Maternal and Perinatal Morbidity and Mortality Associated With Anemia in Pregnancy

Maternal Anemia and Long-Term Offspring Infectious Morbidity

OBJECTIVE

 Anemia of pregnancy is a common condition associated with adverse obstetric outcomes. However, little is known about its long-term effect on the offspring. This study aimed to evaluate a possible association between anemia during pregnancy and the long-term incidence of infectious morbidity in the offspring.

STUDY DESIGN

 A large population-based retrospective study was conducted at the Soroka University Medical Center, the sole tertiary medical center in the south of Israel. The study included deliveries between the years 1991 and 2014 and compared long-term infectious morbidity of offspring of women with and without anemia during pregnancy (defined as hemoglobin level below 11 g/dL). The long-term incremental incidence of hospitalizations of offspring up to 18 years of age due to infectious morbidity was evaluated using Kaplan-Meier survival curves, while Cox's regression model was used to control for confounders.

RESULTS

 During the study period, 214,244 deliveries met the inclusion criteria, of which 110,775 (51.7%) newborns were born to mothers with anemia during pregnancy. The overall infectious-related hospitalization rate was significantly higher in children from the exposed group (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.04-1.10, p < 0.01). Kaplan-Meier survival curves showed a significantly higher cumulative incidence of hospitalizations due to infectious diseases as compared with children in the unexposed group (log-rank test, p < 0.01). The Cox model demonstrated a significant and independent association between maternal anemia and the long-term risk for hospitalization due to infectious diseases of the offspring (adjusted hazard ratio [aHR]: 1.09, 95% CI: 1.06-1.12, p < 0.01).

CONCLUSION

 Offspring of anemic mothers are at a greater risk for infectious-related hospitalizations in their first 18 years of life.

KEY POINTS

· Anemia is highly common in pregnancy.. · Maternal anemia has multiple short-term implications.. · Our study shows anemia of pregnancy is independently associated with long-term offspring infectious morbidity..

The magnitude and associated factors of immediate postpartum anemia among women who gave birth in Ethiopia: systematic review and meta-analysis, 2023

BACKGROUND

The immediate postpartum period is a very crucial phase for both the life of the mother and her newborn baby. Anemia is the most indirect leading cause of maternal mortality. However, anemia in the immediate postpartum period is a neglected public health problem in Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the pooled magnitude of immediate postpartum anemia and the pooled effect size of associated factors in Ethiopia.

METHODS

Searching of published studies done through PubMed, Medline, Cochrane, African index Medicus, List of Reference Index, Hinari, and Google Scholar. This systematic review and meta-analysis follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) godliness. The quality of studies was assessed by using a Newcastle- Ottawa Scale (NOS) assessment tool. Analysis was performed using a random effect model by using STATA 17 version software. Egger's weighted regression and I2 test were used to evaluate publication bias and heterogeneity respectively.

RESULTS

In this systematic review and meta-analysis, a total of 6 studies were included. The pooled magnitude of immediate postpartum anemia in Ethiopia was 27% (95%CI: 22, 32). Instrumental mode of delivery (OR = 3.14, 95%CI: 2.03, 4.24), mid-upper arm circumference (MUAC) measurement < 23 cm (OR = 3.19, 95%CI: 1.35, 5.03), Antepartum Hemorrhage (OR = 4.75, 95%CI: 2.46, 7.03), postpartum hemorrhage (OR = 4.67, 95%CI: 2.80, 6.55), and no iron/foliate supplementation (OR = 2.72, 95%CI: 1.85, 3.60) were the identified factors associated with developing anemia in the immediate postpartum period.

CONCLUSION

The overall pooled magnitude of anemia in the immediate postpartum period among Ethiopian women was still a moderate public health problem. Instrumental mode of delivery, mid upper arm circumference (MUAC) measurement < 23 cm, antepartum hemorrhage, postpartum hemorrhage, and no iron/foliate supplementation were the identified factors associated with higher odds of developing anemia among immediate postpartum women in Ethiopia. Therefore, midwives, and doctors, shall focus on prevention of maternal hemorrhage, nutritional advice and counseling including iron /foliate supplementation, and avoid unnecessary instrumental delivery to prevent and reduce anemia related maternal mortality and morbidity in Ethiopia.

PROSPERO REGISTRATION

CRD42023437414 with registration date on 02/08/2023.

Prevalence and influencing factors of anemia among pregnant women across first, second and third trimesters of pregnancy in monitoring areas, from 2016 to 2020: a population-based multi-center cohort study

OBJECTIVE

To assess the prevalence of anemia among pregnant women across their entire pregnancy and the factors affecting it in the monitoring areas.

METHODS

A total of 108,351 pregnant women who received antenatal health care and delivered from January 1, 2016 to December 31, 2020 in 15 monitoring counties of 8 provinces in the Maternal and Newborn Health Monitoring Program (MNHMP) of National Center for Women and Children's Health (NCWCH) were selected as the study subjects. The anemia status among the subjects across their first, second and third trimester of pregnancy and the influencing factors were analyzed.

RESULTS

From 2016 to 2020, the prevalence of anemia at any stage during pregnancy in the monitoring areas was 43.59%. The prevalence of anemia among pregnant women across all three trimesters was 3.95%, and the prevalence of mild and moderate-to-severe anemia was 1.04% and 2.90%, respectively. Protective factors were living in the northern area (OR = 0.395) and being a member of an ethnic minority (OR = 0.632). The risk factors were residing in rural areas (OR = 1.207), with no more than junior high school education (OR = 1.203), having ≥ 3 gravidities (OR = 1.195) and multiple fetuses (OR = 1.478).

CONCLUSIONS

Although the prevalence of anemia among pregnant women across all trimesters in the monitoring area was low, the severity of anemia was high. Since the prevalence of anemia among pregnant women across their entire pregnancy in the monitoring area is affected by many different factors, more attention should be paid to pregnant women living in rural areas, with low literacy, ≥ 3 gravidities and multiple fetuses for early intervention.

A Comprehensive Assessment of Prescription Patterns for Anemia Management in Pregnant Women: A Study From Anand District, India

Introduction Pregnancy induces various physiological changes, often leading to complications. Physiological anemia of pregnancy, resulting from increased plasma volume and erythropoietin levels, poses significant health risks. Adverse outcomes associated with anemia during pregnancy include maternal and perinatal mortality, premature delivery, and low birth weight. Drug utilization research aims to promote rational drug use for improving health outcomes. The Food and Drug Administration (FDA) categorizes drugs based on teratogenic risk, providing guidance for clinicians. This study aims to analyze prescription trends and FDA risk categories for anemia in pregnant women in the Anand district. Materials and methods The study received institutional ethics approval and involved 816 pregnant women attending antenatal clinics from December 2021 to March 2023. Participants provided informed consent, and data collection included hemoglobin (Hb) levels at each trimester, categorizing participants into anemic (Hb < 11 gm/dL) and non-anemic groups. Prescribed drugs were recorded, and their essentiality was assessed using the WHO Essential Medicines List (WHO-EML) and the National List of Essential Medicines-2022 (NLEM-2022). FDA drug risk categories were utilized for assessing drug safety. Descriptive and statistical analyses were performed. Results Anemia prevalence across trimesters ranged from 62.50% to 65.93%, with an overall average of 64.42%. Iron and folic acid supplementation were significant across trimesters, with varying rates of prescription. Calcium supplementation showed fluctuations, with 100% prescription rates in later trimesters. Ascorbic acid was significantly prescribed in anemic pregnant women throughout pregnancy. Multivitamins were consistently prescribed, emphasizing their importance. The WHO-EML and NLEM-2022 highlighted essential micronutrients, while FDA categories indicated drug safety. Conclusion Anemia prevalence remained high throughout pregnancy, emphasizing the need for consistent supplementation. Prescription patterns aligned with evidence-based guidelines, focusing on iron and folic acid supplementation. Variations in calcium prescription suggest trimester-specific considerations. Prescription trends reflect a responsible approach to managing anemia during pregnancy, emphasizing prophylactic iron and folic acid therapy. The absence of high-risk medications underscores cautious prescribing practices. This study contributes valuable insights into evidence-based pharmacotherapy and maternal health care.

Sex-specific association between maternal mild anemia and children's behavioral development: a birth cohort study

There has been limited research on maternal anemia affecting children's behavioral development, with a lack of studies focusing on sex differences in this association. Based on the Ma'anshan Birth Cohort, 2132 mother-child pairs were included. Maternal anemia was evaluated based on the hemoglobin concentration and children's behavioral development was assessed by Achenbach Child Behavior Checklist 1.5-5. Binary logistic regression models indicated that compared with children born of mothers without anemia throughout pregnancy, maternal mild anemia during pregnancy or only anemia in the 3rd trimester was associated with increased risks of aggressive behaviors in boys. Maternal mild anemia only in the 2nd trimester was associated with increased risks of attention problems in boys. In girls, maternal mild anemia during pregnancy was associated with increased risks of withdrawn, internalizing problems and total problems. Girls born of mothers with mild anemia only in the 2nd trimester had higher risks of total problems. Maternal mild anemia in both 2nd and 3rd trimesters was associated with increased risks of internalizing problems in girls. Our study identified sex-specific effects of maternal mild anemia during pregnancy on children's behavioral development problems.

