Bruns, Danette

Abstract Background Pregnancy-related acute kidney injury (PrAKI) is an uncommon but serious complication associated with adverse maternal and neonatal outcomes, with limited data in high-resource settings. Methods We conducted a retrospective cohort study of 29 586 deliveries at Mayo Clinic hospitals between 2017 and 2022. PrAKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) creatinine criteria. Maternal characteristics, nephrotoxin exposure, clinical interventions, and neonatal outcomes were compared between patients with and without PrAKI. Results PrAKI occurred in 341 patients (1.15%). Compared with controls, PrAKI was associated with higher rates of chronic hypertension (28.7% vs 5.2%), cesarean delivery (68.5% vs 35.1%), intensive care unit (ICU) admission (59.1% vs 6.2%), and nephrotoxin exposure (58.7% vs 31.6%) (all P < .0001). Dialysis was required in 7.1% of patients with PrAKI, with 1.17% remaining dependent at discharge and 0.88% at 30 and 90 days; no control patients required dialysis. Neonates of mothers with PrAKI had higher rates of prematurity and neonatal ICU (NICU) admission (48.7% vs 9.8%; P < .0001). Maternal mortality was rare. Conclusions PrAKI is a marker of severe maternal illness and is associated with adverse maternal and neonatal outcomes. Although most patients recover kidney function, a subset develop persistent dysfunction. Early identification, cautious use of nephrotoxic medications, and structured postpartum follow-up are essential.

Abstract Introduction: Iron deficiency (ID) is a global epidemic with discrepant definitions of both ID and anemia in pregnancy. Iron requirements increase during pregnancy and deficiencies should be corrected to avoid adverse maternal-fetal outcomes. Current guidelines recommend only screening for ID during pregnancy in the presence of anemia despite the global epidemic of ID in reproductive-age females and availability of ferritin as a high-value biomarker. To address this unmet need and gap in care, we implemented a standardized approach to screening and treating ID in pregnancy. Methods: In March 2024 at the ASH Quality Improvement Training Institute, our multidisciplinary team with representatives from hematology, obstetrics, anesthesiology, and patient blood management developed a quality improvement (QI) initiative to standardize an approach to screening and treating ID in pregnancy. After local dissemination and education of the standardized care pathway via patient/provider handouts and divisional presentations, obstetric providers paired ferritin testing with two standard hemoglobin assessments in early (8-12 weeks gestation) and late (24-28 weeks gestation) pregnancy to minimize lab draws and optimize logistics. The process was facilitated by modifying prenatal order sets in the electronic medical record. ID was defined as a ferritin <50 mcg/L and anemia was defined as a hemoglobin <11 g/dL. If ID was present in early pregnancy, oral iron supplementation was offered; if ID was present in late pregnancy, an IV iron infusion (low molecular weight iron dextran, 1 gram) was offered regardless of anemia status. Results: Obstetric data were captured pre-intervention from January 2023 – February 2024 (n=2097 pregnancies) and post-intervention from March 2024 – June 2025 (n=2429 pregnancies). Ferritin screening rates improved from 10% (205/2097) to 63% (1534/2429). Of those ferritin tests, 66% demonstrated ID in the pre-intervention cohort and 69% demonstrated ID in the post-intervention cohort. Anemia rates by measured hemoglobin during pregnancy were 25% in both the pre-intervention and post-intervention cohorts despite 92% having documentation of prenatal vitamins containing iron (PNV). Iron dextran infusion rates improved from 0.9% (18/2097) to 21% (507/2429). Of those receiving IV iron dextran, 39% had documentation of both PNV as well as additional oral iron supplementation. Overall, the median hemoglobin improved from 10.7 to 11.8 g/dL in those receiving IV iron dextran. This included increases from 12.0 to 12.8 g/dL in those without anemia and from 11.2 to 12.1 g/dL in those with ferritin 30-50 mcg/L after IV iron. Prior to initiation of this QI project, 3.1% of pregnancies (65/2097) required a blood transfusion during admission for delivery. After initiation of this project, 2.7% of pregnancies (65/2429) required a blood transfusion, of which 46 did not receive IV iron and 33 did not have a ferritin checked. Conclusions: ID in pregnancy is underrecognized and undertreated. Through a multidisciplinary QI initiative, screening for ID improved from 10% to over 60% of pregnancies within one year of project initiation. Over the same period, there was a 20-fold increase in the number of IV iron dextran infusions resulting in an increase in median hemoglobin by over 1 g/dL and a signal for decreased transfusion requirements. This occurred despite almost universal supplementation with a PNV. This standardized approach to screening and treating ID was performed by the obstetrics teams and could be implemented within varied practice models. Given the potential implications for reevaluation of appropriate reference ranges and equitable prenatal care globally, additional studies are warranted to better characterize ID in pregnancy as well as clinical sequelae for both mothers and infants. Simultaneously, discussions are needed around current guidelines and recommendations for both screening and treating ID in pregnancy.

