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Anemia during pregnancy increases risk for severe postpartum anemia
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Women who have anemia while pregnant and experience postpartum hemorrhage following Cesarean section deliveries have a greater risk for severe postpartum anemia, according to a study published in Transfusion.
“Postpartum anemia may be associated with a number of important maternal and perinatal morbidities including maternal fatigue, depression and impaired cognition,” Alexander J. Butwick, MD, associate professor of anesthesiology, perioperative and pain medicine at Stanford University Medical Center, told HemOnc Today. “Women who undergo Cesarean delivery may be particularly susceptible to postpartum anemia because their risk for postpartum hemorrhage is higher than women undergoing vaginal delivery. However, there is a dearth of studies examining the frequency of anemia after Cesarean delivery and the relations between postpartum hemorrhage and predelivery anemia with postpartum anemia.”
In the United States, more than 24% of women experience anemia during their pregnancies, prompting the American College of Obstetricians and Gynecologists to recommend screening for anemia and iron deficiency. Postpartum anemia can include morbidities, such as depression, fatigue and impaired cognition, and can impact maternal–child bonding, as well as a mother’s ability to provide newborn care.
In their study, Butwick and colleagues analyzed data collected from 70,939 hospitalizations for Cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as hemoglobin (Hb) level less than 8 g/dL before hospital discharge.
The primary outcome was the association between predelivery anemia and postpartum hemorrhage with severe postpartum anemia.
The overall rate of severe postpartum anemia was 7.3% (95% CI, 7.1-7.4).
Severe postpartum was strongly associated with a predelivery Hb level between 10 and 10.9 g/dL (adjusted OR = 5.4; 95% CI, 4.89-5.91), predelivery Hb level of less than 10 g/dL (adjusted OR = 30.6; 95% CI, 27.21-34.6) and postpartum hemorrhage (adjusted OR = 8.45; 95% CI, 7.8-9.16).
The proportion of women with severe postpartum anemia was highest among those experiencing postpartum hemorrhage but not predelivery anemia (12.2%; 95% CI, 11-13.6) and those who did not incur postpartum hemorrhage nor predelivery anemia (10.7%; 95% CI, 9.6-12).
Butwick said he was surprised to find that among women who underwent cesarean delivery at Kaiser Permanente obstetric centers in Northern California, over 7% had severe postpartum anemia (maternal hemoglobin level less than 8 g/dl) before hospital discharge. He added that predelivery anemia and postpartum hemorrhage were identified as the strongest risk factors for severe postpartum anemia after cesarean delivery.
Researchers noted that their findings have important clinical relevance for several reasons, stating that nearly one in four pregnant women experience anemia and 9% of women who deliver by Cesarean section experience postpartum hemorrhage.
“Monitoring and treatment of antenatal anemia may mitigate the risk for severe postpartum anemia after cesarean delivery,” Butwick said. “This finding is important as anemia detection and treatment is a key facet of patient blood management. National guidelines in obstetrics need to be updated to ensure that antenatal anemia screening and treatment is given more emphasis.”
Until guidelines are updated, hospitals and providers should consider postpartum anemia screening for women with any of the following: antenatal anemia, no predelivery hemoglobin level measured and postpartum hemorrhage, Butwick said.
Additional work is needed to better define approaches to care for women affected by postpartum anemia, Malavika Prabhu, MD, of the department of obstetrics and gynecology at Harvard Medical School, and Brian T. Bateman, MD, MSc, of the department of anesthesiology, critical care and pain medicine at Harvard Medical School, wrote in an accompanying editorial.
“This observation suggests that a large proportion of cases of postpartum anemia may be preventable through better screening and treatment of predelivery anemia,” Prabhu and Bateman wrote.
“Data, reflective of the U.S. obstetric population, should be collected over the course of the postpartum period to better understand the trajectory of Hb and iron stores and to refine our understanding of the impact on trajectories of recovery and maternal well-being after delivery,” they added. “Well-designed trials can be performed to define the risks and benefits associated with oral and IV iron supplementation in women who emerge from Cesarean delivery with persistent anemia. The analysis by Butwick and colleagues is a great step forward in raising awareness of the issue of postpartum anemia in contemporary obstetric practice, but much work lies ahead.” – by Chuck Gormley
For more information:
Alexander J. Butwick, MD, can be reached at Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305; email: ajbut@stanford.edu.
Disclosure: The researchers report no relevant financial disclosures. Bateman reports an investigator role on grants to Brigham and Women’s Hospital from Baxalta, Eli Lilly and Pfizer, as well as a consultant role with Optum. Prabhu reports no relevant financial disclosures.
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