Original Research Ajog - GCIAMT
Original Researchajog.orgOBSTETRICSSingle-unit vs multiple-unit transfusion inhemodynamically stable postpartum anemia: apragmatic randomized controlled trialRebecca F. Hamm, MD; Sarah Perelman, BA; Eileen Y. Wang, MD; Lisa D. Levine, MD, MSCE; Sindhu K. Srinivas, MD, MSCEBACKGROUND: The American Academy of Blood Banks recommendssingle-unit red cell transfusion protocols across medicine to reducetransfusion complications and the use of a scarce resource. There areminimal data regarding single-unit protocols in obstetrics.OBJECTIVE: We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartumanemia.STUDY DESIGN: We performed a randomized trial comparing initialtransfusion with 1 unit of packed red blood cells (single-unit protocol) to2 units of packed red blood cells (multiple-unit protocol) from March2018 to July 2019. Women who required transfusion 6 hours postpartum were approached for consent. Unstable vital signs, hemoglobinlevel 5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusioncriteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additionalpacked red blood cells were given if indicated. The primary outcome wastotal units transfused. Secondary outcomes included length of stay,endometritis, wound separation or infection, venous thromboembolism,and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores wereassessed at 4 to 9 weeks postpartum. A total of 66 women were requiredIntroductionPostpartum anemia is a significantpublic health issue, with rates as high as27% to 80% across the globe.1e3 Tooptimize outcomes and prevent anemia,there are recommendations regardingthe management of an acute postpartumhemorrhage, including the use ofmassive blood transfusion protocolswhen indicated.4 Yet, many postpartumwomen will require transfusion after theacute events of the delivery room, whereCite this article as: Hamm RF, Perelman S, Wang EY,et al. Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmaticrandomized controlled trial. Am J Obstet Gynecol2021;224:84.e1-7.0002-9378/ 36.00ª 2020 Elsevier Inc. All rights 7to detect a 20% reduction in units transfused with a single-unit protocol(power¼80%; a¼0.05).RESULTS: A total of 66 women were randomized (33 per arm). Therewere no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in thesingle-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U;P .001). Only 18.2% of women in the single-unit arm required additionalpacked red blood cells. At posttransfusion assessment, women in thesingle-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL;P .001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-daycomplications, or 4 to 9 week postpartum outcomes.CONCLUSION: In women with hemodynamically stable postpartumanemia, a single-unit protocol avoided a second unit of packed red bloodcells in 80% of women without significant impact on morbidity. Our worksupports the use of single-unit initial transfusion in this population.Key words: breastfeeding, depression, estimated blood loss, fatigue,hemoglobin, maternal attachment, maternal morbidity, packed red bloodcells, red cell, transfusion complicationrecommendations are less clear.5,6Overtransfusion increases the risk ofalloantibody development, infectiousdisease transmission, and complicationssuch as transfusion-related acutelung injury (TRALI) and transfusionassociatedcirculatoryoverload(TACO).7,8 Undertransfusion in postpartum women may theoretically impacthealing, breastfeeding, depression, andthe ability to care for the newborn.8e11There is a paucity of data on the appropriate management of hemodynamicallystable postpartum anemia.Although there is limited evidence, itis common practice in obstetrics to offera transfusion of packed red blood cells(pRBCs) to women in the postpartumperiod with a hemoglobin (Hb) level 7g/dL (hematocrit 20%) and to symptomatic women with even higher Hblevels.12 Transfusions were historicallyinitiated with 2 units of pRBCs.84.e1 American Journal of Obstetrics & Gynecology JANUARY 2021However, the most recent recommendation from the American Association ofBlood Banks (AABB) for a stable patientis to begin tranfusion with 1 unit andreassess.13 The American College ofObstetriciansandGynecologists(ACOG), in the newly released 2017practice bulletin on postpartum hemorrhage, has included the AABB’s statement endorsing the use of single-unittransfusions.14 However, whereas nonobstetric fields have successfullydemonstrated that single-unit transfusion protocols can decrease the number of units transfused withoutincreasing morbidity,15e17 no such trialshave been performed in obstetrics.Therefore, we aimed to comparesingle-unit vs multiple-unit transfusionprotocols in hemodynamically stablepostpartum anemia. We hypothesizedthat a single-unit transfusion protocol canreduce the number of units transfused.
