The Jehovah's Witnesses are a branch of Christiainity dating from the late-nineteenth century that has an estimated 7 million followers.
The Jehovah's Witnesses are a branch of Christianity dating from the late-nineteenth century that has an estimated 7 million followers.1 Adherents represent a unique medical population, particularly in relation to their opposition to blood transfusion. Their refusal of transfusion stems from a literal interpretation of the Bible, specifically Genesis 9 and Leviticus 17, which states that one cannot eat from the bread of life.2 Accordingly, members of this sect believe that accepting blood will lead to their excommunication and eternal damnation.2,3 In fact, a healthcare provider recommending a blood transfusion is considered by many Jehovah's Witnesses to be acting through the devil's influence.
Understanding this core belief is crucial when caring for Jehovah's Witnesses, including pregnant women. Many will decline a blood transfusion, even in life-threatening circumstances, and it is this specific teaching that renders them at an increased risk of morbidity and mortality in cases of profound bleeding. With obstetric hemorrhage being the second-leading cause of maternal mortality in the United States, pregnant Jehovah's Witnesses who refuse all blood transfusion are in exceptional jeopardy, having a 65-fold increased risk of death.4 It is of paramount importance for clinicians caring for pregnant Jehovah's Witnesses to understand the relevant ethical and legal constructs and to be well versed in the management and alternatives available to this population.
Ethics and the law
All physician-patient relationships are governed by a well-established set of ethical principles. Patient autonomy is a moral obligation that physicians have to their patients. This responsibility became legally recognized in the United States with passage of the Patient Self-Determination Act (PSDA) in 1991. The PSDA gives any competent, well-informed person the right to accept or decline any form of treatment. Hence, a competent Jehovah's Witness has legal standing when declining blood transfusion. When this issue was challenged in court, it was ruled that a competent adult has a "paramount right" to refuse a blood transfusion on the basis of religious beliefs, as long as the decision is voluntary, informed, and does not endanger the fetus.5 Despite this precedent, it is noteworthy that laws vary from one state to another and, not unexpectedly, the legal literature includes a number of contradictory rulings. Therefore, it is prudent for a clinician caring for a Jehovah's Witness to seek the advice of risk-management authorities at his or her institution, or even that of the pertinent court, when faced with any legal uncertainty.
An ethical concept that can conflict with autonomy is beneficence, which obligates a healthcare provider to act in the best interest of a patient.6 Yet it is evident that this can be a major dilemma to a provider in the case of a Jehovah's Witness requiring transfusion. Although a blood transfusion may be regarded by a provider as the sole lifesaving option in the setting of a catastrophic hemorrhage, an attempt to transfuse this patient against her will represents a clear violation of her autonomy.
Another ethical principle that comes into play in the management of a Jehovah's Witness is nonmaleficence, or "do no harm." Although a provider may believe that allowing a bleeding patient to die by not transfusing her with blood is clearly causing harm, a devout Jehovah's Witness may perceive far more harm in the belief that eternal damnation will ensue from such a transfusion.
Identifying a patient as a Jehovah's Witness is a key step in her prenatal care. Clinicians should talk with women seeking prenatal care about their religious beliefs and should document their specific wishes regarding medical care, including refusal of blood transfusion. Otherwise, if a Jehovah's Witness patient is not identified, her personal wishes regarding blood products may not be known, which may lead to havoc at the time of a hemorrhagic emergency.
The prevalence of this religion varies by state, and Jehovah's Witnesses represent approximately 0.4% of the US population.1 Accordingly, it is important for a healthcare provider to have an understanding of the prevalence in his or her own geographic area.
The decision-making process starts with the healthcare provider accepting or declining to participate in the management of care for a Jehovah's Witness patient. It is important to emphasize, however, that if a physician decides to transfer a patient out of his or her care, he or she is obligated to ensure that another acceptable provider is willing to accept the responsibility. The prenatal management of any Jehovah’s Witness should include a comprehensive discussion about what blood products are acceptable to her and what alternatives are available. Physicians providing prenatal care to Jehovah’s Witnesses should have a checklist as part of their standardized protocol that would list the different blood products and alternative treatments (Figure). This checklist, which generally includes transfusions with whole blood, fresh frozen plasma, and cryoprecipitate, as well as treatment with albumin, isolated factor preparations, nonblood plasma expanders (such as Lactated Ringer’s solution), hemodilution, and cell-saver technology, will allow the provider to determine which products are acceptable to a particular Jehovah’s Witness. Other products that may be controversial in the management of a Jehovah’s Witness are Rho(D) immune globulin and other intravenous immunoglobulins, interferon, epidural blood patch, and plasmapheresis.
