9a_RIOG0160_07-15.

qxd 7/15/11 11:49 AM Page 86

WOMEN’S HEALTH IN THE DEVELOPING WORLD

The Use of Blood in Obstetrics

and Gynecology in the Developing
World
Julianna Schantz-Dunn, MD, Nawal M. Nour, MD, MPH
Brigham and Women’s Hospital, Division of Global Obstetrics and Gynecology, Harvard Medical School,
Boston, MA

Access to safe blood is critical in comprehensive emergency obstetric care and

for reducing maternal mortality. Many countries have inadequate blood
supplies, and this disproportionately affects women and children in need of
life-saving blood transfusions. Although preventative measures aimed at
reducing postpartum hemorrhage by treating underlying anemia and
infectious diseases are critical, they are insufficient for obstetric hemorrhage.
In the developing world, efforts should focus on alternative means of
providing safe blood in cases of hemorrhage, with particular focus on rapid
testing, donation of warm whole blood, and autologous blood transfusion.
[Rev Obstet Gynecol. 2011;4(2):86-91 doi: 10.3909/riog0160]

© 2011 MedReviews®, LLC

Key words: Blood transfusion • Obstetric hemorrhage • Warm whole blood • Autologous
blood transfusion

I
n the developed world, blood is most frequently used in surgical procedures or
to treat advanced medical diseases such as chemotherapy-related anemia.
However, in the developing world, where blood and transfusion services are
often lacking, obstetric complications are the leading indication for transfusion
(Figure 1). Blood transfusion is recognized as one of the eight essential compo-
nents of comprehensive emergency obstetric care (cEmOC), which has been shown
to reduce rates of maternal mortality.1,2 Efforts to reduce the number of maternal
deaths from hemorrhage should address both the availability of blood and
transfusion services as well as other means to prevent and treat hemorrhage that
do not rely solely on allogenic blood transfusions.

86 VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY

9a_RIOG0160_07-15.qxd 7/15/11 11:49 AM Page 87

Use of Blood in Obstetrics and Gynecology

developing countries), also suffer

A Hematological B
from high rates of maternal mortality.
At a minimum, WHO estimates that a
15% Pregnancy- Trauma Medical country needs available blood supply
Related 18% 19% that is equivalent to 1% to 2% of its
Medical 6% population.
35% 3% Children
Surgery Ensuring blood safety is also of ut-
12%
most importance, as transfusion can
Pregnancy-Related
Children 37%
transmit human immunodeficiency
Surgery
7% 34% 14% virus (HIV), hepatitis, syphilis, Chagas
disease, and malaria. In 2002, 5% to
Trauma 10% of newly acquired HIV infections
were related to infected blood transfu-
Figure 1. (A) Estimated use of red cell transfusion in developed countries. (B) Estimated use of red cell transfu- sions.6 As women and children are the
sion in developing countries. Reproduced with permission from World Health Organization.5 most likely recipients of blood in areas
of both high HIV prevalence and
blood supply shortages, they are at
Background avoidance of unnecessary transfu- disproportionately high risk.7 One unit
Hemorrhage continues to be the sions.5 Each of these cornerstones of blood can be procured, screened,
leading cause of maternal mortality poses challenges in developing coun- and tested for approximately US$40,
worldwide, accounting for 34% of tries, where infrastructure may be and although this is a high price in
maternal deaths in Africa, 31% in limited; the cost of blood procure- many resource-poor countries, WHO
points out that it is ultimately cheaper
Hemorrhage continues to be the leading cause of maternal mortality world- than the cost of HIV transmission or
morbidity associated with having no
wide, accounting for 34% of maternal deaths in Africa, 31% in Asia, 21%
safe blood available.
in Latin America, and 13% in developed countries.
Cultural Considerations
Asia, 21% in Latin America, and 13% ment, screening, and storage is high; Variations in religious and cultural be-
in developed countries.3 Although and blood donation is rare. liefs about blood contribute to lower
efforts have centered on prevention The number of blood donations per rates of voluntary donations and
of postpartum hemorrhage by ad- 1000 people can be used as a proxy transfusion acceptance in certain pop-
ministration of uterotonics and ac- for the availability and adequacy of ulations. In many countries in Africa,
tive management of the third stage the blood supply in a given country, for example, blood donors are typi-
of labor, women continue to die of with developing countries typically cally replacement donors, or people
inadequate blood banking. In sub- having the lowest rates of donation. who donate specifically to aid a family
Saharan Africa, it is estimated that
26% of maternal hemorrhagic deaths
are a direct consequence of the lack Other beliefs, such as fears of losing strength, not having enough blood, or
of blood transfusion services, and depletion of life force reduce voluntary donation in surveyed African and
globally up to 150,000 pregnancy- Chinese groups. Suspicion that blood is being sold as a commodity for the
related deaths could be avoided each benefit of Westerners or for use in witchcraft also limits acceptance of blood
year if women had access to safe donation in certain communities.
blood.4,5

