Severe Postpartum Anemia Research Articles

Intravenous ferric carboxymaltose versus oral ferrous sulphate for the treatment of moderate to severe postpartum anaemia in Nigerian women (IVON-PP): protocol for an open-label randomised controlled type 1 hybrid effectiveness-implementation trial

IntroductionPostpartum anaemia is often caused by iron deficiency with onset during the antepartum period and can be exacerbated by excessive blood loss at birth. Its prevalence is estimated as 50–80%...

The Role of Hypertension for Maternal Outcomes of Women with HELLP Syndrome - a Retrospective Study from a Tertiary Obstetric Center.

HELLP syndrome is a serious disorder that can occur in pregnancy; it has many possible complications and is associated with adverse maternal outcome. Due to the lack of predictive parameters for HELLP syndrome, finding the right time for delivery is challenging. In contrast to preeclampsia, hypertension is not an essential part of the diagnosis; nevertheless, many women with HELLP syndrome are hypertensive. The role and possible implications of hypertension in HELLP syndrome are not fully understood. In this retrospective cohort study, we analyzed the maternal outcomes of 59 patients diagnosed with HELLP syndrome. The patients were divided into three groups according to their blood pressure levels during their stay in hospital. These three groups were compared in terms of patient characteristics and maternal outcomes. A combined endpoint for adverse maternal outcome was defined which included blood pressure and antihypertensive medication at discharge from hospital, severe postpartum anemia, and eclampsia. Women with hypertensive crises had an unfavorable outcome compared to women with lower blood pressure levels. Patients with higher blood pressure during pregnancy were more likely to be hypertensive at discharge and needed a combination of antihypertensive agents significantly more often. The risk of an adverse maternal outcome increased with the severity of hypertension. An increase in systolic blood pressure by 10mmHg raised the risk of an adverse outcome by 74% (95% CI: 1.22-2.66). Hypertension not only plays an important role in preeclampsia but also affects the outcomes of patients with HELLP syndrome. These patients need to be identified quickly and treated accordingly as they are at risk of cardiovascular impairment. Patients should be followed up closely after delivery to reduce cardiovascular morbidity.

Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis.

Intravenous iron (IV-iron) is used as an alternative to, or alongside, red blood cell transfusion (RBC-T) to treat more severe postpartum anemia (PPA), although optimal treatment options remain unclear. No previous systematic reviews have examined IV-iron and RBC-T, including patient-reported outcomes and hematological responses. A systematic review and meta-analysis of randomized trials comparing IV-iron and RBC-T with each other, oral iron, no treatment, and placebo for the treatment of PPA. Key inclusion criteria were PPA (hemoglobin < 12g/dL) and IV-iron or RBC-T as interventions. Key exclusion criteria were antenatal IV-iron or RBC-T. Fatigue was the primary outcome. Secondary outcomes included hemoglobin and ferritin concentrations, and adverse events. From 27th August 2020 to 26th September 2022, databases, registries, and hand searches identified studies. A fixed-effect meta-analysis was undertaken using RevMan (5.4) software. The quality of the studies and the evidence was assessed using the Cochrane Risk of Bias table, and Grading of Recommendations, Assessment, Development, and Evaluation. This review is registered with the Prospective Register of Systematic Reviews (CRD42020201115). Twenty studies and 4196 participants were included: 1834 assigned IV-iron, 1771 assigned oral iron, 330 assigned RBC-T, and 261 assigned non-intervention. Six studies reported the primary outcome of fatigue (1251 participants). Only studies of IV-iron vs. oral iron (15 studies) were available for meta-analysis. Of these, three reported on fatigue using different scales; two were available for meta-analysis. There was a significant reduction in fatigue with IV-iron compared to oral iron (standardized mean difference - 0.40, 95% confidence interval (CI) - 0.62, - 0.18, I2 = 0%). The direction of effect also favored IV-iron for hemoglobin (mean difference (MD) 0.54g/dL, 95% confidence interval (CI) 0.47, 0.61, I2 = 91%), ferritin, (MD 58.07mcg/L, 95% CI 55.74, 60.41, I2 = 99%), and total adverse events (risk-ratio 0.63, 95% CI 0.52, 0.77, I2 = 84%). The overall quality of the evidence was low-moderate. For all outcomes, the evidence for RBC-T, compared to IV-iron, non-intervention, or dose effects of RBC-T is very limited. Further research is needed to determine whether RBC-T or IV-iron for the treatment of PPA is superior for fatigue and hematological outcomes.

