An Assessment of Medical Resource Utilization and Hospitalization Cost Associated with a Diagnosis of Anemia in Women with Obstetrical Bleeding in the United States

Acute blood loss anemia in hospitalized patients is associated with adverse outcomes: An analysis of the Nationwide Inpatient Sample

BACKGROUND

Acute blood loss anemia is the most common form of anemia and often results from traumatic injuries or gastrointestinal bleeding. There are limited studies analyzing outcomes associated with acute blood loss anemia in hospitalized patients.

METHODS

The Nationwide Inpatient Sample (NIS) was analyzed from 2010 to 2014 (n = 133,809). The impact of acute blood loss anemia on in-hospital mortality, length of stay (LOS), healthcare cost, and disposition was determined using regression modeling adjusted for age, gender, race, and comorbidities.

RESULTS

Hospitalized patients with acute blood loss anemia had significantly higher healthcare cost (adj OR 1.04; 95% CI: 1.04-1.05), greater lengths of stay (adj OR 1.18; 95% CI: 1.17-1.18), and were less likely to be discharged home compared to the general medical population (adj OR 0.27; 95% CI: 0.26-0.28). Acute blood loss anemia was associated with increased risk for mortality in unadjusted models (unadj 1.16; 95% CI: 1.12-1.20) but not in adjusted models (adj OR 0.91; 95% CI: 0.88-0.94). When analyzing comorbidities, a "muscle loss phenotype" had the strongest association with mortality in patients with acute blood loss anemia (adj OR 4.48; 95% CI: 4.35-4.61). The top five primary diagnostic codes associated with acute blood loss anemia were long bone fractures, GI bleeds, cardiac repair, sepsis, and OB/Gyn related causes. Sepsis had the highest association with mortality (18%, adj OR 2.59; 95% CI: 2.34-2.86) in those with acute blood loss anemia.

CONCLUSIONS

Acute blood loss anemia is associated with adverse outcomes in hospitalized patients.

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.

Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management

BACKGROUND

The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV-iron) use in its treatment, are unknown.

AIMS

To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity.

MATERIALS AND METHODS

Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July-December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA.

RESULTS

There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having PPA (0.46, 95% CI 0.37-0.57, P < 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV-iron only, 66 (10%) red blood cell transfusion (RBC-T) only and 155 (23%) both. Of those receiving RBC-T, 40/221 (18%) were actively bleeding. Māori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV-iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding.

CONCLUSION

The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV-iron, with or without RBC-T.

Costs of Severe Maternal Morbidity in U.S. Commercially Insured and Medicaid Populations: An Updated Analysis

Background: The most common reason for hospitalization in the United States is childbirth. The costs of childbirth are substantial. Materials and Methods: This was a retrospective cohort study of hospital deliveries identified in the MarketScan^® Commercial and Medicaid health insurance claim databases. Women with an inpatient birth in the calendar year 2016 were included. Severe maternal morbidity (SMM) was identified using the Centers for Disease Control and Prevention algorithm of 21 International Classification of Diseases-10 codes. Mean costs and cost ratios for women with and without SMM were reported. Generalized linear models were used to analyze demographic and clinical variables influencing delivery costs. Results: We identified 1,486 women in the Commercial population, who had a birth in 2016 and met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $50,212 and $23,795, respectively. In the Medicaid population there were 29,763 births, of which 342 met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $26,513 and $9,652, respectively. A multifetal gestation, a cesarean delivery, maternal age, and pregnancy-related complications were independently predictive of increased delivery costs in both Commercial and Medicaid populations. Conclusions: The occurrence of SMM was associated with an increase in maternity-related costs of 111% in the Commercial and 175% in the Medicaid population. Some of the factors associated with increased delivery hospitalization costs could be treated or avoided.

The Impact of the New Hypertension Guidelines to Low-Dose Aspirin Prophylaxis Eligibility for the Prevention of Preeclampsia: A Cost-Benefit Analysis

OBJECTIVE

American College of Cardiology and American Heart Association (ACC/AHA) published new guidelines which lower the cut-off for hypertension. We sought to evaluate the impact of these guidelines to cost and benefit of various low-dose aspirin prophylaxis approaches.

STUDY DESIGN

Decision tree analysis was created using R software to evaluate four approaches to aspirin prophylaxis in the United States: no aspirin, United States Preventive Service Task Force (USPSTF) with Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines, USPSTF with ACC/AHA hypertension guidelines, as well as universal aspirin prophylaxis. This model was executed to simulate a hypothetical cohort of 4 million pregnant women in the United States.

