Fetal growth in maternal anaemia

Association between maternal anemia and stunting in infants and children aged 0-60 months: A systematic literature review

OBJECTIVES

Maternal anemia is a worldwide health issue and a common pregnancy complication. It leads to consequences including infant mortality, low birth weight, preterm birth, unrecoverable or partially reversible neurobehavioral and cognitive deficits, and short birth length. However, the relationship between maternal anemia and stunting in children is not well defined. This systematic literature review sought to determine whether maternal anemia was associated with height or length and stunting conditions in infants and children ages 0-60 mo in cohort, case-control, and cross-sectional studies carried out in several countries.

METHODS

A systematic review was performed on articles published from 2014-2021 related to maternal anemia and stunting. The electronic databases used were ScienceDirect, PubMed, Scopus, ProQuest, Google Search, and AJOG (American Journal of Obstetrics and Gynecology). The literature search was performed up to December 7, 2021.

RESULTS

Twelve studies were included. Nine studies examined the correlation between maternal anemia and length or weight in children. Seven of the nine studies showed an association between maternal anemia and stunting in children; the others showed an association between maternal anemia and birth length. Three studies found no association between maternal anemia and stunting in children under age 5 y.

CONCLUSIONS

The current review emphasizes that stunting in children may be associated with maternal anemia, specifically in developing countries. This implies that it is crucial to prevent anemia in adolescent girls and women before and during pregnancy as a part of programs to eliminate stunting in children.

Association of Maternal Anemia and Cesarean Delivery: A Systematic Review and Meta-Analysis

Anaemia during pregnancy is associated with an increased incidence of caesarean delivery (CD). This study was conducted to explore the association between CD and maternal anaemia. The PubMed/MEDLINE, Cochrane, Google, Google Scholar and ScienceDirect databases were searched for relevant studies on this topic. The assessment and review were conducted with the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. The studies were assessed using the modified Newcastle−Ottawa quality assessment scale. Data were collected in an Excel sheet, and the ‘meta’ package of the R 4.0.3 software was used for statistical analysis. Fourteen studies that enrolled 336,128 pregnant women were included in the meta-analysis. Women with anaemia were found to be at a higher risk for CD (OR = 1.63, 95% CI = 1.23−2.17). As heterogeneity was detected in the studies, the random-effects model was used for the pooled meta-analysis (Q = 96.7, p < 0.001). In the subgroup analysis, anaemic women were found to be at higher risk for CD in studies from both low-middle-income (7) and high-income countries (7). In meta-regression analysis, none of the investigated covariates were associated with the pooled OR of CD. This evidence demonstrates with a moderate level of certainty that anaemic pregnant women are more likely to have CD than non-anaemic pregnant women.

Maternal Hemoglobin Concentrations and Birth Weight, Low Birth Weight (LBW), and Small for Gestational Age (SGA): Findings from a Prospective Study in Northwest China

Birth weight and related outcomes have profound influences on life cycle health, but the effect of maternal hemoglobin concentration during pregnancy on birth weight is still unclear. This study aims to reveal the associations between maternal hemoglobin concentrations in different trimesters of pregnancy and neonatal birth weight, LBW, and SGA. This was a prospective study based on a cluster-randomized controlled trial conducted from July 2015 to December 2019 in rural areas of Northwest China. Information on maternal socio-demographic status, health-related factors, antenatal visits, and neonatal birth outcomes were collected. A total of 3748 women and their babies were included in the final analysis. A total of 65.1% and 46.3% of the participants had anemia or hemoglobin ≥ 130 g/L during pregnancy. In the third trimester, maternal hemoglobin concentration was associated with birth weight in an inverted U-shaped curve and with the risks of LBW and SGA in extended U-shaped curves. The relatively higher birth weight and lower risks for LBW and SGA were observed when hemoglobin concentration was 100–110 g/L. When maternal hemoglobin was <70 g/L or >130 g/L, the neonatal birth weight was more than 100 g lower than that when the maternal hemoglobin was 100 g/L. In conclusion, both low and high hemoglobin concentrations in the third trimester could be adverse to fetal weight growth and increase the risks of LBW and SGA, respectively. In addition to severe anemia, maternal hemoglobin >130 g/L in the third trimester should be paid great attention to in the practice of maternal and child health care.

The effects of Helicobacter pylori infection on pregnancy-related diseases and fetal development in diabetes in pregnancy

Background

This study aimed to determine the association of Helicobacter pylori (H. pylori) infection with pregnancy-related diseases and fetal development in women with diabetes in pregnancy (DIP).

