Iron deficiency in pregnancy, obstetrics, and gynecology

Expert consensus on improving iron deficiency anemia management in obstetrics and gynecology in Asia

Iron deficiency anemia (IDA) is a major health burden among women in Asia. Key issues in IDA management in Asia are under-diagnosis and under-treatment. The lack of Asia-specific guidelines, and suboptimal utilization of treatment compounds the management of IDA. To address these gaps, a panel of 12 experts in obstetrics, gynecology, and hematology from six regions in Asia convened to review current practices and clinical evidence and provide practical guidance on IDA diagnosis and management in Asian women. The Delphi approach was used to obtain objective opinions and attain consensus on statements pertaining to awareness, diagnosis, and management of IDA. In total, 79 statements attained consensus and are summarized to provide guidance on raising awareness of IDA and approaches for improved diagnosis and treatment of IDA among women in various settings: pregnancy, postpartum, heavy menstrual bleeding, gynecologic cancers, and perioperative care. This clinician-led consensus integrates appropriate recommendations based on clinical evidence and best practices and is intended to guide decision making in the management of iron deficiency/IDA in women. The expert panel raises a call for timely diagnosis and utilization of appropriate treatment, including use of high-dose intravenous iron, stringent blood management, and interdisciplinary collaboration, for optimization of IDA management among women in Asia.

Fetal Alcohol Spectrum Disorder and Iron Homeostasis

Prenatal alcohol exposure results in a spectrum of behavioral, cognitive, and morphological abnormalities collectively referred to as fetal alcohol spectrum disorder (FASD). FASD presents with significant phenotypic variability and may be modified by gestational variables such as maternal nutritional status. Iron serves a critical function in the development of and processes within central nervous system (CNS) structures. Gestational iron deficiency alters CNS development and may contribute to neurodevelopmental impairment in FASD. This review explores the relationship between iron deficiency and fetal alcohol spectrum disorder as described in small animal and human studies. Consideration is given to the pathophysiologic mechanisms linking iron homeostasis and prenatal alcohol exposure. Existing data suggest that iron deficiency contributes to the severity of FASD and provide a mechanistic explanation linking these two conditions.

Global Prevalence of Anemia in Pregnant Women: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

Anemia is one of the most critical health conditions affecting people worldwide. The disease is silent, with a slow progression and a few physical symptoms. Anemia during pregnancy carries the risk of premature birth, low birth weight, and fetus malformations and can impose additional costs on society and families. Therefore, the aim of this study is to conduct a systematic review and meta-analysis on the prevalence of anemia in pregnant women worldwide.

METHODS

In this work, we have conducted a systematic review and meta-analysis of the studies that have examined the prevalence of anemia in pregnant women globally. The Google Scholar, Cochrane, ScienceDirect, Medline (PubMed), and Web of Science (WoS) databases were searched for articles published between 1991 and 2021. The search keywords were anemia, pregnancy, prevalence, and meta-analysis. In order to analyze the eligible studies, the stochastic effects model was used, and the heterogeneity of the studies was examined using the I² index. Data analysis was performed within the Comprehensive Meta-Analysis software (Version 2).

RESULTS

The search resulted in 338 deduplicated studies, of which 52 studies with a total sample size of 1,244,747 people were included in this review. According to the results of the meta-analysis, the overall prevalence of anemia in pregnant women is 36.8% (95% confidence interval: 31.5-42.4%). The highest prevalence of anemia is mild at 70.8 (95% CI 58.1-81) and highest in the third trimester of pregnancy with the prevalence of 48.8 (95% CI 38.7-58.9), while the highest prevalence of anemia in pregnant women was in Africa with the prevalence of 41.7 (95% CI 32.3-49.4).

CONCLUSION

The results of this study show a high prevalence of anemia among pregnant women worldwide, and the highest of this prevalence is mild anemia. The prevalence of anemia in the third trimester was higher than in the first and second trimesters. Anemia in pregnant women in developing countries is significantly higher than in developed countries due to pregnancy's economic, sociological, and health factors.

Prevalence and determinants of anemia among Iranian population aged ≥35 years: A PERSIAN cohort-based cross-sectional study

Background

So far, no comprehensive studies have been performed to assess burden and determinants of anemia in Iran. In the present study, we aimed to answer this query using the data obtained from the Prospective Epidemiological Research Studies in IrAN (PERSIAN).