Effectiveness Of Nutrition Booklet To Improve Participation In The Management Of Anemia In Cesarean Mothers

Background: Severe postpartum anemia after cesarean is strongly associated with predelivery and postpartum Hb levels in maternal. The adverse effects of anemia impact health and economic development. WHO estimates that 12.8% of maternal deaths in Asia can be attributed to anemia.Objective: This study aims to identify the effect of the anemia booklet on the perception, participation, and hemoglobin level of cesarean mothers in the management of anemia.Method: This quasi-experiment with the pre-posttest without control groups design was conducted to measure the effectiveness of education using a nutrition booklet on the level of Haemoglobin and perception variable. 30 respondents were involved, and the data analysis was carried out using a Statistical test using paired t-test with a CI of 95%.Result: The relationship between Hb before and after giving the booklet was revealed with a correlation coefficient of 0.333 and a significance of 0.84 (p-value 0.05). Perceptions before and after understanding the booklet obtained p-value = 0.000 0.05. Management before and after giving the booklet obtained p-value = 0.005 0.05. The interviews found that after receiving information, mothers' perceptions improved regarding understanding anemia, recognizing signs and symptoms, preventing anemia, consuming protein, consuming drinks, and good nutrition for anemia management. After giving anemia management communication through booklets, there was an increase in the mother's participation in consuming snacks, drinking after mealtime, and improving personal and environmental hygiene.Conclusion: Education through booklets affected maternal perceptions and management actions in preventing anemia but did not affect hemoglobin (Hb). It could also increase mothers' perception and participation in consuming snacks, drinking after mealtimes, and personal and environmental hygiene. Furthermore, nurses could use booklets as a medium of counseling.

Addition of oral iron bisglycinate to intravenous iron sucrose for the treatment of postpartum anemia—randomized controlled trial

Studies that have compared the effectiveness of oral with intravenous iron supplements to treat postpartum anemia have shown mixed results. The superiority of one mode of treatment vs the other has yet to be demonstrated. Therefore, despite guidelines and standards of care, treatment approaches vary across practices. A single 500 mg dose of iron sucrose, which is higher than what is usually administered, has not been evaluated to treat postpartum moderate to severe anemia. This study aimed to compare the efficacy of intravenous iron sucrose alone with intravenous iron sucrose in combination with oral iron bisglycinate supplementation in treating moderate to severe postpartum anemia. A randomized controlled trial was conducted between February 2015 and June 2020. Women with postpartum hemoglobin level of ≤9.5 g/dL were treated with 500 mg intravenous iron sucrose after an anemia workup, which ruled out other causes for anemia. In addition to receiving intravenous iron, women were randomly allocated to receive either 60 mg of oral iron bisglycinate for 45 days or no further iron supplementation. The primary outcome was hemoglobin level at 6 weeks after delivery. Secondary outcomes were iron storage parameters and quality of life. Of 158 patients who participated, 63 women receiving intravenous and oral iron, and 44 women receiving intravenous iron-only, completed the study and were included in the analysis. Baseline and obstetrical characteristics were similar between the study cohorts. Although statistically significant, postpartum hemoglobin levels were only 0.4 g/dL higher in the intravenous and oral iron than intravenous iron-only cohort (12.4 g/dL vs 12.0 g/dL, respectively; P=.03), with a respective increase from baseline of 4.2 g/dL vs 3.7 g/dL (P=.03). There was no difference in the rate of women with hemoglobin level of <12.0 or 11.0 g/dL. Iron storage and health quality were not different between the cohorts. Oral iron treatment was associated with 29% rate of adverse effects. Compliance and satisfaction from treatment protocol were high in both cohorts. Intravenous 500 mg iron sucrose treatment alone is sufficient to treat postpartum anemia without the necessity of adding oral iron treatment.