Challenges Lack of blood directly affects maternal member who needs or will soon need
According to the World Health Orga- mortality, and as Figure 2 demonstrates, blood. Because blood defines family
nization (WHO), the four cornerstones it is not surprising that developing bonds, these populations may be less
of a safe and effective blood donor countries such as those in sub-Saharan likely to donate blood for the benefit of
service are a national system, volun- Africa, with the lowest donation rates a stranger.8 Other beliefs, such as fears
teer donations, blood testing, and ( 5/1000 versus  30/1000 in many of losing strength, not having enough

VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY 87

9a_RIOG0160_07-15.qxd 7/15/11 11:49 AM Page 88

Use of Blood in Obstetrics and Gynecology continued

*Data of 2006 are used for 22 countries

5
5-9.9
10-19.9
20-29.9
ⱖ 30
0 1500 3000 6000 km
Data not available

The boundaries and names shown and the designations used on this map do not imply Data Source: World Health Organization
the expression of any opinion whatsoever on the part of the World Health Organization Map Production: Blood Transfusion
concerning the legal status of any country, territory, city or area of its authorities, or Safety (BTS) World Health Organization
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps
represent approximate border lines for which there may not yet be full agreement.

Figure 2. Blood donations per 1000 population (2007). Reproduced with permission from World Health Organization. http://www.who.int/mediacentre/factsheets/donations_
per1000_population_20091110.pdf.

blood, or depletion of life force reduce women would refuse a blood transfu- carded when found to be viral screen
voluntary donation in surveyed sion. Blood transfusion should be dis- positive.13 In postpartum hemorrhage,
African and Chinese groups.9,10 Suspi- cussed with pregnant women as early rapid screens are useful if willing
cion that blood is being sold as a com- as possible so that misconceptions donors are available when pre-
modity for the benefit of Westerners or can be addressed or alternate treat- screened blood is not. In fact, the use
for use in witchcraft also limits accep- ment options considered should the of warm whole blood in place of
tance of blood donation in certain need for blood arise.11,12 blood components (like packed red
communities.8 blood cells or plasma) is often essen-
A review of maternal deaths in the Solutions tial. Recent data from combat trauma
United Kingdom in 2002 determined Although efforts are ongoing to in- warrant more research into the ad-
that women who refused blood trans- crease blood donations and improve vantages of warm whole blood over
fusions had higher death rates than blood supply through national bank- stored blood components.14
those who accepted blood products. ing systems in developing countries, Other alternatives to allogenic
In a subsequent survey, religious be- other improvements to maternal blood transfusion proposed to cir-
liefs (primarily those of Jehovah’s health need to be explored. For exam- cumvent the difficult issues of dona-
Witnesses) and fear of disease trans- ple, where HIV or the hepatitis C virus tion, testing, safety, storage, and
mission were the two primary reasons (HCV) is endemic, predonation rapid cost include preoperative autologous
for refusal. Another survey of Jordan- testing has been proposed to decrease blood donation, perioperative hemo-
ian women cited fear of complica- the overall cost of blood banking by dilution, and intraoperative autologous
tions as the most frequent reason reducing the amount of blood dis- transfusion.