Methods

In this cross-sectional study, we included 161,686 adult participants (aged 35 years and older) from 16 provinces of Iran. Anemia was defined as a hemoglobin concentration of <13 g/dL in males and <12 g/dL in females. To evaluate the association between anemia and different factors, we used the multivariable Poisson regression analysis with robust variance by applying adjusted prevalence ratio (PR) with 95% confidence interval (CI).

Results

Of the total number of subjects, 72,387 (44.77%) were male and others were female. Mean age was 49.39±9.15 years old. The overall age- and sex-standardized prevalence of anemia was 8.83% (95% CI: 8.70–8.96%) in the included population. The highest and the lowest age- and sex-standardized prevalence of anemia pertained to Hormozgan (37.41%, 95% CI: 35.97–38.85%) and Kurdistan (4.57%, 95% CI: 3.87–5.27%) provinces, respectively. Being female (PR = 2.97), rural residence (PR = 1.24), being retired (PR = 1.53) and housewife (PR = 1.11), third and fourth wealth status quartiles (PR = 1.09 and PR = 1.11, respectively), being underweight (PR = 1.49), drug user (PR = 1.35), inadequate sleep (PR = 1.16), poor physical activity (PR = 1.15), diabetes (PR = 1.09), renal failure (PR = 2.24), and cancer (PR = 1.35) were associated with increased risk of anemia. On the other hand, illiteracy (PR = 0.79) and abdominal obesity (PR = 0.77) decreased the risk of anemia.

Conclusions

According to the results, a variable prevalence of anemia was observed across the included provinces. We tried to provide an informative report on anemia prevalence for health professionals and authorities to take measures for identification and management of the cases of anemia in high-prevalence areas.

Prevalence and determinants of anemia among pregnant women in East Africa; A multi-level analysis of recent Demographic and Health Surveys

Introduction

Anemia during pregnancy is a public health problem that leads to different life-threatening complications and poor pregnancy outcomes. So far, the evidence is scarce on pooled prevalence and determinants of anemia during pregnancy in East Africa for integrated intervention. Therefore, this study aimed to assess the prevalence and determinants of anemia among pregnant women in eastern Africa using recent Demographic and Health Surveys.

Method

Secondary data analysis was conducted using data from recent Demographic and Health Survey datasets from 10 East African countries. A total of 8583 (weighted sample) pregnant women were included in the analysis. The multi-level mixed-effects generalized linear model (Poisson regression with robust error variance) was fitted to identify determinants of anemia. Finally, the adjusted prevalence ratio (aPR) with 95% CI and random effects for the multilevel generalized linear mixed-effects model was reported.

Results

In this study, the overall prevalence of anemia among pregnant women was 41.82% (95% CI: 40.78, 42.87) with a large difference between specific countries which ranged from 23.36% in Rwanda to 57.10% in Tanzania. In the multi-level analysis, teenage pregnant women (aPR = 1.22;95%CI:1.02, 1.40), unmarried women (aPR = 1.14; 95% CI;1.02,1.28), pregnant women who had unimproved toilet facility (aPR = 1.17;95%CI:1.06,1.27), and those women from countries with high illiteracy level (aPR = 1.12;95%CI; 1.07,1.18) had a higher prevalence of anemia during pregnancy.

Conclusion

Anemia is still a public health problem in East Africa. Therefore, enabling the households to have improved toilet facilities by strengthening the existing health extension program, reducing teenage pregnancy, and improving the community literacy level is vital to reduce the prevalence of anemia during pregnancy in East Africa.

