Clinical Guideline for: The Management of Inpatient Postpartum Anaemia

Transcription

1 Clinical Guideline for: The Management of Inpatient Postpartum Anaemia For Use in: By: For: Division responsible for document: Key words: Name of document author: Job title of document author: Name of document author s Line Manager: Job title of author s Line Manager: Supported by: Assessed and approved by the: Maternity Services Maternity care health professionals / Laboratory staff The management of postpartum anaemia Women and Children Anaemia, postpartum, blood transfusion, iron supplementation Alastair McKelvey Consultant Martin Cameron Clinical Director Martin Cameron Clinical Director Maternity Guidelines Committee If approved by committee or Governance Lead Chair s Action; tick here Date of approval: 29/10/2015 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this 29/10/2018 date but will be under review To be reviewed by: Alastair McKelvey Reference and / or Trust Docs ID No: PO3 Version No: 3 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Clinical Standards Group and Effectiveness Sub- Board New template No N/A Clinical Guidelines for: The Management of Postpartum Anaemia Author/s: Alastair McKelvey Author/s title: Consultant Approved by: Maternity Guidelines Committee Date approved: 29/10/2015 Review date: 29/10/2018 Available via Trust Docs: Version: 3 Trust Docs ID: PO3 Page 1 of 6

2 Quick reference guidelines * for woman who poorly tolerate oral iron, the dose can be reduced to ferrous sulphate 200mgs bd

3 Clinical Guideline for: The Management of Inpatient Postpartum Anaemia Objective This guideline is designed to ensure all postnatal women managed at the NNUH are assessed and treated consistently for anaemia. Rationale Women who have recently given birth are significantly at risk of suffering from the condition of anaemia, with it occurring in about 25-30% of new mothers (Glazener et al 1995). A recent audit of postnatal anaemia at NNUH has shown the management that women received was variable - with different units of blood being given; seemingly unrelated to haemoglobin levels and significant variation in the frequency and duration of ferrous sulphate prescriptions (Dearman 2009). The Royal College of Obstetricians and Gynaecologists (RCOG) state that if a woman s haemoglobin is <7g/dL in labour or the immediate postpartum period, the decision to transfuse should be made according to the individual s medical history, age and symptoms (RCOG 2007). The Department of Health (DoH) are more specific in their guidance: in their document Better Blood Transfusion; Appropriate Use of Blood they state that the standardised treatment for acute and non-haemodynamically compensated anaemia depends greatly on the extent of it; which is routinely determined by the haemoglobin. Red blood cell transfusion in a postpartum woman becomes essential when haemoglobin is <5 g/dl (DoH 2002). A strong indication for transfusion is a haemoglobin concentration <7 g/dl (DoH 2002). Haemoglobin between 7g/dl - 8g/dl with symptoms will be individually assessed as to whether they need a transfusion; clinical status and symptoms are helpful in defining transfusion requirements (DoH 2002). Patients with a haemoglobin concentration between 8g/dL - 10g/dL will routinely be treated with an iron supplement (usually ferrous sulphate). If the patient s haemoglobin is >10g/dl, transfusion and further intervention is rarely indicated (DoH 2002). In the majority of cases the decision to transfuse red cells is based upon the patient s presentation of symptoms. The acute life-threatening complications of blood transfusion include: acute haemolytic transfusion reaction; reaction to infusion of a bacterially contaminated unit; transfusionrelated acute-lung injury; acute fluid overload and severe allergic reaction or anaphylaxis. Between there were 21 transfusion related deaths, and 994 adverse reactions/events reported (McClelland 2007) Consequently, it is important to perform a thorough risk benefit analysis before prescribing blood. Slowly titrating the amount of blood to relieve anaemic symptoms, by giving single units of blood rather than a blanket lets give 2 or 3 units is more logical approach in attempting to reduce blood transfusion complications. Many women who are symptomatic with a Hb between 6-8g/dl may become asymptomatic with 1 unit transfusion, and by halving the amount of blood given you can halve the risk of a transfusion related complication. Clinical Guidelines for: The Management of Postpartum Anaemia Author/s: Alastair McKelvey Author/s title: Consultant Approved by: Maternity Guidelines Committee Date approved: 29/10/2015 Review date: 29/10/2018 Available via Trust Docs: Version: 3 Trust Docs ID: PO3 Page 3 of 6