RESULTS

The new guidelines would expand the aspirin eligibility by 8% (76,953 women) in the USPSTF guidelines. Even with this increased eligibility, the USPSTF guidelines continue to be the approach with the most cost savings ($386.5 million) when compared with universal aspirin and no aspirin prophylaxis. The new hypertension guidelines are projected to increase the cost savings of the USPSTF approach by $9.4 million.

CONCLUSION

Despite the small change in aspirin prophylaxis, using ACC/AHA definition of hypertension still results in an annual cost-saving of $9.4 million in the United States when compared with JNC7.

Women and inherited bleeding disorders - A review with a focus on key challenges for 2019

The area of women and inherited bleeding disorders has undergone quick expansion in recent years. More patients are being identified and expertise to diagnose and manage these patients is now essential for practising physicians. Programs to help educate and empower patients and caregivers are now in place. Common inherited bleeding disorders affecting women include von Willebrand disease (VWD), inherited platelet disorders, and rare inherited bleeding disorders such as factor VII (FVII) deficiency and factor XI (FXI) deficiency. Specific clinical tools have been developed to help clinicians and patients screen for the presence of these bleeding disorders in both adult and pediatric populations. Affected women can experience heavy menstrual bleeding and resulting iron deficiency anemia, postpartum hemorrhage, and hemorrhagic ovarian cysts which need to be properly managed. Excessive bleeding can adversely affect quality of life in these women. Front line therapy for bleeding in mild cases focuses on the use of non-specific hemostatic agents such as DDAVP ®, tranexamic acid and hormonal agents but specific factor replacement and/or blood products may be required in more severe cases, in severe bleeding or as second line treatment when bleeding is not responsive to first line agents. Iron status should be optimised in these women especially in pregnancy and use of an electronic app can now help clinicians achieve this. These patients should ideally be managed by a multidisciplinary team whenever possible even remotely. Although clinical research has closed some knowledge gaps regarding the diagnosis and management of these women, there remains significant variation in practise and lack of evidence-based guidelines still exists in many spheres of clinical care in which caregivers must rely on expert opinion. Ongoing efforts in education and research will continue to improve care for these women and restore quality of life for them.

A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial

BACKGROUND

Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking.

OBJECTIVES

To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use.

DESIGN

Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded.

SETTING

A total of 26 UK obstetric units.

PARTICIPANTS

Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated.

INTERVENTIONS

Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed.

MAIN OUTCOME MEASURES

Primary - donor blood transfusion. Secondary - units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer-Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes - costs of resources and service provision taking the UK NHS perspective.

RESULTS

We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at £8110 per donor blood transfusion avoided.

CONCLUSIONS

The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective.

FUTURE WORK

Research into risk of alloimmunisation among women exposed to cell salvage is needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66118656.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 2. See the NIHR Journals Library website for further project information.

Outcomes of subsequent pregnancy following obstetric transfusion in a first birth

Background

Increasing rates of postpartum haemorrhage and obstetric transfusion mean that more women are entering subsequent pregnancies with a history of blood transfusion. This study investigates subsequent pregnancy outcomes of women with a prior obstetric red cell transfusion, compared to women without a transfusion.

Methods

All women with a first pregnancy resulting in a liveborn singleton infant of at least 20 weeks gestation delivering in hospitals in New South Wales, Australia, between 2003 and 2012 were included in the study, with followup for second births until June 2015. Linked hospital and births data were used to identify women with a transfusion and/or postpartum haemorrhage in their first birth, time to second pregnancy and adverse birth outcomes (including transfusion, postpartum haemorrhage and severe morbidity) in their subsequent birth.

Results

There were 358,384 singleton births to primiparous women, with 1.4% receiving an obstetric blood transfusion. Sixty-three percent of women had at least one subsequent birth. The relative risk (RR) of requiring a transfusion in a second birth was 4.9 (95% CI 4.1,6.1) for women with a previous transfusion compared with women without. The risk (RR) of severe morbidity in a second birth was 4.1 times higher (95% CI 2.2,7.4) for those receiving a transfusion without haemorrhage in their first birth compared with women with neither haemorrhage nor transfusion.

Conclusion

It is important to consider a woman’s history of transfusion and/or haemorrhage as part of her obstetric history to ensure management in a manner that minimises risk in subsequent pregnancies.