Prediction of anemia at delivery

We aimed to assess risk factors for anemia at delivery by conducting a secondary analysis of a prospective cohort study database including 1527 women who delivered vaginally ≥ 36 gestational weeks. Anemia (Hemoglobin (Hb) < 10.5 g/dL) was assessed at delivery. A complete blood count results during pregnancy as well as maternal and obstetrical characteristics were collected. The primary endpoint was to determine the Hb cutoff between 24 and 30 gestational weeks that is predictive of anemia at delivery by using the area under the curve (AUC) of the receiver operating characteristic curve. Independent risk factors for anemia at delivery were assessed using stepwise multivariable logistic regression. Hb and infrequent iron supplement treatment were independent risk factors for anemia at delivery (OR 0.3 95%CI [0.2–0.4] and OR 2.4 95%CI [1.2–4.8], respectively; C statistics 83%). Hb 10.6 g/dL was an accurate cutoff to predict anemia at delivery (AUC 80% 95%CI 75–84%; sensitivity 75% and specificity 74%). Iron supplement was beneficial to prevent anemia regardless of Hb value. Altogether, Hb should be routinely tested between 24 and 30 gestational weeks to screen for anemia. A flow chart for anemia screening and treatment during pregnancy is proposed in the manuscript.

Trial registration: ClinicalTrials.gov Identifier: NCT02434653.

Intravenous iron vs blood for acute post-partum anaemia (IIBAPPA): a prospective randomised trial

BACKGROUND

Acute post-partum anaemia can be associated with significant morbidity including a predisposition for postnatal depression. Lack of clear practice guidelines means a number of women are treated with multiple blood transfusions. Intravenous iron has the potential to limit the need for multiple blood transfusions but its role in the post-partum setting is unclear.

METHODS/DESIGN

IIBAPPA is a multi-centre randomised non-inferiority trial. Women with a primary post-partum haemorrhage (PPH) >1000 mL and resultant haemoglobin (Hb) 5.5-8.0 g/dL after resuscitation with ongoing symptomatic anaemia who are otherwise stable (no active bleeding) are eligible to participate. Patients with sepsis or conditions necessitating rapid Hb restoration are excluded. Eligible participants are randomised to receive a blood transfusion or a single dose of intravenous iron polymaltose calculated using the Ganzoni formula. Primary outcome measures include Hb, Ferritin and C-Reactive Protein levels on Day 7. Secondary outcomes evaluate (i) Hb, Ferritin and CRP levels on Day 14, 28, (ii) anaemia symptoms on Day 0, 7, 14 and 28 using structured health related quality of life questionnaires, (iii) treatment safety by assessing adverse reactions and infection endpoints and (iv) the quantitative impact of anaemia on breast feeding quality using a hospital designed questionnaire.

DISCUSSION

If equivalence in Hb and ferritin levels, symptom scores and safety endpoints is demonstrated, intravenous iron may become the preferred treatment for women with acute post-partum anaemia to minimise transfusion reactions and costs.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12615001370594 on 16th December, 2015 (prospective approval).

Sociodemographic factors influencing adherence to antenatal iron supplementation recommendations among pregnant women in Malawi: Analysis of data from the 2010 Malawi Demographic and Health Survey

BACKGROUND AND AIM

Maternal morbidity and mortality statistics remain unacceptably high in Malawi. Prominent among the risk factors in the country is anaemia in pregnancy, which generally results from nutritional inadequacy (particularly iron deficiency) and malaria, among other factors. This warrants concerted efforts to increase iron intake among reproductive-age women. This study, among women in Malawi, examined factors determining intake of supplemental iron for at least 90 days during pregnancy.

METHODS

A weighted sample of 10,750 women (46.7%), from the 23,020 respondents of the 2010 Malawi Demographic and Health Survey (MDHS), were utilized for the study. Univariate, bivariate, and regression techniques were employed. While univariate analysis revealed the percent distributions of all variables, bivariate analysis was used to examine the relationships between individual independent variables and adherence to iron supplementation. Chi-square tests of independence were conducted for categorical variables, with the significance level set at P < 0.05. Two binary logistic regression models were used to evaluate the net effect of independent variables on iron supplementation adherence.

RESULTS

Thirty-seven percent of the women adhered to the iron supplementation recommendations during pregnancy. Multivariate analysis indicated that younger age, urban residence, higher education, higher wealth status, and attending antenatal care during the first trimester were significantly associated with increased odds of taking iron supplementation for 90 days or more during pregnancy (P < 0.01).

CONCLUSIONS

The results indicate low adherence to the World Health Organization's iron supplementation recommendations among pregnant women in Malawi, and this contributes to negative health outcomes for both mothers and children. Focusing on education interventions that target populations with low rates of iron supplement intake, including campaigns to increase the number of women who attend antenatal care clinics in the first trimester, are recommended to increase adherence to iron supplementation recommendations.

