Dataset Information

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

ABSTRACT:

Background

Iron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.

Methods and findings

In order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael's Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%-14.11%]; post-intervention 10.6% [95% CI 9.6%-11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.

Conclusions

The introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

SUBMITTER: Abdulrehman J

PROVIDER: S-EPMC6701755 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Publications

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

Abdulrehman Jameel J Lausman Andrea A Tang Grace H GH Nisenbaum Rosane R Petrucci Jessica J Pavenski Katerina K Hicks Lisa K LK Sholzberg Michelle M

PLoS medicine 20190820 8

<h4>Background</h4>Iron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.<h4>Methods and findings</h4>In order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improve ...[more]

PMID: 31430296

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Project description:Background:The effect of maternal weights on the risk of iron deficiency anemia (IDA) during pregnancy remains unclear. The study aimed to investigate the association between maternal weight indicators and IDA during pregnancy. Methods:We conducted a cohort study to examine the association between maternal weight indicators, including prepregnancy body mass index and the rate of gestational weight gain (GWG), and the risk of IDA among Chinese pregnant women. Data about new-onset IDA at different trimesters from a national cross-sectional survey were collected; information regarding baseline variables and rate of GWG from women participating in the survey were retrospectively collected. Tested IDA and reported IDA were documented. Multilevel logistic regression to examine the association between maternal weight indicators and the risk of IDA after adjusting for potential confounders was conducted. Results:This study enrolled 11,782 pregnant women from 24 hospitals from September 19, 2016, to November 20, 2016. Among those, 1515 (12.9%) IDA events were diagnosed through test (test IDA); 3915 (33.3%) were identified through test and patient reporting (composite IDA). After adjusting for confounders and cluster effect of hospitals, underweight pregnant women, compared with normal women, were associated with higher risk of test IDA (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.17-1.57 and composite IDA (aOR: 1.35, 95% CI: 1.21-1.51); on the contrary, overweight and obese women had lower risk of test IDA (aOR: 0.68, 95% CI: 0.54-0.86 overweight; aOR: 0.30, 95% CI: 0.13-0.69 obese) and composite IDA (aOR: 0.77, 95% CI: 0.67-0.90 overweight; aOR: 0.34, 95% CI: 0.21-0.55 obese). The higher rate of GWG was associated with higher risk of IDA (test aOR: 1.86 95% CI: 1.26-2.76; composite aOR: 1.54, 95% CI: 1.16-2.03). Conclusions:Pregnant women who are underweight before pregnancy and who have faster GWG are more likely to develop IDA. Enforced weight control during pregnancy and use of iron supplements, particularly among underweight women, may be warranted.

Project description:Metal-on-metal (MoM) bearing surfaces were historically used for young patients undergoing total hip arthroplasty (THA), and remain commonplace in modern hip resurfacing. A substantial number of female patients with MoM bearings subsequently gave birth following implantation of the bearings before a full understanding of metal ions exposure in these patients was established. In theory, it has been postulated that metal ions released from such implants may cross the placental barrier and cause harm to the fetus. In light of this potential risk, recommendations against the use of MoM components in women of child-bearing age have been advocated. The purpose of this systematic review was to evaluate: (I) the MoM bearing types and ion levels found; (II) the concentrations of metals in maternal circulation and the umbilical cord; and (III) the presence of abnormalities in the fetus or delivered child. A comprehensive literature review was conducted of studies published between January 1st, 1975 and April 1st, 2019 using specific keywords. We defined the inclusion criteria for qualifying studies for this review as follows: (I) studies that reported on the women who experienced pregnancy and who had a MoM hip implant; (II) studies that reported on maternal metal ions blood and umbilical cord levels; and (III) studies that reported on the occurrence of fetal complications. Data on cobalt and chromium ion levels in the maternal blood and umbilical cord blood, as well as the presence of adverse effects in the infant were collected. Age at parturition and time from MoM implant to parturition were also collected. A total of six studies were included in the final analysis that reported on a total of 21 females and 21 infants born. The mean age at parturition was 31 years (range, 24 to 41 years), and the mean time from MoM implantation to parturition was 47 months (range, 11 to 119 months). Maternal blood cobalt levels were found as a weighted average of 34.09 µg/L (0.425 to 138 µg/L), while umbilical cord blood cobalt levels were found to be 22.61 µg/L (0.52 to 51.11 µg/L). Cobalt levels were reduced by an average of 34% between maternal and umbilical cord blood. Maternal cord blood chromium levels were found as a weighted average of 18.18 µg/L (0.225 to 75 µg/L), while umbilical cord chromium levels were found to be 3.96 µg/L (0.14 to 11.96 µg/L). Chromium levels were reduced by an average of 78% between maternal and umbilical cord blood. No cobalt or chromium was detected in the umbilical cord blood of three patients. Out of the 21 infants born to women with MoM implants, 20 were born healthy with no adverse effects or complications. Only one complication was recorded in single infant that did not appear to be related to the maternal MoM implant. To date, there is a lack of consensus as to whether MoM hip arthroplasty implants are to be avoided in the child-bearing female population and whether they constitute a hazard to the fetus in utero. Both chromium and cobalt ions were markedly reduced in levels when transitioning from maternal to cord blood. In particular, chromium showed a greater reduction on average than cobalt (78% vs. 34%). Based on the current evidence, there appears to be no correlation between the presence of metal ions in umbilical cord blood and complications, as none of the infants experienced abnormalities uniquely attributable to the presence of metal ions.

Dataset Information

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

Background

Methods and findings

Conclusions

Publications

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

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