Season 2, Episode 13: Anemia in Pregnancy

We have all heard about anemia, but have you ever thought about the significance behind treating it in a sensitive population, like pregnant mothers? Tune in as Dr. Suzanne Dixon and Katlyn Moss BSN define anemia during pregnancy; especially highlighting the importance of screening for anemia regularly. Treating anemia during pregnancy can decrease the risk of maternal morbidity, problems with breastfeeding, and decrease the occurrence of neuro-development disorders and low-birth weight. This episode will foreground the lab numbers and procedures to best treat anemia in pregnancy.
California Maternal Quality Care Collaborative Toolkits:https://www.cmqcc.org/resources-tool-kits/toolkits
Anemia is included in the OB Hemorrhage Toolkit:https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
WNC Perinatal Providers Toolbox https://mahec.net/regional-initiatives/mhi-clinical-resources
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Transcript

Intro [00:00]: Hi everyone, and welcome or welcome back to our podcast, Just Us Before Birth and Beyond. We're so glad to have you here with us today. My name is Katlyn, and I have been a nurse in Western North Carolina for the past 10 years, and now I'm also a host for this podcast, and today I'm here to introduce the episode. So, I will actually be interviewing another host of ours, Dr. Suzanne Dixon, who is an OBGYN generalist over at Mahec OBGYN in Asheville, also seeing patients in Franklin, North Carolina, and today our topic is anemia in pregnancy. So, we do try and have a couple of didactic episodes every season of our podcast, and we've done one on OB hemorrhage, and now we are tackling the topic of anemia. So, there aren't many rare causes of anemia, but this episode will focus primarily on iron deficiency anemia in pregnancy, we're going to talk about lab values, and treatment protocols that you could have or add to your inpatient hospital units. Just a lot of really good information in this episode. So, turn your listening ears on, and without further ado, let's get into it.

Katlyn[01:19]: Hi everyone, and welcome to Just Us Before Birth and Beyond. Thank you for being here with us today. My name is Katlynand I am one of the hosts of our podcast, and I have here with me today Dr. Suzanne Dixon, who is my co-host. Hey, Dr. Dixon.

Dr. Suzanne Dixon [01:36]: Good morning. How are you?

Katlyn[01:38]: I'm good. How are you?

Dr. Suzanne Dixon [01:40]: I'm great.

Katlyn[01:42]: And we're here today to talk about anemia.

Dr. Suzanne Dixon [01:47]: Yes. Anemia and pregnancy and really focusing on the most common cause. Iron deficiency, anemia, and pregnancy.

Katlyn[01:55]: Okay. And so now anemia in pregnancy is something that has been going on for a very long time. This has always been an issue or something that we're paying extra in attention to in pregnancy. So why are we talking about it today? What has changed maybe in the last couple of years? And why is this such an important topic to keep talking about during pregnancy?

Dr. Suzanne Dixon [02:22]: Well, you're definitely right. We have known that maternal anemia has been a cause of poor prenatal outcomes for quite some time. It's been associated with preterm birth, low birth weight, prenatal mortality, and more recently some of the neurodevelopment disorders that babies and children can be diagnosed with such as autism spectrum disorder, ADHD, and intellectual disabilities. But now there are studies that link anemia to severe maternal morbidity. We now know that pregnant people with a first-trimester hemoglobin of less than nine are at a very high risk of severe maternal morbidity at the time of delivery. And persistent postpartum anemia has increased the risk of things like postpartum depression, fatigue, poor wound healing, and problems with breastfeeding.

Katlyn[03:17]: Wow.

Dr. Suzanne Dixon [03:18]: Yeah, and the incidence of prevalence in developed countries for anemia after a patient has delivered is up to 50%. So, it's much greater than that worldwide.

Katlyn[03:28]: My goodness. I did not know about the neurodevelopment disorders linkage. I mean, I feel like that's something that's probably been discovered in the last few years. I think it's so important to remember that there are things in pregnancy that we can help make better difference things way far down the road that you don't even really think about when it comes to the pregnant patient. So, yeah, that's just very interesting. I can't believe that that's true.