Appropriate counseling is critical and should begin at the initial visit so that the patient has ample time to learn about these options and to discuss them within her community. The patient should be counseled at least once in the absence of any family members or acquaintances. This step ensures that the wishes expressed by the patient are genuine and are her own beliefs. In fact, confidentiality must be emphasized, and it should be explained to the patient that her wishes, including acceptance of a blood transfusion, would remain confidential. At the first prenatal visit or soon afterward, if the patient has been identified as a Jehovah’s Witness, an information package should be provided containing a refusal of blood transfusion, healthcare proxy, and a plan of care to give her time to read over and discuss with her family. This paperwork should be reviewed with the patient and signed at a following visit remote from term. The signed paperwork should be given to the patient and kept on file in the office and hospital and made accessible to all staff members anytime. The plan of care should include the checklist of products and alternatives that she is willing to accept or decline.
The presence of a formal, informed consent signed by the patient and her physician clearly documenting her treatment preferences theoretically releases her providers from the liability of not proceeding with a clinically indicated blood transfusion. It is noteworthy that significant variation exists among Jehovah’s Witnesses over their willingness to accept specific blood products and treatment alternatives. The transfusion preferences of patients were explored in a retrospective study of all Jehovah’s Witnesses presenting to labor and delivery who completed New York State Health Care Proxies at Mount Sinai Medical Center in New York between 1997 and 2002.7 A total of 61 patients were identified, 39.3% of whom agreed to accept a variety of donated blood products and 9.8% of whom consented to packed red blood cell transfusion. However, 50.1% said that they would accept neither product from a homologous donor. In relation to nonstored autologous blood, 55% of patients said that they would accept either intraoperative normovolemic hemodilution or transfusion of their own blood through a cell-saver system. Predelivery preparations should include making end-of-life decisions. Advance directives are particularly essential in the case of a Jehovah’s Witness. Assignment of a healthcare proxy and a next of kin to her children will convey to the patient the substantial effect of her decisions and the potential consequences of blood refusal.8 Furthermore, this step will avert a court order reversal of such refusal.
Once the decision has been made to accept a Jehovah's Witness as a patient, several steps should be taken to ensure a favorable pregnancy outcome. In fact, many institutes have designed standardized protocols to ensure consistency of care.8 It is imperative to acknowledge that efficient management of a pregnant Jehovah’s Witness relies on a multidisciplinary approach that incorporates providers from different disciplines. Ideally, a pregnant Jehovah’s Witness should be seen in consultation by an obstetrician with expertise in high-risk obstetrics, such as a maternal-fetal medicine, if available. The patient should also been seen in consultation by an obstetric anesthesiologist, as well as any other pertinent service. For instance, an interventional radiologist should be consulted for a patient with suspected placenta accreta.
In addition, the delivery of a Jehovah’s Witness should be planned at a tertiary care center with the resources needed to combat a potential massive hemorrhage. All providers directly involved in the care of this patient should be in agreement with the management plan, including not transfusing a patient who does not desire this intervention, even if it means she may die. Fortunately, the prenatal course of a Jehovah’s Witness is a valuable opportunity for those providers to build trust and rapport with the patient, 2 qualities that can be of great value during her intrapartum care.
During the initial visit, all routine laboratory tests should be sent, including a complete blood count with platelets. Serial assessment of hematocrit is also warranted, generally at 28, 32, and 36 weeks’ gestation; more assessments may be necessary if anemia has been diagnosed. It is critical to optimize the patient’s hematocrit early in the pregnancy and to keep this level above 40%. At this level, the patient can have a major blood loss and still maintain a hematocrit above 20%. An initial abnormal hematocrit should trigger a comprehensive workup for potential causes of anemia, the most common of which is iron deficiency. During the initial prenatal visit, all patients with a hematocrit below 40% should be started on daily iron and vitamin C, which enhances the intestinal absorption of enterally administered iron.