Methods

All the participants were recruited before 16 weeks of gestation. According to their medical history and the results of a 75-g oral glucose tolerance test at the 24^th week of pregnancy, the participants were divided into a normal control group (NC group), a gestational diabetes mellitus group (GDM group), and a pre-pregnancy diabetes mellitus group (PGDM group). According to the results of an H. pylori serum antibody detection test, each group was further divided into two subgroups: an H. pylori positive subgroup (HP+ subgroup) and an H. pylori negative group (HP- subgroup). The incidences of pregnancy-related diseases, the fetal developmental status, and the newborn status were compared among the groups.

Results

This study recruited 356 pregnant women. The infection rates of type I H. pylori were significantly higher in the GDM group and the PGDM group than in the NC group (χ²=6.949, P=0.031). With the exception of the NC-HP+ subgroup, there were higher incidences of pregnancy-related diseases in the HP+ subgroups than in the HP− subgroups (P<0.05). Furthermore, the incidences of pregnancy-induced hypertension (PIH), preeclampsia, and premature delivery were significantly higher in the GDM-HP+ subgroup and the PGDM-HP+ subgroup than in the NC-HP+ subgroup (P<0.05). At the end of pregnancy, all 3 HP− subgroups showed better fetal development than the HP+ subgroups (P<0.05), and the NC-HP+ subgroup showed better fetal development than the GDM-HP+ and PGDM-HP+ subgroups (P<0.05). Meanwhile, the PGDM-HP+ subgroup showed poor fetal development, even in the 2^nd trimester of pregnancy.

Conclusions

H. pylori infection is extremely common in DIP. For women with DIP, infection with H. pylori can increase the risks of pregnancy-related diseases and poor fetal development. H. pylori screening and eradication therapy before pregnancy may aid in preventing pregnancy-related diseases and improve fetal development.

Maternal anaemia and risk of adverse obstetric and neonatal outcomes in South Asian countries: A systematic review and meta-analysis

Background

The occurrence of maternal anaemia is common in South Asian countries which increase the risk of adverse maternal obstetric and birth outcomes. This may adversely affect the achievement of the Sustainable Development Goals’ (SDG) targets of reducing maternal and under-five deaths by 2030.

Objectives

To summarize the evidence on the association of maternal anaemia with adverse birth and maternal obstetric outcomes.

Methods

We adopted the PRISMA consensus statement. PubMed, CINAHL and Web of Science databases were searched on February 20, 2020. A total of 38 studies was included, of which 25 articles were included in the quantitative synthesis and meta-analysis.

Results

Maternal anaemia was associated with a significantly higher risk of low birth weight (OR, 1.90; 95% CI, 1.06-2.60, p ​< ​0.05), preterm birth (OR, 1.96; 95% CI, 1.20-2.41, p ​< ​0.05) and perinatal mortality (OR, 2.90; 1.97-3.78, p ​< ​0.05). Non-significant associations were seen with neonatal mortality (OR, 1.80; 95% CI, 0.90-27.77, p ​= ​0.7), miscarriage (OR, 1.68; 95% CI, 0.48-3.20, p ​= ​0.08), preeclampsia (OR, 2.66; 95% CI, 0.61-11.52, p ​= ​0.6) and caesarean delivery (OR, 1.18; 95% CI, 0.36-2.80, p ​= ​0.07).

Conclusion

Maternal anaemia increases the risk of low birth weight, preterm birth and perinatal mortality. Improving maternal nutritional status and iron supplementation during pregnancy are important for reducing these adverse outcomes.

Anemia in Pregnancy is Still a Public Health Problem: A Single Center Study with Review of Literature

Anemia is a significant public health problem during pregnancy and its prevalence varies in different cohorts. Correct identification of this problem in a given population is important for implementation of various health schemes. This study was carried out at a tertiary care hospital in Haryana. The prevalence of anemia in females at the time pregnancy diagnosis during first trimester was studied. The study period was January 2018 to June 2019. Severity of anemia was categorized as mild (hemoglobin 10-10.9 gm/dl), moderate (hemoglobin 7-9.9 gm/dl) and severe (hemoglobin < 7 gm/dl) as per the WHO definition. Relevant review of literature on prevalence of anemia in pregnancy in different Indian states was done. The median age of 388 females with diagnosis of pregnancy during first trimester was 27 years. Mean hemoglobin concentration was 10.47 gm/dl. 264 (68%) females had anemia. Out of these 191 (72.3%) had mild anemia, 65 (24.6%) had moderate anemia and eight had severe anemia. Out of the total study population, 270 (69.58%) were from rural and 118 (30.41%) were from urban background. Among the anemic pregnant females, 179 (67.8%) belonged to rural areas and 85 (32.20%) belonged to urban areas. Out of 264 patients with anemia, 87 (32.95%) patients were primigravida and 177 (67.04%) were multiparous females. The results of literature review showed a high prevalence of anemia in the other Indian states also. There is high prevalence of anemia in females at the time of diagnosis of pregnancy. Rates of anemia are higher in females with higher parity.