Introduction: There are discrepant definitions of both iron deficiency and anemia in pregnancy. It is recognized that iron requirements increase during pregnancy, particularly in the third trimester, and that deficiencies should be corrected to avoid adverse maternal-fetal outcomes. While low dose iron supplementation is recommended for all pregnant persons (ACOG Bulletin 233), dosing through prenatal vitamins varies widely. Additionally, despite the epidemic of iron deficiency in reproductive-age females globally and availability of high-value biomarkers (e.g., ferritin), current guidelines only recommend screening for iron deficiency during pregnancy in the presence of anemia. As anemia is the terminal manifestation of iron deficiency and reference ranges vary by organization, these guidelines and practices warrant further investigation and discussion. Methods: Retrospective review and analysis of the electronic health record at Mayo Clinic (Rochester, MN) was performed for obstetric deliveries between June 2022 and May 2023. Iron deficiency was defined as a ferritin <50 mcg/L and anemia was defined as a hemoglobin <11 g/dL. Results: A total of 2,141 unique deliveries were identified. The median age at delivery was 31 years old (range: 15 - 45) with 82% identifying as white. Anemia was documented in 42% (n=904) of pregnancies at least once throughout gestation, with an increasing frequency of 2% (n=43) in the first trimester, 11% (n=230) in the second trimester, 17% (n=361) in the third trimester, and 38% (n=803) from admission for delivery through the peri-partum period. There were five documented pRBC transfusions prior to admission for delivery; however, from admission for delivery through the peri-partum period, there were a total of 102 documented pRBC transfusions. In total, 15% (n=318) of pregnancies were screened for iron deficiency through ferritin testing. Ferritin levels were measured 415 times with 23% (n=96) occurring between the last menstrual period and 12 weeks gestational age (WGA), 24% (n=100) occurring between 13-27 WGA, 40% (n=164) occurring between 28-40 WGA, and 13% (n=55) occurring post-partum. Iron deficiency was found in 70% (n=67), 79% (n=79), 80% (n=164), and 78% (n=43) of measured ferritin levels, respectively. Despite the paucity of screening, prescriptions for oral iron increased throughout gestation with supplementation in pregnancy for 8% (n=170) prior to 12 WGA, 14% (n=290) for those 13-27 WGA, and 23% (n=489) for those 28-40 WGA. Similarly, intravenous iron infusions increased throughout gestation with supplementation in pregnancy for 0.3% (n=7) prior to 12 WGA, 0.7% (n=16) for those 13-27 WGA, and 4% (n=95) for those 28-40 WGA. Prenatal vitamins were documented in over 90% of pregnancies throughout gestation, although the majority were non-prescription and contained variable amounts of elemental iron. Conclusions: Iron deficiency in pregnancy is underrecognized and undertreated. It follows that the accuracy of current reference ranges for anemia in pregnancy are suspect without rigorous verification of replete iron stores in the reference population. Given potential implications for blood product utilization and prenatal care, additional studies are warranted to better characterize iron deficiency in pregnancy as well as clinical sequelae for both mothers and infants. Simultaneously, discussions are needed around current guidelines and recommendations for both screening and treating iron deficiency in pregnancy. Providers, institutions, and professional societies should pursue pragmatic quality improvement initiatives and equitable healthcare delivery efforts to optimize care for this vulnerable patient population at high risk of iron deficiency.

AbstractBackground and ObjectivesOptimizing perioperative analgesia for patients undergoing major lower‐extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower‐extremity amputation is unknown.MethodsWe conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower‐extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression.ResultsA total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59).ConclusionsPeripheral nerve blockade is associated with reduced opioid requirements after lower‐extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.