Pre-delivery Haemoglobin Research Articles

Antepartum Intravenous Iron Reduces Peripartum Blood Transfusions [27B

INTRODUCTION: Studies have demonstrated that antepartum intravenous iron sucrose infusion (IVFe) is safe and improves pre-delivery hemoglobin (Hb). Yet, the effect of IVFe on maternal morbidity is unknown. We sought to determine whether antepartum IVFe could reduce peripartum packed red blood cell (pRBC) transfusions. METHODS: This is a retrospective cohort study. In 6/2015, our institution began recommending IVFe for patients with Hb<9.5 g/dL who failed oral ferrous sulfate, as determined by persistent severe anemia in the third trimester. Patients who obtained prenatal care and delivered at our institution from 10/1/2015-10/1/2016 with third trimester Hb<9.5g/dL were included. Hemoglobinopathies were excluded. Decision to proceed with IVFe, timing, and number of doses was left up to patient and provider. Patients receiving ≥1 antepartum dose of 300mg of IVFe at least 48 hours before delivery were included in the IVFe group. Our primary outcome was rate of blood transfusions among those who did vs. did not receive IVFe. Fisher’s exact test was used to compare proportions. RESULTS: 389 of 3961 (9.8%) delivering patients met Hb criteria and were included. Of those, 25 (6.4%) were in the IVFe group. Third trimester Hb was lower in the IVFe group compared to the No IVFe group (8.6g/dL vs. 9.4g/dL; p<0.0001). Patients in the IVFe group significantly increased their Hb from third trimester to pre-delivery compared to those in the No IVFe group (Δ1.6g/dL vs Δ-0.1g/dL, p<0.0001). 57 of 389 (14.7%) received ≥1 unit of pRBCs during delivery admission. IVFe decreased the rate of peripartum blood transfusion compared to those who did not get IVFe (0% vs. 15.7%, p=0.035). The 57 transfused patients, none of whom received IVFe, required an average of 2.39 units of pRBCs per person. CONCLUSION: Despite lower starting Hb in the IVFe group, antepartum IVFe reduced transfusions in patients with a third trimester Hb<9.5g/dL. Future hemorrhage bundle work should highlight the use of IVFe to reduce peripartum pRBC transfusion and maternal morbidity.

795: Timing of intravenous iron sucrose affects pre-delivery hemoglobin levels

795: Timing of intravenous iron sucrose affects pre-delivery hemoglobin levels

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies.

Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype. To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ≥1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models. For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI], 4.9-99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI, 4.2-15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI, 3.4-11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI, 1.7-17.1), multiple pregnancies (aOR = 3.2; 95% CI, 1.7-6.3), and a predelivery hemoglobin ≤ 9.9 g/dL (aOR = 3.0; 95% CI, 1.3-6.9; reference group = predelivery hemoglobin ≥ 11 g/dL). Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.

Can Intravenous Injection of Tranexamic Acid Be Used in Routine Practice With Active Management of the Third Stage of Labor in Vaginal Delivery? A Randomized Controlled Study

Obstetric hemorrhage accounts for ∼25% of maternal morbidity. Many methodologies are used to promote active management of the third stage of labor. Tranexamic acid successfully reduces blood loss and transfusion requirements in nonobstetric conditions. This double-blind, randomized, controlled trial was undertaken to estimate the effects of adding tranexamic acid to an active management protocol. The parturients were at 34 to 42 weeks’ gestation, with a live fetus in cephalic presentation, and expecting vaginal birth. The experimental group (n = 228) received 1 g/10 mL tranexamic acid diluted with 20 mL 5% glucose; the placebo group (n = 226) received 30mL5%glucose. Tranexamic acid or placebo was administered intravenously over 5 minutes at delivery of the fetus’ anterior shoulder. Standard management of the third and fourth stages of labor was applied. The primary outcome was the volume of blood loss during the third and fourth stages of labor. Other outcomes were the incidence of postpartum hemorrhage (PPH; >500 mL), severe PPH (>1000 mL), need for blood transfusion, need for additional uterotonic drugs, and adverse effects of tranexamic acid. Participants were contacted 3 weeks after delivery to assess the incidence of thromboembolic events. Data were analyzed on an intent-to-treat basis. The final analysis included 220 and 219 in the tranexamic acid and control groups, respectively. The groups were similar in patient characteristics and risk factors for PPH. At the third and fourth stages of labor, mean estimated blood losses were 261.5 ± 146.8 and 349.98 ± 188.85 mL in the tranexamic acid and control groups, respectively (P < 0.001). Four patients (1.8%) in the tranexamic acid group and 15 (6.8%) in the control group had PPH of greater than 500 mL (RR, 3.76; 95% CI, 1.27–11.15; P = 0.01). Six (2.7%) and 19 (8.7%) women in the tranexamic acid and control groups, respectively, required additional uterotonic agents (RR 3.18; 95% CI, 1.29–7.81; P = 0.007). The groups did not differ in need for blood transfusion. Predelivery hemoglobin and hematocrit levels were the same in the 2 groups, but at 1 day postpartum, hemoglobin levels were 9.9 T 1.4 and 9.3 T 0.9 g/dL (P G 0.001), and hematocrit levels were 30.2% ± 1.2% and 29.0% ± 1.3% (P < 0.001) in the tranexamic acid and placebo groups, respectively. No major complications and no significant changes in prothrombin time, active prothrombin time, or liver or renal function tests were noted in either group. Rates for nausea, vomiting, and diarrhea were 15.0%, 13.6%, and 7.3% in the tranexamic acid group and 5.5%, 6.4%, and 1.8% in the control group. At the clinical checkup 3 weeks postpartum, no episode of thrombosis was reported in patients given tranexamic acid. Tranexamic acid can reduce the average amount of blood loss during the third and fourth stages of labor. Determining the clinical settings in which this medication may be beneficial is critical for future research.

Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes.

During pregnancy, fetal growth causes an increase in the total number of rapidly dividing cells, which leads to increased requirements for folate. Inadequate folate intake leads to a decrease in serum folate concentration, resulting in a decrease in erythrocyte folate concentration, a rise in homocysteine concentration, and megaloblastic changes in the bone marrow and other tissues with rapidly dividing cells To assess the effectiveness of oral folic acid supplementation alone or with other micronutrients versus no folic acid (placebo or same micronutrients but no folic acid) during pregnancy on haematological and biochemical parameters during pregnancy and on pregnancy outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2012) and we contacted major organisations working in micronutrient supplementation, including UNICEF Nutrition Section, World Health Organization (WHO) Maternal and Reproductive Health, WHO Nutrition Division, and National Center on Birth defects and Developmnetal Disabilities, US Centers for Disease Control and Prevention (CDC). All randomised, cluster-randomised and cross-over controlled trials evaluating supplementation of folic acid alone or with other micronutrients versus no folic acid (placebo or same micronutrients but no folic acid) in pregnancy. Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. Thirty-one trials involving 17,771 women are included in this review. This review found that folic acid supplementation has no impact on pregnancy outcomes such as preterm birth (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.73 to 1.38; three studies, 2959 participants), and stillbirths/neonatal deaths (RR 1.33, 95% CI 0.96 to 1.85; three studies, 3110 participants). However, improvements were seen in the mean birthweight (mean difference (MD) 135.75, 95% CI 47.85 to 223.68). On the other hand, the review found no impact on improving pre-delivery anaemia (average RR 0.62, 95% CI 0.35 to 1.10; eight studies, 4149 participants; random-effects), mean pre-delivery haemoglobin level (MD -0.03, 95% CI -0.25 to 0.19; 12 studies, 1806 participants), mean pre-delivery serum folate levels (standardised mean difference (SMD) 2.03, 95% CI 0.80 to 3.27; eight studies, 1250 participants; random-effects), and mean pre-delivery red cell folate levels (SMD 1.59, 95% CI -0.07 to 3.26; four studies, 427 participants; random-effects). However, a significant reduction was seen in the incidence of megaloblastic anaemia (RR 0.21, 95% CI 0.11 to 0.38, four studies, 3839 participants). We found no conclusive evidence of benefit of folic acid supplementation during pregnancy on pregnancy outcomes.

Cord blood haemoglobin and ferritin concentrations in newborns of anaemic and non-anaemic mothers in Lagos, Nigeria