Retrospective Study Comparing Treatment Outcomes in Obstetric Patients With Iron Deficiency Anemia Treated With and Without Intravenous Ferric Carboxymaltose

Introduction Iron deficiency anemia is associated with an increased risk of adverse maternal and perinatal outcomes. Intravenous iron preparation containing ferric carboxymaltose has been shown to be a safe and effective way of increasing hemoglobin (Hb) and mean corpuscular volume (MCV) levels and reducing the need for blood transfusion. In our center, it used to be given as an inpatient procedure because of the risks of potential drug reactions. In 2021, we initiated the administration of intravenous ferric carboxymaltose as an outpatient procedure. We compared the outcomes of patients between 2021 and 2023 after the initiation of outpatient administration of intravenous ferric carboxymaltose in 127 obstetric patients with iron deficiency anemia in the second and third trimesters. Methods In this study conducted in a large maternity unit in Singapore between 2021 to 2023, we compared the changes in maternal hematological parameters among obstetric patients with iron deficiency anemia presenting to the day care unit in the second or third trimester with a Hb level of <8 g/dl treated with a single dose of ferric carboxymaltose injection (Ferinject) against a control group who were referred for treatment but defaulted on and declined treatment. Results Ferric carboxymaltose significantly increased the Hb and MCV levels at delivery in obstetric patients with iron deficiency. The mean Hb at delivery was 10.8 g/dL in the case group compared to 8.8 g/dL in the control group. The percentage of patients with Hb ≥10.0 g/dL was 73.4% in the case group compared to 27.8% in the control group. The incidence of adverse side effects was low and mild (2/127; 1.6%). None of the patients received were hospitalized because of ferric carboxymaltose. Conclusion A single injection dose of ferric carboxymaltose as an outpatient antenatal procedure was easily administered and well tolerated. Obstetric patients with iron deficiency anemia who received intravenous ferric carboxymaltose had a significantly higher level of Hb than those who did not.

Anaemia and red blood cell transfusion in women with placenta accreta spectrum: an analysis of 38,060 cases

Placenta accreta spectrum (PAS) has become a significant life-threatening issue due to its increased incidence and associated morbidity and mortality. Pregnancy is often associated with states of anaemia, and severe maternal haemorrhage represents a major risk factor for red blood cell (RBC) transfusion. The present study retrospectively analyzed the prevalence of anaemia, transfusion requirements and outcome in women with PAS. Using data from the German Statistical Office pregnant patients with deliveries hospitalized between January 2012 and December 2021 were included. Primary outcome was the prevalence of anemia and administration of RBCs. Secondary outcome were complications in women with PAS who received RBC transfusion. In total 6,493,606 pregnant women were analyzed, of which 38,060 (0.59%) were diagnosed with PAS. The rate of anaemia during pregnancy (60.36 vs. 23.25%; p < 0.0001), postpartum haemorrhage (47.08 vs. 4.41%; p < 0.0001) and RBC transfusion rate (14.68% vs. 0.72%; p < 0.0001) were higher in women with PAS compared to women without PAS. Women with PAS who had bleeding and transfusion experienced significantly more peripartum complications than those who did not. A multiple logistic regression revealed that the probability for RBC transfusion in all pregnant women was positively associated with anaemia (OR 21.96 (95% CI 21.36-22.58)). In women with PAS, RBC transfusion was positively associated with the presence of renal failure (OR 11.27 (95% CI 9.35-13.57)) and congestive heart failure (OR 6.02 (95% CI (5.2-7.07)). Early anaemia management prior to delivery as well as blood conservation strategies are crucial in women diagnosed with PAS.

Evaluation of a pharmacist-managed anemia service in pregnant patients

PURPOSE

Studies have shown the positive impact pharmacist-managed services have on patient care. However, little information is available on services for pregnant patients. This study contributes to the current literature by providing data on the impact of a pharmacist-managed service on outcomes in pregnant patients with iron-deficiency anemia.

METHODS

This was a retrospective, data-only, multicenter study comparing pregnant patients with iron-deficiency anemia managed by a pharmacist (n = 100) to those who received standard care (n = 100). During the study period, patients were 16 years of age or older and pregnant with concurrent iron-deficiency anemia. The percentage of patients with a hemoglobin level above goal (>11.0 g/dL) at delivery, the mean hemoglobin level at delivery, and the type of iron supplementation were compared between the groups.

RESULTS

The percentage of patients with a hemoglobin level of greater than 11.0 g/dL at delivery was 87% for the pharmacist-managed group compared to 71% for the group receiving standard care (P < 0.01). The mean hemoglobin level at delivery was significantly higher in the pharmacist-managed group than in the group receiving standard care, at 12.1 g/dL vs 11.6 g/dL, respectively (P < 0.1). There was no difference between the groups in the percentage of patients receiving blood transfusions (4% vs 3%; P = 0.56). The percentage of patients who received intravenous iron was significantly lower in the pharmacist-managed group than in the group receiving standard care (8% vs 21%; P < 0.01). Most patients in the pharmacist-managed group received oral ferrous sulfate (81%).

CONCLUSION

This study showed that including pharmacists in the management of pregnant patients with iron-deficiency anemia significantly improved patient hemoglobin levels at delivery.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia

BACKGROUND

Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging.

STUDY DESIGN AND METHODS

Randomized pilot trial with feasibility surveys.

INCLUSION

hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable.

EXCLUSION

ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T.

PRIMARY OUTCOME

number of recruits; proportion of those approached; proportion considered potentially eligible.

SECONDARY OUTCOMES

fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation.

RESULTS

Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Māori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9).

DISCUSSION

Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

Identification and treatment of iron-deficiency anemia in pregnancy and postpartum: A systematic review and quality appraisal of guidelines using AGREE II

BACKGROUND

Several international guidelines provide recommendations for the optimal management of iron-deficiency anemia (IDA) in the pregnant and postpartum populations.

OBJECTIVES

To review the quality of guidelines containing recommendations for the identification and treatment of IDA in pregnancy and postpartum using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and to summarize their recommendations.

SEARCH STRATEGY

PubMed, Medline, and Embase databases were searched from inception to August 2, 2021. A web engine search was also performed.

SELECTION CRITERIA

Clinical practice guidelines that focused on the management of IDA in pregnancy and/or postpartum populations were included.

DATA COLLECTION AND ANALYSIS

Included guidelines were appraised using AGREE II independently by two reviewers. Domain scores greater than 70% were considered high-quality. Overall scores of six or seven (out of a possible seven) were considered high-quality guidelines. Recommendations on IDA management were extracted and summarized.

MAIN RESULTS

Of 2887 citations, 16 guidelines were included. Only six (37.5%) guidelines were deemed high-quality and were recommended by the reviewers. All 16 (100%) guidelines discussed the management of IDA in pregnancy, and 10 (62.5%) also included information on the management of IDA in the postpartum period.

CONCLUSIONS

The complex interplay of racial, ethnic, and socioeconomic disparities was rarely addressed, which limits the generalizability of the recommendations. In addition, many guidelines failed to identify barriers to implementation, strategies to improve uptake or iron treatment, and resource and cost implications of clinical recommendations. These findings highlight important areas to target future work.

Obstetric blood transfusion in placenta previa patients with prenatal anemia: a retrospective study

BACKGROUND

The appropriate use of obstetric blood transfusion is crucial for patients with placenta previa and prenatal anemia. This retrospective study aims to explore the correlation between prenatal anemia and blood transfusion-related parameters in this population.

METHODS

We retrieved the medical records of consecutive participants who were diagnosed with placenta previa and underwent cesarean section in our hospital. We compared the baseline demographics and clinical characteristics of patients with and without anemia. The correlation between prenatal anemia and obstetric blood transfusion-related parameters was evaluated using multivariate regression analysis.

RESULTS

A total of 749 patients were enrolled, with a mean prenatal hemoglobin level of 10.87 ± 1.37 g/dL. Among them, 54.87% (391/749) were diagnosed with anemia. The rate of obstetric blood transfusion was significantly higher in the anemia group (79.54%) compared to the normal group (44.41%). The median allogeneic red blood cell transfusion volume in the anemia group was 4.00 U (IQR 2.00-6.00), while in the normal group, it was 0.00 U (IQR 0.00-4.00). The prenatal hemoglobin levels had a non-linear relationship with intraoperative allogeneic blood transfusion rate, massive blood transfusion rate, red blood cell transfusion units, and fresh plasma transfusion volume in patients with placenta previa, with a threshold of 12 g/dL.

