Management of pregnancy in a Jehovah s s Witness

Transcription

1 Management of pregnancy in a Jehovah s s Witness Cynthia Gyamfi Bannerman, MD Assistant Clinical Professor Division of MFM, Department of OB/Gyn Gyn, Columbia University Medical Center

2 Case report 34 y/o G4 11+ wks First prenatal visit P Ob Hx: : previous C/S x3, AAP x2, 3 rd elective repeat PSHx: : as above PMHx, PGynHx,, Family Hx negative NKDA

3 Case report Social Hx: : Jehovah s s Witness Refused all blood products Initial hematocrit=29% How do you proceed? Can/should you care for this patient?

4 Background

5 Background Founded in 1872 by Charles Russell Branched from 7 th Day Adventists Second coming of Jesus Christ has occurred in spiritual form Prediction of Armageddon Harrison BG. Visions of glory: a history and memory of Jehovah s Witnesses. New York: Simon and Shuster, 1978.

6 Background Literal translations of the bible Genesis 9 and Leviticus 17 one cannot eat the blood of life In 1945, interpreted to include the exchange of blood products

7 Background Lev. 3:1 7 It shall be a perpetual statute for your generations throughout all your dwellings, that ye eat neither fat nor blood.

8 Background Genesis 9:4 But flesh with the life thereof, which is the blood thereof, shall ye not eat.

9 Background Lev 17:10 And whatsoever man there be of the house of Israel, or of the strangers that sojourn among you, that eateth any manner of blood; I will even set my face against that soul that eateth blood,, and will cut him off from among his people.

10 Background

11 Background 1930 s, 1940 s: ban on vaccination, now vaccination is encouraged : 1980: encouraged to refuse organ transplants, calling it cannibalism ;; now applauded Will views on blood be next?

12 Background

13 Taken from tower to truth website* Considering the organization s track record on vaccinations and organ transplants, should a Jehovah s Witness stake his life, or his child s, on the reliability of the leaders' interpretations prohibiting blood transfusions? *Website for born again Christians converting cult members

14 Counseling Jehovah s Witnesses

15 Counseling First, try to establish your impartiality Different JW have different views Gyamfi, et.al.. Responses by pregnant Jehovah s s Witnesses on health care proxies. Obstet Gynecol, 2004;104: : Reviewed proxies from 1997 to completed proxies

16 Proxy responses New York State Health Care Proxy Approximately 50% accept some form of blood Percent Whole blood Blood products No blood Gyamfi, et.al. Obstet Gynecol, 2004

17 Counseling Are they high risk? Klapholz, Obstet Gynecol,, 1990: 1-2% of all pt on L+D require blood transfusion Singla, Am J Obstet Gynecol,, 2001: If they have a PPH, 44-fold greater risk for maternal mortality Massiah, Arch Gynecol Obstet,, 2006: Risk of mortality with PPH is 65-fold the national rate

18 How to Counsel Next, discuss the different forms to be filled out New York State Health Care Proxy # Departmental forms

19 Health Care Proxy Part One Health Care Instructions I am one of the Jehovah s s Witnesses I will not accept any homologous blood or stored autologous blood

20 Health Care Proxy Part I Health I Care Instructions Blood Fractions None All Some Epogen (albumin) Immunoglobulins (RhoGam) Clotting factors

21 Health Care Proxy Part I Health I Care Instructions Non-stored autologous blood Normovolemic hemodilution Intraoperative or postoperative blood salvage Cardiopulmonary bypass

22 Health Care Proxy End-of of-life Issues To prolong life Not to prolong life Other Part 2: Appointment of health care agent

23 Blood Products

24 Epogen Genetically engineered in 1989 for renal failure pts on dialysis Natural erythropoietin,, a glycoprotein produced by the kidneys, stimulates red blood cell production Erythopoietin increases fold Does not cross the placenta Epogen single- or multi-dose vials contain 2.5mg of albumin

25 Epogen Indications Chronic renal failure patients +/- dialysis HIV patients with anemia Cancer patients on chemotherapy Surgical candidates with anemia

26 Epogen Dosing U/kg sc 3 times per week 40,000 U sc/wk Decrease dose with increases of more than 1g/dL of hemoglobin in 2 weeks

27 Epogen Dosing T ½= = hours when given tid Up to 3xs longer in the weekly form Epogen=Procrit Procrit=epoetin alpha Therapeutic dose is U/kg tiw Responses are not likely to be noted prior to 2 weeks; maximal response by 6 weeks.