Maternal Deworming Research Study (MADRES) protocol: a double-blind, placebo-controlled randomised trial to determine the effectiveness of deworming in the immediate postpartum period

INTRODUCTION

Soil-transmitted helminth infections are endemic in 114 countries worldwide, and cause the highest burden of disease among all neglected tropical diseases. The WHO includes women of reproductive age as a high-risk group for infection. The primary consequence of infection in this population is anaemia. During lactation, anaemia may contribute to reduced quality and quantity of milk, decreasing the duration of exclusive breastfeeding and lowering the age at weaning. To date, no study has investigated the effects of maternal postpartum deworming on infant or maternal health outcomes.

METHODS AND ANALYSIS

A single-centre, parallel, double-blind, randomised, placebo-controlled trial will be carried out in Iquitos, Peru, to assess the effectiveness of integrating single-dose 400 mg albendazole into routine maternal postpartum care. A total of 1010 mother-infant pairs will be randomised to either the intervention or control arm, following inhospital delivery and prior to discharge. Participants will be visited in their homes at 1, 6, 12 and 24 months following delivery for outcome ascertainment. The primary outcome is infant mean weight gain between birth and 6 months of age. Secondary outcomes include other infant growth indicators and morbidity, maternal soil-transmitted helminth infection and intensity, anaemia, fatigue, and breastfeeding practices. All statistical analyses will be performed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained from the McGill University Health Centre (Canada), the Asociación Civil Impacta Salud y Educación (Peru) and the Instituto Nacional de Salud (Peru). A data safety and monitoring committee is in place to oversee study progression and evaluate adverse events. The results of the analyses will be published in peer-reviewed journals, and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT01748929.

The Add-Arm Design for Unimodal Response Curve with Unknown Mode

In a classical drop-loser (or drop-arm) design, patients are randomized into all arms (doses) and at the interim analysis, inferior arms are dropped. Therefore, compared to the traditional dose-finding design, this adaptive design can reduce the sample size by not carrying over all doses to the end of the trial or dropping the losers earlier. However, all the doses have to be explored. For unimodal (including linear or umbrella) response curves, we proposed an effective dose-finding design that allows adding arms at the interim analysis. The trial design starts with two arms, depending on the response of the two arms and the unimodality assumption; we can decide which new arms to be added. This design does not require exploring all arms (doses) to find the best responsive dose; therefore, it can further reduce the sample size from the drop-loser design by as much as 10-20%.

Iron deficiency anemia: a common and curable disease

Iron deficiency anemia arises when the balance of iron intake, iron stores, and the body's loss of iron are insufficient to fully support production of erythrocytes. Iron deficiency anemia rarely causes death, but the impact on human health is significant. In the developed world, this disease is easily identified and treated, but frequently overlooked by physicians. In contrast, it is a health problem that affects major portions of the population in underdeveloped countries. Overall, the prevention and successful treatment for iron deficiency anemia remains woefully insufficient worldwide, especially among underprivileged women and children. Here, clinical and laboratory features of the disease are discussed, and then focus is placed on relevant economic, environmental, infectious, and genetic factors that converge among global populations.

Pregnancy outcomes among patients with sickle cell disease at Korle-Bu Teaching Hospital, Accra, Ghana: retrospective cohort study

Pregnancy in sickle cell disease (SCD) patients is associated with increased risk of maternal and fetal mortality. This study determines pregnancy outcomes among women with SCD delivering at Korle-Bu Teaching Hospital, Accra, Ghana. Nine hundred sixty (960) medical records of pregnant women (131 HbSS, 112 HbSC, and 717 comparison group) from 2007 to 2008 were reviewed. The HbSS women were at increased risk of eclampsia (adjusted odds ratio [AOR] = 10.56, 95% confidence interval [CI] = 3.60-30.96, P < 0.001), intrauterine growth restriction (AOR = 4.00, 95% CI = 1.38-11.64, P = 0.011), and placenta previa (AOR = 22.03, 95% CI = 9.87-49.14, P < 0.001) compared with the comparison group. The HbSC women had increased risk for intrauterine fetal death (AOR = 3.38, 95% CI = 1.15-9.96, P = 0.027) and decreased risk of delivering low birth weight babies (AOR = 0.21, 95% CI = 0.06-0.73, P = 0.014). Women with SCD in Ghana are at a greater risk of morbidity and mortality in pregnancy compared with women without hemoglobinopathies. Improved maternal and fetal outcomes in Ghanaian women with SCD can be achieved through effective intervention by health care providers with thorough knowledge about predisposing factors toward adverse outcomes.

