Lessons and limitations
Conventional practice in obstetrics acknowledges iron deficiency anaemia as a potential cause for morbidity. However, obstetric management guidelines recommend screening pregnant women for anaemia with a FBC only and do not suggest universal screening with ferritin or universal iron replacement in high income countries.10–12 This is despite prior work demonstrating the potential to reduce transfusion with antepartum identification and management of iron deficiency.16 The prevalence of iron depletion is high in young women and pregnancy, particularly during the third trimester when there is an additional strain on iron stores.17 ,18
In response to our own data showing a significant rate of anaemia at delivery (which increased the risk of transfusion postpartum) and new PBM Module 5 guidelines, we implemented a multifaceted quality improvement approach. Examining our processes demonstrated multiple opportunities for improvement, including not identifying pregnant women at risk, lack of appropriate pathology studies to demonstrate iron deficiency, and a failure to intervene when iron deficiency was confirmed. In addition, transfusion practice was liberal, not responding to mounting evidence of lack of efficacy, and potential for harm with such a strategy.
Our interventions were a combination of systemic changes and education. Systemic changes included routine antenatal ferritin testing, the development of patient information and iron prescription forms, standardised management algorithms at antenatal clinics, and intravenous iron infusions available within the antenatal clinic. The results showed a clear benefit in terms of the rate of anaemia at delivery and the number of transfusions. The algorithms and patient information have been made publicly available through the Blood Service, enabling easy and rapid adaptation for other institutions. The results are limited by relatively short follow up, although the systemic interventions have shown considerable benefit and have been embedded within clinical practice.
Education reinforced the systemic changes and was well-accepted by clinical stakeholders. Transfusion practice based on transfusion thresholds did not show a statistically significant benefit, and is the one area within our process completely dependent on education of clinicians alone. Some recidivism is frequently seen in quality improvement strategies reliant solely on education once the initial enthusiasm for intervention wanes. It is hoped that as clinicians get more comfortable with managing anaemic women for short periods of time while their haemoglobin increases, the transfusion thresholds may improve.10 The results of our intervention are less dependent on education than the antenatal haemoglobin optimisation interventions.
Our project is also limited by a lack of formal cost benefit analysis. Red cells are expensive to acquire and administer, and a direct cost saving will occur from reduced usage. With a reduction in red cell transfusions of nine units per month, there are direct cost savings of $401.94 per unit19 (∼$3,617.46 per month), and the cost saving is even higher if administration costs were taken into account.20 ,21 Expenditure on iron, particularly intravenous iron, offsets some of these savings, with 1000 mg of ferric carboxymaltose costing $306.96,22 and additional administration costs expected. Cost of increased ferritin testing is another direct cost. Indirect costs include time lost for infusions, side effects of iron therapy, and risks of acute transfusion reactions. Importantly, any formal cost benefit analysis should include an assessment of the effect of anaemia on the infant and quality of life for the mother.
The strategy for iron replacement in this project included all women with low iron stores, rather than just those with anaemia. There is conflicting data on the impact of non-anaemic iron deficiency in women,23 ,24 and further research in pregnancy to determine the effect of non-anaemic iron deficiency on fetal welfare is justified. Although our project has shown benefits, there are opportunities to refine the process. Further research may be useful to determine the optimal times to assess iron stores during pregnancy. It is anticipated that more active intervention in early pregnancy with oral therapy may reduce the need for intravenous iron later in gestation. Better awareness of iron deficiency in primary care and proactive screening for women considering pregnancy would also offer an opportunity for further intervention. Strategies to improve the prescribing of blood in postpartum women are also warranted and may need to focus on physician perceptions and experience.25 At postpartum, there are many conflicting causes of symptoms that may be attributed to anaemia and further work could focus on identifying symptoms most specific to anaemia to develop more objective criteria for transfusion prescription.