The impact of postpartum hemoglobin levels on maternal quality of life after delivery: a prospective exploratory study.

Postpartum anemia has been associated with postpartum morbidities, such as depression and poor cognition. However, it is unclear whether postpartum anemia is associated with reduced health-related quality of life. We performed a prospective study to examine the relations between postpartum Hb levels with postpartum health-related quality of life (HRQoL). We collected data from 60 women intending vaginal delivery and assessed HRQoL and maternal fatigue on admission and on the first postpartum day using the RAND 36-Item Short-Form Health Survey (SF-36) and the Multidimensional Fatigue Inventory (MFI), respectively. Maternal Hb levels were measured on admission and on the first postpartum day. We also assessed patients for postpartum depression using the Edinburgh Postpartum Depression Scale (EPDS). We performed unadjusted and multivariate linear regression (adjusting for maternal age, parity, mode of delivery, and race) to assess the associations between postdelivery Hb with each subscale of the SF-36 and MFI. The mean predelivery and postpartum Hb levels were 12.3 (1.2) and 10.8 (1.4) g/dl, respectively. In our unadjusted and adjusted regression analyses, we observed no statistically significant associations between postpartum Hb levels with any SF-36 or MFI subscale (P > 0.05). Based on the EPDS, only one patient was depressed; her postpartum Hb was 11.2g/dl. Our findings suggest that postpartum Hb levels may not influence HRQoL or fatigue. However, our findings may only apply to women without predelivery anemia, severe blood loss or moderate-to-severe anemia after delivery. Future studies are needed to determine whether postpartum Hb influences HRQoL among women with moderate or severe postpartum anemia.

Intravenous ferrous sucrose versus placebo in addition to oral iron therapy for the treatment of severe postpartum anaemia: a randomised controlled trial

The aim of the study was to evaluate the effectiveness of intravenous iron versus placebo added to standard oral iron therapy in the treatment of severe postpartum anaemia. A randomised, double-blind, parallel-group, placebo-controlled clinical trial was performed in a single centre. Hospital Clinic of Barcelona, Barcelona, Spain. A cohort of 72 women with severe postpartum anaemia (6.0-8.0g/dl) treated with oral ferrous sulphate (two tablets of 525mg). Women were randomised to receive either intravenous ferrous sucrose (200mg/24hours for two consecutive days) or intravenous placebo, in addition to standard iron therapy. Clinical and laboratory data were obtained at 1, 2, and 6weeks. Haemoglobin and haematocrit at 1, 2, and 6weeks. Other haematological and clinical parameters, psychological status, and adverse side effects were also evaluated. Haemoglobin and haematocrit values were comparable in women receiving intravenous iron or placebo in addition to oral iron therapy at any of the time points. At 6weeks, haemoglobin level (mean±SD) was 12.2±1.0 versus 12.2±0.9g/dl, with a mean difference of -0.03 (95%CI -0.6 to 0.6), in the placebo and in the intravenous iron groups, respectively. No differences were found between clinical symptoms of anaemia, psychological status, and adverse side effects between groups. Intravenous iron added to oral iron therapy did not show significant benefits over placebo, neither in haemoglobin rise nor in symptoms or adverse side effects.

