Red blood cell transfusion and cesarean section Laurel A. Dickason, BA, and Mara ], Dinsmoor, MD Richmond, Virginia OBJECTIVE: Our objective was to determine the incidence of blood transfusion in patients delivered by cesarean section and to identify factors predictive of the need for transfusion. STUDY DESIGN: A chart review was performed on cesarean patients receiving blood transfusion over a year at the Medical College of Virginia Hospital and an equal number of randomly selected cesarean patients. RESULTS: Sixty-one (6.8%) patients received a packed red blood cell transfusion intraoperatively or postoperatively. Transfusion was associated with lower gestational ages, antepartum bleeding, arrest of descent, and longer postoperative stays. After stepwise logistic regression analysis, only antepartum bleeding and preoperative hemoglobin were significant independent predictors of the need for blood transfusion. CONCLUSION: Transfusion with cesarean section is common and is associated with antepartum bleeding and other primarily intrapartum and unpredictable factors. (AMJ OBSTET GYNECOL 1992;167:327-32.)

Key words: Blood transfusion, autologous donation, cesarean section Patient concerns about receiving a blood transfusion have progressively increased in the past decade, due primarily to concerns about infectious complications, specifically hepatitis and human immunodeficiency virus infections. In some preoperative patients, the risk of infectious complications can be minimized by the use of preoperative autologous blood transfusions. Blood donation for autologous transfusion has been performed in the third trimester of pregnancy without major complications. )·3 However, in contradistinction to many other surgical patients, it is difficult to predict which obstetric patients will need blood transfusions. A recent retrospective study of over 30,000 deliveries reported that 2.6% of obstetric patients received 2: 1 U of blood" Patients at increased risk for transfusion included those with more than one prior abortion or a multiple gestation, patients undergoing cesarean section, particularly a primary cesarean section, and patients with abnormalities in placentation and amniotic fluid volume. Patients who received a transfusion also had a significantly lower gestational age and neonatal birth weight and a significantly higher estimated blood loss. However, many of these factors are closely interrelated, and no regression analysis was performed. Because one group at relatively high risk for hemorrhage requiring transfusion consists of patients undergoing cesarean section,':" our aim was to describe From the Department of Obstetrics and Gynecology, Medical College of Virginia/Virginia Commonwealth University. Presented as Invited Guest at the Fifty-fourth Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, Palm Beach, Florida, January 26-29, 1992. Reprints not available.

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those patients requiring blood transfusion at the time of cesarean section in an attempt to identify factors that might predict a need for transfusion. In addition, we wished to determine whether those patients who underwent blood transfusion were at increased risk for prolonged hospital stay and other postoperative complications.

Material and methods All patients discharged between July 1, 1988, and June 30, 1989, with the diagnosis of cesarean section were identified and their blood bank records reviewed. Those patients who were identified as having received blood products during their hospitalization constituted our study group. To create a comparison group, we matched each transfused patient with the next cesarean section patient on the alphabetic discharge list in the same time period who did not receive a transfusion. We reviewed the hospital charts for these patients and extracted data on patient demographics, obstetric and medical history, type of cesarean section performed, indications for surgery, anesthesia, preoperative and postoperative blood counts, estimated blood loss at the time of surgery, postoperative complications, and postoperative stay. Timing of the transfusion in relation to surgery and vital signs at the time of transfusion were also recorded for the study group. Statistical analysis was performed with True Epistat and SAS statistical packages. Fisher's exact test and X2 analysis were used, as appropriate, for discrete variables. The Student t test was used for continuous variables. The stepwise logistic regression analyses were performed with SAS software. A p value of :s0.05 was considered significant.

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328 Dickason and Dinsmoor

August 1992 Am J Obstet Gynec ol

Table I. Comparison of characteristics of mothers and babies deliv ered by cesarean section with and without blood tr an sfusion

Variable

Age (yr) Nul liparous (No.) Ratio abortions to deliveries Pri or cesar ean section (No .) Gest ational age (wk) Birth weight (gm)* Intrauterine growth retardation* (No.)

Blood transf usion (n = 61)

No blood transf usion (n = 69)

25.6 ± 6.1 26 (43 %) 0.2 1 ± 0.26

25 .0 ± 6.0 29 (42%) 0.13 ± 0.20

17 (28 %)

19 (28%)

35 .3 ± 5.1 2456 ± 1150 4/6'1 (6%)

37.0 ± 4 .1 2696 ± 888 8/76 (11%)

Values represent mean ± SD. *Includes 10 sets of twins .

