Implementation of a protocol for management of antepartum iron deficiency anemia: a prospective cohort study

Published:November 19, 2021DOI:https://doi.org/10.1016/j.ajogmf.2021.100533

      ABSTRACT

      BACKGROUND

      In randomized trials, antepartum intravenous iron sucrose is effective at improving predelivery hemoglobin in iron deficiency anemia. Yet, there is a gap between this knowledge and its implementation into care.

      OBJECTIVE

      We aimed to determine if the implementation of a standardized protocol for the management of antepartum anemia outside of a clinical trial improves intravenous iron sucrose utilization and clinical outcomes.

      STUDY DESIGN

      We performed a prospective cohort study evaluating the incorporation of an anemia protocol into routine clinical care for women with antepartum hemoglobin <11.0 g/dL. Our protocol, developed with multidisciplinary stakeholders, included (1) serial third trimester hemoglobin assessment, (2) oral iron supplementation for antepartum hemoglobin 9.5–11 g/dL, and (3) antepartum intravenous iron sucrose use (300 mg weekly for 3 weeks) for hemoglobin <9.5 g/dL. We compared 6-months preimplementation (January 2018 to June 2018) to 6-months postimplementation (January 2019 to June 2019). The outcomes evaluated were antepartum intravenous iron sucrose utilization, the number of intravenous iron sucrose dosages, predelivery hemoglobin, and blood transfusion.

      RESULTS

      A total of 1423 women were included (pre=778; post=645) without significant baseline differences. The antepartum hemoglobin nadir was no different between the groups (pre: 10.2; interquartile range [9.6–10.6] vs post: 10.2; interquartile range [9.6–10.6]; P=.77). The implementation of a standardized protocol for the management of antepartum anemia was associated with 80% increased odds of receiving intravenous iron sucrose than the preimplementation group (pre: 4.8% vs post: 8.2%, P=.008; odds ratio, 1.79; 95% confidence interval, [1.16–2.77]). The implementation of a standardized protocol for the management of antepartum iron deficiency anemia was also associated with higher hemoglobin at admission for delivery (pre: 10.9; interquartile range [10.1–11.6] vs post: 11.0; interquartile range [10.3–11.7], P=.048). There were no significant differences between the groups in blood product transfusion (pre: 7.1% vs post: 5.1%, P=.13).

      CONCLUSION

      Implementation of a standardized antepartum anemia protocol is associated with increased intravenous iron sucrose utilization and improvement in predelivery hemoglobin.