Background:Pre-delivery haemoglobin and serum ferritin concentrations of anaemic and non-anaemic mothers were determined, and cord blood haemoglobin and serum ferritin concentrations of their newborns were compared. This is to establish the mean values for pre-delivery haemoglobin and serum ferritin concentrations of anaemic and non-anaemic mothers and the cord blood haemoglobin and serum ferritin concentrations of their newborns at term.Materials and Methods:A case–control study was done involving 142 pregnant women and their newborns. They were divided into two groups - the anaemic group (n = 65) and the non-anaemic (n = 77) group. Five millilitres of blood was collected from each woman and 2 ml was collected from the cord of their newborns into ethylenediaminetetraacetic acid (EDTA) bottle and plain bottle for full blood count analysis and ferritin assay, respectively.Results:The mean pre-delivery haemoglobin concentrations of the women in anaemic group and non-anaemic group were 9.5 ± 1.01 g/dl and 12.15 ± 1.07 g/dl, respectively, and their mean serum ferritin concentrations were 64.45 ± 138.76 μg/l and 32.83 ± 35.36 μg/l, respectively. The mean cord blood haemoglobin concentrations for anaemic and for non-anaemic groups were 12.54 ± 2.54 g/dl and 13.44 ± 2.23 g/dl (P = 0.02), respectively, and the mean cord blood serum ferritin concentrations (non-anaemic, 69.38 ± 78.88 μg/l; anaemic, 7.26 ± 115.60 μg/l) (P = 0.00) were higher in the newborns of non-anaemic than of anaemic mothers. Significant association was found between maternal anaemia and cord blood ferritin concentrations (P = 0.025).Conclusion:Maternal anaemia has significant effects on cord blood haemoglobin and serum ferritin concentrations.

Obstetric Care of Jehovah’s Witnesses: A 14-Year Observational Study

Numerous studies have looked at the outcome of various types of surgery in Jehovah's witnesses (JWs), who refuse blood and blood components, but comparatively little is known about obstetrical outcomes. The investigators reviewed 90 consecutive women who were JWs and who, over a 14-year period, had a total of 116 deliveries at an inner city hospital. They represented 0.2% of all deliveries in the unit during this period. Between 1992 and 2005, the number of JW deliveries increased more than 4-fold. Two-thirds of women had normal vaginal deliveries, while 24% had cesarean deliveries (14 elective and 14 emergent) and 10% had instrumental deliveries. In all instances the patient's status was known well before delivery, the potential risks were discussed, and a management plan formulated. All women received oral hematinics antenatally. In 21 of 116 deliveries the predelivery hemoglobin was less than 11 g/dL. One in 5 women lost more than 500 mL of blood at delivery, and 7 women (6%) lost more than a liter; none of them received transfusions. Following 38 deliveries, the hemoglobin was less than 11 g/dL, but the overall group mean value of 11.1 g/dL did not differ significantly from the mean predelivery hemoglobin of 11.8 g/dL. The rate of admission to intensive care was 2.5%. The single maternal death followed cesarean hysterectomy; it represented a 65-fold increase in the risk of maternal death compared to the national rate. There were 3 premature births before 34 weeks' gestation and a single term stillbirth, but no neonatal deaths.

Obstetric care of Jehovah’s Witnesses: a 14-year observational study

Over a 14-year period, the obstetric outcome of Jehovah's Witnesses in an inner city hospital was reviewed and the effect of refusal of blood on morbidity and mortality evaluated. Ninety women had 116 deliveries and of these, 24% were delivered by caesarean section, 10% had instrumental deliveries and 66% were normal vaginal deliveries. Postpartum haemorrhage of >1,000 mls occurred in 6% and postpartum anaemia was the commonest complication. The mean postdelivery haemoglobin (11.10 +/- 1.15 g/dl) was not significantly less from the mean predelivery haemoglobin level (11.81 +/- 1.62 g/dl) (P > 0.05, paired t test). The single maternal death occurred after caesarean hysterectomy, which when extrapolated, resulted in a 65-fold increased risk of maternal death compared to the national rate. The optimum management of pregnant women who decline transfusion is discussed.

The Correlation of Estimated Blood Loss With Predelivery and Postdelivery Hemoglobin

The Correlation of Estimated Blood Loss With Predelivery and Postdelivery Hemoglobin

Effect of folate supplement on pregnant women with beta-thalassaemia minor

The effect of folate supplement on the haemoglobin concentration and outcome of pregnancy was studied in a group of Chinese women with uncomplicated beta-thalassaemia minor who delivered in our hospital between 1984–1987. The patients who received 5 mg folate daily showed a significant increase in the predelivery haemoglobin concentration, which was significantly higher than that in patients who received 0.25 mg daily. When the effect of parity was analysed we found that: multiparas were significantly older, had lower haemoglobin before delivery, and more of them required transfusion. Folate 5 mg daily significantly increased the predelivery haemoglobin concentration in both nulliparas and multiparas. It is concluded that folate 5 mg daily improves the haemoglobin concentration in pregnant women with beta-thalassaemia minor and that this should be prescribed.