Results

Eight hundred ninety-nin e patients were identified as having undergone cesar ean section during this time peri od. Review of blood bank re cords re vealed that 69 received blood products. Analysis of the hospital charts revealed that two patients in the study group did not, in fact , re ceive blood products. An add itional two patien ts only received blood preoperat ively, and four patien ts were transfused with platelet s or fresh-frozen plasma but did not receive packed red blood cells. These eight patients were elimina ted from further analysis; thus our study group comprised 61 patients (6.8 % of all cesarean sections) who r eceived packed red blood cells intraoperatively or postoperatively. Thirtynine (64%) received the transfusion intraoperatively or immediately po stoperatively. There were no significant differences betw een the two g ro u ps in maternal age, incidence of prior cesarean section, neonatal birth weight, or intrauterine growth retardation (Table I). Although there was no significant difference between the two groups in gravidity, parity, or th e number of prior abortions, th ere was a significant d ifferen ce in the ratio of abortions to del iveries. The mean gestational age at the time of del iver y was significantly lower in the transfused group, although the difference in the number of pati ents delivered prematurely « 37 weeks) was not statistically significant (51% vs 36%, p not significant). Indications for cesarean section deli ver y included elective repeat cesarean section , active ph ase arrest , fetal distress, placenta previa, arres t of des cent in the second stage, and abnormal presentation. Both placenta previa and arrest of d escent were significantly more often cited as indications for cesar ean section in the study group (Table II). There was no difference between the two groups in the frequency of r epeat cesarean sections after a tri al of labor (12% vs 10%).

Table II. Comparison of cesa rea n section characteristics in patients with and without blood transfusion Bl ood transfusion (n

Variable

= 61)

No .

I%

10

9

13

NS

12 26 13 13 15 7

16 16 0 2 18 5

23 23 0 3 26 7

NS NS 0.002 0.045 NS NS

67 23 10

65 4 0

94 6 0

0.004* 0.005* 0.009*

53 34 5 8

20 39 6 4

29 57 9 6

0.007** 0.014** NS NS 0.00 5

No ·1 %

Indication for cesarean section 6 Elective repeat cesarean section Arrest of labor 7 Fetal distress 16 8 Placenta previa Arrest of descent 8 Abnormal presentation 9 4 Other Type of cesarean section Low transverse 41 Vert ical 14 6 Cesar ean h ysterectom y Anest hesia 32 Gen eral 21 Epidural Sp inal 3 5 O the r Pr eoperative hemoglobin 10.8 ± (gm / dl, mean ± SD)

No blood transfusion (n = 69)

1.7 11.6 ± 1.4

P Val ue

NS , Not significant .

*Whe n co m par ed with all other type s of cesar ean section com bined. t When compared with all other forms o f anesthesia combined.

Transfused patients were more likely to have a vertical uterine incision or cesarean hysterectomy and to have undergone general anesthesia. As shown in Table Ill, placenta previa and thirdtrimester bleeding from causes other than place nta previa were significantly more common in the study gro u p . There were no significant differences in the frequency of other antepartum complications, including ch ro nic hypertension, di abetes, multiple gestation, and preterm labor. There were no signifi cant d ifferences in the occurrence of preeclampsia, chorioamnionitis, and disseminated intravascular coa gulation. Not unexpectedly, atony occurred signifi cantly more frequently in th e tran sfu sed patients, and the average estim ated blood loss at the time of surgery was also greater, with 53 (87%) ha ving an estimated blood loss > 1000 ml , com pared with 29 (42%) in the nontransfused patients (p < 0.0001 ). Although patients re ceiving blood had a lon ger mean postoperative stay, there was no difference betw een the two groups in the incidence of infectious complications or wound breakdown (Table IV). The number of patients with prolonged postoperative stays (~5 days) was not significantly different (73% vs 58%, P = 0.067). In spite of transfusion, on the aver age, the

Transfusion and cesarean section 329

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Table III. Co m parison of com plications associa ted with pregn ancy a nd d eli ve ry in pat ien ts with a nd witho ut blood tran sfu sion Blood transfusion (n = 61) Variable

Antepartum Chronic hypertensio n Diabetes Multiple gestation

T hird -tri rnes-

ter bleeding* Placenta previa Pre terrn labor Int rapartum Preeclampsia Chorioarn-

nionitis Disseminated intravascular coagulation Atony Estimated blood loss (ml, mean :±: SO) Estimated blood loss > 1000 ml

I

Table IV. Com parison of postoperative course in patien ts with and without blood transfusions

No blood transfusion (n = 69)

I

Variable

%

P Value

6

9

NS

7 8

6 7

9 10

NS NS

13

21

3

4

0.003

7 18

12 30

0 13

0 19

0.004 NS

II

12

18 20

9 12

13 17

NS NS

2

3

0

0

NS

12

20

0

0

Red blood cell transfusion and cesarean section.

Our objective was to determine the incidence of blood transfusion in patients delivered by cesarean section and to identify factors predictive of the ...
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