Recommendations: Perinatal Transfusion Medicine

Transfusion Medicine

Four Tests and Treatments to Questions in Perinatal Transfusion Medicine

by
Canadian Obstetrical and Pediatric Transfusion Network
Canadian Society for Transfusion Medicine
Last updated: July 2023

Do not routinely perform a group and screen test at the time of delivery unless there is no prior test during the current pregnancy and/or the risk of maternal hemorrhage or transfusion is high.
1

The likelihood of requirement for transfusion at the time of delivery is low. In a patient with a prenatal record confirming maternal ABO, Rh and a negative antibody screen provision of emergency uncrossmatched units is relatively safe when required on rare occasions. Routine pre delivery group and screen is not cost effective given the very low risk of transfusion with either vaginal delivery or routine Caesarean section. In the rare occasion that patients require a blood transfusion, O negative un-crossmatched blood or a stat crossmatch could be done pre-transfusion.

Sources:
Stock et al. Why group & save? Blood transfusion at low-risk elective caesarean section. Aust N Z J Obstet Gynaecol. 2014 Jun;54(3):279-82. PMID: 24576105.

White et al. Guideline for blood grouping and red cell antibody testing in pregnancy. Transfusion Medicine. 2016 Aug;26(4):246-63. PMID: 27074872.
Do not perform serological weak D testing on antenatal samples with weak or variable RhD typing results.
2

Serologically weak reactions with Anti D antisera (≤ 2+) should be investigated with RHD genotyping. Pregnant mothers with weak or variable RhD typing and with pending genotyping results should be treated as RhD negative and should receive RhIg. Patients with genotyping confirming weak D type 1, 2 or 3 should be treated as RhD positive. Patients with other weak and variant RHD genotypes should be treated as RhD negative.

Sources:
Flegel et al. It’s time to phase out “serologic weak D phenotype” and resolve D types with RHD genotyping including weak D type 4. Transfusion. 2020 Apr;60;855–59. PMID: 32163599.

Sandler et al. It’s time to phase in RHD genotyping for patients with a serologic weak D phenotype. Transfusion. 2015 Mar; 55(3): 680–89. PMID: 25438646.
Do not repeat prenatal titrations for mothers with clinically significant antibodies (e.g. RhD, K) if prediction of fetal cognate antigen typing is feasible and is deemed to be negative.
3

Testing of a paternal sample and finding a negative antigen status (when paternity is assured) and/or non-invasive prenatal determination of the fetal genotype from maternal plasma with prediction of a negative antigen status confirm that the fetus is not at risk for hemolytic disease of the fetus and newborn and that ongoing pregnancy monitoring is unnecessary.

Sources:
de Haas et al. Haemolytic Disease of the fetus and newborn. Vox Sang. 2015 Aug;109(2):99–113. PMID: 25899660.

Scheffer et al. Noninvasive fetal blood group genotyping of rhesus D, c, E and of K in alloimmunised pregnant women: evaluation of a 7-year clinical experience. BJOG. 2011 Oct;118(11):1340–8. PMID: 21668766.
Avoid routinely performing direct antiglobulin test on all neonatal cord samples.
4

The DAT is not a screening test for hyperbilirubinemia or hemolytic disease. Routine assessment of the DAT may reveal cases of ABO incompatibility which are clinically insignificant; conversely the DAT may fail to identify significant hemolysis due to non immune causes. The DAT should be performed only when anemia or hyperbilirubinemia is suspected or when maternal alloantibodies are present.

Sources:
Aydin et al. Is the Antiglobulin Test a Good Marker for Predicting the Development of Hemolytic Disease of the Newborn in ABO Incompatibility? Pediatr Neonatol. 2016 Oct; 57(5),449. PMID: 27211278.

Dinish D. Review of positive direct antiglobulin tests found on cord blood sampling. J. Paediatr. Child Health. 2005 Oct; 41(9-10), 504-7. PMID: 16150068.

Judd. Practice guidelines for prenatal and perinatal immunohematology, revisited. Transfusion. 2001 Nov;41(11):1445-52. PMID: 11724993.

Keir et al. Fifteen minute consultation: managing neonatal and childhood herpes encephalitis. Arch Dis Child Educ Pract Ed. 2015 Apr;100(2):58-63. PMID: 25112286.
How the list was created

The Canadian Obstetrics and Pediatric Transfusion Network (COPTN) compiled its Choosing Wisely Canada list of recommendations by putting out a call to its membership for suggested list items. The chairs of COPTN compiled these suggestions and developed the rationale and references. These statements and rationale were presented virtually to the COPTN committee who ranked the suggestions according to their importance and refined the wording and the order of the item lists.

