Risk factors associated with adverse fetal outcomes in pregnancies affected by Coronavirus disease 2019 (COVID-19): a secondary analysis of the WAPM study on COVID-19.

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6+/-9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8-0.9 per week increase; pPeer reviewe

Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection.

OBJECTIVES: To evaluate the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2 infection. METHODS: This was a multinational retrospective cohort study including women with a singleton pregnancy and laboratory-confirmed SARS-CoV-2 infection, conducted in 72 centers in 22 different countries in Europe, the USA, South America, Asia and Australia, between 1 February 2020 and 30 April 2020. Confirmed SARS-CoV-2 infection was defined as a positive result on real-time reverse-transcription polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab specimens. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit (ICU), use of mechanical ventilation and death. RESULTS: In total, 388 women with a singleton pregnancy tested positive for SARS-CoV-2 on RT-PCR of a nasopharyngeal swab and were included in the study. Composite adverse maternal outcome was observed in 47/388 (12.1%) women; 43 (11.1%) women were admitted to the ICU, 36 (9.3%) required mechanical ventilation and three (0.8%) died. Of the 388 women included in the study, 122 (31.4%) were still pregnant at the time of data analysis. Among the other 266 women, six (19.4% of the 31 women with first-trimester infection) had miscarriage, three (1.1%) had termination of pregnancy, six (2.3%) had stillbirth and 251 (94.4%) delivered a liveborn infant. The rate of preterm birth before 37 weeks' gestation was 26.3% (70/266). Of the 251 liveborn infants, 69/251 (27.5%) were admitted to the neonatal ICU, and there were five (2.0%) neonatal deaths. The overall rate of perinatal death was 4.1% (11/266). Only one (1/251, 0.4%) infant, born to a mother who tested positive during the third trimester, was found to be positive for SARS-CoV-2 on RT-PCR. CONCLUSIONS: SARS-CoV-2 infection in pregnant women is associated with a 0.8% rate of maternal mortality, but an 11.1% rate of admission to the ICU. The risk of vertical transmission seems to be negligible. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Pre-operative anaemia management with intravenous iron: a systematic review.

BACKGROUND Iron deficiency anaemia (IDA) is a common condition in patients presenting for surgery and is found in up to 75% of non-cardiac surgical patients. Pre-operative haemoglobin (Hb) is a strong predictor of transfusion requirement and it should, as part of a comprehensive blood conservation approach, be optimised whenever possible. Treatment options for iron deficiency anaemia include oral and intravenous iron or red blood cell transfusion. That both, anaemia and red blood cell (RBC) transfusion expose the patient to unnecessary risks is supported by an ever-increasing body of evidence. Consequently, allogeneic RBC transfusion should be avoided whenever possible and alternative treatment modalities which optimize the patient’s own red cell mass should be exhausted. However, anxiety over the short and long term effects of intravenous iron have limited its more widespread use. Newer dextran-free compounds, however, provide a safer treatment option. OBJECTIVE The objective of this systematic review was to critically appraise, synthesise and present the best available evidence related to the effectiveness and economic aspects of intravenous iron administration on the correction of iron deficiency anaemia in the peri-operative period. DATA SOURCES A comprehensive search was undertaken on major electronic databases from 2001 to 2012. The search was conducted in English, German, Italian and Dutch. REVIEW METHODS Randomized controlled trials, quasi-randomized controlled trials and quasi-experimental studies were included in the review. Critical appraisal and data extraction were undertaken using the Joanna Briggs Institute critical appraisal instrument and the standard data extraction form for evidence of effectiveness. Anaemia correction was as defined by study authors RESULTS The quantitative component of the review identified two randomized controlled trials for inclusion. One study of 76 patients with menorrhagia evaluated the effectiveness of pre-operative intravenous (IV) iron compared with oral iron in anaemic patients scheduled for surgery – the nature of which was not reported, aiming for a 1 g/L haemoglobin increase preoperatively. The intravenous iron group had greater increases in the Hb level than the oral iron group (3.0 vs. 0.8 g/dl, respectively; p < 0.0001). One other study evaluated the effectiveness of pre-operative intravenous (IV) iron compared with placebo in patients with bowel cancer scheduled for resectional surgery, looking at haemoglobin changes between recruitment and day of admission. A small subgroup of these patients was anaemic but no difference was demonstrated in haemoglobin changes between the groups. One additional RCT was found examining the effectiveness of IV iron in cardiac surgical patients, but full text examination and appraisal revealed that the majority of patients enrolled in these studies were not anaemic. The search for the economic component of the review revealed no randomized controlled trials examining the cost effectiveness of preoperative correction of iron deficiency anaemia with intravenous iron CONCLUSIONS Our review found insufficient data to make firm conclusions about the efficacy of pre-operative intravenous iron administration for the correction of anaemia based on clinical trial settings. Neither could we establish firm conclusions on the potential cost savings due to intravenous iron supplementation. IMPLICATIONS FOR PRACTICE There is inadequate RCT evidence at present to guide clinical practice. IMPLICATIONS FOR RESEARCH Our study found insufficient data to make firm conclusions about the efficacy, safety and cost effectiveness of pre-operative intravenous iron administration for the correction of anaemia pre-operatively. Adequately powered RCTs are required that evaluate and report the efficacy, safety and potential cost savings of intravenous iron administration as a treatment modality for iron deficiency anaemia.Thesis (M.Phil.) -- University of Adelaide, School of Translational Health Science, 201