ajog.orgOBSTETRICSAJOG at a GlanceWhy was this study conducted?The American Academy of Blood Banks recommends single-unit red celltransfusion protocols across medicine to reduce transfusion complications andthe use of a scarce resource. There are minimal data regarding single-unit protocols within obstetrics.Key findingsA single-unit transfusion protocol reduced the mean number of units transfusedcompared with a multiple-unit transfusion protocol (1.2 U vs 2.1 U; P .001).Only 18.2% of women transfused with a single-unit required additional packedred blood cells (pRBCs). There were no significant differences in secondaryoutcomes—vital signs or symptoms at postpartum assessment, maternalmorbidity, depression, maternal attachment, breastfeeding, or fatigue scores—between groups.What does this add to what is known?In women with hemodynamically stable postpartum anemia, a single-unit protocol avoids a second unit of pRBCs in 80% of women without significantimpact on morbidity.Materials and MethodsWe performed a randomized controlledtrial of hemodynamically stable postpartum women requiring blood transfusion at the Hospital of the Universityof Pennsylvania from March 2018 toJuly 2019. This study was approvedby the Institutional Review Boardat the University of Pennsylvania andwas registered on ClinicalTrials.gov(NCT03419780).Women were approached for inclusion, and written consent was obtained ifthey met all of the following criteria:aged 18 years, determined to requireblood transfusion by their primary provider (Hb level either 7 g/dL or 7 g/dL with signs or symptoms of anemia,including but not limited to heart rate110e129 beats per minute, blood pressure 81e99 mm Hg systolic or 41e59mm Hg diastolic, fatigue, and/or dizziness), and 6 hours after deliverywithout a contraindication to transfusion. Women were excluded if theymet any of the following criteria:noneEnglish speaking, Hb level 5 g/dL, heart rate of 130 beats per minute,blood pressure 80 mm Hg systolic or 40 mm Hg diastolic, diagnosis ofFIGURE 1Study participantsHamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am J ObstetGynecol 2021.Original Researchhemoglobinopathy, or left ventricularejection fraction 35%. Womenremained eligible if they had received anacute blood transfusion but weredeemed to require additional blood at alater point in their postpartum course.Women were then randomized to 1 of2 arms: (1) single-unit protocol (initialtransfusion of 1 U pRBCs) or (2)multiple-unit protocol (initial transfusion of 2 U pRBCs). Randomizationwas done via computer-generated blockrandomization in a 1:1 scheme. Afterrandomization was performed, the patient and provider were both made awareof arm assignment. In both arms, 4 to 6hours after initial transfusion, a complete blood count, review of patientsymptomatology, and physical examination of the provider were performed.Assessment at this time could includeevaluation of volume status and orthostatic vital signs. In accordance with thepragmatic nature of this trial, additionalblood could be given if deemed necessary by the clinical provider. Additionalblood was given 1 unit at a time until nofurther blood was deemed necessary perprovider discretion.The primary outcome was number ofunits transfused per patient afterrandomization. Secondary outcomesincluded Hb level at 4 to 6 hours posttransfusion, vital signs and symptomatologyatfirstposttransfusionassessment by provider assessment, Hblevel at hospital discharge, use of intravenous iron, and maternal length of stay.Complications, including endometritis,wound infection, venous thromboembolism, intensive care unit admission,and adverse transfusion reaction, wereevaluated during the postpartumadmission and during any contact orreadmission within our health system,both inpatient or outpatient, up to30 days postpartum. We also evaluatedthe following secondary outcomesat the postpartum visit (4e9 weekspostpartum):(1) The Edinburgh Postnatal Depression Scale (EPDS), which is acommonly used screening toolfor depression during pregnancy.It is a self-report 10-question scaleJANUARY 2021 American Journal of Obstetrics & Gynecology84.e2
