Patterns and predictors of severe postpartum anemia after Cesarean section

Abstract

Background Postpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage (PPH)) with severe postpartum anemia after cesarean section. Study Design and Methods Data were collected from 70,939 hospitalizations for cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as a hemoglobin < 8 g/dl before hospital discharge. Using multivariable logistic regression, we assessed the associations between predelivery anemia and PPH with severe postpartum anemia. Distributions of these characteristics among women with severe postpartum anemia were evaluated. Results The overall rate of severe postpartum anemia was 7.3%; 95% confidence interval (CI) = 7.1 – 7.4. Severe postpartum anemia was strongly associated with a predelivery hemoglobin between 10 and 10.9 g/dl (adjusted odds ratio (aOR) 5.4; 95% CI = 4.89– 5.91), predelivery hemoglobin <10 g/dl (aOR 30.6; 95% CI = 27.21– 34.6, and PPH (aOR 8.45; 95% CI = 7.8–9.16). The proportions of women with severe postpartum anemia were highest for those experiencing PPH but no predelivery anemia (12.2%; 95% CI = 11.0 – 13.6), and those who did not incur PPH nor predelivery anemia (10.7%; 95% CI = 9.6 – 12.0). Conclusions Our findings suggest that PPH and predelivery anemia are strong independent risk factors for severe postpartum anemia. Optimization of patients’ hemoglobin prior to delivery may reduce the incidence of severe anemia after cesarean section.

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies

“…These findings are consistent with those by Butwick et al who reported that predelivery anemia is an independent risk factor for severe postpartum anemia after CD, classified by a postpartum Hb≤8 g/dl. 40 Furthermore, several obstetric societies, including The Royal College of Obstetricians and Gynecologists (UK) and the French College of Gynecologists and Obstetricians, have published PPH guidelines recommending that a Hb level above 8 g/dl is a therapeutic goal. 41 These observations, coupled with our findings, have important clinical relevance for several reasons.…”

Caesarean delivery and anaemia risk in children in 45 low‐ and middle‐income countries

“…In a meta-analysis of seven observational studies, Hb levels were 0.51 g/dl lower in neonates born by CD compared with those born vaginally (Zhou et al, 2014). CD may reduce Hb and other haematolog- Additionally, delayed microbiota acquisition in children born by CD can affect their immunophysiological development and increase the risk of infections (Gronlund, Lehtonen, Eerola, & Kero, 1999), which would decrease iron absorption (Hurrell, 2012) may cause maternal anaemia (Butwick, Walsh, Kuzniewicz, Li, & Escobar, 2017) and reduce the amount of iron in breast milk.…”

Postpartum anemia: missed opportunities for prevention and recognition

“…In their article, “Patterns and Predictors of Severe Postpartum Anemia after Cesarean Section,” Butwick and colleagues find that postpartum anemia is common, affecting 7.3% of the post‐Cesarean delivery population. As Cesarean delivery is the most frequently performed surgical procedure in the United States, with 1.3 million Cesarean deliveries in 2014, postpartum anemia after Cesarean delivery affects approximately 100,000 women annually .…”

“…In the analysis by Butwick and colleagues, predelivery anemia was the most important predictor of postpartum anemia, accounting for 31% of cases . This observation suggests that a large proportion of cases of postpartum anemia may be preventable through better screening and treatment of predelivery anemia.…”

“…After the initial test and treatment with these measures, in the absence of profound anemia or clinical symptoms, a CBC is not commonly repeated prior to the delivery admission. The data presented by Butwick and colleagues suggest a relatively high prevalence of predelivery anemia (12.5%, among those with a documented predelivery Hb) in the setting of routine practice . This observation argues that there is a need for additional prevention and that an additional CBC, perhaps at 34 to 36 weeks, may be indicated to allow time for additional predelivery intervention.…”