Iron sucrose with and without recombinant erythropoietin for the treatment of severe postpartum anemia: A prospective, randomized, open-label study

Postpartum anemia is a common problem in obstetrics. Depending on the severity of anemia, it can cause a wide range of symptoms. Obstetrical management should be focused on avoiding blood transfusion in young and otherwise healthy women. The aim of this study was to examine the effectiveness of recombinant human erythropoietin (rhEPO) combined with iron sucrose compared to iron sucrose alone in patients with severe postpartum anemia. A prospective randomized study was conducted in women with severe postpartum anemia (Hb < 8.5 g/dL). The first group received 200 mg iron sucrose intravenously daily on days 1-4. The second group received 200 mg iron sucrose plus 10.000E rhEPO in the same regimen. Twenty women were enrolled in each group. The follow-up period was two weeks. Baseline Hb was 7.1 g/dL and 7.5 g/dL, respectively, depending on the subgroup. Hemoglobin values increased close to normal values within two weeks in both groups treated with iron sucrose alone or in combination with rhEPO (10.5 g/dL, 10.7 g/dL, respectively). In general, iron sucrose alone is a sufficient anemia therapy agent. A subgroup of patients (i.e. with a more pronounced inflammatory response after cesarean section) may benefit from additional rhEPO therapy. Despite being severely anemic, none of our patients required transfusion. Iron sucrose as well as rhEPO was very well tolerated. The benefit of the therapy lies in the avoidance of allogenic blood transfusions with their potential side effects. In cases of severe anemia after operative delivery, additional rhEPO therapy can result in a faster Hb increase and, therefore, faster recovery.

Prevalence and risk factors for early postpartum anemia

Objective To assess the prevalence and evaluate the most important risk factors for early postpartum anemia. Study design The perinatal process data of 43 807 women delivering between 1993 and 2008 (90.1% of all deliveries) in the largest university obstetric department in Germany were analyzed, and the associations of Hb < 8 g/dl with maternal characteristics, pregnancy risks, delivery mode and estimated delivery blood loss were calculated. Multivariable logistic regression models were applied to compute odds ratios. Additionally, the impact of these risk factors for delivery blood loss was estimated with multivariable linear regression analysis. Results Twenty-two percent of mothers had Hb < 10 g/dl, and 3% had Hb < 8 g/dl. The adjusted odds ratios (OR) for Hb < 8 g/dl were 4.8 ( p = 0.001) for placenta previa, 2.9 ( p < 0.001) for mothers of African origin, 2.7 ( p < 0.001) for diagnosed anemia in pregnancy, 2.2 ( p < 0.001) for multiple pregnancy, and 2.1 ( p = 0.021) for bleeding in late pregnancy. However, the delivery blood loss was the most important risk factor for postpartum anemia. The adjusted OR for an estimated blood loss of 500–1000 ml was 15.3 ( p < 0.001), and for a loss of >1000 ml was 74.7 ( p < 0.001). Conclusion The estimated obstetric blood loss is the most important risk factor for severe postpartum anemia, and the volume of blood lost is especially high in cesarean deliveries, which should be considered when electing delivery procedures. Also, measures to boost iron stores in pregnancy should be established.

Severe anaemia in the immediate post-partum period. Clinical practice and value of intravenous iron

