Evaluation of postpartum anaemia screening to improve anaemia diagnosis and patient care: A prospective non-randomized before-and-after anaemia screening protocol implementation study

Non-invasive Hemoglobin Screening for Detection of Postpartum Anemia

Introduction

Postpartum period is a critical period for a woman, where the body of the woman is in healing stage. In this situation, there arises the risk for developing anemia, if proper diet is not maintained. So, it is necessary to routinely determine the hemoglobin levels during this period to avoid chances of developing anemia and assist in early diagnosis.

Methodology

A cross-sectional study was carried out at the maternity ward of Kalinga Institute of Medical Sciences Hospital, Bhubaneswar. The study was conducted for a period of 5-6 months by received approval from the concerned institutional committee. The study involved women participants having age above 18 years and who had recently undergone delivery. Written informed consent was taken from all the participants prior to their enrolment for this study.

Results

A total of 670 women were involved in this study and more than 50% of the women were found to be affected by anemia. A Pearson's correlation of 0.87 was observed with sensitivity of 95.69% and specificity of 67.06% between the hematology analyzer and non-invasive EzeCheck device in determining anemia.

Conclusion

Women often neglect their health situations and always prioritize their family's wellbeing and health over their own. This avoidance results in the development of a chronic disease which in the long run becomes difficult to be cured. So, in such situations, it is necessary to inculcate certain routine tests for the women during their healing period (such as postpartum stage) to keep an eye on their health status. Use of non-invasive devices can help in achieving this in a painless and much effective manner with instant reporting of the results.

Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

INTRODUCTION

Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM.

OBJECTIVE

To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice.

MATERIAL AND METHODS

A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3).

RESULTS

Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term".

CONCLUSIONS

There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

Factors Influencing Women's Attendance to Postnatal Clinics in the Primary Healthcare Centers in the Kingdom of Bahrain, 2023

BACKGROUND

Despite the significance of postnatal care for maternal health, the attendance rate of mothers at postnatal clinics (PNCs) in primary healthcare (PHC) centers in Bahrain is low. This study aims to identify factors influencing women's attendance at PNC in PHC centers in the Kingdom of Bahrain and to propose strategies for service improvement.

METHODS

 In January 2023, we conducted a cross-sectional study. We selected mothers who gave birth between six and 12 months before the survey and met inclusion criteria using systematic simple random sampling and obtained consent (n = 319). Data collection utilized an electronic, structured, interviewer-administered questionnaire, and analysis was carried out using SPSS version 28 (IBM Corp., Armonk, NY).

RESULTS

Out of the 319 participants, 31% were unaware of the existence of PNC, 42% were aware but did not attend, and 27% were aware and had attended the clinic. Mother and child department clerks, doctors, health education boards, and midwives served as the primary sources of information about the PNC for only 34%, 16%, 16%, and 11% of participants, respectively. Understanding the importance of PNC, the services offered by a healthcare worker, the booking process, having a vaginal delivery, and prior experience with a PNC visit were significantly associated with PNC attendance (p = 0.0046, p = 0.027, p < 0.001, p = 0.028, and p < 0.001, respectively). The attendance of 81 mothers, representing 94% of the total women who attended the clinic, was driven by their acknowledgment of the service's importance. Childcare responsibilities, perception of the visit as unimportant, and reluctance to undergo a pelvic examination were the top reasons for not attending the clinic, despite 41%, 38%, and 37% of participants being aware of it.

CONCLUSION

 Postnatal care attendance remains suboptimal for mothers in Bahrain. Awareness of the clinic's presence, counseling by healthcare providers, and prior experience with PNC visits were found to be significant determinants of attendance.

Prevalence of anaemia and its associated factors among lactating mothers in eastern Sudan: a cross-sectional study

BACKGROUND

Lactating mothers are susceptible to anaemia. Little published data are available on lactational anaemia in Africa, including Sudan. This study was conducted to assess the prevalence of and associated factors for anaemia among lactating mothers in eastern Sudan.

METHODS

A cross-sectional study was conducted and sociodemographic and clinical characteristics were gathered through a questionnaire.

