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Hemoglobin-Based Oxygen Carriers: Not Enough for a Pregnant Jehovah’s Witness Patient and the Lessons Learned
Abstract Number: SU-94
Abstract Type: Case Report/Case Series
Introduction: Jehovah’s Witnesses are a subset of the Christian religion whose interpretation of lines from the bible lead them to prohibit the use of whole blood products and major blood fractions including red blood cells, white blood cells, platelets, and plasma. Studies report varied rates of maternal death from postpartum hemorrhage in Jehovah’s Witnesses to be somewhere between 44 (1) and 130 (2) times that of women who accept blood products. After the death of a Jehovah’s Witness obstetric patient, our institution undertook an analysis of points of prevention and created a more proactive prenatal and intrapartum care pathway for patients declining blood products.
Case: A G2P1 Jehovah's Witness patient with morbid obesity and anemia (hemoglobin of 10.4mg/dl) who had a prior cesarean section presented to labor and delivery at 40 and 5/7th weeks gestation with spontaneous rupture of membranes. Her prenatal care had been provided by a certified nurse midwife and the patient was non-adherent to ferrous sulfate supplementation. The decision for cesarean section was undertaken based on a low-predicted success rate of a vaginal birth after cesarean. Preoperatively, the patient refused all blood products. Intraoperatively, significant adhesions and inability to deliver the baby necessitated a high transverse and vertical uterine incision leading to an estimated blood loss of 2L. Due to ongoing post-partum hemorrhage with a hemoglobin of 6.9mg/dl, a left uterine artery embolization was performed. Post intervention, the patient was transferred to the surgical intensive care unit and found to have a hemoglobin of 1.6mg/dl. Intensive care strategies included decreasing oxygen consumption and iatrogenic blood loss and the compassionate use of experimental hemoglobin-based oxygen carriers. However, the patient ultimately experienced marked acidosis with vasopressor-resistant cardiovascular collapse and death.
Discussion: A root-cause analysis was undertaken and while there were multiple aspects of the patient’s care that were beyond our control, a number of recommendations were made for future care. A 10-point plan was developed with an understanding of the Jehovah’s Witnesses’ principles of blood usage and with a goal of improving their understanding of the risks of potential acute, large volume blood loss that is inherent in obstetrics. Six points focus on the prenatal period with an early multidisciplinary team approach to patient education, optimization and decision making. Two additional points focus on intraoperative techniques to mitigate blood loss. The two final points focus on the availability of Radiology and the use of Anesthesiology to monitor and stabilize the patient in the immediate postoperative period. Our hope is that with the implementation of this plan, future morbidity and mortality can be reduced.
1. Singla AK. Am J Obstet Gynecol. 2001 Oct: 893-5.
2. Van Wolfswinkel ME. BJOG. 2009 Jul: 1103-8.