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Iron deficiency anemia (IDA) in pregnancy is highly prevalent and if left unrecognized or untreated, IDA can affect maternal and fetal morbidity and mortality.1 However, the best clinical approaches to detection and treatment of IDA remain highly debated. The most effective treatment regimen is unknown; however, use of intravenous (IV) iron formulations has shown promise.2 Previous studies have suggested a role for IDA treatment algorithms to be adopted for prenatal care,3 while a recent randomized controlled trial with liberal use of IV iron formulations did not show improvement in achieving a non-anemia state in the primary analysis.4 We designed a pre- and post-implementation cohort study at a single academic center with approximately 3400 births annually and a medically diverse population to assess the impact of implementing a standardized approach to IDA. Prior to implementing a standard IDA diagnosis and treatment algorithm developed by our coauthors based on the available literature1-3 (Figure S1), our prenatal clinics had no standardized approach for IDA. We hypothesized that implementing a protocol with liberal use of IV iron (mostly a single dose of IV iron carboxymaltose, 750 mg if Hbg >9 g/dL or 1500 mg if Hgb <9 g/dL mid-trimester) in the late second or early third trimester would improve the rate of anemia defined as Hgb <11 g/dL at time of hospital admission for birth. This study was approved by Atrium Health Wake Forest Baptist Institutional Review Board (IRB# 00067715). Due to its quality improvement nature, the IRB found that the study met criteria for expedited review and waiver of consent under 45 CFR 46(d) due to no more than minimal risk to human subjects. Statistical analysis was performed using STATA SE 17 (StataCorp LLC, College Station, TX, USA), with the χ2-test for categorical and the t-test for continuous variables. Baseline maternal characteristics were similar between the pre-implementation group (n = 200) and the post-implementation group (n = 176) regarding maternal age, pre-pregnancy body mass index (BMI), health insurance coverage type, gestational age at delivery, mid-trimester ferritin levels, and rate of IDA at the standard 24–28-week mid-trimester blood draw (30% pre vs. 32% post). Among those with midtrimester anemia, initial mean hemoglobin levels upon hospital admission for birth were similar pre versus post implementation (10.9 g/dL ±1.2 standard deviation [SD] vs. 11.1 g/dL ±1 SD, P = 0.35) and, although the observed rate of pre-delivery anemia was lower in the post-implementation group, rates of anemia at birth admission defined as Hgb <11 g/dL were statistically similar between groups (53% pre vs. 40% post, P = 0.16). Comparing the average rise in hemoglobin among those with midtrimester IDA (i.e. delta hemoglobin), we observed a greater rise in hemoglobin post-protocol implementation, but this was not statistically significant (Hgb g/dL rise 0.55 vs. 0.9, P = 0.08). IV iron utilization increased from pre-implementation to post-implementation among prenatal patients with IDA from 0% to 30% (P < 0.01). The peripartum blood transfusion rate remained static across the two periods (2.5% vs. 2.3%); however, we were underpowered for this rare outcome. The trend in birth admission hemoglobin is displayed as a scatter chart in Figure 1, with a washout period accounting for introduction of our department's quality improvement protocol (Figure S1). The hemoglobin trend was flat across time periods and within periods. In summary, our standardized protocol for IDA markedly increased IV iron utilization in the third trimester without substantially affecting the rates of anemia just prior to delivery at time of birth hospitalization. While this pre–post cohort quality improvement study has limitations regarding study design and potential biases, we are not the only center caring for high-risk obstetric patients who have yet to demonstrate firsthand the potential benefits of IV iron protocol implementation in moving the needle on anemia at time of birth admission as a surrogate for peripartum blood transfusion risk.5 Our study did suggest trends in lower rates of anemia at birth, and in post-hoc power analysis we reached sufficient power to have detected 14.4% absolute reduction in anemia rates. However, improvement of a smaller magnitude might be considered clinically significant, especially if IV iron therapies could be better tailored for the highest risk populations. Therefore, future larger studies are needed to better identify those patients predicted to have optimum response to IV treatment and at highest risk for anemia at birth if left untreated. All authors were involved in the study's design, planning, conduct, data analysis/interpretation, and manuscript drafting/revision, and all approved the final manuscript. The authors have nothing to report. Dr. Zuber is a consultant obstetrics topic editor for DynaMed, EBSCO Industries. Research data are not shared. Figure S1. Atrium Health Wake Forest Baptist iron deficiency anemia (IDA) diagnosis and treatment protocol. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.