Effects of sanitation practices on adverse pregnancy outcomes in India: a conducive finding from recent Indian demographic health survey

Background

Several risk factors predisposing women and their live-borns to adverse outcomes during pregnancy have been documented. Little is known about sanitation being a factor contributing to adverse pregnancy outcomes in India. The role of sanitation in adverse pregnancy outcomes remains largely unexplored in the Indian context. This study is an attempt to bring the focus on sanitation as a factor in adverse pregnancy outcome. Along with the sanitation factors, few confounder variables have also been studied in order to understand the adverse pregnancy outcomes.

Methods

The study is based on the fourth round of National Family Health Survey (NFHS-IV) covering 26,972 married women in the age-group 15–49. The study variables include the mother’s age, Body Mass Index (BMI), education, anemia, and Antenatal care (ANC) visits during their last pregnancy. The household level variable includes place of residence, religion, caste, wealth index, access to toilet, type of toilet, availability of water within toilet premises, and facility of hand wash near the toilet. Children study variables include Low Birth Weight (LBW), the order of birth (Parity), and the death of the children of the women in the last 5 years. The target variable Adverse Pregnancy Outcome (APO) was constructed using children born with low birth weight or died during the last pregnancy.

Results

We calculated both adjusted as well as unadjusted odds ratios for a better understanding of the association between sanitation and adverse pregnancy outcomes. Findings from the study showed that women who did not have access to a toilet within the house had a higher risk of adverse pregnancy outcome. In the multivariable model, no association was observed for adverse pregnancy outcome among women who did not have access to toilet and women who used shared toilet. Teenage (15–19 years), uneducated, underweight and anemic mothers were more likely to face APO as compare to other mothers in similar characteristics group.

Conclusions

Our findings contribute to the decidedly less available literature on maternal sanitation behaviour and adverse pregnancy outcomes. Our results support that sanitation is a very significant aspect for women who are about to deliver a baby as there was an association between sanitation and adverse pregnancy outcome. Education on sanitation practices is the need of the hour as much as it needs to follow.

Anaemia is associated with an increased risk for caesarean delivery

OBJECTIVE

To investigate the association between anemia and cesarean delivery.

METHODS

A case-control study was conducted in Saad Abu-Alela Hospital in Khartoum, Sudan from March 1 to November 30, 2107. The cases were women who had cesarean delivery; women who delivered vaginally were the controls. Obstetrics history was gathered using a questionnaire.

RESULTS

There was no significant difference in age, parity, residence, job, education, and newborn gender between women who delivered by cesarean (n=130) and women who delivered vaginally (n=260). While mean (SD) of the body mass index (29.3 (5.4) kg/m² vs 26.3 (5.6) kg/m² , P<0.001) was significantly higher, hemoglobin level (103.0 (8.0) g/L vs 107.0 (8.0) g/L, P=0.001) was significantly lower in women who delivered by cesarean compared with women who delivered vaginally. In logistic regression analyses, age, gravidity, occupation, education, history of miscarriage, and newborn gender were not associated with cesarean delivery; overweight (adjusted odds ratio [AOR] 2.30, 95% confidence interval [CI] 1.24-4.26), obesity (AOR 7.17, 95% CI 3.64-14.13) and anemia (AOR 2.45, 95% CI 1.47-4. 11) were associated with cesarean delivery.

CONCLUSION

The significant association between anemia and cesarean delivery has important implications for the prevention and treatment of anemia among these women.

Maternal anaemia and maternal, fetal, and neonatal outcomes in a prospective cohort study in India and Pakistan

OBJECTIVE

To describe the association of maternal anaemia with maternal, fetal, and neonatal outcomes.

DESIGN

Prospective cohort study.

SETTING

Rural India and Pakistan.

POPULATION

Pregnant women residing in the study catchment area.