Dr. Suzanne Dixon [04:05]: And we're just, you know, finishing our podcast on maternal hemorrhage, and this kind of dovetails nicely into that in a way of not preventing hemorrhage per se, but really allowing patients to deplete their stores of iron, build their hemoglobin up so they'll be much safer going into their delivery and possibly avoid blood transfusions.

Katlyn[04:28]: And all of these problems postpartum. I mean postpartum depression, the poor wound healing if they have a C-section that makes such a big difference.

Dr. Suzanne Dixon [04:37]: Yeah, I just didn't realize that iron deficiency anemia affects 16% of pregnancies in the United States and 38% globally during pregnancy.

Katlyn[04:46]: Wow, and that's a lot, and that's the ones that we're catching. I mean, if they're not coming for prenatal care or not getting the appropriate labs being drawn, it really could be even more than that.

Dr. Suzanne Dixon [05:00]: Oh, definitely.

Katlyn[05:02]: So, do you see any differences in anemia based on race and ethnicity? We know that, you know black women and non-white women when it comes to delivery and in the postpartum period. So, are we seeing some of the similar differences when it comes to the rates of anemia?

Dr. Suzanne Dixon [05:28]: Yes. So, that makes us another really important topic and something that has changed fairly recently in our recommendations from a cog. There actually used to be race-based definitions of anemia in pregnancy that because we were seeing lower hemoglobin's in black women and non-Hispanic, or excuse me, non-Hispanic black women and Hispanic women, there were different cutoffs actually that were established as normal. So, it was actually 0.8 test liters per or milligrams per deciliter. Drop in hemoglobin was considered normal, and that really was not based on any science whatsoever. So, we think now that those differences in relative hemoglobin rates that do occur across ethnic and racial groups are probably more related to the social socioeconomic things like social determinants of health, possibly food deserts in communities of color where there are not as many opportunities to access foods that boost your iron. It also increased incidents of medical conditions that exacerbate or prolonged menstrual blood loss, like fibroids and obesity, early age of monarchy, and then just we know so much more now about what we think are the toxic effects of systemic racism, and so those specified cutoffs for you know, based on racial and ethnic backgrounds have been eliminated, and we have the same definition for everyone.

Katlyn[07:08]: Okay, great, that was going to be my next question. Did we fix this? We're not. Okay everybody's on the same level now. We're looking at the same levels.

Dr. Suzanne Dixon [07:17]: Yeah, and I think that might have contributed historically too, you know, differences in outcomes for moms.

Katlyn[07:26]: Sure.

Dr. Suzanne Dixon [07:27]: Moms needing more blood transfusions and have more incidences of severe maternal morbidity. So, I'm relieved and glad that this has been eradicated.

Katlyn[07:38]: Yeah, we're doing, we've got to do better. We've got to do better. So, backtracking a little bit, we're talking about anemia and pregnancy and anemia. Can we just clarify what the definition of anemia specifically in pregnancy is? Because we know that the blood volume of a pregnant patient changes so much when they're pregnant. So, what do those cutoffs actually look like?

Dr. Suzanne Dixon [08:04]: Right. So, the ACOG and the Center for Disease Control in the United States share the same definition of anemia, and that's 11.0 in the first and the third trimester, and then 10.5 milligrams per deciliter in the second trimester. The World Health Organization is a little bit different in their recommendation. They just hold with the 11.0 throughout, which I find a little bit easier to you know, counsel patients about and manage. And it doesn't make much sense to have a changing goal in the middle of the pregnancy to me if you are supplementing someone. So I think we need to follow ACOG guidelines for sure, but kind of when you're counseling patients, use that 11.0 as the goal I bet.