Assessment of intravenous iron sucrose in the management of anemia in gynecological and obstetrical practice

OBJECTIVE

The present study was undertaken to assess the impact of intravenous iron sucrose (Feronia IV) in the treatment of iron deficiency anemia observed in gynecological and obstetrical practice.

METHODS

Seventy-seven practicing gynecologists and obstetricians throughout India collaborated in the recruitment of 145 women over a period of 1 year, of which 143 were analyzable cases.

RESULTS

The overall mean rise in hemoglobin level was observed to be 2.43 gm % at the end of 4 weeks. The dose of iron sucrose administered ranged from 100 to 1,050 mg. In women who received 200 mg of the drug, and the mean Hb rise was found to be 2.21 ± 1.06 gm %. The highest observable rise in hemoglobin level was 5.5 gm % with 800 mg of iron sucrose. No serious adverse reactions were reported during the observation period.

CONCLUSION

Intravenous Iron sucrose is a safe and effective treatment for the rapid reversal of iron deficiency anemia, in obstetric and gynecological settings.

Bonding in women with postnatal anaemia: a pilot case control study looking at postnatal bonding in women who have been diagnosed with anaemia at a University Hospital in the East of England

PURPOSE

Anaemia is common postpartum; however, the effect of anaemia on mother-infant bonding is presently unknown. This case controlled study was designed to evaluate the effects of anaemia on mother and baby bonding in the first month following delivery.

METHODS

945 consecutive postpartum women who gave birth at home or in the obstetric unit at a university hospital in the East of England were identified from the hospital computer records. Blood counts had been performed on 279 of these women within 48 h of delivery, entirely at the discretion of the clinical team. The women with available blood count data were sent a self-reporting questionnaire which included a validated postpartum bonding questionnaire (PBQ). Data were collected from the 115 (41%) responses and analysed for the evidence of an effect of anaemia on bonding.

RESULTS

57 (50%) of women responding to the questionnaire were anaemic (haemoglobin < 10 g/dL). There was no evidence of a difference between maternal, age, parity, mode of delivery, gestational age, baby weight or baby age at the time of completing questionnaire between the anaemic and non-anaemic groups. Moreover, there was no evidence of a difference in maternal perception of mother-infant bonding between the anaemic and non-anaemic groups.

CONCLUSION

Our study suggested no evidence of an association between postnatal anaemia and the mother's ability to bond with the baby; however a small but significant effect may still exist which we were not able to detect due to a possible lack of power, hence we suggest, further larger studies to be conducted.

Expert recommendations for the diagnosis and treatment of iron-deficiency anemia during pregnancy and the postpartum period in the Asia-Pacific region

Anemia during pregnancy and the postpartum period is commonly caused by iron deficiency and is a significant worldwide issue with severe consequences for both mother and developing fetus. From a worldwide perspective, iron-deficiency anemia (IDA) during pregnancy is highest in the Asia-Pacific region; however, there has been little guidance in this region for safe and effective treatment. An expert panel was convened to develop a concise and informative set of recommendations for the treatment of IDA in pregnant and postpartum women in the Asia-Pacific region. This manuscript provides these recommendations and aims to reduce the morbidity and mortality associated with IDA in pregnant and postpartum women in the Asia-Pacific region. The consensus recommendations define anemia as a hemoglobin (Hb) level <10.5 g/dL during pregnancy and <10 g/dL during the postpartum period, and provide cut-off Hb levels to initiate therapy with oral iron, intravenous iron or red blood cell transfusion.

