Gasner, Sara

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.

Background Patients with self-reported antibiotic allergies have a higher cost of care, more frequent infections with resistant bacteria and worse health outcomes than patients without antibiotic allergies. Ultimately, less than 5% of patients who report a penicillin allergy have a clinically significant immune-mediated hypersensitivity reaction when tested. As 10%–30% of the population of pregnant patients are colonised for group B Streptococcus (GBS) and guidelines recommend penicillin as the treatment of choice for GBS, current recommendations support penicillin allergy testing in pregnant patients who report an allergy. Methods and intervention In this quality improvement project, nursing staff used an algorithm outlining inclusion and exclusion criteria to determine which patients were eligible to have penicillin allergy testing completed. Penicillin allergy testing consisted of a skin test using benzylpenicilloyl polylysine (Pre-Pen), penicillin G potassium, amoxicillin and alkaline hydrolysis mix (penicilloate) as a prick skin test, followed by intradermal skin test and finally an oral challenge with either amoxicillin or penicillin. Patient outcomes were analysed to evaluate the impact of the intervention. Results Of the 1266 patients receiving prenatal care during the intervention, 236 (19%) reported a history of penicillin allergy, and 212 if these were eligible for testing. 150 of the eligible patients were offered penicillin allergy testing. 101 patients (67%) completed testing and 49 (33%) declined testing. Seven patients (7%) had positive penicillin allergy testing, while 94 patients (93%) had negative penicillin allergy testing and were immediately de-labelled as penicillin allergic. Seventeen of the de-labelled patients subsequently tested positive for GBS colonisation, and all received intrapartum penicillin without adverse events. Conclusions Pursuing penicillin allergy testing for pregnant patients with reported penicillin allergy is a safe and feasible approach, allowing for allergy de-labelling and safe, guideline-driven antimicrobial therapy during subsequent labour and delivery hospitalisations. Cost-effectiveness of the allergy testing and impact on later episodes of care should be further investigated.