OB Hemorrhage - Jehovah's Witness Resources

OBJECTIVE: To review the treatment options presented on the New York State Health Care Proxy for Jehovah’s Witnesses, which is signed by pregnant women when they present for care. METHODS: Chart reviews were performed for all women who presented to labor and delivery at our institution from 1997 to 2002 and identified themselves as Jehovah’s Witnesses. A patient was included in the study if a completed health care proxy was available in her chart. Data were derived from the health care proxy and from the Mount Sinai School of Medicine’s Blood Product Checklist for Jehovah’s Witness Patients. Variables of interest included age, race, parity, and antenatal and perinatal complications. RESULTS: A total of 61 patients were identified. Of these, 39.3% agreed to accept a variety of donated blood products, 9.8% would accept donated packed red blood cells, and 50.1% would accept neither from a homologous donor. With respect to nonstored autologous blood, 55% of respondents would accept either intraoperative normovolemic hemodilution or transfusion of their own blood obtained by a cell salvage system. No significant differences in responses were noted for any of the above-mentioned variables. CONCLUSION: This review refutes the commonly held belief that all Jehovah’s Witnesses refuse to accept blood or any of its products. In this population of pregnant women, the majority were willing to accept some form of blood or blood products. This information can be used to help health care providers counsel a patient when she is initially faced with considering these issues and may help to remove the stigma of accepting one of the options. (Obstet Gynecol 2004;104:541– 4. © 2004 by The American College of Obstetricians and Gynecologists.)

In the successful management of a pregnant Jehovah's Witness, many issues must be addressed beyond those normally required for routine prenatal care. The clinician who undertakes such care should be well versed in the potential complications related to blood refusal, the antepartum management of anemia, and the intrapartum management of obstetric hemorrhage. Furthermore, these patients should be delivered in a tertiary care center because this increases their options for obtaining alternative management of hemorrhage. A woman who is well informed about her options can then decide exactly what she wants done in the event of a life-threatening obstetrical hemorrhage.

Jehovah’s Witnesses comprise a unique obstetric population. Their refusal of blood stems from an interpretation of a literal translation of the Bible, and it is this belief that puts them at an increased risk of morbidity and mortality if hemorrhage occurs. Many Jehovah’s Witnesses feel that accepting a blood transfusion will lead them to eternal damnation. A patient’s self-determination, or autonomy, allows her to make decisions regarding her care. The decision to refuse blood or blood products has been upheld in court. This brings a new twist to the physician’s obligation to “do no harm.” When one undertakes the care of one of these patients, it is important to understand the ethical and medicolegal ramifications. The decision to be the primary caregivers can only be made once the physicians have decided they can let the patient die when all other options have been exhausted. This commentary discusses the ethical concerns and reviews the alternatives available to a Jehovah’s Witness. (Obstet Gynecol 2003;102:173– 80. © 2003 by The American College of Obstetricians and Gynecologists.) Several unique issues arise when health professionals agree to provide obstetric care to observant Jehovah’s Witnesses. It has been shown that if such women have an obstetric hemorrhage, they are at a 44-fold increased risk of maternal mortality.1 Both ethical and medical concerns should be considered before undertaking the care of one of these patients.

PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness.
CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.
CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.

Over a 14-year period, the obstetric outcome of Jehovah's Witnesses in an inner city hospital was reviewed and the effect of refusal of blood on morbidity and mortality evaluated. Ninety women had 116 deliveries and of these, 24% were delivered by caesarean section, 10% had instrumental deliveries and 66% were normal vaginal deliveries. Postpartum haemorrhage of >1,000 mls occurred in 6% and postpartum anaemia was the commonest complication. The mean postdelivery haemoglobin (11.10 +/- 1.15 g/dl) was not significantly less from the mean predelivery haemoglobin level (11.81 +/- 1.62 g/dl) (P > 0.05, paired t test). The single maternal death occurred after caesarean hysterectomy, which when extrapolated, resulted in a 65-fold increased risk of maternal death compared to the national rate. The optimum management of pregnant women who decline transfusion is discussed.

Jehovah's Witnesses are primarily known to physicians for their refusal of blood transfusions. Conflict arises at times with the medical staff concerning how best to manage their care. This article will begin with a brief description of the beliefs of Jehovah's Witnesses and will then recommend specific clinical strategies highlighting newer potential therapies according to the principles of bloodless medicine. The scenarios of bleeding and acute and chronic anemia will be discussed in detail for the care of these patients refusing red blood cell transfusions. An update in the use of blood substitutes will be mentioned as well as the surgical advances used today that can minimize blood loss for all patients. The experience of organ transplantation in Jehovah's Witnesses will be detailed. Further resources for physicians with questions in the care of these patients will be listed. Stressed throughout the article will be the need for a team approach and good communication between physicians to successfully care for their patients who are Jehovah's Witnesses.

OBJECTIVE: The purpose of this study was to determine the rates of obstetric hemorrhage and maternal mortality in women who are Jehovah's Witnesses and to evaluate a protocol that uses erythropoietin to optimize the red blood cell mass before delivery.
STUDY DESIGN: Obstetric outcomes were described for all of the women who were Jehovah's Witnesses and who delivered at Mount Sinai Medical Center during an 11-year period. The risk of maternal death was compared with our general obstetric population during this interval.
RESULTS: A total of 332 women who were Jehovah's Witnesses had 391 deliveries. An obstetric hemorrhage was experienced in 6% of this population. There were 2 maternal deaths among the women who were Jehovah's Witnesses, for a rate of 512 maternal deaths per 100,000 live births versus 12 maternal deaths per 100,000 live births (risk ratio, 44; 95% CI, 9-211). Erythropoietin was associated with a nonsignificant increase in hematocrit level.
CONCLUSION: Women who are Jehovah's Witnesses are at a 44-fold increased risk of maternal death, which is due to obstetric hemorrhage. Patients should be counseled about this risk of death, and obstetric hemorrhage should be aggressively treated, including a rapid decision to proceed to hysterectomy when indicated.

OBJECTIVE: To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah's witnesses in The Netherlands.
DESIGN: A retrospective study of case notes.
SETTING: All tertiary care centres, general teaching hospitals and other general hospitals in The Netherlands.
SAMPLE: All cases of maternal mortality in The Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in The Netherlands between 2004 and 2006.
METHODS: Study of case notes using two different nationwide enquiries over two different time periods.
MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR) and risk of serious maternal mortality.
RESULTS: The MMR for Jehovah's witnesses was 68 per 100,000 live births. We found a risk of 14 per 1000 for Jehovah's witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000.
CONCLUSIONS: Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population.