Indispensable and replaceable amino acids in the blood serum and their relationship with macro- and microelements in the newborns of Fe-deficient anemic mothers (in conditions of an industrial city)

Anemia of the newborn is undoubtedly an actual problem in pediatrics. The imbalance between amino acids and biologically active macro- and microelements participating in hematopoiesis and Fe metabolism play an important role in its pathogenesis. Therefore knowledge of amino acid metabolism in the newborn helps to gain insight into pathogenetic mechanisms and to choose the right therapy. A complex inspection of 169 newborns of 18-34-year-old women was done. The control group consisted of 42 newborns of women with normal pregnancy and parturition. The case group consisted of 127 newborns of women with Fe-deficit anemia. Unquestionably one of the factors of Fe-deficit anemia of women aggravates the gestation period, delivery and after-birth period, and has an injurious effect on the newborn. Changes in the trace element and free amino acid metabolism were interconnected in the "mother-newborn" system as evidenced from correlations between the levels of some amino acids, trace element metabolism and erythropoiesis. The pathogenetic importance of the disturbance of the trace element and amino acid metabolism dictates the choice of the correct therapy of Fe-deficit anemia of pregnant women. The experience and results of our investigations support the necessity of preventive estimation of the content of macro- and microelements and amino acids in the blood serum of newborn to correct metabolic disturbances.

Anemia and iron deficiency in pregnant Ghanaian women from urban areas

OBJECTIVES

To determine the prevalence and identify risk factors for iron deficiency and anemia in pregnant Ghanaian women from urban areas.

METHODS

A cross-sectional study of 452 healthy pregnant women receiving prenatal care in Accra, Ghana, was conducted. A sociodemographic health questionnaire was performed and hematologic parameters were measured. Logistic regression methods were used to identify risk factors for anemia and iron status.

RESULTS

Complete data were available for 428 women. Anemia (hemoglobin <11 g/dL) was present in 144 (34%), iron deficiency (ferritin < or =16 microg/L) in 69 (16%), and iron deficiency anemia in 32 (7.5%) women. The adjusted odds ratio (OR) for anemia was 3.4 and 9.8 if iron deficiency and malaria parasitemia were present, respectively; the OR was 0.6 if women were at > or =36 weeks of pregnancy. The adjusted OR for iron deficiency was 2.7 if women were at > or =36 weeks of pregnancy and 0.12 if they had sickle trait.

CONCLUSION

Although anemia and iron deficiency remain substantial problems in pregnant Ghanaian women from urban areas, their prevalence is less than previously reported.

Intravenous versus oral iron therapy for postpartum anaemia

OBJECTIVE

Postpartum iron deficiency anaemia (IDA) is common in women. Most women are treated with either oral iron supplementation or blood transfusion. Hence, the aim of our study was to compare the effect of treatment with either oral ferrous sulphate or intravenous ferrous sucrose on postpartum IDA.

DESIGN

A single centre, prospective randomised controlled trial.

SETTING

Women's Centre, John Radcliffe Hospital, Oxford, UK.

POPULATION

Forty-four women with haemoglobin (Hb) of <9 g/dl and ferritin of <15 microgram/l at 24-48 hours postdelivery.

METHODS

Women were randomised to receive either oral ferrous sulphate 200 mg twice daily for 6 weeks (group O) or intravenous ferrous sucrose 200 mg (Venofer; Vifor International Ltd, St Gallen, Switzerland), two doses given on days 2 and 4 following recruitment (group I).

RESULTS

were analysed by the Students t-test, chi-square test and analysis of variance.

MAIN OUTCOME MEASURES

Hb, haematocrit, red cell indices, ferritin and serum iron levels were measured on days 0, 5, 14 and 40. Results By day 5, the Hb level in women treated with intravenous iron had risen from 7.3 +/- 0.9 to 9.9 +/- 0.7 g/dl, while there was no change in those treated with oral iron. Women treated with intravenous iron had significantly higher Hb levels on days 5 and 14 (P < 0.01) than those treated with oral iron; although by day 40, there was no significant difference between the two groups. Throughout the study, ferritin levels rose rapidly in those treated with intravenous iron and remained significantly higher than in those treated with oral iron (P < 0.01).

CONCLUSIONS

Intravenous iron sucrose increases the Hb level more rapidly than oral ferrous sulphate in women with postpartum IDA. It also appears to replenish iron stores more rapidly. However, this study was not large enough to address the safety of this strategy.