If iron deficiency is identified, however, the iron dose should be adjusted accordingly, and a stool softener such as docusate sodium should be added. The amount of iron should be increased on the basis of the percentage of hematocrit and should be increased to 3 times daily if the hematocrit is below 30%. Ferrous sulfate is typically used for iron supplementation. If the use of enteral iron is marked by lack of clinical response, intolerance, or noncompliance, parenteral iron becomes an option. There are numerous forms that can be used, including iron dextran, iron gluconate, and iron sucrose. Iron sucrose is thought to have the lowest risk of allergic reaction. Iron sucrose is administered intravenously over a 2- to 5-minute period. The dose is generally 100 mg, although appropriate dosage depends on the patient’s iron requirements as determined by her iron studies. The initial dose may be repeated at variable intervals, with a total cumulative dose of 1,000 mg in a 14-day period. Heart monitoring is not indicated in individuals without any known medical conditions, and the product labeling does not specify the need for a test dose in product-naive patients. An adjunct approach to medical therapy is making the necessary dietary changes to ensure an optimal hematocrit, which includes eating foods high in heme content such as meat, poultry, and fish.3 It is noteworthy that vegetarian diets are low in heme, so additional iron supplementation is warranted in this group of patients.9
Erythropoietin, a hormone normally produced by the kidneys to accelerate erythropoiesis, is often used in pregnancy, particularly in cases of refractory anemia. Erythropoietin is known to maximize red blood cell production by the bone marrow in the presence of adequate iron stores, thus its potential use in the Jehovah’s Witness population as a means to avoid blood transfusion. The use of erythropoietin may be considered for a patient with a hematocrit of less than 30% who is refractory to iron supplementation or with a hematocrit of 35% if the patient is at high risk of obstetric hemorrhage (eg, accreta or large uterine fibroids).
In a study by Sifakis and colleagues that included 26 pregnant women with severe anemia (hemoglobin <8.5 g/dL) who had been ineffectively treated with iron supplementation, recombinant human erythropoietin was used for a total of 4 weeks.10 After the treatment period, during which erythropoietin was used 3 times per week in addition to parenteral iron, a rapid response was noted in 73% of those patients, with hemoglobin returning to normal levels within the first 2 weeks of treatment.
A study by Koenig and colleagues reported the successful use of erythropoietin in a pregnant Jehovah’s Witness who presented at 28 weeks’ gestation with intrauterine fetal demise and brisk vaginal bleeding secondary to placenta previa. The patient underwent an emergency cesarean delivery, with an estimated blood loss of 3 liters.11 Postoperatively, the patient’s hematocrit dropped to a nadir of 5.6%. In view of the patient’s refusal of blood transfusion in the setting of profound anemia, she received recombinant human erythropoietin, parenteral iron, and oxygen with a rapid rise in hematocrit. However, it is important to acknowledge that all formulations of recombinant erythropoietin in the United States contain albumin, a blood product that is not accepted by many members of the sect. Thus, this pertinent point should be emphasized when counseling a Jehovah’s Witness patient.
Obstetric hemorrhage is the single most significant cause of maternal mortality around the world, accounting for 30% of all direct maternal deaths.12 The goal of the intrapartum management of a Jehovah’s Witness patient is to prevent a potential massive hemorrhage. On admission of a Jehovah’s Witness patient to the labor and delivery unit, the standard obstetric consent should be obtained promptly, including a thorough discussion about the risks of postpartum hemorrhage. Ideally, this patient has been counseled antenatally and has a healthcare proxy prepared. If not, a checklist should be filled out and placed in the chart on admission.
Postpartum hemorrhage can complicate up to 5% of all deliveries.13,14 Hence, it is critical to be fully prepared for a postpartum hemorrhage in any patient who is admitted to labor and delivery, particularly a Jehovah’s Witness. It is important to ensure adequate intravenous access, preferably with 2 large bore catheters. If increased bleeding is encountered, fundal massage should be initiated, which generally stimulates the uterus to contract. Because uterine atony is the most common cause of postpartum hemorrhage, preparedness should also include familiarity with and availability of different uterotonic agents. These include oxytocin, methylergonovine, carboprost tromethamine, and misoprostol. Additionally, there are intraoperative techniques such as uterine artery ligation, hypogastric artery ligation, or B-lynch stitch that can be used for refractory atony. However, it is important to emphasize to the patient that there is a lower threshold to hysterectomy in the case of a significant postpartum hemorrhage, so it would be performed much earlier than would be the case in women who will accept blood transfusions. Expectant management in the event of a massive hemorrhage can be associated with greater blood loss, which may be life-threatening if blood transfusion is declined.