88 VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY

9a_RIOG0160_07-15.qxd 7/15/11 11:50 AM Page 89

Use of Blood in Obstetrics and Gynecology

Preoperative Autologous Blood Dona- Autologous Transfusion After clots and debris are filtered out,
tion and Perioperative Hemodilution Intraoperative autologous blood the blood is then aspirated with a
Preoperative autologous blood dona- transfusion has a long history in the sterile syringe and injected into trans-
tion has been proposed to reduce the treatment of hemorrhage from rup- fusion bags preprepared with citrate-
need for allogenic blood in pregnan- tured ectopic pregnancies, and is fre- phosphate-dextrose-adenine (CPDA)
cies at high risk for hemorrhage be-
cause it greatly reduces the infectious Intraoperative autologous blood transfusion has a long history in the treat-
and immunologic risks of blood
ment of hemorrhage from ruptured ectopic pregnancies, and is frequently
transfusion. Although predonation
has been shown to be safe and effec- and safely used in areas with minimal resources.
tive in managing pregnancies compli-
cated by high-risk conditions such as quently and safely used in areas with anticoagulant solution. All manual
placenta previa or placenta accreta, it minimal resources. In both developed systems rely on some version of re-
does require an established blood and developing countries, autologous trieval, filtering, and reinfusion.18
banking system.15 Furthermore, pre- transfusion is effective and safe and Other methods described in the litera-
donation appears to be well tolerated avoids risks such as ABO incompati- ture use various collecting devices
such as a sterile soup ladle20 or a
small sterile dish to collect the blood,
Although predonation has been shown to be safe and effective in managing
sterile gauze to filter the blood, and
pregnancies complicated by high-risk conditions such as placenta previa or sterile glass bottles with rubber tops
placenta accreta, it does require an established blood banking system. for reinfusion (Figure 4). If CPDA
solution is not readily available, the
by women in the third trimester of bility, infection, and blood storage tubing can be heparinized. Of note,
pregnancy, but those studies were in problems. Whereas developed coun- automated blood salvage devices
women in the developed world, where tries have used blood salvage devices (such as the Cell Saver) do not appear
other problems contributing to base- such as the Cell Saver® (Haemonetics to offer advantages over manual de-
line anemia such as malnutrition, Corp., Braintree, MA) to process and vices, although no comparisons have
malaria, and HIV are not as preva- retransfuse salvaged blood, several been made in randomized trials.
lent.16 Finally, a system of predona- simple manual systems have also Whereas autologous blood transfu-
tion assumes accurate predication of been described.18 sion is well established for ruptured
a particular patient’s risk of hemor- The success and safety of the Tan- ectopic pregnancy, there are few data
rhage, which is rarely the case. guieta funnel was demonstrated in a on the safety and efficacy of auto-
Acute normovolemic hemodilution review of over 200 cases of blood transfusion for postpartum hemor-
is another perioperative strategy to salvage and autotransfusion for the rhage. Exploration of autotransfusion
limit the need for allogenic blood treatment of ruptured ectopic pregnancy as a treatment modality has been
transfusions. A patient exchanges in Benin, West Africa (Figure 3).19 A stymied by the theoretical risks of
some of her own blood for an equal perforated funnel is placed in the amniotic fluid embolus (AFE) and in-
volume of crystalloid, diluting the peritoneal cavity to collect blood. fectious complications. However, one
blood and technically limiting the
amount lost in the surgical field. At Figure 3. Setting up a Tanguieta funnel for blood
the end of the procedure, her own collection in hemoperitoneum. Reproduced with
permission from Priuli G et al.19
blood is retransfused, restoring the
hematocrit. Benefits include preserv-
ing the freshness of the blood, includ-
ing other essential components such
as platelets and clotting factors. Al-
though this approach has been suc-
cessful in cases of malplacentation, it
should be used with caution because
pregnant women are already in phys-
iologic hemodiluted anemia.15,17

VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY 89

9a_RIOG0160_07-15.qxd 7/15/11 11:50 AM Page 90

Use of Blood in Obstetrics and Gynecology continued

Figure 4. Filtering blood through gauze into health/files/guidelinesformonitoringavailability

sterile bottles for subsequent autotransfusion ofemoc.pdf. Accessed June 14, 2011.
in a ruptured ectopic pregnancy. Photo cour- 2. Obaid TA. No woman should die giving life.
tesy of Julianna Schantz-Dunn. Lancet. 2007;370:1287-1288.
3. Khan KS, Wojdyla D, Say L, et al. WHO analysis
of causes of maternal death: a systematic review.
Lancet. 2006;367:1066-1074.
4. Bates I, Chapotera GK, McKew S, van den Broek
N. Maternal mortality in sub-Saharan Africa: the
contribution of ineffective blood transfusion ser-
vices. BJOG. 2008;115:1331-1339.
5. World Health Organization (WHO) Essential
Health Technologies. Blood Transfusion Safety.
Geneva: WHO; undated. http://www.who.int/
bloodsafety/en/Blood_Transfusion_Safety.pdf.
Accessed June 14, 2011.
6. World Health Organization (WHO) Department of
Blood Safety and Clinical Technology. Blood
Safety: Aide-Memoire for National Programmes.
historical cohort study of 139 patients women and children this too often Geneva: WHO; 2002. http://www.who.int/blood-
undergoing autotransfusion at ce- has deadly consequences. safety/transfusion_services/en/Blood_Safety_En
g.pdf. Accessed June 14, 2011.
sarean delivery showed no increased Until adequate national blood
7. Dhingra N. Making Safe Blood Available in
risk of complications compared with banks are in place, we should con- Africa. Geneva: World Health Organization;
allogenic blood transfusion and re- tinue to explore alternatives to allo- 2006. http://www.who.int/bloodsafety/makingsafe
ported no cases of AFE.21 One group genic blood transfusion for obstetric bloodavailableinafricastatement.pdf. Accessed
June 14, 2011.
of authors suggest that “. . . as our and gynecologic hemorrhage. Treat- 8. Polonsky NJ, Renzaho AM, Brijnath B. Barriers
understanding of the pathophysiology ments such as fibrinogen recombi- to blood donation in African communities in
Australia: the role of home and host country cul-
of AFE has increased, it could be nant factors (which are stored in
ture and experience [published online ahead of
argued that this theoretical risk has powder form and do not require print February 18, 2011]. Transfusion. doi:
been overestimated” and call for a refrigeration) would be useful in 10.1111/j.1537-2995.2010.03053.x.
9. Umeora OU, Onuh SO, Umeora MC. Socio-
trial to accurately assess the risks and many resource-poor settings, but are
cultural barriers to voluntary blood donation for
benefits of cell salvage at cesarean still prohibitively expensive. Autolo- obstetric use in a rural Nigerian village. Afr J
delivery.22 For countries with limited gous transfusion holds promise even Reprod Health. 2009;9:72-76.
10. Tison GH, Liu C, Ren F, et al. Influences of gen-
resources, this study would need to in the treatment of postpartum hem-
eral and traditional Chinese beliefs on the deci-
evaluate outcomes from autologous orrhage, and efforts should be under- sion to donate blood among employer-organized
transfusion using manual as well as taken to develop safe and simple and volunteer donors in Beijing, China. Transfu-
sion. 2007;47:1871-1879.
automated devices. techniques.
11. Khadra M, Rigby C, Warren P, et al. A criterion
audit of women’s awareness of blood transfusion in
Conclusions References pregnancy. BMC Pregnancy Childbirth. 2002;2:7.
Although we acknowledged World 1. United Nations Children’s Fund (UNICEF), World 12. Abu-Salem AN, Qublan HS. Blood transfusion in
Blood Donor Day on June 14, 2011, Health Organization (WHO), United Nations Pop- obstetrics: the pregnant women’s point of view.
ulation Fund (UNFPA). Guidelines for Monitoring J Obstet Gynaecol. 2009;29:220-222.
we must not forget that blood remains the Availability and Use of Obstetric Services. 13. Owusu-Ofori S, Temple J, Sarkodie F, et al.
scarce in many parts of the world. For New York: UNICEF; 1997. http://www.unicef.org/ Predonation screening of blood donors with

