Pre-cesarean blood bank orders: a safe and less expensive approach.

OBJECTIVES: To 1) characterize pre-cesarean blood bank testing, 2) describe the transfusion experience in a large series of cesarean patients, and 3) evaluate safety and cost implications of a "hold clot" order for patients at low risk for transfusion. METHODS: A review of 1111 consecutive cesarean patients used computerized perinatal and blood bank data bases and a detailed chart review of all cross-matched patients. Information collected included indications for cesarean and transfusion, etiology of hemorrhage, transfusion number and type, admission and lowest hemoglobin level, and information regarding the events leading to transfusion. A blinded review of the cross-matched patient's information assessed whether a cross-match was appropriate or could have been replaced safely by a "hold clot" (current clot tube in blood bank) order. RESULTS: Nineteen patients (1.7%) were transfused. The only patients requiring a transfusion were diagnosed with placenta previa, placenta accreta, anemia, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP syndrome), or hemorrhage. A comparison of two blood banking approaches (routine pre-cesarean type and screen testing versus a "hold clot" order for cesarean patients at low risk for transfusion) indicated that the latter would reduce costs by $45 per cesarean, or $95,000 annually. CONCLUSIONS: The incidence of transfusion was low (1.7%) and associated with specific diagnoses (previa, accreta, anemia, preeclampsia/HELLP, or hemorrhage). The data support the replacement of pre-cesarean type and screen testing with a "hold clot" order for patients at low risk for transfusion with negative prenatal antibody screen. This approach is safe and would reduce cost substantially.

Maternal glucose intolerance and the subcutaneous terbutaline pump.

OBJECTIVE: Our hypothesis was that use of the subcutaneous terbutaline pump does not affect maternal glucose tolerance. STUDY DESIGN: With the 1-hour glucose tolerance test, we examined the incidence of glucose intolerance in 37 patients using the pump compared with that of 54 patients receiving oral terbutaline and 634 control subjects without risk factors for gestational diabetes. The frequency of gestational diabetes and the need for insulin to maintain glycemic control were subjected to chi 2 analysis. RESULTS: The incidence of gestational diabetes was 6% in the control subjects, 5% in patients using the pump (p = 0.8), and 11% in those on the oral therapy regimen (p = 0.4). A total of 8% of controls who had gestational diabetes required both insulin and diet, compared with 100% using the pump (p less than 0.01) and 50% on the oral terbutaline regimen (p = 0.03). CONCLUSION: The incidence of gestational diabetes is not increased in patients receiving terbutaline via the subcutaneous pump. The use of terbutaline by any route significantly increases the need for insulin to achieve glycemic control.

Pulmonary hypertension.

Pulmonary hypertension may be primary, of unknown etiology, or secondary to existing cardiorespiratory disease. In general, the prognosis is poor, but the superimposed physiologic changes of pregnancy, labor, and delivery may produce a lethal condition. Pregnancy prevention is better than any proposed care. If pregnancy occurs, termination is suggested in the first or early second trimesters. If the choice is to continue the pregnancy, a well-coordinated intensive management plan is necessary. This plan should include midsecond trimester hospital admission of the patient, continuous hemodynamic monitoring during the intrapartum period and immediately after delivery, and preferably elective induction with hemodynamically stable epidural anesthesia for labor and delivery.

Cost-effective approach to office screening for gestational diabetes.

Gestational diabetes is a common problem during pregnancy. There are numerous screening programs, all of which are costly and time consuming. During a 6-month period, 50 patients were screened for gestational diabetes with a standard 50-g oral glucose load, and 1 hour later a capillary blood specimen was evaluated by means of a reflectance meter and a venous sample was evaluated in the hospital laboratory. We found that the capillary blood glucose determination was accurate, but we recommend that specific cutoff values for each meter be established for each facility. By using the glucose reflectance meter, 90% of patients will not require laboratory studies, which results in significant cost savings. Besides cost savings, the immediate results obtained by a reflectance meter allow for prompt identification of an abnormal screen and prompt scheduling for further evaluation of glucose intolerance during the pregnancy.

Safety of predeposit autologous blood donation in the third trimester of pregnancy.

The option of predeposit autologous blood donation (PABD) before elective surgery has been gaining popularity as a means of eliminating the transmission of the acquired immune deficiency syndrome and hepatitis. It also prevents potential antigen sensitization and transfusion reactions. The use of PABD in pregnant women has been described, but its safety for both mother and fetus, especially in the first and third trimester, has not been established. After studying 16 third-trimester pregnant women with antenatal surveillance techniques and continuous fetal monitoring, we concluded that PABD is a safe procedure for both mother and fetus.

Developing a maternal-fetal intensive-care unit.

Advances in perinatal health care have allowed more women the opportunity for a successful pregnancy despite medical complications. A maternal-fetal intensive-care unit (MFICU) can provide these patients with medical and nursing care equivalent to that of a medical/surgical intensive-care unit while meeting the complex physical and psychosocial needs associated with pregnancy. Successful development of a MFICU mandates consideration of administrative aspects, educational programs, and clinical issues. The key to a successful maternal-fetal intensive-care unit lies in thorough planning, careful implementation, and timely evaluation.