Katlyn[08:53]: Okay, and then when are we, because you mentioned two different cutoffs, although again, we're, we're kind of just focusing on that one number with patients because it is a little bit less confusing. But when are we screening prenatally for anemia? Is this something we're just doing in the second, or third trimester, or are we just doing it once? How, what do you feel the best recommendation is as far as screening times go?

Dr. Suzanne Dixon [09:21]: Well, our institutional standard, and I think this is true across the country, is to include ACBC at the new OB visit, and then again, repeat that at the start of the third trimester. So, when the patient is coming in for their glucose screening for gestational diabetes, that's a good time to include labs that we need to know about for the third trimester. So, ACBC is done twice in most pregnancies at the beginning, whenever the patient initiates care, and then again at the start of the third trimester, and so we're really using that for patients under 11.0 in the first trimester, really starting to talk to them about possibly being treated for iron deficiency anemia during pregnancy. There are also levels of anemia that are addressed kind of differently. According to acog mild anemia is considered 10.0 to 10.9, moderate 7.0 to 9.9, and then severe anemia 4.0 to 6.9. So, depending on the level of anemia, the severity of it, and when it's diagnosed, our approach is pretty different.

Katlyn[10:34]: Okay. So, why is it that pregnant people are more likely to develop anemia? You know, we talked at the top of the hour about the fact that this is not a new thing that's coming about in pregnancy. It's always kind of been an issue that some pregnant people deal with. So, what is it about pregnancy that makes someone more likely to develop anemia?

Dr. Suzanne Dixon [10:59]: Well, we know that you know, there are great hemodynamic changes associated with the pregnancy that cause sort of delusional anemia, and so your plasma volume when you become pregnant I guess from the very beginning until the second trimester, so increases by up to 60% while the red blood cell volume only increases by about 15 to 20%, and so, the causes relative anemia that we know about, and they have done studies looking at anemia prevalence in the first trimester, second trimester and third trimester, and it does increase in percentage. So, it starts at less than 5% for all patients up to in the twenties by the time the patient is ready to deliver.

Katlyn[11:43]: Okay.

Dr. Suzanne Dixon [11:44]: And we know that hemoglobin in the early part of the pregnancy, so less than nine or so, really does predict that severe maternal morbidity more than the more mild hemoglobin ranges.

Katlyn[12:00]: Okay.

Dr. Suzanne Dixon [12:01]: Also, in pregnancy, in addition to the physiologic changes with the hemodynamic and everything your iron needs goes up in pregnancy. So, I know you're building a little fetus and a placenta, and that requires more iron than red blood cell volume does go up, which requires iron, and then there is naturally more maternal loss. I was surprised to learn that only about one to two milligrams per day are absorbed with the oral administration of iron. So, if somebody starts out a little bit low and we start supplementing them with oral iron, it can take a long time for that to actually get to the point where they're truly repeated. The other little thing that can happen in pregnancy that is, it's not a little thing, it's a big thing is inflammation. So, we know there are lots of causes of inflammation in pregnancy, and then some people enter their pregnancies with a more of an inflammatory state than others, and that definitely can exacerbate iron deficiency anemia, and it can kind of interfere with our ability to tell the patient for sure that it is iron deficiency based on their blood test.

Katlyn[13:10]: Okay. So, now these are all related to, again, that blood volume change in pregnancy. Are there any other causes of anemia or if someone is diagnosed with anemia, are we doing a little bit of deep diving and, you know, to make sure that we understand what's causing it? Or if there is something outside of just that natural change in blood volume during pregnancy that's causing it?

Dr. Suzanne Dixon [13:37]: Yes. So, certainly, iron deficient anemia added to those changes that happen in pregnancy probably causes greater than 90% of cases of anemia in pregnancy. But you have to always kind of keep in the back of your mind that there are certainly other causes, and when we just check that CBC or the hemoglobin at the beginning and it's low, that is definitely not specific for iron deficiency anemia. It can show, it can be a kind of a little red flag for lots of other potential underlying causes of anemia that people are entering their pregnancy with. We don't always do huge big blood work for folks that are diagnosed, but again, depending on the severity of anemia when it's diagnosed and their response to initial treatment, then more of a workup is often deemed necessary. So, when you're thinking about the different causes of anemia besides iron deficiency, oh, I just finished helping the chief residents with their oral board prep.