Original Researchajog.orgOBSTETRICSTABLE 1Baseline demographicsSingle-unitprotocol (n¼33)Multiple-unitprotocol (n¼33)P-value29 (6)29 (6)1.00Black26 (78.8)24 (72.7)White4 (12.1)7 (21.2)Asian3 (9.1)1 (3.0)Other01 ispanic1.0032 (97.0)32 (97.0)1 (3.0)1 (3.0)BMI at initial prenatal visita27.3 (6.9)27.0 (6.7).86Nulliparous12 (36.4)14 (42.4).80Twin gestation4 (12.1)4 (12.1)1.00Placental abnormalities1 (3.0)4 (12.1).36Gestational diabetes1 (3.0)3 (9.1).61Pregestational diabetes1 (3.0)1 (3.0)1.00Chronic hypertension2 (6.1)1 (3.0)1.00History of venous thromboembolism01(3.0)1.00Maternal cardiac disease1 (3.0)1 (3.0)1.00Hypothyroidism1 (3.0)3 (9.1).61Fibroids1 (3.0)1 (3.0)1.00Initial prenatal11.0 (1.7)11.1 (1.4).91Third trimester10.4 (1.5)10.3 (1.2).76Antepartum intravenous ironsucrose administered5 (15.2)4 (12.1)1.00Antepartum red blood cellblood transfusion1 (3.0)01.00Hemoglobin, g/dLaData are presented as number (percentage) unless noted otherwise.BMI, body mass index.aPresented as mean (standard deviation).Hamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am JObstet Gynecol 2021.on affective and cognitive featuresof depression in the 7 days preceding delivery; each item is scoredon a 4-point scale of 0 to 3, with atotal score of 30. Higher ,19(2) The Maternal Attachment Inventory (MAI), which measuresmaternal affectionate attachment. Itis a self-report, 26-item instrument;each item is scored from 1 (almostnever) to 4 (almost always), with apossible range of scores from 26 to104. Higher scores indicate highermaternal attachment to the infant.20(3) The Multidimensional Fatigue Index (MFI), which measures 5 dimensions of fatigue: general fatigue,physical fatigue, reduced activity,reduced motivation, and mentalfatigue. Although not specifically84.e3 American Journal of Obstetrics & Gynecology JANUARY 2021designed for the postpartum period,the MFI has high feasibility, reliability, and validity in chronicallyanemic and postpartum women andhas been used in multiple randomized controlled trials related topostpartum anemia. It is a selfreport, 20-item instrument; eachitem is scored on a 5-point scaleindicating to what extent the statement applies to the mother. Scoresrange from 20 to 100. Higher scoresindicate a higher degree offatigue.21e23The mothers were enquired aboutbreastfeeding at this visit as, “Are youfeeding your baby with any breastmilk?”To determine our sample size, weanalyzed baseline data at our institutionfrom 2013 to 2015, when most providerswere using multiple-unit transfusionprotocols. Women transfused for hemodynamically stable postpartum anemia received an average of 1.9 U, with astandard deviation of 0.3 U.24 Thus, wedetermined that we would require 33women per arm to have 80% power todemonstrate a 20% reduction in meanunits transfused, from 1.9 to 1.5 U perpatient with a standard deviation of 0.5U, using a 2-sided a of 0.05. This wouldresult in a decrease of 38 U for every 100women transfused, which was felt to beclinically significant.Fisher exact tests and chi-square testswere used for categorical variables and ttests or Wilcoxon rank sum tests wereused for continuous variables, whereappropriate. Analysis was performed asintention-to-treat. Statistical analyseswere performed with Stata 15 (StataCorp, College Station, TX) and statisticalsignificance was set at P .05.ResultsFrom March 2018 to June 2019, a total of102 eligible women were approached, ofwhom 66 (64.7%) provided writteninformed consent and underwentrandomization. A total of 33 womenwere randomized to the single-unitprotocol and 33 to the multiple-unitprotocol (Figure 1).Baseline demographics were similarbetween groups (Table 1). In addition,