28 Dosing Healthy patients 40,000 u sc wkly Transferrin saturation should be at least 20% Ferritin at least 100 ng/ml

29 Starting Dose Epogen Response Hematocrit increase Points per day Points per 2 weeks 50 U/kg U/kg U/kg

30 Epogen Side Effects hypertension headache arthralgias nausea

31 Epogen Contraindications Uncontrolled hypertension Hypersensitivity to albumin Hypersensitivity to mammalian cell-derived products Pregnancy category C delayed C ossification in rats at 5xs the normal dose.

32 Darbepoetin alfa Longer acting form, 2001 Aranesp Dosing q2wk T 1/2 3 times as long Dosing: multiply weekly dose of Epogen x2, then use conversion chart Same efficacy Comes in a recombinant form

33 RhoGam Human Immune Globulin Each dose contains enough Anti-D D to suppress the immune response of 15 cc of Rh positive red blood cells Yes, this is a blood product!

34 Health Care Proxy Part I Health I Care Instructions Non-stored autologous blood Normovolemic hemodilution Intraoperative or postoperative blood salvage Cardiopulmonary bypass

35 Normovolemic Hemodilution Removal of whole blood in the immediate perioperative period Replacing this with crystalloid or colloid Removal of red cells results in optimal tissue perfusion shift of O 2 dissociation curve to right optimizing the O 2 carrying capacity Replace the whole blood once the major blood loss has resolved

36 Cell Saver Closed conduit where blood is filtered and returned to the patient Risks Rhesus isoimmunization Amniotic fluid embolism

37 Cell Saver and AFE One case report Jehovah s s Witness with HELLP syndrome Pre-op Hgb 7.1/ plt 48K Clinical evidence of DIC intra-op EBL was 600, 200 cc salvaged blood returned 10 minutes later cardiopulmonary arrest and death Autopsy never confirmed AFE

38 Cell Saver and AFE Exact cause of AFE is unknown Several studies to show leukocyte depletion filters can remove tissue factor and amniotic fluid from blood, less likely for fetal squames Bernstein, Anesth Analg,, 1997: : TF was removed completely after filtration Catling et.al,, Waters et.al: : reduction in amniotic fluid components, squamous cells, trophoblastic tissue

39 Cell Saver and AFE Catling,, BJOG, 2005 Theorectical risk of AFE has never been shown Cell saver underused in obstetrics Transfusion of fetal cells greater risk (if mother Rh neg) perform Kleihauer- Betkhe post op for RhoGam dosing

40 Other Techniques Controlled hypotensive anesthesia Sedation Muscular paralysis

41 Controlled hypotensive anesthesia Reduce MAP to 50mmHg Minimum required for tissue perfusion Decreases amount of arterial bleeding Risk: falsely ensure hemostasis

42 Sedation Used in conjunction with muscular paralysis Peri- and post-operatively operatively Decrease O 2 consumption

43 Recombinant Factor VII Synthetic blood product Developed for pts with Factor VII deficiency 272 women with PPH, largest case series, 85% reduction of bleeding Most common adverse event is VTE, 2.5% Literature VTE risk 1-2% 1 to 9.8%

44 The blood substitute No FDA approved blood substitute Ideally, volume expansion, high O 2 affinity Perfluorocarbons,, fold increase in O 2 affinity compared to H 2 O Stroma-free hemoglobin, phase III trials, causes hypertension, renal damage