METHODS

We performed an analysis of a prospective pregnancy registry in which haemoglobin is commonly obtained as well as maternal, fetal, and neonatal outcomes for 42 days post-delivery. Women 40 years or older who delivered before 20 weeks or had a haemoglobin level of <3.0 g/dl were excluded. Our primary exposure was maternal anaemia, which was categorised in keeping with World Health Organization criteria based on a normal (≥11 g/dl), mild (>10-10.9 g/dl), moderate (7-9.9 g/dl) or severe (<7 g/dl). haemoglobin level. The primary maternal outcome was maternal death, the primary fetal outcome was stillbirth, and the primary neonatal outcome was neonatal mortality <28 days.

RESULTS

A total of 92 247 deliveries and 93 107 infants were included, of which 87.8% were born to mothers who were anaemic (mild 37.9%, moderate 49.1%, and severe 0.7%). Maternal mortality (number per 100 000) was not associated with anaemia: normal 124, mild 106, moderate 135, and severe 325 (P = 0.64). Fetal and neonatal mortality was associated with severe anaemia: stillbirth rate (n/1000)-normal 27.7, mild 25.8, moderate 30.1, and severe 90.9; P < 0.0001; 28-day neonatal mortality (n/1000)-normal 24.7, mild 22.9, moderate 28.1, and severe 72.6 (P < 0.0001). Severe maternal anaemia was also associated with low birthweight (<2500 and <1500 g), preterm birth, and postpartum haemorrhage.

CONCLUSION

Severe maternal anaemia is associated with higher risks of poor maternal, fetal, and neonatal outcomes but other degrees of anaemia are not. Interventions directed at preventing severe anaemia in pregnant women should be considered.

TWEETABLE ABSTRACT

Severe maternal anaemia is associated with adverse fetal and neonatal outcomes in low/middle-income countries.

Predictors of anemia and iron status at birth in neonates born to women carrying multiple fetuses

BACKGROUND

Iron (Fe) status of neonates born to women carrying multiple fetuses might be compromised as a consequence of the high prevalence of maternal Fe deficiency and anemia coupled with an increased risk of preterm birth. This study aimed to characterize and identify determinants of anemia in this neonatal population.

METHODS

Umbilical cord blood obtained from 183 neonates was utilized to assess hemoglobin (Hb), ferritin (SF), soluble transferrin receptor (sTfR), hepcidin, serum Fe, erythropoietin, folate, vitamin B-12, C-reactive protein, and interleukin-6. Associations with maternal Fe status were explored.

RESULTS

Cord Hb or SF did not change significantly as a function of gestational age at birth (25-38 wks). Neonates born to women who were obese prior to pregnancy or smoked cigarettes during pregnancy had a 4-5-fold greater odds of anemia at birth. Cord sTfR was the strongest indicator of cord Hb (P < 0.0001), and it was significantly associated with maternal sTfR at mid-gestation (P = 0.01) and delivery (P = 0.002). Cord Fe indicators were significantly associated with cord hepcidin, but not maternal hepcidin.

CONCLUSION

Screening for Fe status in neonates born to women carrying multiple fetuses is warranted, especially for those born to smokers or to women who are obese at entry into pregnancy.

Infant Mortality Rate as a Measure of a Country's Health: A Robust Method to Improve Reliability and Comparability

Researchers and policymakers often rely on the infant mortality rate as an indicator of a country's health. Despite arguments about its relevance, uniform measurement of infant mortality is necessary to guarantee its use as a valid measure of population health. Using important socioeconomic indicators, we develop a novel method to adjust country-specific reported infant mortality figures. We conclude that an augmented measure of mortality that includes both infant and late fetal deaths should be considered when assessing levels of social welfare in a country. In addition, mortality statistics that exhibit a substantially high ratio of late fetal to early neonatal deaths should be more closely scrutinized.

Asthma as a disruption in iron homeostasis

Over several decades, asthma has evolved from being recognized as a single disease to include a diverse group of phenotypes with dissimilar natural histories, pathophysiologies, responses to treatment, and distinctive molecular pathways. With the application of Occam's razor to asthma, it is proposed that there is one cause underlying the numerous phenotypes of this disease and that the responsible molecular pathway is a deficiency of iron in the lung tissues. This deficiency can be either absolute (e.g. asthma in the neonate and during both pregnancy and menstruation) or functional (e.g. asthma associated with infections, smoking, and obesity). Comparable associations between asthma co-morbidity (e.g. eczema, urticaria, restless leg syndrome, and pulmonary hypertension) with iron deficiency support such a shared mechanistic pathway. Therapies directed at asthma demonstrate a capacity to impact iron homeostasis, further strengthening the relationship. Finally, pathophysiologic events producing asthma, including inflammation, increases in Th2 cells, and muscle contraction, can correlate with iron availability. Recognition of a potential association between asthma and an absolute and/or functional iron deficiency suggests specific therapeutic interventions including inhaled iron.