      Key words

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      References

        • World Health Organization
        Worldwide prevalence of anaemia 1993–2005.
        WHO global database on anaemia, 2008 (Available at: http://apps.who.int/iris/bitstream/handle/10665/43894/9789241596657_eng.pdf?sequence=1. Accessed Dec. 1, 2021)
        • Chang S
        • Zeng L
        • Brouwer ID
        • Kok FJ
        • Yan H.
        Effect of iron deficiency anemia in pregnancy on child mental development in rural China.
        Pediatrics. 2013; 131: e755-e763
        • Drukker L
        • Hants Y
        • Farkash R
        • Ruchlemer R
        • Samueloff A
        Grisaru-granovsky S. Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for cesarean section and adverse maternal and neonatal outcomes.
        Transfusion. 2015; 55: 2799-2806
        • Klebanoff MA
        • Shiono PH
        • Selby JV
        • Trachtenberg AI
        • Graubard BI.
        Anemia and spontaneous preterm birth.
        Am J Obstet Gynecol. 1991; 164: 59-63
        • Ren A
        • Wang J
        • Ye RW
        • Li S
        • Liu JM
        • Li Z.
        Low first-trimester hemoglobin and low birth weight, preterm birth and small for gestational age newborns.
        Int J Gynaecol Obstet. 2007; 98: 124-128
        • Tran TD
        • Tran T
        • Simpson JA
        • et al.
        Infant motor development in rural Vietnam and intrauterine exposures to anaemia, iron deficiency and common mental disorders: a prospective community-based study.
        BMC Pregnancy Childbirth. 2014; 14: 8
        • Wang J
        • Ren AG
        • Ye RW
        • et al.
        [Study on the third trimester hemoglobin concentrations and the risk of low birth weight and preterm delivery].
        Zhonghua Liu Xing Bing Xue Za Zhi. 2007; 28: 15-18
        • Carson JL
        • Stanworth SJ
        • Roubinian N
        • et al.
        Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.
        Cochrane Database Syst Rev. 2016; 10CD002042
        • Axelsson D
        • Brynhildsen J
        • Blomberg M.
        Postpartum infection in relation to maternal characteristics, obstetric interventions and complications.
        J Perinat Med. 2018; 46: 271-278
        • Butwick AJ
        • McDonnell N.
        Antepartum and postpartum anemia: a narrative review.
        Int J Obstet Anesth. 2021; 47102985
        • Al RA
        • Unlubilgin E
        • Kandemir O
        • Yalvac S
        • Cakir L
        • Haberal A.
        Intravenous versus oral iron for treatment of anemia in pregnancy: a randomized trial.
        Obstet Gynecol. 2005; 106: 1335-1340
        • Bayoumeu F
        • Subiran-buisset C
        • Baka NE
        • Legagneur H
        • Monnier-barbarino P
        • Laxenaire MC.
        Iron therapy in iron deficiency anemia in pregnancy: intravenous route versus oral route.
        Am J Obstet Gynecol. 2002; 186: 518-522
        • Khalafallah A
        • Dennis A
        • Bates J
        • et al.
        A prospective randomized, controlled trial of intravenous versus oral iron for moderate iron deficiency anaemia of pregnancy.
        J Intern Med. 2010; 268: 286-295
        • Wong L
        • Smith S
        • Gilstrop M
        • et al.
        Safety and efficacy of rapid (1,000 mg in 1 hr) intravenous iron dextran for treatment of maternal iron deficient anemia of pregnancy.
        Am J Hematol. 2016; 91: 590-593
        • Milman N
        • Byg KE
        • Bergholt T
        • Eriksen L.
        Side effects of oral iron prophylaxis in pregnancy–myth or reality?.
        Acta Haematol. 2006; 115: 53-57
        • Kochhar PK
        • Kaundal A
        • Ghosh P.
        Intravenous iron sucrose versus oral iron in treatment of iron deficiency anemia in pregnancy: a randomized clinical trial.
        J Obstet Gynaecol Res. 2013; 39: 504-510
        • Nash CM
        • Allen VM.
        The use of parenteral iron therapy for the treatment of postpartum anemia.
        J Obstet Gynaecol Can. 2015; 37: 439-442
        • Singh K
        • Fong YF
        • Arulkumaran S.
        Anaemia in pregnancy–a cross-sectional study in Singapore.
        Eur J Clin Nutr. 1998; 52: 65-70
        • Hamm RF
        • Blauvelt C
        • Wang EY
        • Srinivas SK.
        Effectiveness of antepartum intravenous iron sucrose: dose timing and impact on outcomes.
        J Matern Fetal Neonatal Med. 2021; 34: 1983-1990
        • Stewart T
        • Lambourne J
        • Thorp-Jones D
        • Thomas DW.
        Implementation of early management of iron deficiency in pregnancy during the SARS-CoV-2 pandemic.
        Eur J Obstet Gynecol Reprod Biol. 2021; 258: 60-62
      1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 95: anemia in pregnancy.
        Obstet Gynecol. 2008; 112: 201-207
        • Hamm RF
        • Wang EY
        • Levine LD
        • Srinivas SK.
        Association between race and hemoglobin at delivery or need for transfusion when using race-based definitions for treatment of antepartum anemia.
        Obstet Gynecol. 2021; 138: 108-110