Implementation of a Standardized Protocol for Postpartum Anemia: A Prospective Cohort Study

Abstract

Objective

Implementation of standardized protocols for antepartum anemia increases intravenous iron (IVFe) use and improves predelivery hemoglobin (Hb). However, this condition is often overlooked and inadequately treated in postpartum care settings. We aimed to determine if implementation of a standardized protocol for postpartum anemia increases postpartum IVFe use and affects clinical outcomes.

Study Design

We performed a prospective cohort study evaluating implementation of a standardized inpatient protocol for postpartum anemia. This protocol, implemented in December 2021, recommends (1) IVFe for postpartum Hb 7.0 to 8.9 g/dL and (2) oral iron for postpartum Hb 9.0 to 9.9 g/dL. We compared all postpartum inpatients at a single site from April 2021 (preimplementation period [PRE]) to April 2022 (postimplementation period [POST]). The primary outcome was any IVFe use. Secondary outcomes included number of IVFe doses, oral iron supplementation at discharge, postpartum complications, and length of stay.

Results

A total of 805 patients were included (PRE = 401; POST = 404). Patients in the PRE and POST groups differed in ethnicity (PRE: 8.2% Hispanic vs. POST: 14.9% Hispanic, p = 0.003). IVFe use significantly increased from PRE to POST (PRE: 6.0% vs. POST: 11.1%, p = 0.009) even when controlling for differences between groups (adjusted odds ratio: 2.48, 95% confidence interval: [1.08–5.67]). Patients receiving IVFe in the POST group were more likely to receive the recommended three doses of IVFe compared with patients receiving IVFe in the PRE group (POST: 29% vs. PRE: 4%, p = 0.04). Patients in the POST group had shorter lengths of stay than in the PRE group (POST: 1.69 days vs. PRE: 1.81 days, p < 0.001). There were no significant differences in blood transfusion, oral iron supplementation, or postpartum complications.

Conclusion

Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay.

Key Points

• Postpartum anemia is associated with postpartum depression, fatigue, impaired cognition, and altered maternal–infant bonding.

• IVFe is more effective and better tolerated than oral iron.

• Implementation of standardized protocols for antepartum anemia has been shown to increase IVFe use.

• Implementation of a standardized protocol for postpartum anemia increased IVFe use without increasing length of stay.

Keywords

postpartum anemia - intravenous iron - protocol - implementation - postpartum hemorrhage

Note

Data from these manuscript were presented as a poster presentation at the 43^rd annual pregnancy meeting of the Society for Maternal-Fetal Medicine, San Francisco, CA, February 6–11, 2023.

Publication History

Received: 03 April 2024

Accepted: 11 September 2024

Accepted Manuscript online:
19 September 2024

Article published online:
08 October 2024

• References

• 1 Ruiz de Viñaspre-Hernández R, Gea-Caballero V, Juárez-Vela R, Iruzubieta-Barragán FJ. The definition, screening, and treatment of postpartum anemia: a systematic review of guidelines. Birth 2021; 48 (01) 14-25
• 2 Butwick AJ, McDonnell N. Antepartum and postpartum anemia: a narrative review. Int J Obstet Anesth 2021; 47: 102985
• 3 Holm C. Intravenous iron treatment in the puerperium. Dan Med J 2018; 65 (04) B5471
• 4 Wassef A, Nguyen QD, St-André M. Anaemia and depletion of iron stores as risk factors for postpartum depression: a literature review. J Psychosom Obstet Gynaecol 2019; 40 (01) 19-28
• 5 al-Momen AK, al-Meshari A, al-Nuaim L. et al. Intravenous iron sucrose complex in the treatment of iron deficiency anemia during pregnancy. Eur J Obstet Gynecol Reprod Biol 1996; 69 (02) 121-124
• 6 Pukale RS. H BK. Oral iron versus parenteral iron sucrose in a rural tertiary care hospital of Southern India. Int J Sci Res 2021; 48-50
• 7 Saad AF, Stepanek R, Kothmann M. et al. Intravenous iron compared with oral iron supplementation for the treatment of postpartum anemia: a randomized controlled trial. Obstet Gynecol 2023; 141 (06) 1052-1055
• 8 Hamm RF, Wang EY, Levine LD, Speranza RJ, Srinivas SK. Implementation of a protocol for management of antepartum iron deficiency anemia: a prospective cohort study. Am J Obstet Gynecol MFM 2022; 4 (02) 100533
• 9 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 (06) 590-593
• 10 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 (03) 286-295
• 11 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 (03) 518-522
• 12 Abdulrehman J, Lausman A, Tang GH. et al. Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): a before-and-after study. PLoS Med 2019; 16 (08) e1002867
• 13 Sultan P, Bampoe S, Shah R. et al. Oral vs intravenous iron therapy for postpartum anemia: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221 (01) 19-29.e3