Influence of tobacco smoking on transferrin sialylation during pregnancy in smoking and non-smoking women with iron deficiency

OBJECTIVES

Tobacco smoking influence on proteins is leading to despaired foetal nourishment. Transferrin, is an essential metal-binding protein responsible for iron transport and proper foetal development. This study examines influence of tobacco smoking on transferrin sialic acid residues and its connection to foetal nourishment at women with iron deficiency.

METHODS

The study involved 190 samples from pregnant women in 1st, 2nd and 3rd trimester. Women were divided in terms of tobacco smoking and iron deficiency.

RESULTS

During pregnancy, the levels of 2-, 5- and 6-sialo transferrin were increasing while 3- and 4-sialo transferrin were decreasing in all groups. Transferrin isoforms showed positive correlation with lowered iron stores in the blood of non-smoking women.

CONCLUSION

Tobacco smoking has an influence on number of sialic acids residues in the transferrin and seems to change conversion of Tf isoforms, and this may disturb iron transport and in consequence influence on foetal development and nourishment.

Determinants of Persistent Anemia in Poor, Urban Pregnant Women of Chandigarh City, North India: A Mixed Method Approach

BACKGROUND

Maternal anemia continues to be a public health problem in India, despite existence of multipronged governmental programs to combat it.

OBJECTIVE

This study explores the determinants of persistent anemia in poor pregnant women in an urban population in Chandigarh, India.

METHODS

A mixed method approach was used to examine the causes of maternal anemia. Three focus group discussions with pregnant women from different socioeconomic groups and 2 with female health workers were conducted to explore their perceptions and beliefs about maternal anemia and iron folic acid (IFA) tablets in urban settings in 2009. This was followed by interviews of 120 pregnant women about their nutrition knowledge and practices. Food frequency questionnaires were used to estimate daily consumption of nutrients. Finally, a follow-up survey in health clinics explored issues of stock-outs of IFA.

RESULTS

Sixty-five percent of respondents had hemoglobin less than 11g/dL and were anemic. Only 35% respondents obtained free IFA through public health programs. While 53% of respondents knew that they should eat green leafy vegetables, only 8% reported daily consumption of these vegetables. Focus group discussions highlighted issues around lack of food, especially for slum women, and low decision-making power in the household. Stock-outs of IFA in facilities often pushed women to purchase IFA from chemist shops.

CONCLUSIONS

Clear gaps emerged in pregnant women's knowledge and practice regarding diet and IFA tablet use. Lack of control over decision-making due to their low status of women was also hindering IFA use and healthy eating.

Maternal Anaemia and Neonatal Outcome: A Prospective Study on Urban Pregnant Women

INTRODUCTION

Maternal anaemia is a major contributor of adverse neonatal outcomes, particularly compromised birth weight and head circumference.

OBJECTIVE

To assess the relationship between maternal anaemia and neonatal measures in a sample of low-middle income group urban mothers.

MATERIALS AND METHODS

One hundred pregnant women with population representative prevalence of anaemia were enrolled. Socio-demographic, anthropometry, obstetric profile (parity, abortion history, food habits, gap period with last pregnancy etc), and systolic/diastolic blood pressure were documented. Neonatal outcomes (gestational age and type of delivery), and birth anthropometry (weight, length, and head circumference) were measured at delivery. Univariate and multivariate regression analysis for associating maternal haemoglobin levels and neonatal outcomes were performed.

RESULTS

The anaemic and non-anaemic pregnant women differed significantly in interval between previous & index pregnancy (p=0.031), parity (p=0.009), systolic blood pressure (p=0.026), diastolic blood pressure (p=0.042), maternal Hb (p<0.01). The mean gestational age (p<0.01), weight (p<0.01), length (p<0.01) and head circumference (p<0.01) of the neonates differed significantly between the two groups. On using maternal haemoglobin as a continuous variable, these anthropometric birth outcomes were positively correlated with maternal haemoglobin (p<0.05). Further, univariate linear regression showed similar associations between maternal haemoglobin (g/dL) and birth weight (p=0.004), length (p=0.010) and head circumference (p=0.003).

CONCLUSION

Maternal haemoglobin has a positive relationship with the neonatal measures of weight, length and head circumference.

