Postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality both in developed and developing countries. In the Netherlands, we reported an incidence of severe PPH (defined as ≥1000 ml blood loss) of 4·5% in the period 2000–2008. As the majority of women who experience PPH have no identifiable clinical or historical risk factors, all women must be considered at risk and active third‐stage management is recommended in all women to prevent PPH. Red blood cell (RBC) transfusion is often necessary in the treatment of women who suffered from PPH. However, the current awareness of transfusion‐related complications (blood‐borne infections, transfusion reactions and immunologic effects) and the cost prompted a re‐evaluation of the transfusion practice. With only small differences in physical fatigue scores and no differences in secondary outcomes, we recommend implementation of a restrictive transfusion policy for women with PPH without severe anaemic complaints. This restrictive transfusion policy saves €438 per woman compared to a liberal transfusion policy. In addition, we recommend implementation of health‐related quality of life scores for counselling and decision‐making in clinical practice regarding transfusion policy after PPH.

OBJECTIVE:To determine clinical predictors of escape red blood cell (RBC) transfusion in postpartum anaemic women, initially managed expectantly, and the additional predictive value of health-related quality of life (HRQoL) measures. DESIGN:Secondary analysis of women after postpartum haemorrhage, either randomly allocated to, or opting for expectant management. SETTING:Thirty-seven hospitals in the Netherlands. POPULATION:A total of 261 randomised and 362 nonrandomised women. METHODS:We developed prediction models to assess the need for RBC transfusion: one using clinical variables (model 1), and one extended with scores on the HRQoL-measures Multidimensional Fatigue Inventory (MFI) and EuroQol-5D (model 2). Model performance was assessed by discrimination and calibration. Models were internally validated with bootstrapping techniques to correct for overfitting. MAIN OUTCOME MEASURES:Escape RBC transfusion. RESULTS:Seventy-five women (12%) received escape RBC transfusion. Independent predictors of escape RBC transfusion (model 1) were primiparity, multiple pregnancy, total blood loss during delivery and haemoglobin concentration postpartum. Maternal age, body mass index, ethnicity, education, medical indication of pregnancy, mode of delivery, preterm delivery, placental removal, perineal laceration, Apgar score and breastfeeding intention had no predictive value. Addition of HRQoL-scores (model 2), significantly improved the model's discriminative ability: c-statistics of model 1 and 2 were 0.65 (95% CI 0.58-0.72) and 0.72 (95% CI 0.65-0.79), respectively. The calibration of both models was good. CONCLUSIONS:In postpartum anaemic women, several clinical variables predict the need for escape RBC transfusion. Adding HRQoL-scores improves model performance. After external validation, the extended model may be an important tool for counselling and decision making in clinical practice.

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Background Red blood cell ( RBC ) transfusion is frequently used to treat women with acute anaemia after postpartum haemorrhage. We aimed to assess the economic consequences of red blood cell transfusion compared to non‐intervention in these women. Methods A trial‐based cost‐effectiveness analysis was performed alongside the Well‐Being of Obstetric patients on Minimal Blood transfusions (WOMB) trial. Women with acute anaemia [Hb 4·8–7·9 g/dl (3·0–4·9 m m )] after postpartum haemorrhage, without severe anaemic symptoms, were randomly allocated to RBC transfusion or non‐intervention. Primary outcome of the trial was physical fatigue (Multidimensional Fatigue Inventory, scale 4–20; 20 represents maximal fatigue). Total costs per arm were calculated using a hospital perspective with a 6 weeks time horizon. Results Per woman, mean costs in the RBC transfusion arm ( n = 258) were €1957 compared to €1708 in the non‐intervention arm ( n = 261; P = 0·024). The 13% difference in costs between study arms predominantly originated from costs of RBC units, as costs of RBC units were six times higher in the RBC transfusion arm. RBC transfusion led to a small improvement in physical fatigue of 0·58 points per day; thus, the costs to improve the physical fatigue score with one point would be €431. Conclusion In women with acute anaemia after postpartum haemorrhage ( PPH ), RBC transfusion is on average €249 more expensive per woman than non‐intervention, with only a small gain in HRQ oL after RBC transfusion. Taking both clinical and economic consequences into account, implementation of a non‐intervention policy seems justified.