Nationwide incidence of serious complications of epidural analgesia in the United States

BACKGROUND

This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States.

METHODS

The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately.

RESULTS

A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home.

CONCLUSIONS

This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.

Why group & save? Blood transfusion at low-risk elective caesarean section

Women undergoing elective caesarean section (CS) routinely have a group and save ordered as part of their preoperative assessment, whereas women with expected vaginal birth do not. Our aim was therefore to determine the rate of blood transfusion at elective CS compared with vaginal birth in a large Australian maternity hospital. A retrospective cohort study was performed using routinely collected de-identified data of 35 477 women, over 4 years, who delivered at the Mater Mothers' Hospital, Brisbane, Australia. After excluding women with established risk factors for transfusion, the likelihood of blood transfusion following elective CS was significantly lower compared to vaginal birth (aOR 0.47 (0.29, 0.77)).

Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence?

PURPOSE

The decline in the use of forceps in operative deliveries over the last two decades raises questions about teaching hospitals' ability to provide trainees with adequate experience in the use of forceps. The authors examined (1) the number of operative deliveries performed in teaching and nonteaching hospitals, and (2) whether teaching hospitals performed a sufficient number of forceps deliveries for physicians to acquire and maintain competence.

METHOD

The authors used State Inpatient Data from nine states to identify all women hospitalized for childbirth in 2008. They divided hospitals into three categories: major teaching, minor teaching, and nonteaching. They calculated delivery volumes (total operative, cesarean, vacuum, forceps, two or more methods) for each hospital and compared data across hospital categories.

RESULTS

The sample included 1,344,305 childbirths in 835 hospitals. The mean cesarean volumes for major teaching, minor teaching, and nonteaching hospitals were 969.8, 757.8, and 406.9. The mean vacuum volumes were 301.0, 304.2, and 190.4, and the mean forceps volumes were 25.2, 15.3, and 8.9. In 2008, 31 hospitals (3.7% of all hospitals) performed no vacuum extractions, and 320 (38.3%) performed no forceps deliveries. In 2008, 13 (23%) major teaching and 44 (44%) minor teaching hospitals performed five or fewer forceps deliveries.

CONCLUSIONS

Low forceps delivery volumes may preclude many trainees from acquiring adequate experience and proficiency. These findings highlighted broader challenges, faced by many specialties, in ensuring that trainees and practicing physicians acquire and maintain competence in infrequently performed, highly technical procedures.

Systematic literature review of the costs of pregnancy in the US

BACKGROUND

The cost of pregnancy is increasing over time despite the decline in pregnancy rates.

OBJECTIVE

To fully elucidate and evaluate the cost drivers of pregnancy in the US for payers, a systematic review was conducted to understand the main cost components and primary factors that contribute to the direct costs of pregnancy, pregnancy-related complications and unintended pregnancy among women of childbearing age (15-44 years).

DATA SOURCES

We performed electronic searches in the PubMed database from January 2000 to December 2012, and major women's health and pharmacoeconomics conference proceedings from 2011 to 2012.

STUDY SELECTION

The systematic review is comprised of studies that reported pregnancy, pregnancy-related complications, unplanned pregnancy, and pregnancy-induced monetary costs. The review excluded narrative reports, systematic reviews, model-derived cost of pregnancy papers, non-US-based studies, and reports based solely on expert opinions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers independently applied the inclusion criteria and assessed the quality of the data collected. Disagreements between reviewers were resolved by consensus or by arbitration through a third party, with reference to the original sources. We collected information on the study design and outcomes for each included study. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in designing, performing, and reporting of the systematic review.

RESULTS

We identified 40 studies from electronic and handsearching methods. We classified studies based on the primary research topic focusing on the overall cost of pregnancy (N = 10), cost of pregnancy-related complications (N = 26), cost of unintended pregnancy (N = 2), cost of planned pregnancy (N = 1), or cost of pregnancy by facilities (N = 1). In the quality assessment, randomized, non-randomized, and retrospective database studies had low to moderate risk of bias. We determined primary cost drivers based on the highest cost reported in each study. The identified cost drivers were inpatient care, pregnancy delivery, multiple births, complicated cesarean sections, high-risk pregnancy, preterm birth, low birth weight, complications due to conditions such as hypertension, diabetes, anemia, and cancer, and in vitro fertilization. In 2008, the overall mean cost per hospital stay for pregnancy-related incidence ranged from $3,306 to $9,234 in 2012 dollars. The mean cost of pregnancy-related complications that led to preterm birth was as high as $326,953 for an infant born at 25 weeks. It is estimated that over 50 % of live births were unintended in the US. The difference in the cost of unintended pregnancy and intended pregnancy was approximately $536 million.