Peri-operative and peri-partum anaemia management

Thesis (Ph.D.) (Research by Publication) -- University of Adelaide, School of Translational Health Science, 2016

"Simplified International Recommendations for the Implementation of Patient Blood Management” (SIR4PBM)

BACKGROUND: More than 30% of the world's population are anemic with serious medical and economic consequences. Red blood cell transfusion is the mainstay to correct anemia, but it is also one of the top five overused procedures and carries its own risk and cost burden. Patient blood management (PBM) is a patient-centered and multidisciplinary approach to manage anemia, minimize iatrogenic blood loss, and harness tolerance to anemia in an effort to improve patient outcome. Despite resolution 63.12 of the World Health Organization in 2010 endorsing PBM and current guidelines which include evidence-based recommendations on the use of diagnostic/therapeutic resources to provide better health care, many hospitals have yet to implement PBM in routine clinical practice. METHOD AND RESULTS: A number of experienced clinicians developed the following "Simplified International Recommendations for Patient Blood Management." We propose a series of simple, cost-effective, best-practice, feasible, and evidence-based measures that will enable any hospital to reduce both anemia prevalence on the day of intervention/surgery and anemia-related unnecessary transfusion in surgical and medical patients, including obstetrics and gynecology

Assessing the costs and benefits of perioperative iron deficiency anemia management with ferric carboxymaltose in Germany

Background: Perioperative administration of ferric carboxymaltose (FCM) was previously shown to reduce both the need for transfusions and the hospital length of stay in patients with preoperative iron deficiency anemia (IDA). In this study, we estimated the economic consequences of perioperative administration using FCM vs usual care in patients with IDA from the perspective of a German hospital using decision-analytic modeling. Materials and methods: The model was populated with clinical inputs (transfusion rates, blood units transfused, hospital length of stay) from a previously reported randomized trial comparing FCM vs usual care for managing IDA patients undergoing elective abdominal surgery. We applied a hospital perspective to all costs, excluding surgery-related costs in both treatment arms. One-way sensitivity analyses were undertaken to evaluate key drivers of cost analysis. Results: The average costs per case treated using FCM compared to usual care were (sic)2,461 and (sic)3,246, respectively, for resource expenses paid by hospital per case. This would suggest potential savings achieved with preoperative intravenous iron treatment per patient of (sic)786 per case. A sensitivity analysis varying the key input parameters indicated the cost analysis is most sensitive to changes in the length of stay and the cost of hospitalization per day. Conclusion: Perioperative administration of FCM results in cost savings to hospitals based on reduced blood transfusions and length of stay following elective abdominal surgery

Are Pregnant Women Who Are Living with Overweight or Obesity at Greater Risk of Developing Iron Deficiency/Anaemia?

Low-grade inflammation is often present in people living with obesity. Inflammation can impact iron uptake and metabolism through elevation of hepcidin levels. Obesity is a major public health issue globally, with pregnant women often affected by the condition. Maternal obesity is associated with increased pregnancy risks including iron deficiency (ID) and iron-deficiency anaemia (IDA)—conditions already highly prevalent in pregnant women and their newborns. This comprehensive review assesses whether the inflammatory state induced by obesity could contribute to an increased incidence of ID/IDA in pregnant women and their children. We discuss the challenges in accurate measurement of iron status in the presence of inflammation, and available iron repletion strategies and their effectiveness in pregnant women living with obesity. We suggest that pre-pregnancy obesity and overweight/obese pregnancies carry a greater risk of ID/IDA for the mother during pregnancy and postpartum period, as well as for the baby. We propose iron status and weight gain during pregnancy should be monitored more closely in women who are living with overweight or obesity.</jats:p