Abstract Objectives Post-partum anaemia is a very frequent condition affecting 4 to 27% of women who have given birth. Our study had the dual aim of investigating daily clinical practice in dealing with severe anaemia of the immediate post-partum period and of determining the place and efficacy of treatment with intravenous iron: Venofer®. Patients and methods We conducted a retrospective study in 4292 women who gave birth from April 2001 to March 2003 in the Department of Obstetrics and Gynaecology of Belfort Regional Hospital. All patients who had a haemoglobin of less than 8 g/dL within 48 hours post-partum (217 women or 5% of women who gave birth) were included and divided into two groups depending on the availability or lack of availability of iron treatment by the intravenous route at the time when they gave birth. A range of clinical and laboratory parameters related to delivery were analysed. Results The mean haemoglobin level in the 48 hours after delivery was: 5.81 g/dL for transfused women; 6.88 g/dL for patients treated with intravenous iron and 7.43 g/dL for patients treated with oral iron. Fifteen patients were transfused in the year prior to the introduction of treatment with intravenous iron and only five the following year. A mean increase in haemoglobin of 1.9 g/dL within 7 days was obtained with intravenous iron and of 3.1 g/dL within 14 days without any serious side effect. Discussion and conclusion These results suggest efficacy of treatment with intravenous iron for severe post-partum anaemia with entirely acceptable clinical tolerability. This treatment undoubtedly allows some blood transfusions to be avoided in young women, even though the indication for transfusion is unquestionable in the context of an emergency. Abstract Post-partum anaemia is a very frequent condition affecting 4 to 27% of women who have given birth. Our study had the dual aim of investigating daily clinical practice in dealing with severe anaemia of the immediate post-partum period and of determining the place and efficacy of treatment with intravenous iron: Venofer®. We conducted a retrospective study in 4292 women who gave birth from April 2001 to March 2003 in the Department of Obstetrics and Gynaecology of Belfort Regional Hospital. All patients who had a haemoglobin of less than 8 g/dL within 48 hours post-partum (217 women or 5% of women who gave birth) were included and divided into two groups depending on the availability or lack of availability of iron treatment by the intravenous route at the time when they gave birth. A range of clinical and laboratory parameters related to delivery were analysed. The mean haemoglobin level in the 48 hours after delivery was: 5.81 g/dL for transfused women; 6.88 g/dL for patients treated with intravenous iron and 7.43 g/dL for patients treated with oral iron. Fifteen patients were transfused in the year prior to the introduction of treatment with intravenous iron and only five the following year. A mean increase in haemoglobin of 1.9 g/dL within 7 days was obtained with intravenous iron and of 3.1 g/dL within 14 days without any serious side effect. These results suggest efficacy of treatment with intravenous iron for severe post-partum anaemia with entirely acceptable clinical tolerability. This treatment undoubtedly allows some blood transfusions to be avoided in young women, even though the indication for transfusion is unquestionable in the context of an emergency.

The WHO antenatal care model: the defects

The WHO antenatal care model: the defects

WHO Antenatal Care Randomised Trial for the Evaluation of a New Model of Routine Antenatal Care

Summary Background We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits. Methods Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), preeclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation.

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care

We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits. Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), pre-eclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation. Women attending clinics assigned the new model (n=12568) had a median of five visits compared with eight within the standard model (n=11958). More women in the new model than in the standard model were referred to higher levels of care (13.4% vs 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.68% vs standard model 7.14%; stratified rate difference 0.96 [95% CI -0.01 to 1.92]), postpartum anaemia (7.59% vs 8.67%; 0.32), and urinary-tract infection (5.95% vs 7.41%; -0.42 [-1.65 to 0.80]). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.69% vs 1.38%; 0.21 [-0.25 to 0.67]). Adjustment by several confounding variables did not modify this pattern. There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were, in general, satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost. Provision of routine antenatal care by the new model seems not to affect maternal and perinatal outcomes. It could be implemented without major resistance from women and providers and may reduce cost.

Prevalence and clinical significance of postpartum endometritis and wound infection

