the disability. If there are no wishes, the decision to transfuse is made by the legal guardian. In the case of rejecting the transfusion, inform the judge on duty. In the case of voluntary discharge, inform the judge and wait for a decision.	Respect the patient’s wishes if they had been expressed before the disability. If there are no wishes, the decision to transfuse is made by the legal guardian. In the case of rejecting the transfusion: transfuse and inform the judge on duty as soon as possible.
Pregnancy		If the baby has not yet been born: transfuse in the case of an emergency and inform the court as soon as possible. Once the neonate is born: continue with the therapeutic measures available excepting transfusion, following the same statements as mentioned previously.

Obstetric patients who reject blood transfusion are considered at high risk and should ideally be seen prior to presentation in labour and delivery in order that the specific blood management protocol can be selected, taking into consideration that not all Jehovah’s Witnesses refuse all blood products and each case is different. Thus, the specific management protocol must be decided after ample discussion with the patient regarding which transfusion alternatives she could accept, who her surrogate will be, what information can be discussed with family members, which decisions can be kept private from family, etc.

For these patients, in addition to the appropriate pre-operative preparation (e.g., optimisation of Hb level, diagnosis and correction of defects of haemostasis), intra-operative cell salvage is recommended, if the patient accepts its use, taking into account two important strategies^5–7.

1. Use leucocyte-reduction filters in the reinfusion line of salvaged blood to avoid the transfusion of amniotic cells. Furthermore, although pulmonary embolism has not been described, it is recommended that a separate suction system is used to aspirate the amniotic fluid, as a preventive measure⁸.

2. Use a specific assembling procedure in Jehovah’s Witness patients, by connecting the salvaged blood reinfusion line to the patient at the beginning of the procedure and performing retrograde priming of the line, thus ensuring a closed circuit.

As the patient in this case report presented in labour, pre-operative optimisation was not possible. We, therefore, applied the intra- and post-operative parts of the protocol in which consulting teams from anaesthesiology, obstetrics and gynaecology, haematology, and critical care were involved, both during the acute events and during the prolonged recovery.

Treatment of massive bleeding proceeds as for other patients, but without blood components: provide volume resuscitation with goal-directed fluid replacement to restore an effective volaemia, maximise oxygen supply, and get effective haemostasis through pharmacological and/or surgical means.

Regarding oxygen supply, the contribution of plasma oxygen under normal circumstances is negligible. However, in the event of severe anaemia, hyperoxia may contribute to more than 50% of the oxygen consumed⁹. Therefore, protective lung ventilation with a high FiO₂ to attain a PaO₂>200 mmHg is recommended in these situations^10–11.

Finally, to improve responsiveness to vasoactive drugs and pro-coagulant treatment (fibrinogen, tranexamic acid, prothrombin complex, activated factor VII), it must be ensured that the plasma calcium levels are above 1 mmol/L and any acidosis is corrected^12–14. As platelet transfusions cannot be administered to these patients, correction of haemostatic derangements will be more difficult.

Conclusions

The therapeutic restriction imposed by a patient who rejects blood component transfusion may foster barriers to adequate treatment of episodes of massive bleeding. Thus, the availability of specific patient blood management protocols for these situations may facilitate physicians’ task and improve the patient’s safety and quality of assistance.