CONCLUSIONS

Our findings suggest that prenatal anemia is associated with a higher rate of blood transfusion-related parameters in women with placenta previa when the hemoglobin level is < 12 g/dL. These results highlight the importance of promoting prenatal care in placenta previa patients with a high requirement for blood transfusion.

Prevalence of anemia and comparison of perinatal outcomes among anemic and nonanemic mothers

BACKGROUND

The prevalence of anemia is a significant public health challenge. Approximately half of all pregnant women in India experience anemia during pregnancy. This study aims to determine the prevalence of anemia and perinatal outcomes among anemic and nonanemic pregnant mothers.

MATERIALS AND METHODS

The quantitative research approach was adopted using a descriptive comparative design. The study was conducted in the Obstetrics and Gynecology and Pediatric departments of a tertiary care hospital. Hemoglobin (Hb) was recorded using antenatal records of pregnant mothers in their III trimester. Based on their Hb level, subjects were divided into two groups, anemic and nonanemic as per World Health Organization criteria. The subjects were followed up until the first week after birth.

RESULTS

The prevalence of anemia was 48% [N = 410]; 70.6% had mild, 13.7% had moderate, and 15.7% had severe. The anemic group had a significantly higher incidence of low birthweight (30.9% vs 10.3%, P = 0.001) and preterm births (24.2% vs 3.2%, P = 0.001) compared to the nonanemic group. Additionally, there were significant differences in various quantitative perinatal parameters such as weight (P = 0.001), length (P = 0.001), head circumference (P = 0.001), chest circumference (P = 0.034), APGAR score at one minute (P = 0.022), and APGAR score at five minutes (P = 0.001) between the anemic and nonanemic.

CONCLUSION

The maternal anemia is associated with increased risk of unfavorable perinatal outcomes. Identifying and managing anemia among pregnant women is critical to minimize adverse outcomes. Adequate antenatal care can play a significant role in preventing avoidable complications associated with anemia during the third trimester.

A district-level geospatial analysis of anaemia prevalence among rural men in India, 2019-21

BACKGROUND

Despite its considerable impact on health and productivity, anemia among men has received limited attention. In a country as diverse as India, characterized by extensive geographic variations, there is a pressing need to investigate the nuanced spatial patterns of anemia prevalence among men. The identification of specific hotspots holds critical implications for policymaking, especially in rural areas, where a substantial portion of India's population resides.

METHODS

The study conducted an analysis on a sample of 61,481 rural men from 707 districts of India, utilizing data from the National Family Health Survey-5 (2019-21). Various analytical techniques, including Moran's I, univariate LISA (Local Indicators of Spatial Association), bivariate LISA, and spatial regression models such as SLM (Spatial Lag Model), and SEM (Spatial Error Model) were employed to examine the geographic patterns and spatial correlates of anaemia prevalence in the study population.

RESULTS

In rural India, three out of every ten men were found to be anemic. The univariate Moran's I value for anaemia was 0.66, indicating a substantial degree of spatial autocorrelation in anaemia prevalence across the districts in India. Cluster and outlier analysis identified five prominent 'hotspots' of anaemia prevalence across 97 districts, primarily concentrated in the eastern region (encompassing West Bengal, Jharkhand, and Odisha), the Dandakaranya region, the Madhya Pradesh-Maharashtra border, lower Assam, and select districts in Jammu and Kashmir. The results of SLM revealed significant positive association between anaemia prevalence at the district-level and several key factors including a higher proportion of Scheduled Tribes, men in the 49-54 years age group, men with limited or no formal education, individuals of the Muslim faith, economically disadvantaged men, and those who reported alcohol consumption.

CONCLUSIONS

Substantial spatial heterogeneity in anaemia prevalence among men in rural India suggests the need for region-specific targeted interventions to reduce the burden of anaemia among men in rural India and enhance the overall health of this population.

Hemoglobin on Admission for Childbirth and Postpartum Acute Care Use in a Southeastern Health Care System

OBJECTIVE

 Our objective was to evaluate whether hemoglobin on admission for childbirth is associated with postpartum acute care use (ACU).

STUDY DESIGN

 We conducted a retrospective cohort study of patients giving birth at a southeastern quaternary care hospital from January 2018 through June 2021 using electronic health records. Predelivery hemoglobin was categorized as <9, 9- < 10, 10- < 11, 11- < 12, and ≥12 g/dL. Acute care was defined as a visit to obstetric triage, the emergency department, or inpatient admission within 90 days postpartum. Generalized estimating equations quantified the crude and multivariable-adjusted association between predelivery hemoglobin and ACU.

RESULTS

 Among 8,677 pregnancies, 1,467 (17%) used acute care in the system within 90 days postpartum. In unadjusted models, those with predelivery hemoglobin <9 had twice the risk of postpartum ACU compared to those with hemoglobin ≥12 (95% confidence interval [CI]: 1.59-2.69), with a decrease in risk for each increase in hemoglobin category (9- < 10 g/dL: risk ratio [RR]: 1.47, CI: 1.21-1.79; 10- < 11 g/dL: RR: 1.44, CI: 1.26-1.64; 11- < 12 g/dL: RR: 1.20, CI: 1.07-1.34). The adjusted model showed a similar trend with smaller effect estimates (<9 g/dL: RR: 1.50, CI: 1.14-1.98; 9- < 10 g/dL: RR: 1.22, CI: 1.00-1.48; 10- < 11 g/dL: RR: 1.22, CI: 1.07-1.40; 11- < 12 g/dL: RR: 1.09, CI: 0.98-1.22).

CONCLUSION

 Low hemoglobin at childbirth admission was associated with increased postpartum ACU. Low hemoglobin on admission could signal to providers that additional follow-up, resources, and ongoing support are warranted to identify and address underlying health needs. Because hemoglobin is routinely assessed during the childbirth hospitalization, this indicator may be especially valuable for risk assessment among patients with limited prior engagement in health care.

KEY POINTS

· Low hemoglobin on admission for birth is associated with postpartum acute care use.. · Hemoglobin on admission may aid in risk-stratification during childbirth hospitalization.. · Point-of-care metrics may help identify high-risk patients with limited preventive health care..

Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study

BACKGROUND

Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria.

METHODS

In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA.

RESULTS

Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82).

CONCLUSION

About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

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

BACKGROUND

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.

METHODS

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 < 12 g/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).

RESULTS

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) 0.54 g/dL, 95% confidence interval (CI) 0.47, 0.61, I2 = 91%), ferritin, (MD 58.07 mcg/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.

DISCUSSION

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.

Prevalence and adverse perinatal outcomes of anaemia in the third trimester of pregnancy in Hebei Province, China

BACKGROUND

Anaemia in pregnancy is one of the most frequent complications related to pregnancy and is a public health concern. This article examines the prevalence of anaemia in the third trimester of pregnancy and the associations between anaemia and adverse perinatal outcomes in Hebei Province, China.

METHODS

We used SPSS software to describe the incidence of anaemia in the third trimester of pregnancy in Hebei Province and analysed the clinical characteristics in anaemic patients and the relationship between anaemia and adverse pregnancy outcomes.

RESULTS

The overall prevalence of anaemia in the third trimester of pregnancy was 35.0% in Hebei Province. The prevalence of anaemia in the population with a high education level was lower than that in the population with a low education level. The incidence rate in rural areas was higher than that in urban areas. After adjustment for confounding factors, anaemia in the third trimester of pregnancy is an independent risk factor in terms of placenta previa, placental abruption, uterine atony, pre-eclampsia, gestational diabetes mellitus, heart disease, postpartum haemorrhage, premature birth, laceration of birth canal, puerperal infection, caesarean section and large for gestational age.

CONCLUSIONS

The prevalence of anaemia in the third trimester of pregnancy is associated with an increased risk of adverse perinatal outcomes. A comprehensive approach to prevent anaemia is needed to improve maternal and child health outcomes.

Adolescent pregnancies in Turkey: a single center experience

BACKGROUND

Adolescent pregnancies are more likely to be complicated with adverse perinatal outcomes.

OBJECTIVE

Assess the sociodemographic and clinical characteristics of adolescents who have delivered singleton newborns.

DESIGN

Retrospective cohort.

SETTINGS

A tertiary training and research hospital in Turkey.

PATIENTS AND METHODS

This was a review of adolescents and adults who delivered singleton newborns at a tertiary health center between January 2018 and June 2022. Pregnant adolescents were aged <20 years.

MAIN OUTCOME MEASURES

Adverse maternal and perinatal outcomes.

SAMPLE SIZE

2233 pregnant women (754 adolescents and 1479 adults).