And one of the things we always tell them when they're answering questions on oral blood is to try to classify things. So, when you have a long list of potential ideologies for something try to classify things, and similarly, when you're talking to patients, you don't want to just completely bombard them with all these esoteric things with their mechanisms of actions, but basically simplifying it into categories, and I like the mechanism the best. So, there's anemia due to low production of red blood cells, destruction of red blood cells, and then blood loss. So, those are sort of three simple categories that you can tell patients we're looking for reasons in one of those categories that could be contributing to your anemia.

Katlyn[15:16]: I love that breakdown.

Dr. Suzanne Dixon [15:19]: So, examples of low production would be the deficiencies like iron deficiency, which is by far the most common, but also vitamin B12 and folate deficiencies. Malabsorption falls into this. So, if somebody has Crohn's disease or you know, has had gastric bypass surgery, anybody with bone marrow suppression or bone marrow problems, hypothyroid can cause it, and then just anemia of chronic disease as well. Then the destruction that's more you think of inherited versus acquired hemolytic anemia’s like sickle cell and thalassemia and SP cytosis and things like that, and then loss, we really are thinking about a lot around the time of delivery for hemorrhage related to the delivery, but it can be occurring during the pregnancy as well. Like chronic abruptions GI bleeds, and things like that could be easily missed if you're just assuming that it is pregnancy related, and also mentioned folks that come into their pregnancy with chronic conditions that make them more likely to have had heavy menstrual blood loss during their lives, like fibroids, obesity starting their periods really early. Those are things that could have contributed to chronic anemia prior to the pregnancy.

Katlyn[16:38]: So, it sounds like, I mean, it's, would you say it's possible that there are some people who are entering their pregnancy with these underlying things going on and they don't even know that they have them? And it may be that pregnancy and realizing that their hemoglobin is low is what kind of helps prompt this deep dive into figuring out what else is going on.

Dr. Suzanne Dixon [17:05]: Oh, definitely. I think that we have in the past just empirically treated folks with iron when they show up with hemoglobin that's a little bit low, and we probably have missed the opportunity to help patients understand a cause that might be affecting them their entire lives. So, I think as a nation we only started screening newborns for these hemoglobinopathies that can cause severe anemia later in life at birth in 2006 or 2007, even though it had been recommended a couple of decades earlier. So, people that were born after that time have been screened supposedly. 

So, ACOG just started recommending universal screening for hemoglobinopathies or at least counseling patients and offering that with the new OB labs as well, so that until those people catch up with their.... reach their childbearing age, the ones that were screened in child broke, we had this little gap that we probably do need to at least discuss it with folks and offer screening for things like sickle cell and thalassemia, and when I was coming along in residency, that was all based on where your ethnicity was from, like where you Mediterranean origin or Eastern European, or Sub-Saharan African or South American. And goodness gracious, don't we know now that our country is such a melting pot that those kinds of intricacies are very difficult for patients to even know, much less for us to remember to us? So, that's why universal screening has become more the standard of care.

Katlyn[18:40]: It just makes more sense. So, we're moving towards universal screening, and we're sort of, it sounds like changing the way that we are not only treating anemia but wanting to do this deeper dive into it and not just relating it to pregnancy. So, how are we treating it? You know, you've done the screening, and you find that you have a pregnant patient who has low hemoglobin. What are sort of the steps we're going to take from there to treat this? So, once we've determined that the patient has pretty significant low hemoglobin, what kind of lab work are we doing to determine sort of type of if it is iron deficiency anemia or if something else is going on?

