Implementation of a patient blood management programme in obstetrics: let’s do it!

Patient Blood Management (PBM) consists in the timely application of evidence-based medical and surgical procedures aimed at maintaining haemoglobin concentration, optimising haemostasis, and minimising blood loss to improve patients’ outcomes^1–3. According to this definition, the approach to PBM is multidisciplinary and addressed to each individual in whom significant blood losses are expected and where transfusion of blood products is part of the established treatment⁴. The PBM patient-centred model is based on three pillars: 1) optimising the endogenous erythropoiesis; 2) minimising bleeding and blood loss; and 3) optimising the physiological reserve of anaemia. It typically includes both transfusional and non-transfusional measures⁵.

Although a PBM programme is best known in the perioperative setting, particularly in patients undergoing elective major surgical procedures^6–14, it can also be applied to any procedure likely to result in excessive bleeding requiring the use of blood products. A dramatic example is offered by postpartum haemorrhage (PPH), one of the most important obstetric emergencies¹⁵. Although over the last decades mortality rates from PPH have greatly declined in the developed world, it remains a leading cause of death elsewhere¹⁶. A recent systematic analysis from the World Health Organization (WHO) reported that PPH accounts for almost one-fifth of maternal deaths worldwide, ranging from 8% of all maternal deaths in developed regions to nearly 30% in East Asia and North Africa¹⁷. In a recent population-base cohort study conducted in South Asia and sub-Saharan Africa, obstetric haemorrhage was the most common cause of maternal deaths¹⁸. In spite of the therapeutic advances made in its management^19,20, massive PPH remains a life-threatening condition, and one of the most difficult challenges for the obstetrician and gynaecologists.

In this scenario, in the current issue of Blood Transfusion, Muñoz and Colleagues²¹ have published a consensus statement on the prevention and treatment of PPH. One of the strengths of this report is that the recommendations included are the result of the close collaboration between the most important societies in this field, i.e. the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). This, along with the rigorous method adopted (the GRADE system), makes this publication one of great scientific importance. Another important feature of this consensus paper is its multidisciplinary approach, having been developed by physicians experts in the various disciplines involved in the complex management of PPH (i.e., obstetrics, anaesthesia, haematology, and transfusion medicine). The resulting document is very complete, very up-to-date, and of great practical value. In particular, all the various causes involved in the aetiology of PPH, and the related measures to adopt for PPH prevention and treatment, are carefully analysed.

In conclusion, we are strongly convinced that this paper will be an important tool in daily clinical practice and we recommend that it be adopted by every Obstetric Unit to implement effective management of this severe obstetric complication.