RESULTS

Turkish nationality was significantly less prevalent in pregnant adolescents than pregnant adults (P=.001). Oligohydramnios, fetal growth restriction, perineal injury and postpartum intravenous iron treatment were significantly more prevalent in pregnant adolescents than pregnant adults (P<.05 for all). The neonates born to adolescent mothers had significantly lower birth weight and first minute Apgar score than the neonates born to adult mothers (P=.001 for both). Small for gestational age, need for intensive care and death were significantly more prevalent in neonates born to adolescent mothers than those born to adult mothers (P=.001 for all). Compared with pregnant adults, pregnant adolescents had a significantly higher risk of oligohydramnios (P=.001), preterm delivery (P=.024), intravenous iron treatment (P=.001), and small for gestational age (P=.001).

CONCLUSION

Due to the refugee population received by Turkey, it would be prudent to expect more frequent adolescent pregnancies. Adolescent pregnancies are more likely to be complicated with low birth weight, oligohydramnios, preterm delivery, postpartum iron treatment, lower Apgar scores, need for neonatal intensive care and neonatal death.

LIMITATION

Retrospective.

Temporal trends of hemoglobin among pregnant women: The Mutaba'ah study

BACKGROUND

Low hemoglobin (Hb) level is a leading cause of many adverse pregnancy outcomes. Patterns of changes in Hb levels during pregnancy are not well understood.

AIM

This study estimated Hb levels, described its changing patterns across gestational trimesters, and identified factors associated with these changes among pregnant women.

MATERIALS AND METHODS

Data from the ongoing maternal and child health cohort study-The Mutaba'ah Study, was used (N = 1,120). KML machine learning algorithm was applied to identify three distinct cluster trajectories of Hb levels between the first and the third trimesters. Descriptive statistics were used to profile the study participants. Multinomial multivariable logistic regression was employed to identify factors associated with change patterns in Hb levels.

RESULTS

The three identified clusters-A, B and C-had, respectively, median Hb levels (g/L) of 123, 118, and 104 in the first trimester and 119, 100, and 108 in the third trimester. Cluster 'A' maintained average normal Hb levels in both trimesters. Cluster 'B', on average, experienced a decrease in Hb levels below the normal range during the third trimester. Cluster 'C' showed increased Hb levels in the third trimester but remained, on average, below the normal range in both trimesters. Pregnant women with higher gravida, diabetes mellitus (type 1 or 2), nulliparity or lower level of education were more likely to be in cluster 'B' than the normal cluster 'A'. Pregnant women who reported using iron supplements before pregnancy or those with low levels of education. were more likely to be in cluster 'C' than the normal cluster 'A'.

CONCLUSION

The majority of pregnant women experienced low Hb levels during pregnancy. Changes in Hb levels during pregnancy were associated with parity, gravida, use of iron before pregnancy, and the presence of diabetes mellitus (type 1 or 2).

Maternal anemia is associated with adverse maternal and neonatal outcomes in Mbarara, Uganda

PURPOSE

Maternal anemia is a significant risk factor for maternal morbidity and mortality, increasing risk of preterm birth, intrauterine growth restriction, stillbirth, and death. Moderate and severe anemia in pregnancy is defined as hemoglobin (Hb) <10 g/dl and Hb < 7 g/dl, respectively. We aimed to characterize the association of maternal anemia with maternal, neonatal, and placental outcomes in a resource-limited setting.

METHODS

Data were collected from a prospective cohort of 352 pregnant women at a tertiary academic Ugandan hospital. One hundred and seventy-six (50%) of women were living with HIV. Hemoglobin was measured in labor, and placentas were collected postpartum. Maternal outcomes included mode of delivery, hemorrhage, blood transfusion, intensive care unit admission, and maternal mortality. Neonatal outcomes included gestational age at delivery, birthweight, stillbirth, and neonatal mortality. Placental descriptors included weight and thickness. Categorical variables were analyzed using Chi-squared and Fisher's exact tests.

RESULTS

Hemoglobin < 10 g/dl, was present in 17/352 (5%) of women. Significantly more women with moderate or severe anemia were HIV-infected: 14/17 (82%) versus 162/335 (48%) (p = .006). Blood transfusions (2/17, 12% versus 5/335, 2%, p = .04) and neonatal deaths (2/17, 12% versus 9/335, 3%, p = .01) were more common in the anemia group. Placental thickness was lower in the anemia group (1.4 cm versus 1.7 cm, p = .04).

CONCLUSIONS

Moderate and severe anemia was associated with maternal HIV infection, maternal blood transfusion, neonatal death, and decreased placental thickness. The overall rate of moderate and severe anemia among this cohort was lower than previously reported.

Intravenous iron for treatment of iron deficiency anemia during pregnancy and associated maternal outcomes

BACKGROUND

More than 40% of pregnant patients worldwide are anemic, with at least half resulting from iron deficiency anemia (IDA). Anemia in pregnancy is linked with adverse maternal and neonatal outcomes. Treatment for IDA is iron supplementation; however, the optimal route of administration remains unclear. We sought to investigate whether patients with IDA who received intravenous iron (IVI) had decreased odds of maternal morbidity compared to patients who did not.

METHODS

This is a retrospective cohort study of pregnant patients with presumed IDA with term deliveries at a tertiary hospital from 2013-2021. Data were extracted from the hospital's electronic medical record using standardized definitions and billing codes. Patients who received antepartum IVI were compared to patients who did not. The primary outcome was a maternal morbidity composite inclusive of receipt of blood transfusion, hysterectomy, admission to the intensive care unit or death. Bivariate analyses and multivariable logistic regression modelling were performed adjusting for potential confounders.

RESULTS

Of 45,345 pregnancies, 5054 (11.1%) met eligibility criteria. Of these, 944 (18.7%) patients received IVI while 4110 (81.3%) did not. Patients who received IVI had higher risk baseline characteristics. They experienced a greater increase in hematocrit from pregnancy nadir to delivery admission (4.5% vs. 3.3%, p < .01). Despite this, patients who received IVI had higher odds of the maternal morbidity composite (OR 1.47, 95%CI 1.11-1.95). This finding persisted after adjusting for potential confounders, although the strength of the association became attenuated (aOR 1.37, 95%CI 1.02-1.85). Odds of the morbidity composite were not elevated among patients who received a full IVI treatment course (OR 1.2, 95% CI 0.83-1.90).

DISCUSSION

Odds of the maternal morbidity composite were increased among patients who received IVI despite greater increases in hematocrit. The effect was attenuated after adjusting for potential confounders and was not significant among patients who completed a full treatment course.

Determinants of anemia level among reproductive-age women in 29 Sub-Saharan African countries: A multilevel mixed-effects modelling with ordered logistic regression analysis

BACKGROUND

Despite the implementation of different nutritional and non-nutritional interventions, 43% of reproductive-age women in Africa suffer from anemia. Recent evidence also shows that none of the Sub-Saharan African (SSA) countries are on the track to achieve the nutrition target of 50% anemia reduction by 2030. To date, information on the level of anemia and its determinants among reproductive-age women at the SSA level is limited. Thus, this study aimed to estimate the pooled prevalence of anemia level and its determinants in SSA countries.

METHODS

We used a pooled data of 205,627 reproductive-age women from the recent demographic and health surveys of 29 SSA countries that were conducted between 2010-2021. A multilevel mixed-effects analysis with an ordered logistic regression model was fitted to identify determinants of anemia level and the deviance value was used to select the best-fitted model. First, bivariable ordinal logistic regression analysis was done and the proportional odds assumption was checked for each explanatory variable using a Brant test. Finally, in a multivariable multilevel ordinal logistic regression model, a p-value<0.05 and AOR with the corresponding 95% CI were used to identify determinants of anemia level. All analyses were done using Stata version 17 software.

RESULTS

The pooled prevalence of anemia among women of reproductive age in SSA was 40.5% [95% CI = 40.2%-40.7%], where 24.8% [95% CI: 24.6%-25.0%], 11.1% [95% CI = 10.9%-11.2%], and 0.8% [95% CI = 0.7%-0.8%] had mild, moderate, and severe anemia, respectively. The prevalence significantly varied from the lowest of 13% in Rwanda to the highest of 62% in Mali, and anemia was found as a severe public health problem (prevalence of ≥ 40%) in 18 countries. The regression result revealed that polygamous marriage, women and husband illiteracy, poor household wealth, shorter birth interval, non-attendance of antenatal care, underweight, unimproved toilet and water facilities, and low community-level women literacy were positively linked with high anemia level. Additionally, the likelihood of anemia was lower in women who were overweight and used modern contraception.

CONCLUSIONS

Overall results showed that anemia among women of reproductive age is a severe public health problem in SSA countries, affecting more than four in ten women. Thus, enhancing access to maternal health services (antenatal care and contraception) and improved sanitation facilities would supplement the existing interventions targeted to reduce anemia. Moreover, strengthening women's education and policies regulating the prohibition of polygamous marriage are important to address the operational constraints.