ajog.orgOBSTETRICSTABLE 2Admission and randomization clinical characteristicsSingle-unitprotocol (n¼33)Multiple-unitprotocol (n¼33)P-valueCharacteristics: admission and deliveryHb level at admission, g/dLa10.4 (1.5)10.6 (1.3).71Labor induction14 (42.4)12 (36.4).803 (9.1)4 (12.1)1.00Peripartum magnesium levelGestational ageb37 (36e39)39 (36e40).63Mode of delivery1.00Spontaneous vaginal delivery8 (24.2)9 (27.2)Operative vaginal delivery2 (6.1)1 (3.0)23 (69.7)23 (69.7)Cesarean deliveryOrder of cesarean delivery.09Primary13 (56.5)15 (65.2)Repeat 13 (13.0)7 (30.4)Repeat 24 (17.4)03 (13.0)1 (4.4)6 (26.1)6 (26.1)Repeat 3 or greaterSurgical complicationscThird or fourth degree lacerationEstimated blood lossb2 (20.0)1000 (800e1500)1.000.471000 (800e1200).46Placental abruption3 (9.1)3 (9.1)1.00Acute blood transfusion beforerandomization3 (9.1)2 (6.1)1.00Hb level at randomization, g/dLaHeart rate6.8 (0.6)aDiastolic blood pressure(Table 4). Only 6 women (18.2%) in thesingle-unit arm were determined torequire further transfusion by theirclinical provider. Figure 2 depicts thetotal number of units transfused perarm.Women in the single-unit arm weremore likely to receive intravenous ironsucrose after their initial transfusion(45.5% vs 21.2%; P¼.04) (Table 4).There was no difference between groupsin maternal length of stay. Other secondary outcomes including endometritis,woundinfection,venousthromboembolism, and intensive careunit admission through 30 days postpartum, were not significantly differentbetween groups.Notably, 29 (87.9%) women in thesingle-unit arm and 27 (81.8%) womenin the multiple-unit arm presented forfollow-up 4 to 9 weeks postpartum. Atthis time point, there were no significantdifferences between groups in breastfeeding rates overall, breastfeeding ratesamong those who intended to breastfeedat delivery, EPDS, MAI, or MFI scores(Table 5).CommentPrincipal findingsCharacteristics: randomization examinationSystolic blood pressureaOriginal Research7.0 (0.6).2496 (12.0)92 (14.0).22116 (13.0)117 (19.0).7666 (11.0)66 (13.0).9324 (72.7)29 (87.9).22aLightheadedness/dizziness/fatigueData are presented as number (percentage) unless noted otherwise.Hb, hemoglobin.Mean (standard deviation); b Median (interquartile range); c Defined as 1 of the following: bladder injury, bowel injury,uterine artery laceration, or extension of the uterine incision.Hamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am JObstet Gynecol 2021.amode of delivery, visually estimatedblood loss, and characteristics at time ofrandomization were similar amonggroups (Table 2). Mean Hb level atrandomization was also similar in thesingle-unit and multiple-unit protocolarms (6.8 g/dL and 7.0 g/dL, respectively;P¼.24).All women received their initial randomized assignment without any crossover. At the 4 to 6 hour posttransfusionassessment (Table 3), mean Hb level waslower in the single-unit arm (7.8 g/dL vs8.7 g/dL, P .001). However, there wasno difference in vital signs or report ofanemia symptoms (lightheadedness,dizziness, or fatigue) between groups.For our primary outcome, the meantotal number of units transfused postrandomization was lower in the singleunit protocol than in the multiple-unitprotocol (1.2 U vs 2.1 U; P .001)In this study, no additional bloodwas required beyond the initial 1 Utransfusion for 80% of the