Women who decline blood during labour: Review of findings and lessons learnt from 52 years of Confidential Enquiries into maternal mortality in the United Kingdom (1962-2019).

OBJECTIVE: Patients who decline blood products because of their religious beliefs pose a unique challenge in the context of obstetric haemorrhage. Four large series assessing maternal outcomes in Jehovah's Witnesses from USA, UK, Netherlands and Japan estimate that maternal mortality is increased by between 44 and 160-fold. A review of maternal deaths from obstetric haemorrhage was undertaken in mothers who decline blood transfusion, using UK Confidential Enquiries into Maternal Deaths reports (1967-2019) in order to identify common trends and lessons learnt. DESIGN: Retrospective review using 18 triennial Confidential Enquiries in Maternal Deaths reports between 1967 and 2019. RESULTS: Fifteen maternal deaths from haemorrhage were reported in patients who declined blood products for religious beliefs in the 52 years reviewed. Common themes noted included delay in senior escalation, hesitation to perform life-saving hysterectomy and loss of situational awareness. Placental abruptions (3/15) and curettage for secondary postpartum haemorrhage (2/15) especially warrant senior input and cooperation with Jehovah's Witness Hospital Liaison Committees is recommended. CONCLUSIONS: Guidelines from the UK's Royal College of Obstetricians and Gynaecologists and Royal College of Surgeons highlight the need for collaborative, Montgomery-competent discussions during the antenatal period, as well as the engagement of local Jehovah's Witness Hospital Liaison committees. Consultant-led care, antenatal optimisation of haemoglobin and techniques to mitigate blood loss at delivery are paramount. We advocate using a lower threshold for hysterectomy than was used in the cases analysed, for example when the haemoglobin level drops below 8-9 g/l in the context of ongoing bleeding. As patients increasingly begin to decline blood products for non-religious reasons, the lessons learnt in the management of Jehovah's Witnesses are becoming ever more relevant.

Exploring the Role of Body Mass Index on Balance Reactions and Gait in Overweight Sedentary Middle-aged Adults: A Pilot Study.

BACKGROUND/PURPOSE: Being overweight is defined as having a body mass index greater than 25. Reduced postural control has been implicated in the presence of increased body mass index. The purpose of this study was to assess the effects of body mass index on postural stability in healthy sedentary middle-aged adults. Based on body mass index, subjects were divided into 2 groups (25.00-27.49 and 27.50-29.99) to assess for differences in postural control. METHODS: Twenty healthy sedentary subjects between 40 and 64 years (13 women and 7 men) with a mean age of 52.45 years were recruited by convenience. After determination of body mass index, postural control was assessed on all subjects using the Activities Specific Balance Confidence Scale, Berg Balance Scale, Timed Up and Go Test, gait speed measurement, and Biodex Stability Index testing. RESULTS: The Timed Up and Go Test duration was increased in these subjects when compared with normative data. Gait speed was also reduced in those subjects in the fifth and sixth decades when compared with established norms. Biodex SD balance system scores demonstrated reduced postural stability. A 2-tailed t test revealed no significant difference between body mass index ranges of 25.0 to 27.5 and 27.6 to 29.99. CONCLUSION: There may be increased risk for falls with increases in body mass short of obesity thresholds of body mass index 30% for this sedentary middle-aged adult population. Future studies, with larger groups of subjects, that address postural stability and body mass index are necessary. Although these subjects are younger, falls screening measures may prove beneficial as a prevention strategy for sedentary overweight middle-aged adults.