The Impact of Cefepime and Ampicillin/Sulbactam on Preventing Post-Cesarean Surgical Site Infections, Randomized Controlled Trail

Over the previous three decades, the rate of caesarean sections performed worldwide has grown exponentially. In comparison to a vaginal birth, the risk of all postpartum infections is higher with a cesarean section. One of the key factors contributing to maternal morbidity is the development of infectious complications in the surgical site after a caesarean section. The primary goal of the research was to compare the efficiency of using ampicillin/sulbactam (AMS) and cefepime (CEF) to reduce the incidence of surgical site infections (SSI) following caesarean delivery. This prospective randomized study was conducted among 200 pregnant women scheduled for elective cesarean section. They were collected from the Obstetrics and Gynecology department of Beni-Suef University Hospital, and then they were randomly assigned into two groups. Group (A) received cefepime 30 min before and 12 h after cesarean delivery, while group (B) received ampicillin/sulbactam 30 min before and 12 h after cesarean delivery. The groups were matched regarding the baseline women characteristics. Comparing the cefepime to the ampicillin/sulbactam revealed that the cefepime significantly decreased superficial SSI from 27% to 14% (0.023). A significant decrease was observed in deep SSI with cefepime compared to ampicillin/sulbactam from 24% to 13% (p-value 0.045). Interestingly, when the cefepime was compared to the ampicillin/sulbactam, we noted that the incidence of endometritis significantly decreased from 13% to 5% (p = 0.048). A noted decrease in post-operative fever in cefepime as compared to ampicillin/sulbactam from 18% to 13% (p-value = 0.329). Receiving prophylactic cefepime pre- and post-cesarean delivery significantly decreases post-operative wound infection and endometritis.

Prevalence and factors associated with anaemia among pregnant women attending antenatal care in a district hospital and its feeder community healthcare centre of the Limpopo Province, South Africa

Background

Pregnancy anaemia is a significant public health concern in South Africa (SA), particularly in rural areas, but little is known about its prevalence and risk factors in rural areas. The objective of the study was to determine the prevalence and identify risk factors of pregnancy anaemia in the public health facilities of Limpopo Province (LP), SA.

Methods

A cross-sectional study was conducted among a consecutive sample of 211 pregnant women attending antenatal care at Seshego Hospital and its feeder health centre (May to June 2019). Anaemia was defined as haemoglobin (Hb) <11 g/dL and classified as mild (10-10.9 g/dL), moderate (7-9.9 g/dL) and severe anaemia (<7 g/dL). A multiple logistic regression analysis was used to identify predictors of anaemia.

Results

The mean age of the women was 28.4 ± 5.7 years (range from 18 to 41 years). Over half (52%) had secondary education, 65% were unmarried, 72% were unemployed, 34% were nulliparous, 15% were human immunodeficiency virus (HIV) infected and 67% were in the third trimester. The anaemia prevalence was 18.0% and was significantly associated with parity, HIV status and body mass index (BMI) in a multivariate logistic regression analysis.

Conclusion

This study found that less than one-third of pregnant women were affected by anaemia, associated with parity, HIV infected and BMI. It is essential to promote routine screening for anaemia, health education and prompt treatment of infections to reduce this burden. In addition, further studies on risk factors for anaemia during pregnancy in both urban and rural communities should be conducted to strengthen these findings.

Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity

OBJECTIVE

To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.

METHODS

We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.

RESULTS

In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%.

CONCLUSION

Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.

The Interplay of Hypertension and Anemia on Pregnancy Outcomes

Background Anemia and pregnancy-induced hypertension (PIH) are two significant high-risk conditions that can have a profound impact on maternal health during pregnancy. The scarcity of studies investigating the potential links and interactions between these two conditions adds to the gap in our understanding of their combined impact on pregnant women. This study aimed to assess the impact of PIH in conjunction with anemia and without anemia on pregnancy outcomes. Methods A prospective study was conducted among 150 primi pregnant women (third trimester of pregnancy) from a secondary-care hospital (Government General Headquarters Hospital, Cuddalore) in Tamil Nadu, India. The study population was selected using a purposive sampling technique. Data were collected using a structured questionnaire to assess sociodemographic characteristics, dietary patterns, and outcomes of pregnancy. Clinical parameters such as blood pressure were measured using a sphygmomanometer, and hemoglobin and urine tests for protein were obtained from the patient's medical records. Results The result showed that out of 150 primi pregnant women, 73 (49%) had PIH and 77 (51%) experienced both PIH and anemia. On comparing the outcomes, pregnant women with PIH accompanied by anemia exhibited developing preeclampsia (p<0.001), encountered maternal complications (p=0.034), delivered preterm babies (p=0.03), and gave birth to low-birth-weight babies (p<0.001), and their newborns admitted to the NICU (p=0.02). Additionally, pregnant women with both PIH and anemia demonstrated significantly higher levels of systolic blood pressure after delivery (p=0.009). Conclusion  The study calls for the immediate attention of healthcare providers for vigilant monitoring and addressing anemia in conjunction with PIH to improve maternal and neonatal outcomes.

Is the burden of anaemia among Indian adolescent women increasing? Evidence from Indian Demographic and Health Surveys (2015-21)

Anaemia is a significant public health issue, particularly affecting women in India. However, little is known about the burden of anaemia among adolescent women in India over time. This study aimed to analyse the change in the prevalence of anaemia among adolescent women in India from 2015 to 2021 and identify the factors associated with anaemia in this population. This study used information on 116,117 and 109,400 adolescent women (aged 15-19) from the fourth and fifth round of National Family Health Survey, respectively. Bivariate statistics and multivariable logistic regression were employed to identify the statistically significant predictors of anaemia. The prevalence of anaemia among adolescent women in India increased from 54.2% (99% CI: 53.6-54.8) to 58.9% (99% CI: 58.3-59.5) over the study period (2015-16 to 2019-21). Among the 28 Indian states, 21 reported an increase in the prevalence of anaemia. However, the levels of increase varied across the states. While Assam, Chhattisgarh, and Tripura showed a substantial rise of 15 percentage points, the states of Punjab, Karnataka, Telangana, Bihar, and Madhya Pradesh recorded a marginal increase of less than 5 percentage points. Notably, Uttarakhand and Kerala exhibited a decline in anaemia prevalence during the study period. Additionally, the number of states with anaemia prevalence exceeding 60%, doubled from 5 in 2015-16 to 11 in 2019-21. Several factors were found associated with anaemia, including having more than one child (AOR: 1.33, 99% CI: 1.16-1.51), having no education (AOR: 1.25, 99% CI: 1.16-1.34), belonging to Scheduled Tribes (AOR: 1.47, 99% CI: 1.40-1.53), being in the lowest wealth quintile (AOR: 1.17, 99% CI: 1.12-1.23), year of survey (AOR: 1.26, 99% CI: 1.23-1.29), and being underweight (AOR: 1.10, 99% CI: 1.07-1.12). In conclusion, the rise in anaemia prevalence among adolescent women in India suggests the need for targeted interventions to mitigate the burden of anaemia and enhance the overall health of this population.

Pre-pregnancy body mass index and adverse maternal and perinatal outcomes in twins: A population retrospective cohort study

OBJECTIVE

To examine the association between pre-pregnancy BMI and severe maternal morbidity (SMM), perinatal death and severe neonatal morbidity in twin pregnancies.

METHODS

All twin births at ≥ 20 weeks gestation in British Columbia, Canada, from 2000 to 2017 were included. We estimated rates of SMM, a perinatal composite of death and severe morbidity, and its components per 10,000 pregnancies. Confounder-adjusted rate ratios (aRR) between pre-pregnancy BMI and outcomes were estimated using robust Poisson regression.

RESULTS

Overall, 7770 (368 underweight, 1704 overweight, and 1016 obese) women with twin pregnancy were included. The rates of SMM were: 271.1, 320.4, 270.0, and 225.9 in underweight, normal BMI, overweight and obese women, respectively. There was little association between obesity and any of the primary outcomes (e.g., aRR = 1.09, 95% CI = 0.85, 1.38 for composite perinatal outcome). Underweight women had higher rates of the composite perinatal adverse outcome (aRR = 1.79, 95% CI = 1.32-2.43), driven by increased rates of severe respiratory distress syndrome, and neonatal death.

CONCLUSIONS

There was no evidence of elevated risk of adverse outcomes among twin pregnancies of women who were overweight or obese. Risk was higher in underweight women, who may require specific care when carrying twins.