Obstetric impact of anaemia in pregnant women in United Arab Emirates

Our objective was to determine the effect of anaemia during pregnancy on maternal and perinatal outcome. A retrospective case-control study was conduced on 100 anaemic (haemoglobin level < 11g/dl) and 100 non-anaemic, pregnant women with singleton pregnancies who received antenatal care and delivered vaginally in our hospital. The maternal characteristics of both groups were not different. The causes of anaemia were iron deficiency (91%), beta-thalassaemia trait (8%) and folate deficiency (1%). There was no significant difference in the mean gestational age at delivery (38.9 +/- 2.0 vs 39.6 +/- 1.6 weeks), 5-minute Apgar score (7.8 +/- 0.8 vs 7.9 +/- 0.1) and birth weight (3,150 +/- 530 vs 3,230 +/- 430 g) between both groups. Post-partum haemorrhage (3%), pre-term delivery (4%) and fetal growth restriction (6%) were more frequent in anaemic women but the difference was not significant. Anaemia, therefore, had no significant obstetric adverse effects in our pregnant hospital-population.

Effect of postpartum iron supplementation on red cell and iron parameters in non-anaemic iron-deficient women: a randomised placebo-controlled study

OBJECTIVE

To investigate the effect of oral iron on postpartum red cell and iron parameters in non-anaemic women with iron deficiency.

DESIGN

Randomised study of supplementation with oral iron sulphate 80 mg daily or placebo for 12 weeks starting 24-48 hours after delivery, with visits antepartum and 1, 4, 6 and 12 weeks postpartum.

SETTING

Swiss university hospital obstetric unit.

PARTICIPANTS

Fifty-two women with antenatal iron deficiency (serum ferritin <15 microg/L) and no antenatal or postnatal anaemia (haemoglobin >11 g/dL up to 48 hours before delivery, and >10 g/dL postpartum), divided into two groups comparable in antenatal iron status.

METHODS

Supplementation was started 24-48 hours after delivery (visit 1:V1). Additional tablets were issued one week after V1 (V2), four weeks after V1 (V3) and six weeks after V1 (V4). The last visit took place 12 weeks after visit 1 and 6 weeks after visit 4 (V5). Patients were required to return blisters and boxes whether they were used and unused at each visit and compliance was assessed by counting the tablets. Blood samples for haematology and iron status testing were taken before delivery and at each visit.

MAIN OUTCOME MEASURES

Iron status (serum ferritin, hypochromic red cells, iron, transferrin saturation, soluble transferrin receptor concentration); erythropoiesis (standard parameters, including reticulocyte indices); and inflammatory response (serum neopterin, C-reactive protein, white cell count) in five-datapoint profiles.

RESULTS

Increased ferritin (P= 0.0004) and transferrin saturation (P= 0.03), decreased soluble transferrin receptors (P= 0.02); increased haemoglobin (P= 0.02) and decreased hypochromic red cells (P= 0.04) compared with placebo at 12 weeks, with no differences in other red cell or reticulocyte parameters. There was a positive correlation between C-reactive protein and postpartum ferritin. No correlation was observed in the puerperium between C-reactive protein and hypochromic red cells or soluble transferrin receptors.

CONCLUSIONS

Haemoglobin levels and iron stores in women with term gestational iron deficiency benefit significantly from iron supplementation compared with placebo, even in an industrialised population.

Role of Helicobacter pylori infection in iron deficiency during pregnancy

OBJECTIVE

We investigated the possible role of Helicobacter pylori infection in iron deficiency during pregnancy in a large group of mothers in Germany after the birth of their baby under special consideration of iron supplementation.

STUDY DESIGN

All women who were delivered of their baby between November 2000 and November 2001 at the Department of Gynecology and Obstetrics at the University of Ulm, Germany, were recruited for the study. Hemoglobin levels at various points of time during pregnancy were obtained from the mothers' health charts. Current H pylori infection was determined by 13 C-urea breath test. We used multiple linear regression analyses to assess the impact of infection status on hemoglobin level at the beginning of pregnancy and on hemoglobin change during pregnancy.