womenrandomized to a single-unit blood transfusion protocol. Women in the singleunit arm had similar outcomes in termsof 30-day morbidity and postpartumoutcomes, including breastfeeding rates,depression, mothereinfant bonding, andfatigue scores.ResultsAlthough several other medical disciplines have examined the impact ofsingle-unit transfusion protocols, ourstudy addresses the safety of such aprotocol in the postpartum population.In addition, previous studies were oftenperformed as retrospective or prospective cohort studies, with significant roomfor biases affecting decision-makingaround transfusion.15,16 Our studyremoves at least the initial decision ofnumber of units to transfuse from thehands of the provider through aJANUARY 2021 American Journal of Obstetrics & Gynecology84.e4
Original Researchajog.orgOBSTETRICSTABLE 3Data at 4 to 6 hours posttransfusion assessmentSingle-unitprotocol (n¼33)Posttransfusion Hb level, g/dLHeart rate, (beats per min)aMultiple-unitprotocol (n¼33)7.8 (0.7)a8.7 (0.9)P-value .00190 (13.0)85 (12.0).08Systolic BP (mm Hg)a123 (13.0)121 (18.0).66Diastolic BP (mm Hg)a72 (9.0)71 (12.0).736 (18.8)1.00Lightheadedness/dizziness/fatigueb7 (21.2)BP, blood pressure; Hb, hemoglobin.aPresented as mean (standard deviation); b Presented as number (percentage).Hamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am JObstet Gynecol 2021.randomized trial, decreasing the impactof bias.Clinical implicationsAABB, supported by ACOG, recommends the use of single-unit bloodtransfusion protocols to reduce transfusion complications such as alloantibody development, TRALI, and TACO.Furthermore, blood is a scarceresource.13,14 In obstetrics, we must alsoconsider the implication of producttransfusionandpossibleisoimmunization on future pregnancies.However, traditional obstetrical practiceis to administer a higher quantity ofblood products because of the theoretical concern regarding postpartumhealing, fatigue, depression, newborncare, and breastfeeding. In a qualitativestudy performed in Australia, despitesimilar guidelines promoting single-unitprotocols, 54% of obstetricians still reported they would initiate any postpartum transfusion with 2 units ofpRBCs, citing concern for perceivedTABLE 4Primary and secondary outcomes up to 30 days postpartumSingle-unitprotocol (n¼33)Primary outcome: total units transfusedaMultiple-unitprotocol (n¼33)P-value1.2 (0.5)2.1 (0.4) .0018.2 (0.7)8.9 (0.8).00315 (45.5)Secondary outcomesLast Hb level before discharge, g/dLaPostpartum use of intravenous iron7 (21.2).043.1 (2.5e3.8)3.4 (2.4e4.1).7902 (6.1).492 (6.1)1 (3.0)1.0001 (3.0)1.001 (3.0)1 (3.0)1.00c00c1 (3.0)2 (6.1)Maternal length of staybEndometritiscWound separation or infectionVenous thromboembolismccIntensive care unit admissioncAdverse transfusion reactionsReadmissions within 30 daysNA1.00Hb, hemoglobin; NA, not applicable.aPresented as mean (standard deviation); b Presented as median (interquartile range); c Presented as number (percentage).Hamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am JObstet Gynecol 2021.84.e5 American Journal of Obstetrics & Gynecology JANUARY 2021utility.25 Our data support the adoptionof AABB’s recommendations into obstetrics to decrease the number of unitstransfused without increasing morbidityfor postpartum women with hemodynamically stable anemia.Research implicationsThis small randomized trial providesinitial data supporting the use of singleunit transfusion for hemodynamicallystable postpartum anemia. Further workshould be done to implement single-unitprotocols as the standard of care at anational level. Future research shouldfocus on both clinical and implementation outcomes, such as healthcare cost,provider and patient