The Positive Predictive Value of Hospital Discharge Data for Identifying Severe Maternal Morbidity With and Without Blood Transfusion

BACKGROUND

Blood transfusion is 1 of the 21 indicators for severe maternal morbidity (SMM) as defined by the Centers for Disease Control and Prevention (CDC) using administrative data. The CDC SMM definition is being prepared to measure hospital quality of care; however, transfusion coding reliability has been questioned. The authors assessed the positive predictive value (PPV) of administrative data for identifying gold standard SMM using the CDC SMM definition, with and without the transfusion indicator.

METHODS

A retrospective cohort study of one hospital's childbirth admissions (2016-2019) was performed. Data were screened for CDC SMM, and subgroups were created for those with transfusion as the sole indicator for SMM (transfusion-only SMM) versus those with at least one other SMM indicator (other SMM). Medical chart review classified CDC SMM cases based on gold standard SMM criteria. Gold standard SMM was defined by validated indicators identified by internal hospital quality reviews and confirmed by expert consensus. The PPV was calculated for all CDC SMM cases and the subgroups.

RESULTS

Of 4,212 eligible people, 278 (6.6%) had CDC SMM. Chart review identified 110 gold standard SMM cases among screen-positive cases, yielding an overall PPV of the CDC SMM definition for gold standard SMM of 39.6%. CDC SMM cases identified solely by administrative coding for transfusion were half as likely to meet gold standard criteria, compared to cases identified by other SMM administrative codes (25.9% vs. 49.4%).

CONCLUSION

Blood transfusion, coded as an independent risk factor, had a poor PPV for gold standard SMM. Given efforts to use CDC SMM for quality comparisons, more research is needed to reliably identify cases of SMM without relying on blood transfusion codes.

Intravenous infusions of ferumoxytol compared to oral ferrous sulfate for the treatment of anemia in pregnancy: a randomized controlled trial

BACKGROUND

Iron-deficiency anemia in pregnancy is highly prevalent and presents significant risk to patients. Initial treatment is often with oral medication. We hypothesized that intravenous ferumoxytol would result in superior treatment of anemia as compared to oral ferrous sulfate.

OBJECTIVE

This study aimed to investigate whether 2 infusions of intravenous ferumoxytol are superior to the use of twice-daily oral ferrous sulfate for the treatment of iron-deficiency anemia in pregnancy.

STUDY DESIGN

A randomized controlled trial was performed in which participants with anemic (hemoglobin <11 g/dL and hematocrit <33%) were allocated to receive either 2 infusions of 510 mg of intravenous ferumoxytol approximately 7 days apart, or 325 mg oral ferrous sulfate twice daily from enrollment to the end of their pregnancy. Participants were randomized in a 1:1 ratio to each treatment. Our primary outcome was the change in maternal hemoglobin. Secondary outcomes included maternal iron indices, maternal safety, and maternal tolerability.

RESULTS

There were 124 participants (N=62 per group). In the intravenous iron group, the mean change in hemoglobin was 1.86 g/dL (95% confidence interval, 1.57 g/dL-2.14 g/dL) and in the oral group was 0.79 g/dL (95% confidence interval, 0.42 g/dL-1.17 g/dL) (P<.0001). The median change in ferritin between groups was 64.5 (range, 31-364) vs 8 (range, -436 to +167) (P=.0001). The median change in iron between groups was also statistically significant with 47.5 ug/dL (range, -133 ug/dL to +664 ug/dL) in the intravenous group vs 8.5 ug/dL (range, -313 ug/dL to +437 ug/dL) in the oral iron group (P=.001).

CONCLUSION

Intravenous ferumoxytol was well tolerated, and it was associated with statistically significant increases in maternal hemoglobin, hematocrit, iron, and ferritin compared to oral ferrous sulfate.

Maternal and Neonatal Outcomes of Twin Pregnant Women With Anemia

The aim of this study was to investigate the prevalence of anemia in twin pregnancies and the influence of anemia on maternal and neonatal outcomes. This retrospective study included twin pregnant women who delivered in a tertiary hospital in China from January 2018 to December 2018. Patients were divided by WHO criteria (hemoglobin <11.0 g/dL): the anemic and nonanemic groups. Patients with anemia were further classified as recovered or unrecovered subgroup after oral iron therapy. Maternal and neonatal outcomes in women carrying twins were compared using Student's t test and the chi-squared test or the Fisher exact test. Univariable and multivariable logistic regression models were used to determine the association of maternal and neonatal characteristics with anemia. Linear regression analysis was used to estimate mean birth weight and gestational week. The prevalence of anemia was 42.6% (182/427) in twin pregnancies. The anemic group had higher rates of low 1-minute Apgar score (4.4% vs. 1.8%, p = .028), perinatal death (1.9% vs. 0.2%, p = .012) and neonatal intensive care unit (NICU) admission (27.2% vs. 20.2%, p = .017; adjusted OR, 1.478; 95% CI [1.07, 2.044]). The recovered subgroup had lower NICU admission rate (13.5% vs. 30.3%, p = .006; OR, 0.388; 95% CI [0.186, 0.809]), higher gestational week and birth weight (β, 0.954 week; 95% CI [0.114, 1.794] and β, 171.01 g; 95% CI [9.894, 332.126] respectively). The prevalence of anemia in twin gestation is high. Anemia is associated with adverse neonatal outcomes, and correction of anemia significantly improved the pregnancy outcomes.

Effectiveness of daily educational message on pregnancy anemia prevention behavior and knowledge: A pilot randomized controlled trial

BACKGROUND

Distance education and mobile health (mHealth) usage are yet to be researched widely, particularly in terms of anemia prevention in Indonesian pregnant women. This study aimed to analyze the daily educational messages' effectiveness on anemia prevention behavior and knowledge, in pregnant women in Surakarta City, Indonesia.

MATERIALS AND METHODS

This pilot randomized controlled trial was conducted in two Primary Healthcare Centers in Surakarta in April-September 2022. The target population was pregnant women who conducted Antenatal Care at Primary healthcare Center. The sample was put into two randomized groups consisting of pregnant women in the first and second trimesters: intervention and control. This study included a total of 44 participants. The intervention was a daily educational message sent through WhatsApp for seven weeks. Measurement of anemia prevention knowledge, anemia prevention diet, and Iron and Folic Acid (IFA) tablet consumption was collected at the baseline and follow-up.

RESULTS

The intervention resulted in a significant difference (P value .003) in mean IFA tablet consumption (last 42 days), which was higher in the intervention group (39.54 ± 3.94) than in the control group (34.86 ± 8.13). It has a significant effect on knowledge (P value .007) as well. However, no significant difference in the anemia prevention diet between groups at the end of the intervention.

CONCLUSIONS

The daily educational message improves pregnant women's knowledge and IFA tablet consumption. Conducting a full-scale randomized controlled trial is feasible to confirm the effectiveness of daily educational messages as a pregnant anemia prevention program, considering the needed improvements.

Contributing factors of birth asphyxia in Thailand: a case-control study

BACKGROUND

Birth asphyxia is of significant concern because it impacts newborn health from low to severe levels. In Thailand, birth asphyxia remains a leading cause of delayed developmental health in children under 5 years old. The study aimed to determine the maternal, fetal and health service factors contributing to birth asphyxia.

METHODS

A case-control design was conducted on a sample of 4256 intrapartum chart records. The samples were selected based on their Apgar scores in the first minute of life. A low Apgar score (≤ 7) was chosen for the case group (852) and a high Apgar score (> 7) for the control group (3408). In addition, a systematic random technique was performed to select 23 hospitals, including university, advanced and secondary, in eight health administration areas in Thailand for evaluating the intrapartum care service. Data analysis was conducted using SPSS statistical software.

RESULTS

The odds of birth asphyxia increases in the university and advanced hospitals but the university hospitals had the highest quality of care. The advanced and secondary hospitals had average nurse work-hours per week of more than 40 h. Multivariable logistic regression analysis found that intrapartum care services and maternal-fetal factors contributed to birth asphyxia. The odd of birth asphyxia increases significantly in late-preterm, late-term pregnancies, low-birth weight, and macrosomia. Furthermore, maternal comorbidity, non-reassuring, and obstetric emergency conditions significantly increase the odd of birth asphyxia. In addition, an excellent quality of intrapartum care, a combined nursing model, low nurse work-hours, and obstetrician-conducted delivery significantly reduced birth asphyxia.

CONCLUSION

Birth asphyxia problems may be resolved in the health service management offered by reducing the nurse work-hours. Excellent quality of care required the primary nursing care model combined with a team nursing care model. However, careful evaluation and monitoring are needed in cases of comorbidity, late-preterm, late-term pregnancies, low-birth weight, and macrosomia. Furthermore, increasing the obstetrician availability in obstetric emergencies and non-reassuring fetal status is important.

Semen processing using magnetic-activated cell sorting before ICSI is deemed safe for obstetric and perinatal outcomes: a retrospective multicentre study

RESEARCH QUESTION

Is magnetic-activated cell sorting (MACS) a safe semen sample processing technique for newborns and mothers when used for semen processing prior to intracytoplasmic sperm injection (ICSI) cycles?