45 Management during pregnancy Identify the patient! 0.4% of US 1.9% New Hampshire 1.0% New York State Watchtower Society annual report, 1998

46 Management during pregnancy Initiate discussion on potential complications requiring transfusion Review all components of the Health Care Proxy and other forms if applicable (should be done in consultation with MFM) PRIVATELY Make multiple copies: one for pt, one for office chart, one for L+D

47 First trimester Check baseline hemoglobin/mcv Initiate w/u if anemia is detected Start Fe, folic acid and Vit C as appropriate

48 Treating Fe deficiency anemia Best absorbed in duodenum and proximal jejunum Acidic environment, Vitamin C Do not take with food Do not take with antacids GI side effects increase with amount of elemental Fe

49 Treating Fe deficiency anemia Type of Fe Ferrous fumarate Amount of elemental Fe 106 mg Ferrous sulfate 65 mg Ferrous gluconate 28 to 36 mg

50 Treating Fe deficiency anemia Parenteral Fe Failure to respond Inability to tolerate po iron Non-compliance Fe loss > Fe intake

51 Treating Fe deficiency anemia Parenteral Fe IV (Dextran( can be IM) Iron dextran,, ~1% anaphylactic rxn Iron gluconate (Ferrlecit=125mg/dose), start with test dose Iron sucrose (Venofer( Venofer=100mg Fe/dose)

52 Second trimester Re-evaluate evaluate Fe stores Consider Darbepoetin Re-address proxy Goal hct>40% Discuss RhoGam if applicable

53 Third trimester Anesthesia consult Reassess hct and Fe stores Consider Darbepoetin

54 Proposed management Reevaluate hct at weeks If 40%, continue Fe qd with PNV If 35.0% to 39.9%, low risk, increase Fe to bid; high risk, consider Epogen (check Ferritin) Start at 45 mcg/kg x 2 wks, baseline BP, repeat in 1 week, recheck hct in 2 weeks Consult heme or MFM

55 Proposed management If Hct 30.0% to 34.9%, low risk, Fe bid to tid; ; high risk, Darbo should be encouraged If Hct <30%, strongly encourage Darbo

56 Postpartum hemorrhage Uterine massage, pitocin, methergine, hemabate, misoprotol Low threshold for hysterectomy.

57 Proposed management Need for MFM consultation Mandatory at many institutions Strongly encouraged with patients at high risk for bleeding, or for those with chronic medical problems Transfer care of pt if not comfortable

58 Legally speaking Mercy Hospital Inc. v. Jackson 26 wks, preterm labor with placenta previa 50% chance of needing transfusion Pt refused, risk management/courts consulted Pt was delivered, did well Lower courts upheld pt request; hospital appealed Examine each case individually; should not compromise health of fetus

59 Legally speaking Fetus Brown 35 wks pregnant, admitted for removal of uterine mass Initially did not anticipate blood loss Pt refused blood Circuit court said mother cannot refuse and appointed surrogate for fetus; mom appealed Appeals court overruled, mom could decide for fetus

60 Legally speaking Wons v. Public Health Trust of Dade County 38 y/o with DUB, non-pregnant, admitted with profuse bleeding Refused transfusion Lower court granted transfusion, citing the protection of innocent third parties Overruled by Court of Appeal due to availability of extended family

61 Legally speaking Crouse Irving Memorial Hospital, Inc. v. Paddock Term, anemic mother who required c/s Consented to c/s,, but not to blood Court ordered transfusion, stating Mom may need blood to affect delivery safety of fetus Physician performing surgical procedure could not have limitations on ability to function No appeal

62 Legal Summary Many contradicting rulings Get risk management and courts involved early let let them make the decision Transfusing a woman who is postpartum (e.g., PPH) without consent can be considered battery Get help!

63 Case report Cell saver EBL 800 cc Went home POD#4

64 The End