RESULTS

A total of 650 lactating mothers were included in the analysis. Their median age and parity were 28.0 y (interquartile range [IQR] 23.7‒32.0) and 3.0 (IQR 2.0‒4.0), respectively. Haemoglobin (Hb) levels ranged from 7.0 to 15.0 g/dL (median 11.2 [IQR 10.4‒12.0]). Of the 650 lactating mothers, 442 (68.0%) had anaemia (Hb <12.0 g/dL). In multivariate analysis, lactating mothers with education less than the secondary level (adjusted odds ratio [AOR] 1.58 [95% confidence interval {CI} 1.05 to 2.37]) and lactating mothers who underwent caesarean delivery (AOR 1.74 [95% CI 1.17 to 2.58]) had a higher probability of being anaemic. Employment was associated to a lower frequency of anaemia (AOR 0.39 [95% CI 0.20 to 0.79]).

CONCLUSIONS

This study showed a high prevalence of anaemia among lactating mothers. Public health intervention activities designed towards education would be helpful to reduce anaemia.

Risk factors of anaemia among postpartum women in Bolgatanga Municipality, Ghana

INTRODUCTION

Anaemia is a major public health problem affecting women of reproductive age globally. This study was conducted to assess the prevalence and determinants of anaemia among postpartum women in Bolgatanga Municipality, Ghana.

METHODS

The study employed an analytical cross-sectional study design to recruit 405 women who delivered in the last 6 weeks from 9 health facilities in the Municipality. Data were collected on socio-demographic characteristics, obstetric characteristics, dietary diversity, knowledge on iron-folic acid (IFA), iron and anaemia, and haemoglobin level of the women. Postpartum anaemia (PPA) was defined as hemoglobin < 12 g/dl. Chi-square and logistic regression analysis were used to identify the determinants of PPA.

RESULTS

The mean age of the participants was 27.4 ± 5.3 years and 46.70% of them had PPA. The risk factors of PPA were not meeting dietary diversity [Adjusted Odds Ratio (AOR) = 2.96; 95% Confidence Interval (CI): 1.67-5.25], low knowledge on IFA, iron and anaemia (AOR = 3.03; 95% CI: 1.67-5.25), and first trimester pregnancy anaemia (AOR = 10.39; 95% CI: 1.32-6.95). Kusasi ethnicity was protective of PPA (AOR = 0.35; CI: 0.16-0.75).

CONCLUSION

Anaemia is prevalent in postpartum women in Bolgatanga Municipality and its risk factors are dietary diversity, knowledge on IFA, iron and anaemia, pregnancy anaemia and ethnicity. Nutrition counselling and intervention in pregnancy and after delivery are warranted to reduce the burden of anaemia in this population.

[Patient blood management in the preparation for birth, obstetrics and postpartum period]

The implementation of patient blood management (PBM) is increasingly becoming standard in operative medicine. Recently, interest has also been shown for the vulnerable collective of pregnant women and neonates. As the information regarding anesthesiological procedures for pregnant women and the peripartum period including an informed consent process should be carried out long before childbirth, this provides a good possibility in this connection to incorporate PBM. An anesthesiological risk estimation as well as the diagnostic workup and treatment of potential anemia should be carried out during the pregnancy. Furthermore, loss of blood in anticipation of bleeding complications should be reduced by interdisciplinary preventive measures and an individually coordinated postpartum care should be organized. This results in an early diagnosis of anemia or iron deficiency with subsequent treatment also postpartum, analogous to the prepartum period.

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

BACKGROUND

Studies that have compared the effectiveness of oral with intravenous iron supplements to treat postpartum anemia have shown mixed results. The superiority of one mode of treatment vs the other has yet to be demonstrated. Therefore, despite guidelines and standards of care, treatment approaches vary across practices. A single 500 mg dose of iron sucrose, which is higher than what is usually administered, has not been evaluated to treat postpartum moderate to severe anemia.