DESIGN

This retrospective multicentre cohort study involved patients undergoing ICSI cycles with either donor or autologous oocytes from January 2008 to February 2020. They were divided into two groups: those who underwent standard semen preparation (reference group) and those who had an added MACS procedure (MACS group). A total of 25,356 deliveries were assessed in the case of cycles using donor oocytes, and 19,703 deliveries from cycles using autologous oocytes. Of these, 20,439 and 15,917, respectively, were singleton deliveries. Obstetric and perinatal outcomes were retrospectively assessed. All means, rates and incidences were computed per live newborn in each study group.

RESULTS

There were no significant differences between the main obstetric and perinatal morbidities affecting the mothers' and newborns' well-being between groups using either donated or autologous oocytes. There was a significant increase in the incidence of gestational anaemia in both subpopulations (donor oocytes P = 0.01; autologous oocytes P < 0.001). However, this incidence was within the estimated prevalence for gestational anaemia in the general population. There was a statistically significant decrease in preterm (P = 0.02) and very preterm (P = 0.01) birth rates in the MACS group in cycles using donor oocytes.

CONCLUSIONS

The use of MACS during semen preparation before ICSI using either donor or autologous oocytes appears to be safe for the mothers' and newborns' well-being during pregnancy and birth. Nevertheless, a close follow-up of these parameters in the future is advised, especially concerning anaemia, in order to detect even smaller effect sizes.

Umbilical cord management - the first opportunity to improve healthcare disparities

This review focuses on iron deficiency and iron deficiency anemia in women and children in the United States. These are common, fixable problems that disproportionally affect minority populations. There are many opportunities for successful screening and management. The knowledge and awareness for identification and treatment of our populations' commonest deficiency is crucial.

Rhabdomyolysis After Intravenous Iron Sucrose Infusion During Pregnancy

BACKGROUND

Iron infusions have become increasingly common in the treatment of iron-deficiency anemia during pregnancy. Although iron infusions are generally well tolerated, adverse reactions have been reported.

CASE

A pregnant patient was diagnosed with rhabdomyolysis after receiving a second dose of intravenous (IV) iron sucrose at 32 6/7 weeks of gestation. On admission to the hospital, creatine kinase was 2,437 units/L, sodium was 132 mEq/L, and potassium was 2.1 mEq/L. Intravenous fluids and electrolyte repletion were administered, with improvement of symptoms within 48 hours. Creatinine kinase normalized 1 week after hospital discharge.

CONCLUSION

Rhabdomyolysis can be associated with IV iron infusion during pregnancy.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis

BACKGROUND

Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.

METHODS

We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.

RESULTS

The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.

CONCLUSION

Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

Maternal factors associated with iron deficiency without anaemia in early pregnancy: ECLIPSES study

Several population-specific genetic, sociodemographic, and maternal lifestyle factors are related to iron status in early pregnancy, and their identification would allow preventive actions to be taken. The study aimed to identify maternal factors associated with iron deficiency (ID) in early pregnancy in non-anaemic pregnant women from a European Mediterranean country. Cross-sectional study using the initial population of the ECLIPSES study performed in non-anaemic pregnant women before gestational week 12. Serum ferritin (SF) and haemoglobin concentrations were measured to evaluate iron status, and ID was defined as SF < 15 µg/L. Several sociodemographic and lifestyle data were recorded and used as covariates in the multivariate-adjusted regression models. Out of the 791 participants, 13.9% had ID in early pregnancy. Underweight (OR 3.70, 95%CI 1.22, 15.53) and parity (1 child: OR 2.03, 95%CI 1.06, 3.88; ≥ 2 children: OR 6.96, 95%CI 3.09, 15.69) increased the odds of ID, while a high intake of total meat (≥ 108.57 g/day: OR 0.37, 95%CI 0.15, 0.87), red/processed meat (≥ 74.29 g/day: OR 0.70, 95%CI 0.35, 0.98), protein (≥ 65.05 g/day: OR 0.85, 95%CI 0.30, 0.99), and dietary iron (≥ 8.58 mg/day: OR 0.58, 95%CI 0.35, 0.94) protected against it. Smoking was also associated with a reduction in ID odds (OR 0.34, 95%CI 0.12, 0.99). Baseline BMI, parity, smoking, and diet are associated with ID in early pregnancy in non-anaemic women. Pregnancy planning policies should focus on women at higher risk of ID, such as those who are underweight, multiparous, or following vegetarian diets. This clinical trial was registered at www.clinicaltrialsregister.eu as EudraCT number 2012-005,480-28 and at www.clinicaltrials.gov with identification number NCT03196882.

Peripartum severe acute maternal morbidity in low-risk women: A population-based study

BACKGROUND

Knowledge of severe acute maternal morbidity (SAMM) and its risk factors is constantly growing, but studies have rarely focused on the specific population of low-risk women.

AIM

To estimate the prevalence and to identify subgroups at risk of peripartum SAMM in low-risk women METHODS: From a population-based cohort-nested case-control study conducted in six French regions, i.e., 182 309 women who gave birth at ≥22 weeks in 119 maternity units, we selected women considered at low risk up to the end of pregnancy before labour according to the NICE guidelines and compared those experiencing peripartum SAMM (during birth and up to 7 days postpartum; n = 489) to a 2% random sample of women without peripartum SAMM from the same units (n = 1800). Risk factors for peripartum SAMM were identified by multivariable logistic regression.

FINDINGS

amongst low-risk women, the estimated rate of SAMM was 0.548/100 deliveries (95%CI 0.501-0.599). Severe obstetric haemorrhage was the main cause (83.6% of SAMM cases). Main risk factors for peripartum SAMM were primiparity (aOR 2.4, 95%CI 1.9-3.0), IVF pregnancy (aOR 1.8, 1.0-3.4), third-trimester anaemia (aOR 1.7, 1.3-2.3), being born out of Europe or Africa (aOR 1.9, 1.2-3.0).

CONCLUSION

amongst women considered at low risk up to the end of pregnancy before labour, peripartum SAMM is rare but still exists. Knowledge of risk factors of SAMM in this population will inform the discussion on peripartum risks and the most appropriate place of birth for each woman.

A Case-Control Study of the Factors Associated with Anemia in Chinese Children Aged 3-7 years Old

Background

Anemia in children is still an important public problem in China and can have a profound impact on the physical and mental health of children. The purpose of this study was to explore the risk factors for anemia among Chinese children aged 3-7 years old and to provide some basis for the prevention and control of anemia.

Methods

A matched case-control study was conducted and 1104 children (552 cases and 552 controls) were recruited in this study. Cases were children who were diagnosed with anemia by the doctor of physical examination and checked by one deputy chief physician of pediatrics, and controls were healthy children without anemia. Data were collected using a self-designed structured questionnaire. Univariable and multivariable analyses were used to identify independent determinants of anemia. P values less than 0.05 were used to declare statistical significance.

Results

In the multivariable analyses, maternal anemia before or during pregnancy and lactation (OR = 2.14, 95% CI: 1.10∼4.15; OR = 2.86, 95% CI: 1.66∼4.94; OR = 2.51, 95% CI: 1.13∼5.60), gestational weeks (OR = 0.72, 95% CI: 0.53∼0.96), having G6PD deficiency or thalassemia (OR = 8.12, 95% CI: 2.00∼33.04; OR = 36.25, 95% CI: 10.40∼126.43), having cold and cough in previous two weeks (OR = 1.56, 95% CI: 1.04∼2.34), family income (OR = 0.80, 95% CI: 0.65∼0.97), and being a picky eater (OR = 1.80, 95% CI: 1.20∼2.71) were determinants of anemia in children aged 3-7 years old.

Conclusions

Some of the identified factors are modifiable and could be targeted to reduce childhood anemia. More emphasis should be given by the concerned bodies to intervene in the anemia problem by improving the maternal health education, screening for disease-related anemia, requesting medical services in a timely manner, improving the economic status of households, promoting dietary habits, and improving sanitation and hygiene practices.