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Ten Tests and Treatments to Question in Transfusion Medicine

by
Canadian Society for Transfusion Medicine
Last updated: July 2023

Don’t transfuse blood if other non-transfusion therapies or observation would be just as effective.
1

Blood transfusion should not be given if other safer non-transfusion alternatives are available. For example, patients with iron deficiency without hemodynamic instability should be given iron therapy.

Sources:

Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58. PMID: 22751760.

Retter A, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013 Feb;160(4):445-64. PMID: 23278459.

Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.
Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.
2

Indications for red blood transfusion depend on clinical assessment and the cause of the anemia. In a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after re-assessment of the patient and their hemoglobin value.

Sources:

Bracey AW, et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion. 1999 Oct;39(10):1070-7. PMID: 10532600.

Carson JL, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD002042. PMID: 22513904.

Carson JL, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49-58. PMID: 22751760.

Hebert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409-17. PMID: 9971864.

Marik PE, et al. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit. Care Med. Sep 2008;36(9):2667-2674. PMID: 18679112.

Retter A, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013 Feb;160(4):445-64. PMID: 23278459.

Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.

Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21. PMID: 23281973.

Related Resources:

Toolkit: Why Give Two When One Will Do
Don’t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aPTT) before a procedure.
3

A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

Sources:

Abdel-Wahab OI, et al. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006 Aug;46(8):1279-85. PMID: 16934060.

Estcourt L, et al. Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev. 2012 May 16;(5):CD004269. PMID: 22592695.

Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.
Don’t routinely transfuse platelets for patients with chemotherapy-induced thrombocytopenia if the platelet count is greater than 10 X 109/L in the absence of bleeding.
4

A platelet count of 10 X 109/L or greater usually provides adequate hemostasis. Platelet transfusions are associated with adverse events and risks. Considerations in the decision to transfuse platelets include the cause of the thrombocytopenia, comorbid conditions, symptoms of bleeding, risk factors for bleeding, and the need to perform an invasive procedure.

Sources:

Estcourt L, et al. Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev. 2012 May 16;(5):CD004269. PMID: 22592695.

British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of platelet transfusions. Br J Haematol. 2003 Jul;122(1):10-23. PMID: 12823341.

Slichter SJ, et al. Dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med. 2010 Feb 18;362(7):600-13. PMID: 20164484.

Szczepiorkowski ZM, et al. Transfusion guidelines: when to transfuse. Hematology Am Soc Hematol Educ Program. 2013;2013:638-44. PMID: 24319244.
Don’t routinely use plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists.
5

Patients requiring non-emergent reversal of warfarin can often be treated with vitamin K or by discontinuing the warfarin therapy. Prothrombin complex concentrates should only be used for patients with serious bleeding or for those who need urgent surgery. Plasma should only be used in this setting if prothrombin complex concentrates are not available or are contraindicated.

Sources:

Holbrook A, et al. Evidence-Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e152S-84S. PMID: 22315259.

Keeling D, et al. Guidelines on oral anticoagulation with warfarin – fourth edition. Br J Haematol. 2011 Aug;154(3):311-24. PMID: 21671894.

National Advisory Committee on Blood and Blood Products (NAC). Prothrombin Complex Concentrates [Internet]. 2014 May [cited 2017 May 5].

Scottish Intercollegiate Guidelines Network (SIGN). Sign 129: Antithrombotics: Indications and Management [Internet]. 2013 Jun [cited 2017 May 5].
Don’t use immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
6

Immunoglobulin (gammaglobulin) replacement does not improve outcomes unless there is impairment of antigen-specific IgG antibody responses to vaccine immunizations or natural infections. Isolated decreases in immunoglobulins (isotypes or subclasses), alone, do not indicate a need for immunoglobulin replacement therapy. Exceptions include genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin.

Sources:

Rich R, et al. Clinical Immunology: Principles and Practice, 3^rd edition. Elsevier; 2008.

Bonilla FA, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol. 2005 May;94(5 Suppl 1):S1-63. PMID: 15945566.

Orange JS, et al. Use of intravenous immunoglobulin in human disease: a review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol. 2006 Apr;117(4 Suppl):S525-53. PMID: 16580469.

Stiehm ER, et al. Therapeutic use of immunoglobulins. Adv Pediatr. 2010;57(1):185-218. PMID: 21056739.
Don’t order unnecessary pre-transfusion testing (type and screen) for all pre-operative patients.
7

Pre-operative transfusion testing is not necessary for the vast majority of surgical patients (e.g., appendectomy, cholecystectomy, hysterectomy and hernia repair) as those patients usually do not require transfusion. Ordering pre-transfusion testing for patients who will likely not require transfusion will lead to unnecessary blood drawn from a patient and unnecessary testing performed. It may also lead to unnecessary delay in the surgical procedure waiting for the results. To guide you whether pre-transfusion testing is required for a certain surgical procedure, your hospital may have a maximum surgical blood ordering schedule or specific testing guidelines based on current surgical practices.

