Relationship between patient ethnicity and prevalence of anemia during pregnancy and the puerperium period and compliance with healthcare recommendations - implications for targeted health policy.

BACKGROUND: Anemia is common during pregnancy and the puerperium. The association of ethnicity as well as other characteristics with anemia and compliance with healthcare recommendations has not been studied sufficiently and needs to be explored in order to implement a targeted health policy. We examined the association between ethnicity and the risk for prenatal and puerperium anemia and the compliance with healthcare recommendations. This effort aims to guide reforms in policies and practices that will assist in decreasing anemia prevalence in Israel. METHODS: This study was a secondary analysis of a prospective cohort study database including 1558 women who delivered vaginally at Emek Medical Center. Anemia was assessed before delivery by obtaining a complete blood count (CBC). After delivery, CBCs were taken in cases of postpartum hemorrhage, symptoms consistent with anemia, prenatal anemia or other clinical indications. The study population was divided according to their ethnicity (Jews and Arabs). The primary outcomes were anemia before delivery, anemia in the immediate postpartum and 6 weeks postpartum, and compliance with healthcare recommendations, which was defined as the rate of women who performed a routine CBC test 6-weeks-postpartum. RESULTS: The rates of anemia before delivery and in the puerperium period were similar between Jews and Arabs (before delivery: 88 (11%) versus 98 (14%); 6 weeks postpartum: 55 (21%) vs 68 (28%), respectively;p > 0.05). Iron supplementation was high in both groups during pregnancy (~ 90%) and lower during the postpartum for Jews compared to Arabs (72% vs 83%,respectively; P < .0001). Only one third of the patients performed a CBC 6-weeks-postpartum regardless of ethnicity. CONCLUSION: Overall compliance with health recommendation was high during pregnancy but low postpartum and was reflected in anemia persistence regardless of ethnicity. Because of the adverse long term impact of anemia on patient's health, new policies need to be developed to improve patient's compliance postpartum. A possible strategy is to combine the follow-up of the mother with the one of the newborn in the family health stations (Tipat Halav) and the community clinics similarly to the close follow-up during pregnancy. Additional methods may include active summoning for CBC test and assuring iron supplement consumption.

Hemoglobin drop following postpartum hemorrhage.

Postpartum hemorrhage (PPH) is defined as blood loss of ≥ 500-1000 ml within 24 h after delivery. Yet, assessment of blood loss is imprecise. The present study aimed to profile the hemoglobin (Hb) drop after vaginal delivery with versus without PPH. This was a secondary analysis of a prospective cohort study of women who delivered vaginally. Women were included if complete blood counts (CBC) before and after delivery were taken until stabilization (N = 419). Women were categorized into the PPH group and controls, for whom post-delivery CBCs were performed due to indications unrelated to bleeding. The PPH patients were then classified as either overt or occult PPH (symptoms related to hypovolemia without overt bleeding) subgroups. The primary endpoint was mean Hb drop after delivery. One hundred and ten (26%) and 158 (38%) women presented with overt PPH or occult PPH, respectively; 151 (36%) women were included in the control group. Mean Hb decrease from baseline was 3.0 ± 1.6, 2.0 ± 1.4 and 0.9 ± 1.0 g/dl, respectively (p < 0.0001). In all groups, maximal rate of Hb decline was in the first 6-12 h postpartum and plateaued after 24-48 h. At 48 h post-delivery, 95% and 86% of women who had dropped to Hb ≤ 9.5 and < 7 g/dl, respectively, reached those thresholds. Taken together, an Hb decrease ≥ 2 g/dl was consistent with PPH diagnosis and should be followed for at least 48 h after delivery.

Evaluation of postpartum anaemia screening to improve anaemia diagnosis and patient care: A prospective non-randomized before-and-after anaemia screening protocol implementation study.

We assessed the efficacy of a screening protocol for postpartum anaemia diagnosis and treatment in the maternity ward. A prospective non-randomized before-and-after anaemia screening protocol implementation study during two consecutive periods was conducted. Women who were scheduled for vaginal birth were tested for haemoglobin (Hb) before delivery. During the first period (June 29-October 10, 2015; N = 803) Hb was measured postpartum for women with anaemia-related symptoms, postpartum haemorrhage, or pre-delivery severe anaemia (Hb < 8 g/dL; "symptoms" group). During the second period (October 11, 2015-January 27, 2016; N = 755) Hb was also measured in all women with pre-delivery anaemia [i.e., Hb < 10.5 g/dL] ("screening" group). The primary outcomes were the rates of women with (1) postpartum anaemia diagnosis (Hb < 10 g/dL) and (2) administration of parenteral iron sucrose (indicated for postpartum Hb ≤ 9.5 g/dL). The detection rate of postpartum anaemia was higher in the screening group compared with the symptoms group (140 (19%) versus 100 (12%), ORadjusted 2.2 95%CI [1.6-3.0], respectively). The iron sucrose treatment rate was also higher (110 (15%) versus 88 (11%), ORadjusted 2.0 95%CI [1.4-2.7], respectively). A total of 122 women were diagnosed with moderate-severe anaemia in the screening group, 27 of whom (22%) were diagnosed solely due to the screening protocol. The results demonstrated that a routine screening of women with predelivery anaemia for postpartum anaemia led to increased anaemia diagnosis and consequently better medical care.

Long-term outcome of obstetric anal sphincter injury repaired by experienced obstetricians.

OBJECTIVE: To examine the long-term outcomes of women with obstetric anal sphincter injury (OASI) repaired by obstetricians without the involvement of colorectal surgeons. METHODS: A retrospective cohort study was undertaken of women who had been admitted for delivery between 2004 and 2012. All OASIs had been repaired by experienced obstetricians using the end-to-end technique. An unexposed group (no OASI) was matched at a ratio of 1:1. Fecal incontinence was graded using a modified Wexner questionnaire. RESULTS: Overall, 113 OASIs were recorded. Sixty-seven (59.3%) and 71 (62.8%) women from the exposed and unexposed groups, respectively, agreed to participate in the study (P=0.9). Continence to both stool and gas was reported by 48 (71.6%) and 64 (90.1%) women in the exposed and unexposed groups, respectively (P=0.03). The incidence of urgency, dyspareunia, and use of a pad or constipating agents was the same in both groups. CONCLUSION: The long-term outcome of OASI repair performed by experienced obstetricians is comparable to that reported in the literature. Some women who did not sustain an OASI reported fecal incontinence, which suggests that only a proportion of fecal incontinence can be attributed to OASI.