OBJECTIVE

This study aimed to compare the efficacy of intravenous iron sucrose alone with intravenous iron sucrose in combination with oral iron bisglycinate supplementation in treating moderate to severe postpartum anemia.

STUDY DESIGN

A randomized controlled trial was conducted between February 2015 and June 2020. Women with postpartum hemoglobin level of ≤9.5 g/dL were treated with 500 mg intravenous iron sucrose after an anemia workup, which ruled out other causes for anemia. In addition to receiving intravenous iron, women were randomly allocated to receive either 60 mg of oral iron bisglycinate for 45 days or no further iron supplementation. The primary outcome was hemoglobin level at 6 weeks after delivery. Secondary outcomes were iron storage parameters and quality of life.

RESULTS

Of 158 patients who participated, 63 women receiving intravenous and oral iron, and 44 women receiving intravenous iron-only, completed the study and were included in the analysis. Baseline and obstetrical characteristics were similar between the study cohorts. Although statistically significant, postpartum hemoglobin levels were only 0.4 g/dL higher in the intravenous and oral iron than intravenous iron-only cohort (12.4 g/dL vs 12.0 g/dL, respectively; P=.03), with a respective increase from baseline of 4.2 g/dL vs 3.7 g/dL (P=.03). There was no difference in the rate of women with hemoglobin level of <12.0 or 11.0 g/dL. Iron storage and health quality were not different between the cohorts. Oral iron treatment was associated with 29% rate of adverse effects. Compliance and satisfaction from treatment protocol were high in both cohorts.

CONCLUSION

Intravenous 500 mg iron sucrose treatment alone is sufficient to treat postpartum anemia without the necessity of adding oral iron treatment.

Prediction of anemia at delivery

We aimed to assess risk factors for anemia at delivery by conducting a secondary analysis of a prospective cohort study database including 1527 women who delivered vaginally ≥ 36 gestational weeks. Anemia (Hemoglobin (Hb) < 10.5 g/dL) was assessed at delivery. A complete blood count results during pregnancy as well as maternal and obstetrical characteristics were collected. The primary endpoint was to determine the Hb cutoff between 24 and 30 gestational weeks that is predictive of anemia at delivery by using the area under the curve (AUC) of the receiver operating characteristic curve. Independent risk factors for anemia at delivery were assessed using stepwise multivariable logistic regression. Hb and infrequent iron supplement treatment were independent risk factors for anemia at delivery (OR 0.3 95%CI [0.2–0.4] and OR 2.4 95%CI [1.2–4.8], respectively; C statistics 83%). Hb 10.6 g/dL was an accurate cutoff to predict anemia at delivery (AUC 80% 95%CI 75–84%; sensitivity 75% and specificity 74%). Iron supplement was beneficial to prevent anemia regardless of Hb value. Altogether, Hb should be routinely tested between 24 and 30 gestational weeks to screen for anemia. A flow chart for anemia screening and treatment during pregnancy is proposed in the manuscript.

Trial registration: ClinicalTrials.gov Identifier: NCT02434653.

The definition, screening, and treatment of postpartum anemia: A systematic review of guidelines

BACKGROUND

Postpartum anemia can negatively affect maternal health and interfere with early parenting. Thus, it is important to have clear, evidence-informed recommendations on its diagnosis and treatment.

OBJECTIVE

To compare global recommendations regarding the appropriate management of postpartum anemia and to highlight similarities and differences.

METHODS

Systematic searches were conducted in the databases PubMed, CINAHL, LILACS, TRIP database, and Scopus, and in the websites of health institutions and scientific societies. Search terms were related to anemia and the postpartum period. Two hundred and eighty papers were identified; the full texts of 30 sets of guidelines were reviewed, with seven being included in the final analysis. Recommendations were extracted through an evaluation of the evidence on the definition, screening, and diagnosis of anemia. The quality of the guidelines was assessed using the AGREE II instrument.

RESULTS

Two sets of guidelines have been elaborated by international organizations, and the rest were produced by professional associations within high-resource countries. The discrepancies found in the guidelines are important and affect the definition of anemia, the criteria for screening asymptomatic women, or the criteria guiding treatment. The quality of the guidelines commonly scored between 4 and 6 on a scale of 0 to 7. Recommendations with poor-quality evidence predominated over recommendations with high-quality evidence.