acceptability, andadoption into practice.Strengths and limitationsThere are several strengths to our work.This study was performed as a randomized controlled trial, removing providerbias from the initial decision for singleunit or multiple-unit transfusion. Inaddition, we were able to assess many ofthe variables that reflect commonly citedreasons for providing multiple units toobstetrical patients, such as wound outcomes, postpartum fatigue, depression,and breastfeeding, with no differencesbetween groups.There are also several limitations. Thedecision to proceed with transfusion forany given patient depended on the provider. As strict cutoffs for anemiaseverity were not employed as enrollment criteria, our population may haveincluded patients for whom anotherprovider may not have thought transfusion was necessary, which could havebiased our results. In addition, the decision to give additional product afterthe posttransfusion assessment alsodepended on the provider. As providerswere not blinded to study assignment,observer bias could have influenced thedecision-making process at this timepoint. Yet, the lack of stringent criteriaregarding initial or subsequent transfusion adds a pragmatic aspect to thisstudy, increasing its generalizability.Finally, our small sample size was notpowered to detect differences in some ofour less common secondary outcomes
ajog.orgOBSTETRICSOriginal Researchof single-unit transfusion protocolshas the potential to reduce healthcarecost, conserve a scarce resource, andprevent rare but deadly transfusionreactions.nFIGURE 2Number of units transfused by trial armReferencesHamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am J ObstetGynecol 2021.such as wound infection and readmission. In addition, more women in thesingle-unit arm received intravenousiron sucrose postpartum, which mayhave impacted postpartum outcomes.However, it is reassuring that no largedifferences were noted between thegroups.ConclusionA second unit of pRBCs can be avoidedin most postpartum women requiringhemodynamically stable transfusionwithout significant impact on shortterm or postdischarge morbidity. Ourwork supports single-unit initial transfusion in this population. Large-scale useTABLE 5Secondary outcomes at 4 to 9 weeks postpartum visitSingle-unitprotocolSecondary outcomesPresented for postpartum visitaMultiple-unitprotocolP-value29/33 (87.9)27/33 (81.8).73Breastfeeding (any) overall16/29 (55.2)15/27 (55.6).89Breastfeeding (any) if intended tobreastfeed at delivery16/26 (61.5)14/22 (63.6)1.004 (1e11)5.5 (2e8).34104 (102e104)104 (102e104).5544 (34e55)53 (38e70).13aEdinburgh Postnatal Depression Scaleb,cMaternal Attachment Inventoryb,dMultidimensional Fatigue Inventoryab,ePresented as number (percentage); b Presented as Median (interquartile range); c Higher scores indicate increaseddepressive symptoms; d Higher scores indicate higher rates of maternal-infant attachment; e Higher scores indicate greaterfatigue.Hamm et al. Randomized controlled trial of single-unit vs multiple-unit transfusion in postpartum anemia. Am JObstet Gynecol 2021.1. Bodnar LM, Scanlon KS, Freedman DS,Siega-Riz AM, Cogswell ME. High prevalence ofpostpartum anemia among low-income womenin the United States. Am J Obstet Gynecol2001;185:438–43.2. Butwick AJ, Walsh EM, Kuzniewicz M, Li SX,Escobar GJ. Patterns and predictors of severepostpartum anemia after cesarean section.Transfusion 2017;57:36–44.3. Milman N. Postpartum anemia I: definition,prevalence, causes, and consequences. AnnHematol 2011;90:1247–53.4. Main EK, Goffman D, Scavone BM, et al.National Partnership for Maternal Safety:consensus bundle on obstetric hemorrhage.Obstet Gynecol 2015;126:155–62.5. Petty K, Waters JH, Sakamoto