Prenatal Iron Deficiency in Guinea Pigs Increases Locomotor Activity but Does Not Influence Learning and Memory

The objective of the current study was to determine whether prenatal iron deficiency induced during gestation in guinea pigs affected locomotor activity and learning and memory processes in the progeny. Dams were fed either iron-deficient anemic or iron-sufficient diets throughout gestation and lactation. After weaning, all pups were fed an iron-sufficient diet. On postnatal day 24 and 40, the pups’ locomotor activity was observed within an open-field test, and from postnatal day 25 to 40, their learning and memory processes were assessed within a Morris Water Maze. The behavioural and cognitive tests revealed that the iron deficient pup group had increased locomotor activity, but solely on postnatal day 40, and that there were no group differences in the Morris Water Maze. In the general discussion, we propose that prenatal iron deficiency induces an increase in nervousness due to anxiety in the progeny, which, in the current study, resulted in an increase of locomotor activity.

Evaluation of hemoglobin concentration in pregnancy and correlation with different altitude: a study from balochistan plateau of pakistan

BACKGROUND

Anemia refers to a condition having low hemoglobin concentration. Anemia is considered a major risk factor for unfavorable pregnancy outcomes. This is the first study describing the pattern of hemoglobin concentration during pregnancy and its relationship to areas of high and low altitudes in Balochistan (the largest of Pakistan's four provinces). The main objective of this study was to observe hemoglobin levels and prevalence of anemia among pregnant women living in the high or low altitude areas of Balochistan.

METHODS

A randomized survey was conducted and blood samples were collected from 132 healthy full term pregnant women subjects and 110 unmarried females. The subjects of the current study were selected from two different areas of Balochistan (Quetta and Uthal). Hemoglobin levels of the subjects were analyzed on Microlab 300 by Merck kit. Dietary status of the subjects was assessed based on simplified associated food frequency questionnaire. The factors effecting hemoglobin in full term pregnancy at different altitudes were multi gravidity/parity (increased number of pregnancies/children), age, socio-economic and educational status.

RESULTS

Anemia was highly prevalent in low-altitude region (68.33%). We found statistically significant difference in mean hemoglobin level at high-altitude region (11.81 ± 1.02) and low-altitude region (10.20 ± 1.28) in pregnant females of Balochistan plateau (P < 0.001). Higher maternal age (> 35 years) has shown significantly higher anemic frequency at both high (57.89%; p < 0.002) and low (41.46%; p = 0.067) altitudes. A balanced-diet that is rich in meat products has also shown significant correlation with reduced incidences of anemia among pregnant women at both altitudes.

CONCLUSION

Hemoglobin concentration increases in the body with elevated altitudes and, thus, anemia was less frequent at high-altitude region. Factors affecting hemoglobin concentration in full term pregnancy at different altitudes included old maternal age, low body-mass index, education and diet.

A review of the impact of dietary intakes in human pregnancy on infant birthweight

Studies assessing maternal dietary intakes and the relationship with birthweight are inconsistent, thus attempting to draw inferences on the role of maternal nutrition in determining the fetal growth trajectory is difficult. The aim of this review is to provide updated evidence from epidemiological and randomized controlled trials on the impact of dietary and supplemental intakes of omega-3 long-chain polyunsaturated fatty acids, zinc, folate, iron, calcium, and vitamin D, as well as dietary patterns, on infant birthweight. A comprehensive review of the literature was undertaken via the electronic databases Pubmed, Cochrane Library, and Medline. Included articles were those published in English, in scholarly journals, and which provided information about diet and nutrition during pregnancy and infant birthweight. There is insufficient evidence for omega-3 fatty acid supplements’ ability to reduce risk of low birthweight (LBW), and more robust evidence from studies supplementing with zinc, calcium, and/or vitamin D needs to be established. Iron supplementation appears to increase birthweight, particularly when there are increases in maternal hemoglobin concentrations in the third trimester. There is limited evidence supporting the use of folic acid supplements to reduce the risk for LBW; however, supplementation may increase birthweight by ~130 g. Consumption of whole foods such as fruit, vegetables, low-fat dairy, and lean meats throughout pregnancy appears beneficial for appropriate birthweight. Intervention studies with an understanding of optimal dietary patterns may provide promising results for both maternal and perinatal health. Outcomes from these studies will help determine what sort of dietary advice could be promoted to women during pregnancy in order to promote the best health for themselves and their baby.