Dr. Suzanne Dixon [19:36]: Right. So, the workup has the recommendations for workup have evolved a little bit. To be more specific, we traditionally would just treat folks with oral iron in the past who had low hemoglobin, and then if they didn't respond, do more blood work that's called empiric or presumptive treatment. But now there's a push to actually be a little bit more certain that the patient does have iron deficiency anemia before starting just because there are some risks of side effects and things with supplementation. So, besides the classification that we talked about above, which was either low production destruction or loss, you can also classify anemia into what the red blood cell indices look like on your CBC, and so microcytic normocytic or macrocytic anemias are sort of the three classifications there, and microcytic anemia is almost always going to be for pregnant patients at least, it's almost always going to be iron deficient anemia.

Dr. Suzanne Dixon [20:36]: So, if you have a microcytic anemia then you and the hemoglobin is not terribly low, it would be okay to do presumptive treatment, but if it's lower than 10, then you probably want to go ahead and do some iron studies to confirm that before starting. So, ferritin, if it's less than 30% now is the cutoff to consider iron deficiency anemia, and that's pretty sensitive actually. Ferritin is an acute phase that reacts though, so it can go up in an inflammatory state. So, that can be a little bit confusing. So, then you can also check a transparent, and if that's lower than 20%, that's also leading you more towards the diagnosis of iron deficient anemia. You can also check a total iron binding capacity, and then the MCV is what we're using to determine the blood cell indices.

But pregnancy, your red blood cell volume goes up just because of pregnancy as well. So, you could still have a patient who has iron-deficient who either has a norm, really has a normal RBC volume or NCB mean corpus volume, they could still be iron deficient because their pregnancy was making their blood cells a little bit bigger. So, those are the things to get to make sure that it is iron-deficient anemia if the patient has severe anemia or you know if they're presenting later in the pregnancy and you just don't have the luxury of time to try oral iron, and then if those things do not pan out if it doesn't look like iron deficiency, you should also consider a peripheral smear to look for some of the hemolytic anemia’s screening for the hemoglobinopathy traits that we talked about, and the chance of having a hemoglobinopathy in the United States is about 1 in 66 people. So, we definitely screen for things that are, you know less common than that for sure, especially with our new genetic carrier screening tests that we offer for folks. So, those are just some guidelines for moving from the CBC into iron studies and what those iron studies might tell you to help you manage your patient.

Interestingly the fact about inflammation exacerbating iron deficiency anemia, if the patient has an inflammatory state, some folks are proposing a cutoff for the ferritin to be just less than a hundred. So, that's quite a big difference from 30 to a hundred as help and diagnosis of iron deficiency anemia. So, you can see that might be confusing when you get those iron studies back. So, mild anemia that's diagnosed in the first trimester, so if the patient screens and their hemoglobin comes back less than 11.0 or even between 11 and 12.0 with lower ferritin, those patients should be started immediately in the first trimester, hopefully when they presented for care with a low dose of oral iron, and there has been a little bit of a change in the way that we are recommending taking that oral iron.

So, during pregnancy, it's thought that the average patient who is not anemic needs about 27 milligrams of elemental iron per day in their dietary intake or their, you know, prenatal vitamin intake. The average diet in America, we only get 15 per day. So, even if you are not diagnosed with anemia at the beginning, adding a little bit of iron either in your prenatal vitamin or even supplemental is not a bad idea, and then if you've been diagnosed with mild anemia, definitely adding that extra iron to your prenatal vitamin. So, 60 to a hundred milligrams of elemental iron depending on the level of anemia is recommended orally, and it is now a thought that every other day administration is actually tolerated better with similar results in the iron indices that we're looking at to see if you actually are responding.

There has been in the past also this thought that taking your iron with a big glass of orange juice or something with vitamin C will help absorption, and that's been questioned recently as maybe not being quite as evidence-based, but still a lot of places, and I think in our region, the standard of cares to recommend every other day on an empty stomach with a big glass of orange juice to help with absorption really your [Inaudible 25:20] will start bumping up just within a couple of weeks of doing that if you truly do have iron deficiency anemia, and then your hemoglobin will take another couple months to really show an increase. So, it takes a little longer for oral iron to absorb and then to cross that hemoglobin increase but the creation of that red blood cells and everything happens immediately after starting in the [Inaudible 00:25:46] is a good index of that. So, people...