SB, Yazer MH.Antenatal anemia increases the risk of receivingpostpartum red blood cell transfusions althoughthe overall risk of transfusion is low. Transfusion2018;58:360–5.6. Prabhu M, Bateman BT. Postpartum anemia:missed opportunities for prevention and recognition. Transfusion 2017;57:3–5.7. Brown MR, Jennings PR. Avoiding overtransfusion: an update on risks and latest indications. JAAPA 2012;25:42–5.8. Lenfant C. Transfusion practice should beaudited for both undertransfusion and overtransfusion. Transfusion 1992;32:873–4.9. Maeda Y, Ogawa K, Morisaki N,Tachibana Y, Horikawa R, Sago H. Associationbetween perinatal anemia and postpartumdepression: a prospective cohort study ofJapanese women. Int J Gynaecol Obstet2020;148:48–52.10. Milman N. Postpartum anemia II: prevention and treatment. Ann Hematol 2012;91:143–54.11. Rioux FM, Savoie N, Allard J. Is there a linkbetween postpartum anemia and discontinuation of breastfeeding? Can J Diet Pract Res2006;67:72–6.12. John M. Eisenberg Center for ClinicalDecisions and Communications Science. Management of postpartum hemorrhage: currentstate of the evidence. In: Comparative effectiveness review summary guides for clinicians.Rockville, MD: Agency for Healthcare Researchand Quality; 2016.13. Carson JL, Guyatt G, Heddle NM, et al.Clinical practice guidelines from the AABB: redblood cell transfusion thresholds and storage.JAMA 2016;316:2025–35.14. CommitteeonPracticeBulletinsObstetrics. Practice Bulletin No. 183: postpartumhemorrhage. Obstet Gynecol 2017;130:e168–86.JANUARY 2021 American Journal of Obstetrics & Gynecology84.e6
Original ResearchOBSTETRICS15. Berger MD, Gerber B, Arn K, Senn O,Schanz U, Stussi G. Significant reduction of redblood cell transfusion requirements by changingfrom a double-unit to a single-unit transfusionpolicy in patients receiving intensive chemotherapy or stem cell transplantation. Haematologica 2012;97:116–22.16. Hogervorst EK, Rosseel PM, van deWatering LMG, et al. Intraoperative anemia andsingle red blood cell transfusion during cardiacsurgery: an assessment of postoperative outcomeincluding patients refusing blood transfusion.J Cardiothorac Vasc Anesth 2016;30:363–72.17. Shander A, Javidroozi M, Ozawa S,Hare GMT. What is really dangerous: anaemia ortransfusion? Br J Anaesth 2011;107(Suppl1):i41–59.18. Cox JL, Holden JM, Sagovsky R. Detectionof postnatal depression. Development of the 10item Edinburgh Postnatal Depression Scale. Br JPsychiatry 1987;150:782–6.19. GibsonJ,McKenzie-McHargK,Shakespeare J, Price J, Gray R. A systematicreview of studies validating the EdinburghPostnatal Depression Scale in antepartum andpostpartum women. Acta Psychiatr Scand2009;119:350–64.20. Müller ME. A questionnaire to measuremother-to-infant attachment. J Nurs Meas1994;2:129–41.21. Holm C, Thomsen LL, Norgaard A,Langhoff-Roos J. Single-dose intravenousiron infusion or oral iron for treatment offatigue after postpartum haemorrhage: a randomized controlled trial. Vox Sang 2017;112:219–28.22. Jansen AJG, Essink-Bot ML, Duvekot JJ,van Rhenen DJ. Psychometric evaluation ofhealth-related quality of life measures in womenafter different types of delivery. J PsychosomRes 2007;63:275–81.23. Smets EM, Garssen B, Bonke B, DeHaes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res1995;39:315–25.24. Hamm RF, Wang E, Romanos A, O’Rourke K,Srinivas SK. Implementation of quantification ofblood loss does not improve prediction of hemoglobin drop in deliveries with average blood loss.Am J Perinatol 2018;35:134–9.25. Mayson E, Shand AW, Ford JB. Single-unittransfusions in the obstetric setting: a qualitativestudy. Transfusion 2016;56:1716–22.84.e7 American Journal of Obstetrics & Gynecology JANUARY 2021ajog.orgAuthor