Main Points
• In sub-Saharan Africa, it is estimated that 26% of maternal hemorrhagic deaths are a direct consequence of the lack of blood trans-
fusion services, and globally up to 150,000 pregnancy-related deaths could be avoided each year if women had access to safe
blood.
• According to the World Health Organization (WHO), the four cornerstones of a safe and effective blood donor service are a national
system, volunteer donations, blood testing, and avoidance of unnecessary transfusions.
• Blood transfusion should be discussed with pregnant women as early as possible so that misconceptions can be addressed or
alternate treatment options considered should the need for blood arise.
• Alternatives to allogenic blood transfusion proposed to circumvent the difficult issues of donation, testing, safety, storage, and
cost include preoperative autologous blood donation, perioperative hemodilution, and intraoperative autologous transfusion.

90 VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY

9a_RIOG0160_07-15.qxd 7/15/11 11:50 AM Page 91

Use of Blood in Obstetrics and Gynecology

rapid tests: implementation and efficacy of a an obstetrics and gynaecology department. Br J sub-Sahelian West Africa. Vox Sang. 2009;97:
novel approach to blood safety in resource-poor Obstet Gynaecol. 1993;100:571-574. 317-323.
settings. Transfusion. 2005;45:133-140. 17. Estella NM, Berry DL, Baker DW, et al. Normo- 20. Ansaloni L, Gaines C, Tocalli E. ‘Soup ladle’
14. Spinella PC. Warm fresh whole blood transfusion volemic hemodilution before cesarean hysterectomy autotransfusion. Br J Surg. 1996;83:104.
for severe hemorrhage: U.S. military and poten- for placenta percreta. Obstet Gynecol. 1997;90: 21. Rebarber A, Lonser R, Jackson S, et al. The safety
tial civilian applications. Crit Care Med. 2008; 669-670. of intraoperative autologous blood collection
36:S340-S345. 18. Selo-Ojeme DO, Onwude JL, Onwudiegwu U. Au- and autotransfusion during cesarean section. Am
15. Santoso JT, Lin DW, Miller DS. Transfusion totransfusion for ruptured ectopic pregnancy. Int J Obstet Gynecol. 1998;179:715-720.
medicine in obstetrics and gynecology. Obstet J Gynaecol Obstet. 2003;80:103-110. 22. Geoghegan J, Daniels JP, Moore PA, et al. Cell
Gynecol Surv. 1995;50:470-481. 19. Priuli G, Darate R, Perrin RX, et al. Multicentre salvage at caesarean section: the need for an
16. O’Dwyer G, Mylotte M, Sweeney M, Egan EL. experience with a simple blood salvage technique evidence-based approach. BJOG. 2009;116:
Experience of autologous blood transfusion in in patients with ruptured ectopic pregnancy in 743-747.

VOL. 4 NO. 2 2011 REVIEWS IN OBSTETRICS & GYNECOLOGY 91