The impact of early nutrition on the ageing trajectory

Epidemiological studies, including those in identical twins, and in individuals in utero during periods of famine have provided robust evidence of strong correlations between low birth-weight and subsequent risk of disease in later life, including type 2 diabetes (T2D), CVD, and metabolic syndrome. These and studies in animal models have suggested that the early environment, especially early nutrition, plays an important role in mediating these associations. The concept of early life programming is therefore widely accepted; however the molecular mechanisms by which early environmental insults can have long-term effects on a cell and consequently the metabolism of an organism in later life, are relatively unclear. So far, these mechanisms include permanent structural changes to the organ caused by suboptimal levels of an important factor during a critical developmental period, changes in gene expression caused by epigenetic modifications (including DNA methylation, histone modification and microRNA) and permanent changes in cellular ageing. Many of the conditions associated with early-life nutrition are also those which have an age-associated aetiology. Recently, a common molecular mechanism in animal models of developmental programming and epidemiological studies has been development of oxidative stress and macromolecule damage, specifically DNA damage and telomere shortening. These are phenotypes common to accelerated cellular ageing. Thus, this review will encompass epidemiological and animal models of developmental programming with specific emphasis on cellular ageing and how these could lead to potential therapeutic interventions and strategies which could combat the burden of common age-associated disease, such as T2D and CVD.

Prevalence of anemia in pregnant women and its effect on neonatal outcomes in Northeast India

OBJECTIVES

To determine the prevalence of anemia in pregnant women and characterize its effect on neonatal outcome in Northeast India.

PATIENTS AND METHODS

Four hundred and seventy mothers and their newborn infants during a one month period were included. The association between maternal hemoglobin (Hb) at delivery and neonatal outcomes were determined.

RESULTS

Anemia (Hb < 110 g/L) was present in 421 (89.6%) mothers with 35 (8.3%) having severe anemia(Hb < 70 g/L). After adjusting for maternal and neonatal variables, each 10 g/L decrease in maternal Hb was associated with 0.18 week decrease in gestational length (p = 0.003) and 21 g decrease in birth weight (p = 0.093). Severe maternal anemia was associated with 0.63 week (95% CI, 0.03-1.23week) shorter gestation, 481 g (95% CI, 305-658 g) lower birth weight and 89% increased risk of small-for-gestation (OR 1.89, 95% CI, 1.25-2.86)in the offspring, compared with those born to mothers without anemia (p < 0.001).

CONCLUSION

Maternal anemia was highly prevalentin this population. Lower gestational age and birth weight, and increased risk of small-for-gestation were associated with maternal anemia, especially when maternal Hb was <80 g/L. Maternal anemia needs urgent attention to improve neonatal outcome in this population.

Correlation of haemoglobin and red cell indices with serum ferritin in Indian women in second and third trimester of pregnancy

BACKGROUND

Iron deficiency anaemia (IDA) is the most common cause of anaemia in pregnancy in Indians and is associated with increased risk of low birth-weight infants. Studies from developed countries recommend iron supplementation based on serum ferritin levels. However, screening by serum ferritin is not feasible in all cases in India. This study was undertaken to document haematological profile of pregnant Indian women.

METHODS

We studied the correlation between second and third trimester ferritin concentration and haemoglobin (Hb) and red cell indices in 100 consecutive ANC cases to select the best haematologic characteristic to identify women who needed iron therapy. Hb and red cell indices, RBC count, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red cell distribution width were analysed and PBS studied to subtype anaemia if present.

RESULTS

Proportion of iron deficiency anaemia in pregnancy was 34% and significant correlation was found between serum ferritin and RDW-CV% and TRBC. No correlation was found between ferritin levels and Hb, MCV, MCH and MCHC. Serum ferritin levels were <12 ng/mL in 30 out of 52 non-anaemic cases suggesting prevalence of sub-clinical iron deficiency in 58% cases. None of the red cell indices correlated with ferritin level in this group. Only TRBC showed some correlation with ferritin (r = -0.090, p > 0.05).

CONCLUSION

All pregnant women in India should continue to get iron supplements unlike what is recommended in the developed countries where iron supplementation is based on serum ferritin levels.

Can anemia in the first trimester predict obstetrical complications later in pregnancy?

OBJECTIVE

The present study examines whether there is an association between anemia during the first trimester and the risk to develop preterm delivery (PTD), intrauterine growth restriction, and other obstetrical complications.

METHODS

The study population included all registered births between 2000 and 2010. Anemia was defined as hemoglobin <10 g/dl. A comparison of obstetrical characteristics and perinatal outcomes was performed between women with and without anemia. Multiple logistic regression models were used to control for confounders.

