Student Research Proposes New Protocol to Reduce Iron Deficiency Anemia and Improve Maternal Health
Summary
- Dr. Paloma Toledo and medical student J.P. Russo are studying iron deficiency anemia with the hope of reducing the elevated rates of anemia in the delivery room.
- Russo and Dr. Toledo performed a retrospective analysis of 4,713 deliveries and found 33 percent of patients were anemic at admission.
- They implemented an effective protocol that included early and repeated screening for anemia and iron deficiency, clear treatment pathways for oral and IV iron, standardized timing for follow‑up labs and escalation based on hemoglobin or ferritin values.
In a recent analysis of countries with advanced economies, the United States had a higher maternal mortality rate than almost any other industrialized country. In fact, the U.S. maternal mortality rate in 2022 was about 55% higher than the nation with the second-highest rate among those evaluated in the study.
One major driver behind these trends is severe blood loss after childbirth. Postpartum hemorrhage remains one of the leading causes of maternal death and complications worldwide.
It’s a topic of great interest to University of Miami Miller School of Medicine medical student Jean‑Paul (JP) Russo, a Miller School Dean’s Research Excellence Award in Medicine (DREAM) scholar, and his research mentor, Paloma Toledo, M.D., M.P.H., F.A.S.A., a professor and the chief of obstetric anesthesiology at the Miller School. Dr. Toledo and Russo are studying a particularly important and preventable contributor to postpartum hemorrhage outcomes, iron deficiency anemia. Their goal is to reduce the elevated rates of anemia at delivery and reduce the need for blood transfusions for women in labor through a targeted anemia management intervention.
“We wanted to take a look at the proportion of women who had anemia, but also had iron deficiency, which is the most common cause of anemia during pregnancy,” Russo said. “We want to reduce the chance of needing to expose a pregnant patient to blood transfusions and its associated risks by treating anemia in the outpatient setting prior to delivery.”
“We have high rates of hemorrhage and transfusions and a very high proportion of patients with anemia, so it is the perfect setting to evaluate if an intervention to treat anemia before delivery can improve outcomes after delivery,” Dr. Toledo said.
A Growing Problem with Serious Consequences
Postpartum hemorrhage affects up to 4 percent of pregnancies in the U.S. and can lead to significant complications, including blood transfusion, organ injury and, possibly, emergency hysterectomy. When patients begin labor and delivery with low hemoglobin levels, they cannot tolerate blood loss as effectively, making them more vulnerable to the complications that can arise following a hemorrhage.
As a first step, Russo and Dr. Toledo performed a retrospective analysis of 4,713 deliveries over one year. They found one out of every three patients were anemic at admission. Iron studies, which measure lab values such as ferritin in the blood, provided an even clearer picture for the team. Among 2,426 patients with available iron studies, 73% had iron deficiency and 29% had iron deficiency and anemia.
How Anemia Increases Hemorrhage Risk
To understand the impact of anemia on hemorrhage, the research team examined postpartum blood loss across hemoglobin ranges. The results showed a clear, stepwise relationship. As hemoglobin decreased, the likelihood of postpartum hemorrhage increased significantly.
The team next analyzed 25 cesarean deliveries that required transfusion in anemic women. Using standard formulas for allowable blood loss, a concept that allows for calculation of the amount of blood a patient can lose before requiring a blood transfusion, they modeled how transfusion needs would change if the patient’s hemoglobin had increased by just one gram per deciliter, an increase which is possible through outpatient anemia management.
“We saw that 23 out of the 25 women in that cohort could have potentially avoided a blood transfusion if their hemoglobin was one g/dL higher,” Russo said. “So even if those patients still had anemia or other risk factors, just by increasing their hemoglobin by one g/dL, we could potentially have reduced 92% of blood transfusions.”
A Standardized Protocol to Break the Cycle
National guidelines offer limited guidance on when or how to screen and treat iron deficiency anemia during pregnancy. To address this gap, the team developed a trimester‑based iron deficiency anemia screening and management protocol.
The protocol includes:
• Early and repeated screening for anemia and iron deficiency
• Clear treatment pathways for oral and intravenous (IV) iron
• Standardized timing for follow‑up labs
• Built‑in escalation based on hemoglobin or ferritin values
Before implementation, the team aimed to identify barriers that might limit success. The highest‑priority issue was a delay in IV iron, due to insurance authorization. To address this, Russo developed a smart template in the electronic medical record system to streamline insurance requests.
“We had to figure out the specific language insurance companies were looking for,” he said. “Once we had that information, we created smart phrases or shortcuts for the electronic medical record, which make the process much simpler for providers. When the obstetricians want to prescribe IV iron, they can now just type ‘IV iron’ and then everything the insurance company is looking for will automatically populate in the medical record.”
After implementation, Dr. Toledo and Russo found that patients whose prenatal care included their protocol had statistically significant lower rates of iron deficiency compared to patients whose care didn’t involve the protocol. The protocol was already helping reduce anemia by the time of delivery.
Looking Ahead
Dr. Toledo and Russo, who presented the work at the Miller School’s most recent DREAM symposium, will extend the research to further assess protocol adherence, evaluate improvements in hemoglobin, iron stores, and patient outcomes at delivery and, ultimately, expand the protocol to other practices.
The work has also changed Russo’s trajectory in medicine.
“When I first came to medical school, I never imagined I would be dedicating a full year to research,” he said. “With my background in public health, I was hoping to find ways to improve the health of the community. I was fortunate enough to meet Dr. Toledo and be a part of this research, which has been the most transformative experience of my time at the Miller School.”
“When you are a physician-scientist, your job is to find the people who are going to be the next generation of researchers and get them excited about research,” said Dr. Toledo. “JP was fantastic to work with. Knowing that he will likely continue on in this research going forward as part of residency and beyond is really the most fulfilling thing to me.”
Tags: anemia, anesthesiology, Department of Anesthesiology, Dr. Paloma Toledo, medical students, pregnancy, student research