LIMITATIONS

One limitation of the systematic review was the exclusion of model-based cost studies which were excluded because of the high level of variation and heterogeneity across sources of reported cost. Another limitation of the review is that the cost of pregnancy perspective is restricted to the US.

CONCLUSION

Preventing pregnancy-related complications and reducing unintended pregnancies may lower the overall economic burden of pregnancy on the US health care system.

The association between hospital obstetrical volume and maternal postpartum complications

OBJECTIVE

The purpose of this study was to examine the relationship between delivery volume and maternal complications.

STUDY DESIGN

We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles.

RESULTS

We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and 8.5% vs 7.6%, respectively; P < .0001). Sixty percent of decile 1 and 2 hospitals were located within 25 miles of the nearest greater volume hospital.

CONCLUSION

Women who deliver at very low-volume hospitals have higher complication rates, as do women who deliver at exceedingly high-volume hospitals. Most women who deliver in extremely low-volume hospitals have a higher volume hospital located within 25 miles.

Anesthetic management as a risk factor for postpartum hemorrhage after cesarean deliveries

OBJECTIVE

This population-based study aimed to compare the risk of postpartum hemorrhage (PPH) for patients who underwent cesarean section delivery (CS) with general vs spinal/epidural anesthesia.

STUDY DESIGN

We identified 67,328 women who had live singleton births by CS by linking the Taiwan National Health Insurance Research Dataset and the national birth certificate registry. Multivariate logistic regression was carried out to explore the relationship between anesthetic management type and PPH.

RESULTS

Women who received general anesthesia had a higher rate of PPH than women who received epidural anesthesia (5.1% vs 0.4%). The odds of PPH in women who had CS with general anesthesia were 8.15 times higher (95% confidence interval, 6.43-10.33) than for those who had CS with epidural anesthesia, after adjustment was made for the maternal and fetal characteristics.

CONCLUSION

The odds that women will experience cesarean PPH with general anesthesia are approximately 8.15 times higher than for women who undergo CS with epidural anesthesia.

[Iron deficiency anemia and pregnancy. Prevention and treatment]

OBJECTIVE

To assess the effectiveness and the safety of prevention and treatment of iron deficiency anemia during pregnancy.

METHODS

French and English publications were searched using PubMed and Cochrane library.

RESULTS

Early screening of iron deficiency by systematic examination and blood analysis seemed essential. Maternal and perinatal complications were correlated to the severity and to the mode of appearance of anemia. Systematic intakes of iron supplements seemed not to be recommended. In case of anemia during pregnancy, iron supplementation was not associated with a significant reduction in substantive maternal and neonatal outcomes. Oral iron supplementation increased blood parameters but exposed to digestive side effects. Women who received parenteral supplementation were more likely to have better hematological response but also severe potential side effects during pregnancy and in post-partum. The maternal tolerance of anemia motivated the choice between parenteral supplementation and blood transfusion.

CONCLUSION

Large and methodologically strong trials are necessary to evaluate the effects of iron supplementation on maternal health and pregnancy outcomes.

Can intravenous iron therapy meet the unmet needs created by the new restrictions on erythropoietic stimulating agents?

In 2008, after reports of an association between erythropoietic stimulating agent (ESA) therapy and the potential for either thrombotic cardiovascular events or more rapid tumor progression in some cancers, the Food and Drug Administration changed the product labeling for ESAs, adding a black box warning as well as more restrictive indications, especially in oncology patients. In addition the Centers for Medicare and Medicaid Services has placed significant restrictions on payments for ESA therapy. These new limitations on ESA have led to increased use of transfusions in anemic cancer patients. This increase in allogeneic transfusions potentially will place an additional burden on the US blood supply. Although allogeneic blood transfusion is one answer to ESA restrictions, the use of intravenous iron therapy (IV iron) is another possible alternative. We will discuss the use of IV iron as primary therapy for anemia, the use of combination IV iron and ESA therapy to improve efficiency and decrease costs, and evidence that IV iron with and without ESA therapy can reduce allogeneic blood transfusions in surgical patients. We will also review the available IV iron agents and their comparative safety profiles.