Implementation of a protocol for management of antepartum iron deficiency anemia: a prospective cohort study.

BACKGROUND: In randomized trials, antepartum intravenous iron sucrose is effective at improving predelivery hemoglobin in iron deficiency anemia. Yet, there is a gap between this knowledge and its implementation into care. OBJECTIVE: We aimed to determine if the implementation of a standardized protocol for the management of antepartum anemia outside of a clinical trial improves intravenous iron sucrose utilization and clinical outcomes. STUDY DESIGN: We performed a prospective cohort study evaluating the incorporation of an anemia protocol into routine clinical care for women with antepartum hemoglobin <11.0 g/dL. Our protocol, developed with multidisciplinary stakeholders, included (1) serial third trimester hemoglobin assessment, (2) oral iron supplementation for antepartum hemoglobin 9.5-11 g/dL, and (3) antepartum intravenous iron sucrose use (300 mg weekly for 3 weeks) for hemoglobin <9.5 g/dL. We compared 6-months preimplementation (January 2018 to June 2018) to 6-months postimplementation (January 2019 to June 2019). The outcomes evaluated were antepartum intravenous iron sucrose utilization, the number of intravenous iron sucrose dosages, predelivery hemoglobin, and blood transfusion. RESULTS: A total of 1423 women were included (pre=778; post=645) without significant baseline differences. The antepartum hemoglobin nadir was no different between the groups (pre: 10.2; interquartile range [9.6-10.6] vs post: 10.2; interquartile range [9.6-10.6]; P=.77). The implementation of a standardized protocol for the management of antepartum anemia was associated with 80% increased odds of receiving intravenous iron sucrose than the preimplementation group (pre: 4.8% vs post: 8.2%, P=.008; odds ratio, 1.79; 95% confidence interval, [1.16-2.77]). The implementation of a standardized protocol for the management of antepartum iron deficiency anemia was also associated with higher hemoglobin at admission for delivery (pre: 10.9; interquartile range [10.1-11.6] vs post: 11.0; interquartile range [10.3-11.7], P=.048). There were no significant differences between the groups in blood product transfusion (pre: 7.1% vs post: 5.1%, P=.13). CONCLUSION: Implementation of a standardized antepartum anemia protocol is associated with increased intravenous iron sucrose utilization and improvement in predelivery hemoglobin.

The Association between Implementation of an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery.

OBJECTIVE: This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. STUDY DESIGN: We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. RESULTS: Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03). CONCLUSION: Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. KEY POINTS: · An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..

The Psychological Experience of Obstetric Patients and Health Care Workers after Implementation of Universal SARS-CoV-2 Testing.

OBJECTIVE: This study was aimed to describe the hospitalization and early postpartum psychological experience for asymptomatic obstetric patients tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as part of a universal testing program and report the impact of this program on labor and delivery health care workers' job satisfaction and workplace anxiety. STUDY DESIGN: This is a cohort study of asymptomatic pregnant women who underwent SARS-CoV-2 testing between April 13, 2020 and April 26, 2020. Semistructured interviews were conducted via telephone at 1 and 2 weeks posthospitalization to assess maternal mental health. Depression screening was conducted using the patient health questionnaire-2 (PHQ-2). An online survey of labor and delivery health care workers assessed job satisfaction and job-related anxiety before and during the novel coronavirus disease 2019 (COVID-19) pandemic, as well as employees' subjective experience with universal testing. Patient and employee responses were analyzed for recurring themes. RESULTS: A total of 318 asymptomatic women underwent SARS-CoV-2 testing during this 2-week period. Six of the eight women (75%) who tested positive reported negative in-hospital experiences secondary to perceived lack of provider and partner support and neonatal separation after birth. Among the 310 women who tested negative, 34.4% of multiparous women reported increased postpartum anxiety compared with their prior deliveries due to concerns about infectious exposure in the hospital and lack of social support. Only 27.6% of women, tested negative, found their test result to be reassuring. Job satisfaction and job-related anxiety among health care workers were negatively affected. Universal testing was viewed favorably by the majority of health care workers despite concerns about delays or alterations in patient care and maternal and neonatal separation. CONCLUSION: Universal testing for SARS-CoV-2 in obstetric units has mixed effects on maternal mental health but is viewed favorably by labor and delivery employees. Ongoing evaluation of new testing protocols is paramount to balance staff and patient safety with quality and equality of care. KEY POINTS: · Women with SARS-CoV-2 had a negative hospital experience.. · A negative SARS-CoV-2 test was not reassuring for patients.. · COVID-19 negatively impacts healthcare workers' well-being..

Nausea, emesis, and muscle weakness in a pregnant adolescent.

BACKGROUND: Gitelman syndrome is a rare autosomal recessive disorder that presents in early adulthood with fatigue, muscle cramps and electrolyte abnormalities. CASE: A 17-year-old African-American woman presented at 17 weeks of pregnancy with nausea, emesis, profound lower extremity proximal muscle weakness, hypokalemia, and hypomagnesemia. After a thorough evaluation, Gitelman syndrome was diagnosed. The patient was maintained on high levels of potassium and magnesium supplementation throughout the rest of her pregnancy and delivered a healthy infant. CONCLUSION: In pregnancy, nausea and emesis is most commonly attributed to hyperemesis gravidarum. However, an atypical presentation of these symptoms and/or the coexistence of less common complaints warrant further investigation.