and article informationFrom the Maternal and Child Health Research Center,Department of Obstetrics and Gynecology, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, PA.Received April 8, 2020; revised June 7, 2020;accepted July 7, 2020.The authors report no conflicts of interest.This research was funded by the National Improvement Challenge for Obstetric Hemorrhage through theCouncil for Patient Safety in Women’s Health and a T32Training Grant to the University of Pennsylvania by theNational Institutes of Health (T32HD007440).None of the funders had any role in the study design,data collection, data analysis, interpretation of data, thewriting of the report or the decision to submit the articlefor publication. The content is solely the responsibility ofthe authors and does not necessarily represent the officialviews of the National Institutes of Health.This study was registered on ClinicalTrials.gov (clinicaltrial number NCT03419780).Data from this manuscript were presented at the 40thAnnual Pregnancy Meeting, Society for Maternal-FetalMedicine, Grapevine, TX, February 3e8, 2020.Corresponding author: Rebecca F. Hamm, MD.Rebecca.feldmanhamm@uphs.upenn.edu
The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit pro-tocols within obstetrics. Key findings A single-unit transfusion protocol reduced the mean number of units transfused
YAMAHA N MAX 125 euro 5 2021- 5519121 280.80 RPM limiter : 1000 RPM CDI version MAPS Exhaust Cylinder Ø Kit CC Head Camshaft Filter Original Malossi Curve 0 Original Original Original Original Original 10.000 11.000 Curve 1 Original 3117968 63 183 Original Original Original Malossi Curve 2 Original Original Original Original Original
OBSTETRICS A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy Ilan E. Timor-Tritsch, MD; Ana Monteagudo, MD; Terri-Ann Bennett, MD; Christine Foley, MD;
determine the attributes of ABO-cards (technique, result tsforcompletion. 2.4. Dataanalysis Data was entered and analyzed in Microsoft excel 2010.
Quaker Instant Grits Original Quaker Instant Oatmeal Original CANNOT BUY Hot cereals less than 11.8 oz. Added raisins, fruit, or nuts Variety packs Organic cereals Cereal (Hot) Quaker Instant Grits Original Quaker Instant Oatmeal Original Cream of Rice Wheat Original 1 Minute Wheat Original 2.5 Minutes Malt O Meal Original
Geometry Construction Project Grading Rubric Creativity: 16-20 Original design is very clever; creatively designed Original design is either completely original or combines non-original designs in an original way. Coloring, etc. on all designs is creative and shows care and creativity. 10-15 Original design displays creative thinking Some portion of the original design is .
152 bacardi limon original citrus rum 375 660 153 bacardi limon original citrus rum 180 330 154 bacardi o original orange rum 750 1320 155 bacardi o original orange rum 180 330 156 bacardi orange original orange rum 750 1320 157 bacardi orange original orange rum 375 660 158 bacardi orange original orange rum 180 330 159 bacardi cola 275 140
2666-5778 AJOG Global Reports Open access 2,000 1,750 1,570 219,320 0741-8329 Alcohol Hybrid 2,800 2,440 2,200 300,910 1110-0168 Alexandria Engineering Journal Open access 860 750 670 92,420 2211-9264 Algal Research Hybrid 3,530 3,080 2,770 379,360 1323-8930 Allergology International Open ac
PK-2 Next Generation ELA Standards at a Glance . PK-2 Reading Standards (Literary and Informational Text) Review the . PK, K, 1. st, and 2 nd grade ELA introductions for information regarding: guidance and support, range of student reading experiences, text complexity, English language learners/multilingual learners, and students with disabilities. Key Ideas and Details PK K 1 2 PKR1 .