Katlyn[25:50]: I assume once this kind of treatment is started, you are rechecking the hemoglobin more frequently throughout the pregnancy than maybe you would have had this not been caught in that first trimester.

Dr. Suzanne Dixon [26:05]: Yes. If it's real mild anemia, and the patient is tolerating her oral iron and, and you know, remembers to take it in and is not having any bad side effects, you could wait and check it in the second trimester.

Katlyn[26:19]: Ok.

Dr. Suzanne Dixon [26:19]: Assuming it's going to go up. But if it's severe anemia or moderate anemia or you're uncertain of the diagnosis, then recheck in again in four to six weeks even would be reasonable.

Katlyn[26:30]: So, that was what we're doing with, you said the mild anemia, so that 10, 10 to 11, maybe even, you know, 11.5 range does it differ when it comes to the moderate, or severe anemia?

Dr. Suzanne Dixon [26:44]: Yes, certainly. So, if someone's hemoglobin is less than 10 in the first trimester then bumping up on that elemental iron intake, a hundred milligrams to 180 milligrams of elemental iron again every other day does help absorption. They don't really show any difference in the absorption. There's something about after you take oral iron, there's very limited absorption for 24 hours after that, and so waiting another day will actually help bolster your absorption, and then checking for someone with moderate anemia, I would initiate the higher dose every other day but then check their hemoglobin more aggressively to make sure they're responding. If they're not really bumping up their hemoglobin and they're [Inaudible27:26] is staying about the same, then you have to consider that maybe it's not iron deficiency anemia, maybe it's one of those other more rare things, or they have a coexisting problem in addition to iron deficiency. Maybe they're not taking it, or they took it and it made them really constipated and they've stopped taking it, they had side effects to it.

Katlyn[27:45]: How many times have you heard a patient say, I just can't take the iron?

Dr. Suzanne Dixon [27:51]: I mean, it is really hard on your GI system to take oral iron for a lot of patients and you could try switching to a different iron, salt like I usually use Ferris sulfate, which the 325 milligrams has about 65 milligrams of aluminum iron, but if you get a PHS fumigate that has more elemental iron it and certain ones might be tolerated better by different fix, and they come in liquids versus tablets, that kind of thing. But if you have a patient that's really saying that they're taking it and they're not responding, you have to consider these other things. Right. Surely you would know by the time a patient was pregnant that they had Crohn's disease, but maybe not, maybe this would be a first-time diagnosis, and surely they would have told you at the initiation of their pregnancy about a history of gas bypass surgery, that kind of thing.

And those patients are just notorious for really not absorbing much at all intestines, so they may be a better candidate for IV iron. The other thing that we need to not forget about is those blood loss anemias. So, if the patient does have, if they had a little sub hemorrhage at the beginning of the pregnancy or then a chronic abruption later, they could be having a silent bleed that is not being recognized with vaginal bleeding during the pregnancy, and that can be a way to diagnose that. Or you have to remember about GI loss as well. So, consider a heoc if the patient's not responding. But if all those things come up negative, then it may just be that the patient is a better candidate for IV administration, which in our region we've kind of gone back and forth on recommending that depending on different hemoglobin levels at different stages of pregnancy, and I think the national recommending bodies like ACOG and then the California Quality maternal quality collaborative has really recommended becoming more aggressive about prenatal, parenteral iron administration for folks that don't respond to iron or just not candidates for it.

Katlyn[29:49]: Now, how new is this recommendation? Because I've been doing outpatient OBGYN nursing specifically for a few years now, and this is not something that I am familiar with at all is patients getting prenatal iron IV infusion, so like going to the hospital and getting an IV infusion of iron, is that something that has just come about recently?