RESULTS

Twenty-three percent of the 898 mothers had a H pylori infection, and 20% of the mothers had a hemoglobin level below 12 g/dL at the beginning of pregnancy. Compared with uninfected mothers, mothers with H pylori infection had a lower mean hemoglobin level at the beginning of pregnancy (-0.25 g/dL; 95% CI, -0.49, -0.003) and a more unfavorable change in hemoglobin level during pregnancy (-0.14 g/dL; 95% CI, -0.38, 0.10).

CONCLUSION

This study supports a possible moderate, but still relevant, independent role of H pylori infection in iron deficiency during pregnancy.

Impact of parturition on iron status in nonanaemic iron deficiency

BACKGROUND

Iron-deficient nonanaemic parturients risk underdiagnosis as a result of the reliance on postpartum ferritin and haemoglobin as markers of iron status. Ferritin is an acute-phase protein whose levels increase during the inflammatory response, as occurs after delivery. Our aims were to evaluate the impact of parturition on iron status, erythropoiesis and the inflammatory response, and identify the optimal parameters and timing for diagnosing iron deficiency in the presence of postpartum inflammation.

MATERIALS AND METHODS

Conventional parameters of iron status, erythropoiesis and the inflammatory response (serum ferritin, serum iron, transferrin saturation, C-reactive protein) were compared with more recent parameters [soluble transferrin receptors (sTfR), hypochromic red cells, reticulocyte indices] within 48 h either side of delivery in 64 iron-deficient nonanaemic women (defined by a prepartum serum ferritin < or =15 microg L(-1), and a pre- and postpartum haemoglobin of > or =11.0 g dL(-1) and > or =10.0 g dL(-1), respectively).

RESULTS

Mean sTfR decreased pre to postpartum from 7.3 to 5.8 microg mL(-1) (P<0.01), while mean serum ferritin increased from 9.7 to 16.9 microg L(-1) (P<0.01). Serum ferritin did not correlate with haemoglobin pre or postpartum (r=0.04, P=0.7; r=0.2, P=0.09), but a correlation persisted postpartum between hypochromic red blood cells and haemoglobin (r=-0.26; P<0.05). The percentage of hypochromic red cells remained virtually unchanged pre- and postpartum (4.0% vs. 3.8%; NS). Postpartum mean reticulocyte haemoglobin content (CHr) was 27.1 +/- 1.6 pg.

CONCLUSION

Iron status should be tested prepartum, in the absence of an inflammatory response, rather than in the early postpartum. A valuable additional parameter, where available, might be the hypochromic red cell percentage, which is virtually uninfluenced by the inflammatory response. Furthermore, hypochromic red cell percentage, CHr and sTfR can be helpful to differentiate between functional iron deficiency and depleted iron stores.

A survey of iron deficiency anaemia during pregnancy in Belgium: analysis of routine hospital laboratory data in Mons

Anaemia during pregnancy is a common problem worldwide. In industrialised countries, it is still frequent in some groups of population. This study is based on the retrospective analysis of results of routine blood analysis performed on 15-44 years old women attending prenatal clinics (study group) or other outpatient clinics (non pregnant group) in a public hospital in Mons, Belgium from 1997 to 1999. In the non-pregnant group (2503 women), anaemia (haemoglobin < 12 g/dL) was present in 7.7% of the women. During pregnancy, anaemia was defined as haemoglobin level < 11 g/dL. In our sample, during the 1st trimester of pregnancy, anaemia was present in 4.3% of 887 pregnancies, among which 35% meeting CDC criteria (ferritin < 12 micrograms/L) for iron deficiency anaemia (IDA). Frequency of anaemia increases through pregnancy. Among 1313 pregnancies, 31% suffer from anaemia during the 3rd trimester, among which 75% meet criteria for IDA. Both low haemoglobin and low ferritin levels during the 1st trimester are good predictors of 3rd trimester anaemia. Systematic administration of iron supplement during pregnancy is matter of debate. In order to limit supplementation to pregnant women at risk of 3rd trimester anaemia, we suggest to treat anaemia (haemoglobin level < 11 g/d) detected at the first prenatal visit and to give small doses of iron (30 mg per day) when haemoglobin level is between 11 g/dL and 13 g/dL or ferritin level is less than 20 micrograms/dL. Low doses are generally well tolerated and compliance is better.

Nutritional assessment and support during pregnancy

This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.