Grace, Rachael F

Background: Since publication of the American Society of Hematology 2019 Guidelines for Immune Thrombocytopenia (ITP), new clinical trials have been completed and new treatments have become available. Objective: These evidence-based guidelines from the American Society of Hematology (ASH) are a focused update of the 2019 ASH ITP guidelines, centering on treatment of adults with primary ITP. Methods: ASH formed a multidisciplinary guideline panel including two patient representatives that was balanced to minimize potential bias from conflicts of interest. The University of Oklahoma supported the guideline development process, including updating or performing systematic evidence reviews (up to July 19, 2025). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and identification of areas with new data or where application of new methods would be of benefit. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks and the GRADE framework for multiple comparisons, to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on recommendations in adults with primary ITP regarding initial therapy and second-line treatment in patients who failed first-line corticosteroids. The panel also issued good practice statements on thrombopoietic agent switching and splenectomy. Conclusions: Novel recommendations of these guidelines include: (1) initial therapy with a combination of rituximab plus corticosteroids or a thrombopoietic agent plus corticosteroids rather than corticosteroids alone (conditional recommendation) and (2) a thrombopoietic agent (strong recommendation) or rituximab (conditional recommendation) for patients who failed first-line corticosteroids.

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.