Use of cell salvage and HBOC-201 in a pregnant Jehovah’s Witness with sickle beta+thalassaemia undergoing emergency caesarean section

Abstract

Patients with severe anaemia who refuse or cannot safely receive red cell transfusion present challenges during pregnancy, delivery and the postpartum period. Strategies including HBOC-201 (Hemopure) and intraoperative use of cell salvage have been used in non-pregnant patients to improve oxygen carrying capacity; however, these products pose unique risks in pregnant patients, those with sickle cell disease (SCD) and those undergoing caesarean section (C-section). We describe a case of a pregnant sickle beta+thalasasaemia patient who presented at 27 weeks gestation with pre-eclampsia and severe anaemia. As a Jehovah’s Witness, she declined allogenic blood transfusion. The patient successfully underwent emergent C-section with cell salvage and received HBOC-201 immediately after delivery, during the operative procedure. To our knowledge, this is the first published report documenting a Jehovah’s Witness patient with SCD who successfully received cell salvage and then HBOC-201 immediately postdelivery.

Clinical Issues — May 2023

“…The decision to use intraoperative autologous RBC salvage in specific instances—such as during obstetric procedures 1‐5 or in the presence of malignancy, 6‐10 sickle cell disease, 11‐13 or β‐thalassemia 11,14 —is nuanced and discussed in depth in the literature. Clinical decision making on the use of intraoperative autologous RBC salvage in the presence of relative contraindications can benefit from a detailed understanding of the available evidence, the patient's clinical presentation, and an interdisciplinary team discussion that includes the patient's perspective.…”

“…1 When there is an anticipated need for RBCs during the procedure and relative contraindications for intraoperative autologous RBC salvage exist, physicians and other independent licensed personnel (ie, surgeons, anesthesia professionals) should review the likelihood and severity of the complication and options for mitigating risk and then compare the benefits of intraoperative autologous salvaged RBC administration with the risks of possible allogeneic blood administration. 1,2 The decision to use intraoperative autologous RBC salvage in specific instances-such as during obstetric procedures [1][2][3][4][5] or in the presence of malignancy, [6][7][8][9][10] sickle cell disease, [11][12][13] or β-thalassemia 11,14 -is nuanced and discussed in depth in the literature. Clinical decision making on the use of intraoperative autologous RBC salvage in the presence of relative contraindications can benefit from a detailed understanding of the available evidence, the patient's clinical presentation, and an interdisciplinary team discussion that includes the patient's perspective.…”

“…2 Support for second victims is not always available or accessed, 2,10-14 though support programs are discussed in the literature. 11,[15][16][17][18][19] Additionally, many health care organizations 9,20 and professional organizations [21][22][23] have web sites dedicated to information on second-victim support programs. The University of Missouri and the Agency for Healthcare Research and Quality describe a three-tiered program that includes local support, trained support personnel, and support through referrals.…”