4 Broad recommendations 1. This guideline should only be applied to the haemodynamically stable postnatal patient. 2. This guideline specifically excludes women with cardiac disease the management of these women should be discussed with the consultant obstetrician. 3. Whilst in hospital all postnatal women should be carefully evaluated by the midwife looking after her on at least a daily basis for symptoms and signs of anaemia and if she has concerns should contact the medical staff and ask for a medical assessment. 4. A full blood count for haemoglobin levels should be taken between 24 to 48 hours following delivery if either the last antenatal Hb < 10g/dl or the blood loss at delivery (within first 24 hrs) was measured/estimated to be > 500mls or in all cases of caesarean delivery or if the patient is symptomatic with regard to anaemia (see flow chart in quick reference for symptoms) 5. For women with a Hb > 10g/dl no action is required 6. For women with a Hb between 8-10g/dl then the woman should be prescribed iron therapy (ferrous sulphate 200mg tds). TTO s for 28 days should be arranged. 7. For women with Hb <8g/dl the midwife should record maternal physical observations (temperature, heart rate, blood pressure and respiratory rate) and the medical staff should be informed. A medical assessment should be made of symptoms and signs of anaemia. 8. All women with Hb < 6 g/dl should be considered a candidate for consideration for transfusion to achieve Hb > 6g/dl. 9. If a woman has Hb between 6-8g/dl then decision for transfusion should be discussed between medical staff and patient. For women who are symptomatic with regard to their anaemia or have organ dysfunction then generally transfusion should be seriously considered. For asymptomatic women with Hb between 6-8g/dl then it is appropriate to consider treatment with oral iron (ferrous sulphate 200mg tds) with TTO s for 28 days arranged. 10. For women requiring transfusion, transfuse 1 unit of packed cells, then the medical staff should reassess the patient. Continue transfusing unit by unit until symptoms and signs have resolved. 11. In women requiring transfusion a haemoglobin level should be checked within 24hrs, and ferrous sulphate 200mg tds should be considered if Hb < 10g/dl. 12.For woman who poorly tolerate oral iron, the dose can be reduced to ferrous sulphate 200mgs bd

5 Clinical Guideline for: The Management of Inpatient Postpartum Anaemia Clinical audit standards 1. Number of asymptomatic woman with Hb > 10 g/dl sent home with FeSO4 target is 0% 2. Number of women with Hb between 8-10g/dl discharged home with minimum supply of 28 days of Ferrous sulphate target 100% 3. Number of woman with Hb >8g/dl transfused target is 0% 4. Number of asymptomatic woman with Hb > 6g/dl transfused target is 0% 5. For woman transfused, amount of blood transfused 6. Readmission within 2 weeks of delivery with complications/symptoms associated from anaemia and who require blood transfusion The Maternity Services are committed to the philosophy of clinical audit, as part of its Clinical Governance programme. This standards contained in this clinical guideline will be subject to continuous audit, with multidisciplinary review of the audit results at one of the monthly departmental Clinic Governance meetings. The results will also be summarised and a list of recommendations formed into an action plan, with a commitment to re-audit within three years, resources permitting. Summary of development and consultation process undertaken before registration and dissemination This guideline was developed by Martin Cameron with the help of several of the Consultant Haematologists. It has been approved by the O&G Clinical Guidelines committee. Distribution list/ dissemination method Trust intranet Delivery suite Postnatal ward References/ source document REPORT_FinalWebVersionBookmarked_2012_06_22.pdf DOH (2002), UK blood transfusion and tissue transplantation services: Better Blood Transfusion; Appropriate Use of Blood. Publication=BBT&Section=22&pageid=1337 Accessed on 6 April 2009 Glazener, CMA., MI. Abdalla, P. Stroud, SA. Naji, AA. Templeton and IT. Russell Clinical Guidelines for: The Management of Postpartum Anaemia Author/s: Alastair McKelvey Author/s title: Consultant Approved by: Maternity Guidelines Committee Date approved: 29/10/2015 Review date: 29/10/2018 Available via Trust Docs: Version: 3 Trust Docs ID: PO3 Page 5 of 6

6 (1995), Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 102:282-7 McClelland, DBL (2007), Handbook of Transfusion Medicine. UK Blood Services. 4th Edition. NICE (2006), Routine postnatal care of women and their babies. Clinical Guideline 37 RCOG (2007), Green-top Guideline No. 47. Blood Transfusion in Obstetrics. Safer Childbirth (2007), Minimum Standards for the Organisation and Delivery of Care in Labour. Transfusion Medicine Guidelines (1999), The administration of blood and blood components and the management of transfused patients. British Committee for Standards in Haematology. Blood Transfusion Task Force. 9, 227±238. ## Leanne Dearman: Final Year Medical Student (2009) An Audit Looking at the Appropriateness and Consistency of Anaemia Management in Postnatal Women at the Norfolk and Norwich University Hospital (NNUH) Related Trust Guidelines Trust Guideline for the Management of Reactions to Blood and Blood Products -Guideline reg no CA4029 Trust Guideline for the Use of Cytomegalovirus (CMV) Negative Blood and Blood Products Guideline reg no CA4036 Trust Guideline for the Use of Irradiated Blood and Blood Products - Guideline reg no CA4035 Trust Policy for Monitoring the Patient during Blood and Blood Component Transfusion- Guideline reg no B3 v5/ca10227v5 Trust Guideline for the Use of Blood and Blood Products in Adults and Children guideline reg no: CA2057 Trust Policy for Checking Blood and Blood Components Prior to Administration guideline reg no B4 v6 / CA1025V4 Trust Policy for the Collection and Return of Blood Components from the Norfolk and Norwich University Hospital Transfusion Laboratory Blood Fridges and Incubator, Satellite Blood Fridges guideline reg no B2v6/ CA1026 v5