As the epidemiology of COVID-19 evolves, obstetric care providers and obstetric anesthesiologists must thoughtfully consider routine aspects of inpatient obstetric management and discuss alterations in practice to optimize the safety of our patients and staff. Hospitals should begin collaborations with others in their health region to optimize testing and clinical management protocols for pregnant and postpartum women in their geographic area. These recommendations are not proscriptive and may not apply in your clinical setting. They are intended to introduce concepts to be considered in each setting and give examples of current practices in place. This guidance will be updated as additional data and information emerge. Systems-Level Responses Level of Care Broader health systems and networks should coordinate to identify each hospital's capacity and plans for transferring care as needed to meet both maternal and fetal needs. Communication should frequently occur, as hospital capacities may change rapidly. Cohorting and Other Strategies for Exposure Mitigation One public health intervention to reduce exposure risk is cohorting-co-locating patients who are persons under investigation (PUI) and women who test positive for SARS-CoV2 into a restricted area of the hospital. While not all facilities are able to create an independent obstetrics COVID-19 unit, attempts should be made to designate specific locations for the purposes of containment, which will limit the exposure of unaffected patients and staff.
IMPORTANCE Rates of maternal sepsis are increasing, and prior studies of maternal sepsis have focused on immediate maternal morbidity and mortality associated with sepsis during delivery admission. There are no data on pregnancy outcomes among individuals who recover from their infections prior to delivery. OBJECTIVE To describe perinatal outcomes among patients with antepartum sepsis who did not deliver during their infection hospitalization.
INTRODUCTION: Studies have demonstrated that antepartum intravenous iron sucrose infusion (IVFe) is safe and improves pre-delivery hemoglobin (Hb). Yet, the effect of IVFe on maternal morbidity is unknown. We sought to determine whether antepartum IVFe could reduce peripartum packed red blood cell (pRBC) transfusions. METHODS: This is a retrospective cohort study. In 6/2015, our institution began recommending IVFe for patients with Hb<9.5 g/dL who failed oral ferrous sulfate, as determined by persistent severe anemia in the third trimester. Patients who obtained prenatal care and delivered at our institution from 10/1/2015-10/1/2016 with third trimester Hb<9.5g/dL were included. Hemoglobinopathies were excluded. Decision to proceed with IVFe, timing, and number of doses was left up to patient and provider. Patients receiving ≥1 antepartum dose of 300mg of IVFe at least 48 hours before delivery were included in the IVFe group. Our primary outcome was rate of blood transfusions among those who did vs. did not receive IVFe. Fisher’s exact test was used to compare proportions. RESULTS: 389 of 3961 (9.8%) delivering patients met Hb criteria and were included. Of those, 25 (6.4%) were in the IVFe group. Third trimester Hb was lower in the IVFe group compared to the No IVFe group (8.6g/dL vs. 9.4g/dL; p<0.0001). Patients in the IVFe group significantly increased their Hb from third trimester to pre-delivery compared to those in the No IVFe group (Δ1.6g/dL vs Δ-0.1g/dL, p<0.0001). 57 of 389 (14.7%) received ≥1 unit of pRBCs during delivery admission. IVFe decreased the rate of peripartum blood transfusion compared to those who did not get IVFe (0% vs. 15.7%, p=0.035). The 57 transfused patients, none of whom received IVFe, required an average of 2.39 units of pRBCs per person. CONCLUSION: Despite lower starting Hb in the IVFe group, antepartum IVFe reduced transfusions in patients with a third trimester Hb<9.5g/dL. Future hemorrhage bundle work should highlight the use of IVFe to reduce peripartum pRBC transfusion and maternal morbidity.
CONCLUSION: Consistent with established literature, anemia is a commonly identified complication in our obstetric population. Despite this recognition, a standard work up and directed therapies were not routinely offered, nor were follow up studies investigated for compliance with therapy. This resulted in missed opportunities for interventions that could improve the patient's hematologic status, and thereby potentially avoid associated morbidities. A providerbased educational initiative, along with written protocols for anemia management, should be considered to improve this deficiency in prenatal patient care.
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