OBJECTIVE:To assess the effect of red blood cell (RBC) transfusion on quality of life in acutely anaemic women after postpartum haemorrhage. DESIGN:Randomised non-inferiority trial. SETTING:Thirty-seven Dutch university and general hospitals. POPULATION:Women with acute anaemia (haemoglobin 4.8-7.9 g/dl [3.0-4.9 mmol/l] 12-24 hours postpartum) without severe anaemic symptoms or severe comorbidities. METHODS:Women were allocated to RBC transfusion or non-intervention. MAIN OUTCOME MEASURES:Primary outcome was physical fatigue 3 days postpartum (Multidimensional Fatigue Inventory, scale 4-20; 20 represents maximal fatigue). Non-inferiority was demonstrated if the physical fatigue difference between study arms was maximal 1.3. Secondary outcomes were health-related quality of life and physical complications. Health-related quality of life questionnaires were completed at five time-points until 6 weeks postpartum. RESULTS:In all, 521 women were randomised to non-intervention (n = 262) or RBC transfusion (n = 259). Mean physical fatigue score at day 3 postpartum, adjusted for baseline and mode of delivery, was 0.8 lower in the RBC transfusion arm (95% confidence interval: 0.1-1.5, P = 0.02) and at 1 week postpartum was 1.06 lower (95% confidence interval: 0.3-1.8, P = 0.01). A median of two RBC units was transfused in the RBC transfusion arm. In the non-intervention arm, 33 women received RBC transfusion, mainly because of anaemic symptoms. Physical complications were comparable. CONCLUSIONS:Statistically, non-inferiority could not be demonstrated as the confidence interval crossed the non-inferiority boundary. Nevertheless, with only a small difference in physical fatigue and no differences in secondary outcomes, implementation of restrictive management seems clinically justified.

Dear Sir, With great interest, we read the article by So-Osman et al. [1] concerning the triggers and appropriateness of red blood cell (RBC) transfusions in postpartum patients. It is obvious that this group of patients have to be considered more accurately and different with respect to transfusion triggers. As the authors emphasize, current guidelines are often not complied with [1]. In contradiction with current Dutch guidelines, the indication was based on haemoglobin (Hb) value in only 47.8% of all cases. The author’s defined three possible transfusion triggers although use only Hb levels in their final analysis. Their analysis might have caused a bias leading to a higher percentage of inappropriate RBC transfusions. Although not surprised by the high percentage of patients that received RBC transfusions inappropriately, we think that this percentage is actually lower. In certain circumstances, Hb values alone are not suited as transfusion triggers. In situations where the clinical condition of a recently delivered patient requires immediate RBC transfusion like in massive blood loss leading to shock or imminent shock, the indication is rarely doubtful and will seldom be inappropriate. Unfortunately, the volume of massive blood loss is often underestimated, which makes this parameter an unreliable trigger for RBC transfusion. Another problem with this indication is the unreliability of Hb values in the acute phase. Measuring blood loss accurately and considering the body weight of the patient to estimate the percentage of blood loss are mandatory. After haemodynamic stabilization, redistribution of plasma volume occurs during the first 12–24 h postpartum. Ninety per cent of all RBC transfusions in this audit were administered during the first 24 h, which make it feasible that plasma volume redistribution had not been completed yet and Hb values were still relatively high and considered inappropriate. Clinical symptoms such as dizziness and collapse resulting from haemodynamic instability may not only arise from low Hb levels but also from a relatively large decrease in Hb levels. In the latter, Hb levels may have been considered inappropriate. In our opinion, the most intriguing problem with RBC transfusion postpartum is the patient with an acute postpartum anaemia without haemodynamic consequences or complaints but with low Hb values 12–24 h postpartum. The goal of a RBC transfusion is in these cases improvement of health-related quality of life (HrQoL) and reduction in complications in the postpartum period. Instead of only using Hb values, a combination of Hb values and initial HrQoL should be used as triggers for RBC transfusion in these patients. The WOMB trial (NCT00335023), ongoing in 37 Dutch hospitals, will provide more insight in the transfusion triggers in this specific group of patients.