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Optimal pre-delivery hemoglobin to reduce transfusion and adverse perinatal outcomes

  • Gabriella D COZZI
    Correspondence
    Corresponding author Gabriella D COZZI, MD, Division of Maternal Fetal Medicine, University of Alabama Birmingham, Women & Infants Center 1700 6th Ave South, Birmingham, AL 35249
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham

    Department of Obstetrics and Gynecology, University of Alabama at Birmingham
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  • Ms.Christina T BLANCHARD
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham
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  • Joseph T EDWARDS Jr
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham

    Department of Obstetrics and Gynecology, University of Alabama at Birmingham
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  • Jeff M SZYCHOWSKI
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham

    Department of Obstetrics and Gynecology, University of Alabama at Birmingham

    Department of Biostatistics, University of Alabama at Birmingham
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  • Akila SUBRAMANIAM
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham

    Department of Obstetrics and Gynecology, University of Alabama at Birmingham
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  • Author Footnotes
    # Author A.N.B. was supported by NICHD K23HD103875 during the study. There were no other external sources of funding.
    Ashley N BATTARBEE
    Footnotes
    # Author A.N.B. was supported by NICHD K23HD103875 during the study. There were no other external sources of funding.
    Affiliations
    Center for Women's Reproductive Health, University of Alabama at Birmingham

    Department of Obstetrics and Gynecology, University of Alabama at Birmingham
    Search for articles by this author
  • Author Footnotes
    # Author A.N.B. was supported by NICHD K23HD103875 during the study. There were no other external sources of funding.
Published:November 11, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100810
      • Studies evaluating thresholds to define anemia in a contemporary pregnant population are lacking.
      • The optimal hemoglobin to reduce the need for transfusion at delivery has not been well defined.
      • B. What are the key findings?
      • Maternal anemia before delivery was associated with 5-fold higher odds of pRBC transfusion, as well as higher odds of postpartum readmission and longer postpartum hospitalization.
      • For each 1 g/dL increase in pre-delivery hemoglobin, the odds of transfusion were 56% lower.
      • We identified an optimal pre-delivery hemoglobin of ≥10.6 g/dL to predict peripartum transfusion.
      • C. What does this study add to what is already known?
      • The optimal hemoglobin (10.6 g/dL) for predicting transfusion is similar to the previously identified threshold for anemia endorsed by ACOG (10.5 g/L in the second trimester and 11.0 g/dL in the third trimester).
      • Pre-delivery anemia is associated with higher odds of several adverse maternal outcomes but not neonatal outcomes.
      • Anemia optimization may be primarily for maternal benefit and should be evaluated in prospective studies.

      ABSTRACT

      Background

      Maternal anemia has been associated with poor obstetric outcomes, however the optimal hemoglobin to reduce blood transfusion at delivery has not been well defined.

      Objective

      To measure the association of maternal anemia immediately before delivery with peripartum transfusion and other adverse perinatal outcomes. We also sought to identify the optimal hemoglobin to predict transfusion.

      Study Design

      This was a retrospective cohort study of patients who had hemoglobin or hematocrit collected before delivery of live, non-anomalous neonates at ≥23 weeks’ gestation at a single center (2013-2018). Patients were excluded if they had sickle cell disease or were receiving anticoagulation. Patients were categorized as having anemia or no anemia based on pre-delivery hemoglobin or hematocrit using criteria set by the American College of Obstetricians and Gynecologists. The primary outcome was transfusion of ≥1 unit packed red blood cells during the delivery admission. Secondary outcomes included select adverse perinatal outcomes. Bivariable analyses compared baseline characteristics and outcomes between the anemia and no anemia groups. Multivariable logistic regression estimated the association between anemia and outcomes. The hemoglobin cutoff optimizing sensitivity and specificity for transfusion was identified by the Liu method.

      Results

      Of 18,357 patients included in the analysis, 5,444 (30%) had pre-delivery anemia (mean hemoglobin 10.0 ± 0.8 g/dL) versus 12,913 (70%) without anemia (mean hemoglobin 12.3 ± 1.1 g/dL). Patients with anemia were more likely to be non-Hispanic Black and publicly insured and less likely to be nulliparous. Anemia was associated with a 5-fold higher odds of packed red blood cells transfusion (6.0% vs 1.3%, aOR 5.23 [95% CI 4.09-6.69]) compared to no anemia. For each 1 g/dL increase in pre-delivery hemoglobin, the odds of transfusion were 56% lower (aOR 0.44 [CI 0.40-0.48]). The optimal hemoglobin for the prediction of transfusion was 10.6 g/dL (sensitivity: 80%, specificity: 86%). There was no association between anemia and composite maternal or neonatal morbidity after adjustment for covariates, but anemia was associated with higher odds of postpartum readmission (aOR 1.35 [1.11-1.64]).

      Conclusions

      Maternal anemia before delivery was associated with 5-fold higher odds of packed red blood cells transfusion and postpartum readmission, but not other perinatal morbidity. Optimizing pre-delivery hemoglobin, particularly ≥10.6 g/dL, may reduce peripartum transfusion.

      CONDENSATION

      : Maternal pre-delivery anemia was associated with 5-fold higher odds of transfusion compared to patients without anemia, and the optimal hemoglobin for predicting transfusion was 10.6 g/dL.

      AJOG AT A GLANCE

      : A. Why was the study conducted?

      KEYWORDS

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