Variation Patterns of Hemoglobin Levels by Gestational Age during Pregnancy: A Cross-Sectional Analysis of a Multi-Center Retrospective Cohort Study in China

Background: Pregnancy anemia is a global health concern. However, to our knowledge, there still has little consensus on the reference value of hemoglobin levels. Particularly, little evidence from China was accessible in most existing guidelines. Objective: To evaluate hemoglobin levels and anemia prevalence of pregnant women in China and offer evidence for anemia and its reference values in China. Methods: A multi-center retrospective cohort study was conducted among 143,307 singleton pregnant women aged 15–49 at 139 hospitals in China, with hemoglobin concentrations routinely tested at each prenatal visit. Subsequently, a restricted cubic spline was performed to reveal a non-linear variation of hemoglobin concentrations during the gestational week. The Loess model was used to describe the changes in the prevalence of different degrees of anemia with gestational age. Multivariate linear regression model and Logistic regression model were applied to explore influencing factors of gestational changes in hemoglobin level and anemia prevalence, respectively. Results: Hemoglobin varied nonlinearly with gestational age, and the mean hemoglobin levels decreased from 125.75 g/L in the first trimester to 118.71 g/L in the third trimester. By analyzing hemoglobin levels with gestational age and pregnancy period, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to WHO’s criteria, the prevalence of anemia sustainably increased with gestational age, with 6.2% (4083/65,691) in the first trimester, 11.5% (7974/69,184) in the second trimester and 21.9% (12,295/56,042) in the third trimester, respectively. In subsequent analysis, pregnant women in non-urban residents, multiparity, and pre-pregnancy underweight tended to have lower hemoglobin levels. Conclusions: This research, the first large-sample study to present a set of gestational age-specific reference centiles for hemoglobin levels in China, could be used to obtain a better understanding of the overall levels of hemoglobin in Chinese healthy pregnant women and ultimately offer clues for a more precise hemoglobin reference value of anemia in China.

Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research to advance the health of people with inherited bleeding disorders with the potential to menstruate

BACKGROUND

People who have or had the potential to menstruate (PPM) with inherited bleeding disorders (BD) face particular challenges receiving appropriate diagnosis and care and participating in research. As part of an initiative to create a National Research Blueprint for future decades of research, the National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive all-stakeholder consultations to identify the priorities of PPM with inherited BDs and those who care for them.

RESEARCH DESIGN AND METHODS

Working group (WG) 4 of the NHF State of the Science Research Summit distilled community-identified priorities for PPM with inherited BDs into concrete research questions and scored their feasibility, impact, and risk.

RESULTS

WG4 identified important gaps in the foundational knowledge upon which to base optimal diagnosis and care for PPM with inherited BDs. They defined 44 top-priority research questions concerning lifespan sex biology, pregnancy and the post-partum context, uterine physiology and bleeding, bone and joint health, health care delivery, and patient-reported outcomes and quality-of-life.

CONCLUSIONS

The needs of PPM will best be advanced with research designed across the spectrum of sex and gender biology, with methodologies and outcome measures tailored to this population, involving them throughout.

Comparisons of Severe Maternal Morbidity and Other Adverse Pregnancy Outcomes in Pregnant People With Sickle Cell Disease vs Anemia

IMPORTANCE

Pregnancy in sickle cell disease (SCD) is high risk, but whether prenatal anemia, which is treatable with red blood cell transfusions, is a mediator associated with adverse pregnancy outcomes (APOs) is not known.

OBJECTIVE

To compare rates and odds of severe maternal morbidity (SMM) and other APOs in pregnancies among individuals with SCD vs those without SCD but with prenatal anemia.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from 2012 to 2018 from the National Inpatient Sample, a nationally representative sample of 20% of acute hospital admissions in the United States. All admissions with codes for delivery of a pregnancy among people aged 11 to 55 years were included. Only admissions coded with Black race were included. Data were analyzed from September 2021 through August 2022.

EXPOSURES

Prenatal anemia and SCD.

MAIN OUTCOMES AND MEASURES

SMM was tabulated per the Center for Disease Control and Prevention SMM Index alongside other APOs. Multiple logistic regression was used to compare the odds for APOs and risk ratios (RRs) to compare rates of APOs.

RESULTS

Among 764 455 total delivery admissions among patients identified as Black (mean [SD] age at delivery, 27.00 [6.08] years), 3200 deliveries were coded with maternal SCD, 34 808 deliveries were coded with maternal anemia, and 726 447 deliveries were control. Most patients were publicly insured (499 060 [65.4%]). For most outcomes, including SMM and mortality per 10 000 deliveries, the SCD group had higher rates (SMM: 5.9%; 95% CI, 5.1%-6.8%; maternal mortality: 13.0 deaths; 95% CI, 4.9 to 35.0 deaths) than anemia (SMM: 2.1%; 95% CI, 2.0%-2.3%; maternal mortality: 0.9 deaths; 95% CI, 0.3 to 2.8 deaths) or control groups (SMM: 1.1%; 95% CI, 1.0%-1.1%; maternal mortality: 1.2 deaths; 95% CI, 1.0 to 1.5 deaths). SCD (adjusted odds ratio [aOR], 5.51; 95% CI, 4.71-6.45) and anemia groups (aOR, 2.00; 95% CI, 1.84-2.17) had higher adjusted odds of SMM compared with the control group. However, for many complications associated with ischemia or abnormal placentation, CIs of aORs for SCD and anemia groups overlapped (eg, eclampsia: aOR, 2.74; 95% CI, 1.51-4.96 vs aOR, 1.40; 95% CI, 1.08-1.81). For these complications, RRs for SCD vs anemia were between 1.0 and 2.1 (eg, eclampsia: 1.76; 95% CI, 0.93-3.32). For complications associated with thrombosis or SCD-specific pathologies, rates and aORs were greater for the SCD vs anemia group. For these complications, RRs were between 3.70 and 10.90. For example, rates of acute respiratory distress syndrome, including acute chest syndrome, were 56 of 3144 deliveries (1.8%) vs 122 of 34 686 deliveries (0.4%), and the RR was 4.99 (95% CI, 3.65-6.84).

CONCLUSIONS AND RELEVANCE

This study found that risks associated with prenatal anemia and SCD were similar for many APOs, especially those associated with ischemia and abnormal placentation, suggesting that prenatal anemia may be a mediator associated with pregnancy risk in individuals with SCD.

Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis

OBJECTIVE

This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes.

DATA SOURCES

We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020.

STUDY ELIGIBILITY CRITERIA

Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area.

METHODS

We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis.

RESULTS

We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81).

CONCLUSION

We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Optimal predelivery hemoglobin to reduce transfusion and adverse perinatal outcomes

BACKGROUND

Maternal anemia has been associated with poor obstetrical outcomes; however, the optimal hemoglobin level for reducing blood transfusion at delivery has not been well-defined.

OBJECTIVE

This study aimed 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 level for predicting transfusion.

STUDY DESIGN

This was a retrospective cohort study of patients who had hemoglobin or hematocrit collected before delivery of live, nonanomalous 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 on the basis of predelivery hemoglobin or hematocrit levels using criteria set by the American College of Obstetricians and Gynecologists. The primary outcome was transfusion of ≥1 unit of 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 the 18,357 patients included in the analysis, 5444 (30%) had predelivery anemia (mean hemoglobin, 10.0±0.8 g/dL) vs 12,913 (70%) who did not (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 5-fold higher odds of packed red blood cell transfusion (6.0% vs 1.3%; adjusted odds ratio, 5.23 [95% confidence interval, 4.09-6.69]) compared with no anemia. For each 1 g/dL increase in predelivery hemoglobin, the odds of transfusion were 56% lower (adjusted odds ratio, 0.44 [confidence interval, 0.40-0.48]). The optimal hemoglobin for 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 (adjusted odds ratio, 1.35 [1.11-1.64]).

CONCLUSION

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

Pregnancy outcomes among women affected with thalassemia traits

OBJECTIVE

To compare the maternal and perinatal outcomes between a group of pregnant women diagnosed with thalassemia traits and normal controls.

STUDY DESIGN

A retrospective cohort study was conducted on singleton pregnant women affected and unaffected by thalassemia traits who attended an antenatal care clinic and delivered in Siriraj Hospital. Thalassemia status for all subjects was diagnosed by hemoglobin typing and/or DNA analysis. Patient charts were reviewed from January 2007 to December 2018. The control participants were randomly selected from the same period, with a control-case ratio of around 1:1.

RESULTS

Overall, 1288 women with thalassemia traits (348 with α thal-1 trait, 424 with β thal trait and 516 with HbE trait) and 1305 women in the control group were recruited. Baseline characteristics of both groups were similar, with the exception that the hematocrit level in the first trimester in the thalassemia trait group was significantly lower than that in the control group (34.8 ± 3.4% VS 36.9 ± 3.0%; p < 0.001). The prevalence of pregnancy-induced hypertension (PIH) was higher in the thalassemia trait group, at 6.9% VS 4.7% in the control group; p = 0.018. When subgroups were analyzed between each thalassemia trait, the number of maternal anemias in the first and third trimester was higher for all thalassemia traits compared to the normal group. The β thal and HbE traits increased the risk of PIH, with a relative risk (RR) = 1.67 and 1.66, respectively.

CONCLUSIONS

Thalassemia traits minimally but significantly increase the risk of hypertensive disorders and maternal anemia. In addition, physiological changes during pregnancy may worsen the severity of anemia in the pregnant women with thalassemia traits.