Objective To correlate clinical variables (gestational age, severe pregnancy-induced hypertension, gestational diabetes mellitus, history of previous cesarean sections, fetal distress, perinatal mortality, postpartum anemia, Apgar score ≤3 at 1 minute and ≤7 at 5 minutes, and instrumental delivery) with postpartum endometritis (PPE) and wound infection. Methods Descriptive cross-sectional study of the outcome of 75,947 term and preterm singleton deliveries; vaginally and by cesarean section from 1989–1997. Results The prevalence of PPE after vaginal deliveries was 0.17% (120/68,273). Gestational age of less than 37 weeks, severe pregnancy-induced hypertension, fetal distress, instrumental deliveries, neonatal mortality, postpartum anemia, and Apgar scores of <7 after 5 minutes were significantly associated with PPE. Gestational diabetes and an Apgar score of <3 after 1 minute showed similar frequency with and without PPE. The prevalence of PPE after cesarean section was 2.63% (202/7,677). Preterm cesarean sections, history of previous cesarean sections, anemia, and low Apgar scores were seen more frequently with PPE than without. The incidence of cesarean delivery with gestational diabetes mellitus, fetal distress, and perinatal mortality was similar in presence and absence of PPE. The rate of wound infection after cesarean section was 3.97% (318/7,995). Gestational diabetes mellitus, history of previous cesarean deliveries, and low Apgar scores were significantly more frequent with than without wound infection. Gestational age, severe pregnancy-induced hypertension, fetal distress, perinatal mortality, and postpartum anemia were not associated with wound infection. Conclusions Awareness of the aforementioned associations may prevent and shorten hospital stay by early diagnosis and appropriate treatment. Infect. Dis. Obstet. Gynecol. 8:77–82; 2000. © 2000 Wiley-Liss, Inc.

Prevalence and Clinical Significance of Postpartum Endometritis and Wound Infection

Objective:To correlate clinical variables (gestational age, severe pregnancy-induced hypertension, gestational diabetes mellitus, history of previous cesarean sections, fetal distress, perinatal mortality, postpartum anemia, Apgar score ≤3 at 1 minute and ≤7 at 5 minutes, and instrumental delivery) with postpartum endometritis (PPE) and wound infection.Methods:Descriptive cross-sectional study of the outcome of 75,947 term and preterm singleton deliveries; vaginally and by cesarean section from 1989–1997.Results:The prevalence of PPE after vaginal deliveries was 0.17% (120/68,273). Gestational age of less than 37 weeks, severe pregnancy-induced hypertension, fetal distress, instrumental deliveries, neonatal mortality, postpartum anemia, and Apgar scores of &lt;7 after 5 minutes were significantly associated with PPE. Gestational diabetes and an Apgar score of &lt;3 after 1 minute showed similar frequency with and without PPE. The prevalence of PPE after cesarean section was 2.63% (202/7,677). Preterm cesarean sections, history of previous cesarean sections, anemia, and low Apgar scores were seen more frequently with PPE than without. The incidence of cesarean delivery with gestational diabetes mellitus, fetal distress, and perinatal mortality was similar in presence and absence of PPE. The rate of wound infection after cesarean section was 3.97% (318/7,995). Gestational diabetes mellitus, history of previous cesarean deliveries, and low Apgar scores were significantly more frequent with than without wound infection. Gestational age, severe pregnancyinduced hypertension, fetal distress, perinatal mortality, and postpartum anemia were not associated with wound infection.Conclusions:Awareness of the aforementioned associations may prevent and shorten hospital stay by early diagnosis and appropriate treatment. Infect. Dis. Obstet. Gynecol. 8:77–82; 2000.

Intravenous iron therapy for correction of severe postpartum anaemia

European Society of Anaesthesiologists; 8th Annual Meeting with the Austrian International Congress; Vienna, Austria, 1-4 April 2000

Two cases of severe postpartum anaemia in Jehovah's witnesses

Two cases of severe postpartum anaemia in Jehovah's witnesses

Two cases of severe postpartum anaemia in Jehovah's witnesses

Two cases of severe postpartum anaemia are presented in Jehovah's witnesses who refused blood transfusion. Despite haemoglobin concentrations of less than 3 g/dl both women survived. General management was directed to maximizing oxygen delivery and minimizing oxygen consumption. The use of an emulsified perfluorocarbon was organized for one of the cases, but was not administered because a snow storm prevented its delivery to the hospital. In the other case, recombinant human erythropoietin was used to encourage red cell production. The recovery of haemoglobin concentration in the two cases is compared.