Dr. Suzanne Dixon [30:14]: No, we've had iron infusions available, you know, for decades, but it has kind of in the past we've had this idea that we only use it as a last resort because there were such high risks of really severe anaphylactic type reactions to the iron. But more modern infusion options have way less severe reactions now, and we just have a better understanding now about how long it actually takes in a person who has a normal level of inflammation, who is eating a wonderful diet that's going to be high and iron and not eating things that are going to make it not absorb, even those patients still absorb oral iron at a very slow rate. So, we know that if we really need to bump somebody's iron stores up before delivery, either limited by time or the, you know, severity of the anemia, then IV iron seems to be a better choice.

Katlyn[31:16]: Okay and how are we doing that? Can you tell us a little bit about sort of how much we're giving and what risks we're taking into account and that kind of thing?

Dr. Suzanne Dixon [31:29]: Yeah, so IV iron should be something that's available in most areas. Even. the small town where I practice has an infusion center that's outpatient and we have a little order set, and we can send folks over for IV iron administration there without them having to be admitted or drive an hour and a half over to the delivery hospital. And the infusions that are available do vary hospital system by hospital system and region by region. So, there are several places where those are listed for us in our region. We have a great women's toolkit that's available that list the things that we are using as institutional standard, and then the California Maternal Quality Collaborative has a toolkit that you can download. You do not have to be a member of one of their member hospitals to do that. You just have to register on their website and then download their toolkit, and theirs has a nice order set that's available with instructions to the nurses who are giving the infusions for what to watch for as far as reactions and things like that. So, it's very detailed and I recommend if you don't already have a protocol for that in your practice, maybe just printing that out to send with the patient.

Katlyn[32:48]: And we will have both of those linked down in the show notes below.

Dr. Suzanne Dixon [32:53]: And so, IV iron, like I said, used to be associated with pretty high rates of anaphylaxis. But now with the newer preparations, there was a study recently that showed that it's less than one in 250,000. Have the actual anaphylaxis with it. We still have a couple of strong contraindications. So, patients that have had IV iron in the past and had a true anaphylactic reaction should never do that again, also patients who are experiencing viral infections or liver disease should not get IV iron, and that is the way to tell the difference, I think patients, it's pretty common to have a mild reaction that's not considered anaphylaxis with this, that occurs about two to 6% of patients that get IV iron will have temporary kind of mild symptoms. They describe those in the literature as the fish vein reaction or which can be just kind of myalgia and joint pain kind of hurting everywhere.

And then non-allergic complement act activated reactions that are pseudo allergy reactions. And that would be like itching or rashes or, you know, temporary hypotension that's really mild, but a true anaphylactic reaction is more like a really significant drop in your blood pressure to 90 or below systolic or a 30 milligrams per mercury drop in the mean arterial pressure for a patient that is sustained, and also signs of angioedema of the airway skin or GI tract. So, those are really, really severe reactions that do not abate when the infusion is stopped. So, for those mild reactions symptoms, they just recommend that you hold the infusion for a little bit and see if it doesn't just respond really quickly, and then you can actually start the infusion back up at a lower rate for about 15 minutes and then slowly increase the rate.

Dr. Suzanne Dixon [34:43]: And usually people do fine, but if it's a real severe anaphylaxis reaction that happens less than one in 250,000 times and those patients need to be treated with IV fluids and IV steroids and transferred immediately to the emergency department, and should not ever have IV iron again. But I guess it does still happen, and maybe if we're going to be increasing the numbers of IV iron infusions that we're doing, maybe we'll see more of that. But in our little region, hopefully, it won't be many.

Katlyn[35:16]: Okay. And how many times could a pregnant patient get an iron infusion prenatally? Is it something we're just having to do one time or I'm sure it depends on how early in the pregnancy they're diagnosed but can they get more than one infusion during pregnancy?