Sources:

Guidelines for implementation of a maximum surgical blood order schedule. The British Committee for Standards in Haematology Blood Transfusion Task Force. Clin Lab Haematol. 1990;12(3):321-7. PMID: 2272160.

Government of Newfoundland and Labrador. Guidelines for Maximum Surgical Blood Ordering Schedule, version 1.0 [Internet]. 2012 Dec 28 [cited 2017 May 5].

Ontario Regional Blood Coordinating Network (ORBCoN). Maximum Surgical Blood Order Schedule (MSBOS): Development Tool, version 1 [Internet]. 2014 Dec 5 [cited 2017 May 5].

University of Michigan. Providing Blood Components for Perioperative Patients [Internet]. 2010 Jan 4 [cited 2017 May 5].

Related Resources:

Toolkit: Drop the Pre-Op – A toolkit for reducing unnecessary visits and investigations in pre-operative clinics
Don’t routinely order perioperative autologous and directed blood collection.
8

There is no role for routine perioperative autologous donation or directed donation except for selected patients (for example, patients with rare red blood cell antigen types). Medical evidence does not support the concept that autologous (blood donated by one’s self) or directed blood (blood donated by a friend/family member) is safer than allogeneic blood. In fact, there is concern that the risks of directed donation may be greater (higher rates of positive test results for infectious diseases). Autologous transfusion has risks of bacterial contamination and clerical errors (wrong unit/patient transfused). As well, autologous blood donation before surgery can contribute to perioperative anemia and a greater need for transfusion.

Sources:

Engelbrecht S, et al. Clinical transfusion practice update: haemovigilance, complications, patient blood management and national standards. Med J Aust. 2013 Sep 16;199(6):397-401. PMID: 24033212.

King K, et al. Blood Transfusion Therapy: A Physician’s Handbook, 10^th edition. Bethesda (MD): AABB; 2011.

Clarke G. Preoperative Autologous Donation [Internet]. 2016 Jun 2 [cited 2017 May 5].

Wales PW, et al. Directed blood donation in pediatric general surgery: Is it worth it? J Pediatr Surg. 2001 May;36(5):722-5. PMID: 11329574.
Don’t transfuse O negative blood except to O negative patients and in emergencies for female patients of child-bearing potential of unknown blood group.
9

Males and females without childbearing potential can receive O Rh-positive red cells. O-negative red cell units are in chronic short supply, in some part due to over utilization for patients who are not O-negative. To ensure O-negative red cells are available for patients who truly need them, their use should be restricted to: (1) patients who are O-Rh-negative; (2) patients with unknown blood group requiring emergent transfusion who are female and of child-bearing age. Type specific red cells should be administered as soon as possible in all emergency situations.

Sources:

British Committee for Standards in Haematology, et al. Guidelines on the management of massive blood loss. Br J Haematol. 2006 Dec;135(5):634-41. PMID: 17107347.

Medical Officer’s National Blood Transfusion Committee (UK). The appropriate use of group O RhD negative red cells. Manchester (UK): National Health Service; 2008.

United Blood Services. A New Standard of Transfusion Care: Appropriate use of O-negative red blood cells [Internet]. [Cited 2017 May 5].
Don’t transfuse group AB plasma to non-group AB patients unless in emergency situations where the ABO group is unknown.
10

The demand for AB plasma has increased. Group AB individuals comprise only 3% of Canadian blood donors. Those donors who are group AB are universal donors for plasma, thus are the most in-demand type for plasma transfusion. Type-specific plasma should be issued as soon as possible in emergency situations to preserve the AB plasma inventory for those patients where the blood group is unknown.

Sources:

Canadian Blood Services. Donating Plasma, What You Need to Know About Donating Plasma [Internet]. 2015 [cite 2017 May 5].

Canadian Blood Services. The Facts About Whole Blood [Internet]. 2015 [cited 2017 May 5].

Petraszko T. Transfusion Related Acute Lung Injury (TRALI) [Internet]. 2017 Feb [Cited 2017 May 5].

Yazer M, et al. How we manage AB plasma inventory in the blood center and transfusion service. Transfusion. 2013 Aug;53(8):1627-33. PMID: 23614505.
How the list was created

The Canadian Society for Transfusion Medicine (CSTM) compiled its Choosing Wisely Canada list of recommendations by putting out a call to its membership for suggested list items. Members were asked to provide suggestions, rationale and references. Once all suggestions for list items had been received and the deadline for submissions had passed, the CSTM board voted on the accumulated list and ranked the items according to our assessment of what was most important. We met by conference call to discuss the outcome of the voting and worked together to refine the wording and the order of the list items and to find additional references as required.

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Four Tests and Treatments to Questions in Perinatal Transfusion Medicine

Ten Tests and Treatments to Question in Transfusion Medicine

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