In the event of a significant hemorrhage, all interventions should aim at optimizing tissue perfusion and controlling active bleeding. Cell-salvage (saver) systems may play a role in the management of pregnant Jehovah’s Witnesses and can be regarded as a form of intraoperative autologous blood donation.3,15 Some Jehovah’s Witnesses will agree to using cell-saver technology; others may not find it acceptable. This technique uses centrifugal cell separators that isolate the red cells from plasma, wash them with normal saline, and prepare them for reinfusion. Hence, free blood in the abdomen at the time of a cesarean delivery can be aspirated, filtered, and then reinfused into the patient perioperatively.15 Cell savers have been used in pregnancy and have been shown to be safe and lifesaving.16,17 The theoretical risk of fetal cells entering the maternal circulation, leading to amniotic fluid embolism, has never definitively been substantiated.18 A multicenter historical cohort study that evaluated the safety of intraoperative autologous blood collection and autotransfusion during cesarean delivery showed no increased risk of complications in patients receiving autologous blood collection.19
There are additional intraoperative techniques that must be planned preoperatively that can play a role in the setting of a massive hemorrhage, namely normovolemic hemodilution, controlled hypotensive anesthesia, sedation, and muscle paralysis.8 Normovolemic hemodilution denotes the removal of whole blood in the immediate preoperative period and replacing it with crystalloid or colloid.3 Because the remaining circulating blood is low in red blood cells, there is a shift of the oxygen dissociation curve to the right, optimizing the oxygen-carrying capacity of those red blood cells.15 Hemodilution also allows for a lower concentration of red blood cells in the estimated blood loss. Once the perioperative blood loss has been stemmed, whole blood can be replaced, if the patients agrees to this.
Controlled hypotensive anesthesia is another technique that aims at reducing the mean arterial pressure to 50 mmHg, the minimum requirement for tissue perfusion while minimizing the blood loss in case of massive intraoperative hemorrhage.3 Finally, sedation and muscular paralysis have also been used both perioperatively and postoperatively to decrease oxygen consumption.
A technique that maximizes oxygen delivery is hyperbaric oxygen (HBO) therapy. Increasing the amount of oxygen dissolved in blood constitutes the basis for the use of HBO in the acute management of massive bleeding associated with severe anemia. McLoughlin and colleagues described the case of a pregnant Jehovah’s Witness who presented at 39 weeks with profuse, painful vaginal bleeding.20 On admission, the patient expressed her objection to receipt of blood products, even in a life-threatening setting. She subsequently underwent an emergent cesarean delivery, with intraoperative findings consistent with a massive placental abruption. Postoperatively, a drop of hemoglobin down to 2 g/dL was noted, with concerns for myocardial and intestinal ischemia. Hyperbaric oxygen therapy was used, resulting in reversal of ischemic EKG changes, rise in urine output, decrease in cardiac output, and, finally, decrease in the isotropic requirements.
An alternative that can also be considered in the acute management of a major obstetric hemorrhage is recombinant factor VIIa (rFVIIa), a synthetic product that is not derived from blood and is accepted by many Jehovah’s Witnesses. Laird and Carabine recently reported its use in a Jehovah’s Witness with a twin gestation who underwent a cesarean delivery complicated by postpartum hemorrhage.21 With persistent blood loss, a decline in hemoglobin to 4.4 g/dL, and blood transfusion not being an option, the managing team employed rFVIIa. After the administration of 9 mg of rFVIIa, bleeding subsided within 30 minutes. Of note, this product has been associated with an increased incidence of thromboembolic complications, with an incidence that ranges from a low of 1% to 2 % to as high as 9.8 %.22-25 There are limited data regarding this incidence in pregnant patients, yet it may be higher given the hypercoagulable state of pregnancy.
Ensuring positive outcomes
Jehovah’s Witnesses constitute a unique obstetric population because of their refusal to accept blood products. Hence, the management of a pregnant Jehovah’s Witness requires meticulous coordination and vigilant preparation to achieve a favorable pregnancy outcome. A multidisciplinary approach that ensures an efficient dialogue among different disciplines is the mainstay of her prenatal care. In addition, a standardized procedure of informed consent outlining the different treatment alternatives will permit the clinician to meet the specific needs of a pregnant Jehovah’s Witness and to ensure that her wishes are respected and the best possible outcome achieved.