Dr. Suzanne Dixon [35:34]: Yes, you can, and the older preparations sometimes require several infusions. In order to meet the, usually we want to have a patient get at least one gram of iron that usually and, you know, will start to help replete the stores and help their hemoglobin respond much more quickly. Our goal is to have a hemoglobin of 11 or higher by the time the patient, you know, enters labor and delivery for their birth experience. And so you could do multiple ones, but in most patients just getting a gram of IV iron will suffice to bring it up and replete their stores, and does work so much faster than oral iron.

Katlyn[36:17]: And really is going to prepare the body for delivery when they're going to lose yet more blood.

Dr. Suzanne Dixon [36:24]: Right.

Katlyn[36:26]: Speaking of delivery, do we have any considerations for postpartum? Does that change the way we're treated? Or are we kind of following the same standards there as we would for pregnancy?

Dr. Suzanne Dixon [36:43]: Yes. So, that has been another change in the recommendations from ACOG, and from the California Task Force that presented this toolkit. We are still going to have patients that need blood transfusions and are severely anemic after deliveries, and so their argument is that yes, the blood transfusion will immediately bring the hemoglobin up, but that is indicative of a patient who had definitely re-repeated stores, and so just the blood transfusion is really not enough to last and to help that patient be healthier, and prevent those things that we talked about, like postpartum depression and poor wound healing and fatigue, and so, they recommend, depending on the level of hemoglobin, which I think universally if it's less than 9.0 and the patient needs a blood transfusion, then also accompanying that with IV iron as well to help deplete their iron stores.

Katlyn[37:43]: And this is regardless of how things went prenatally like this could happen to someone who had no problems with their iron during pregnancy, but maybe had a hemorrhage during delivery or something like that. You're still looking at doing the blood transfusion, but also going ahead and doing an IV iron infusion as well.

Dr. Suzanne Dixon [38:05]: That's right, and certainly we think that we have screened everybody really well and diagnosed iron deficiency anemia during pregnancy, but folks that did have a hemorrhage may have had some underlying thing that we were not able to actually pick up during the pregnancy. So, still going back and thinking through the, you know, maybe at the postpartum visit, thinking through the other things that might have contributed and screening appropriately would be a good idea.

Katlyn[38:31]: Ok. Alright. I think that I had, is there anything that we didn't touch on that you want to talk about?

Dr. Suzanne Dixon [38:39]: Yeah, I just think we need to also think about the ideal state and how communities can help each other to prevent this problem. So, really focusing on the postpartum period and the introsusception period and when you have a patient come in to talk about birth control or considering starting a family screening for iron deficient anemia at that time and going ahead, it can take four to six months if someone is iron deficient to build up their stores without doing one of those IV infusions and ideally you'd like to avoid those also if you can, and so educating people about dietary sources of iron that fit with their preferences and cultural availability and what's available in their neighborhood trying to really establish why this is important for lifelong health, but also during pregnancy and help people try to gain access to healthy things like a list of foods that are high on iron that they could choose from, even if they're vegan or vegetarian.

Right. Also, foods that can be eaten with iron-containing foods that'll help with absorption, like acidic things like vitamin C containing fruits and broccoli and peppers and things like that are supposed to really help with absorption, and then avoiding things that are going to decrease absorption. So, dairy is a big culprit for that. And coffee, unfortunately, is, oh no, they also list red wine and things like chocolate. So, kind of the good stuff actually makes you not absorb iron quite as well. So, just the timing of your intake of those things when you're, you know, when you're trying to consume iron supplements or meals that do have iron-containing foods is really helpful to know that I think. So, really building on that a healthy period of time before conception would be an ideal state if possible.

Katlyn[40:41]: I love that, meeting people where they are too, like really understanding what kind of access they have and, and what kind of things they already enjoy eating. I think that's a really good tidbit there. All right, Dr. Dixon, I think that's all the time we have today. Thank you so much for coming and educating us on anemia and pregnancy and letting us know all the things that have changed and, and updated. We really appreciate your time and expertise.

Dr. Suzanne Dixon [41:11]: Thanks. It's a pleasure to be here, and thanks to everybody for tuning in on this important topic.

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