CONCLUSIONS

This review highlights the need to reach a consensus on the definition of postpartum anemia, to agree on what constitutes a problem for maternal health, and to provide recommendations that reach greater consensus on its diagnosis and treatment.

Hemoglobin drop following postpartum hemorrhage

Postpartum hemorrhage (PPH) is defined as blood loss of ≥ 500–1000 ml within 24 h after delivery. Yet, assessment of blood loss is imprecise. The present study aimed to profile the hemoglobin (Hb) drop after vaginal delivery with versus without PPH. This was a secondary analysis of a prospective cohort study of women who delivered vaginally. Women were included if complete blood counts (CBC) before and after delivery were taken until stabilization (N = 419). Women were categorized into the PPH group and controls, for whom post-delivery CBCs were performed due to indications unrelated to bleeding. The PPH patients were then classified as either overt or occult PPH (symptoms related to hypovolemia without overt bleeding) subgroups. The primary endpoint was mean Hb drop after delivery. One hundred and ten (26%) and 158 (38%) women presented with overt PPH or occult PPH, respectively; 151 (36%) women were included in the control group. Mean Hb decrease from baseline was 3.0 ± 1.6, 2.0 ± 1.4 and 0.9 ± 1.0 g/dl, respectively (p < 0.0001). In all groups, maximal rate of Hb decline was in the first 6–12 h postpartum and plateaued after 24–48 h. At 48 h post-delivery, 95% and 86% of women who had dropped to Hb ≤ 9.5 and < 7 g/dl, respectively, reached those thresholds. Taken together, an Hb decrease ≥ 2 g/dl was consistent with PPH diagnosis and should be followed for at least 48 h after delivery.

Relationship between patient ethnicity and prevalence of anemia during pregnancy and the puerperium period and compliance with healthcare recommendations - implications for targeted health policy

Background

Anemia is common during pregnancy and the puerperium. The association of ethnicity as well as other characteristics with anemia and compliance with healthcare recommendations has not been studied sufficiently and needs to be explored in order to implement a targeted health policy. We examined the association between ethnicity and the risk for prenatal and puerperium anemia and the compliance with healthcare recommendations. This effort aims to guide reforms in policies and practices that will assist in decreasing anemia prevalence in Israel.

Methods

This study was a secondary analysis of a prospective cohort study database including 1558 women who delivered vaginally at Emek Medical Center. Anemia was assessed before delivery by obtaining a complete blood count (CBC). After delivery, CBCs were taken in cases of postpartum hemorrhage, symptoms consistent with anemia, prenatal anemia or other clinical indications. The study population was divided according to their ethnicity (Jews and Arabs).

The primary outcomes were anemia before delivery, anemia in the immediate postpartum and 6 weeks postpartum, and compliance with healthcare recommendations, which was defined as the rate of women who performed a routine CBC test 6-weeks-postpartum.

Results

The rates of anemia before delivery and in the puerperium period were similar between Jews and Arabs (before delivery: 88 (11%) versus 98 (14%); 6 weeks postpartum: 55 (21%) vs 68 (28%), respectively;p > 0.05). Iron supplementation was high in both groups during pregnancy (~ 90%) and lower during the postpartum for Jews compared to Arabs (72% vs 83%,respectively; P < .0001). Only one third of the patients performed a CBC 6-weeks-postpartum regardless of ethnicity.

Conclusion

Overall compliance with health recommendation was high during pregnancy but low postpartum and was reflected in anemia persistence regardless of ethnicity.

Because of the adverse long term impact of anemia on patient’s health, new policies need to be developed to improve patient’s compliance postpartum. A possible strategy is to combine the follow-up of the mother with the one of the newborn in the family health stations (Tipat Halav) and the community clinics similarly to the close follow-up during pregnancy. Additional methods may include active summoning for CBC test and assuring iron supplement consumption.