Conclusions
It is of vital importance that medical staff caring for Jehovah's Witnesses be familiar with all management options. In the cases above, the additional input of cell salvage and the work of a multidisciplinary team were crucial and potentially life-saving.
All Jehovah's Witness patients should undergo assessment and discussion with senior consultant haematology, obstetric and anaesthetic staff. Options available as alternatives to red blood cells include prevention of anaemia to maintain haematocrit above 40%. Tranexamic acid was used for patient 2, which is a commonly used medication for patients experiencing bleeding intraoperatively in our unit. Anti-embolic deterrent stockings were used to prevent thrombosis. For elective cases, erythropoietin may also be considered for a patient with a haematocrit of less than 40%. Erythropoietin stimulates the bone marrow to maximise red blood cell production. Not all Jehovah's Witnesses will accept this medication because the drug is packaged with 2.5mL of albumin per dose.
Autologous blood donation involves optimising the patient's haematocrit with oral iron supplementation (or erythropoietin if acceptable) and then having her donate her own blood at least 72 hours (but, ideally, 2 weeks) before elective caesarean delivery or estimated date of delivery.
Aside from allogeneic blood or blood products, other options should also be discussed. In our unit, staff are trained in the correct usage of cell salvage systems and same can be used in an emergency setting. Cell salvage systems are also an option in an elective setting. This can be employed as a form of intraoperative autologous blood donation. "Cell saver" systems allow for free blood in the abdomen to be aspirated, filtered, and then reinfused into the patient perioperatively as an intraoperative autologous transfusion. This is of significant importance given its life-saving capabilities and the fact that it is generally acceptable to members of the Jehovah's Witness community given that it does not involve transfusion of blood products. Consent in this regard is crucial.
In our first case above, the issue of informed consent was raised and the hospital legal team were consulted. The issue of whether or not she may have been in a position to give informed consent was raised given her potential hypoxia and pain, both of which could contribute as extraneous factors to the ability of giving informed consent. It was felt overall that she was of sound mind at the time and thus her consent was considered to be both informed and valid.
Any Jehovah's Witness patient in a life-threatening situation must be reviewed by the most senior available anaesthetic, obstetric and haematological staff. They must be made aware of the gravity of the situation and hospital legal experts should be consulted where necessary.
All options should be discussed and a management plan should be clearly documented.
Our focus was on obstetric and gynaecological care of Jehovah's Witnesses. However, we feel that this discussion could also be relevant in other areas of medicine and surgery. We feel that advances in haematological and pharmaceutical treatments can aid all members of this patient population.