RESULTS

The study population included 33,888 deliveries, of these 5.1% (1718) were with anemia during the first trimester. Women with anemia were significantly older, delivered earlier, and were more likely to be grand multiparous. There were significantly higher rates of PTD and low birth weight (LBW; <2500 g) among patients with anemia (12.3% vs. 9.3%; p < 0.001 and 11.7% vs. 9.0%; p < 0.001, respectively). On the contrary, no significant differences between the groups were noted regarding the rate of intrauterine growth restriction. Using a multivariable analysis, the significant association between anemia and PTD persisted (OR = 1.35; 95% CI 1.2-1.6, p < 0.01).

CONCLUSIONS

Anemia during the first trimester is significantly and independently associated with an increased risk for subsequent PTD.

Oxygen delivery and fetal-placental growth: beyond a question of supply and demand?

Towards the end of the first trimester, blood flow and oxygenation rise within the placenta, supporting an increased capacity for mitochondrial oxidative metabolism in both the placenta and developing fetus. In this regard, the placenta acts uniquely as both a conduit of oxygen to the fetal circulation and a significant consumer of oxygen in order to support its own energy demands for the processes of nutrient transport and protein synthesis for hormone production and growth. When the supply of oxygen becomes restricted, for example during chronic exposure to hypobaric hypoxia at high altitude, placental and fetal tissues respond in order to optimise the allocation of oxygen between competing demands. In this case, the placenta appears to remodel its metabolism to decrease oxygen consumption, probably by increasing ATP production via glycolysis. This process can maintain oxygen supply to the fetus but is still associated with growth restriction. Oxidative stress, a feature of pre-eclampsia, might elicit similar metabolic changes in the absence of hypoxia. This review considers what is known about the metabolic response of the placenta and fetal tissues to hypoxia and oxidative stress, and suggests possible mechanisms that might underlie such metabolic remodelling using lessons from other tissues and organ systems. Aspects of the hypoxia response that remain to be addressed are highlighted and future studies suggested. Much remains unknown about the coordinated metabolic response of the fetal-placental unit to chronic hypoxia and oxidative stress, but it would appear to be more than a simple question of supply and demand.

Maternal micronutrient restriction programs the body adiposity, adipocyte function and lipid metabolism in offspring: a review

Fetal growth is a complex process which depends both on the genetic makeup and intrauterine environment. Maternal nutrition during pregnancy is an important determinant of fetal growth. Adequate nutrient supply is required during pregnancy and lactation for the support of fetal/infant growth and development. Macro- and micronutrients are both important to sustain pregnancy and for appropriate growth of the fetus. While macronutrients provide energy and proteins for fetal growth, micronutrients play a major role in the metabolism of macronutrients, structural and cellular metabolism of the fetus. Discrepancies in maternal diet at different stages of foetal growth / offspring development can have pronounced influences on the health and well-being of the offspring. Indeed intrauterine growth restriction induced by nutrient insult can irreversibly modulate the endocrine/metabolic status of the fetus that leads to the development of adiposity and insulin resistance in its later life. Understanding the role of micronutrients during the development of fetus will provide insights into the probable underlying / associated mechanisms in the metabolic pathways of endocrine related complications. Keeping in view the modernized lifestyle and food habits that lead to the development of adiposity and world burden of obesity, this review focuses mainly on the role of maternal micronutrients in the foetal origins of adiposity.

Identifying a window of vulnerability during fetal development in a maternal iron restriction model

It is well acknowledged from observations in humans that iron deficiency during pregnancy can be associated with a number of developmental problems in the newborn and developing child. Due to the obvious limitations of human studies, the stage during gestation at which maternal iron deficiency causes an apparent impairment in the offspring remains elusive. In order to begin to understand the time window(s) during pregnancy that is/are especially susceptible to suboptimal iron levels, which may result in negative effects on the development of the fetus, we developed a rat model in which we were able to manipulate and monitor the dietary iron intake during specific stages of pregnancy and analyzed the developing fetuses. We established four different dietary-feeding protocols that were designed to render the fetuses iron deficient at different gestational stages. Based on a functional analysis that employed Auditory Brainstem Response measurements, we found that maternal iron restriction initiated prior to conception and during the first trimester were associated with profound changes in the developing fetus compared to iron restriction initiated later in pregnancy. We also showed that the presence of iron deficiency anemia, low body weight, and changes in core body temperature were not defining factors in the establishment of neural impairment in the rodent offspring.Our data may have significant relevance for understanding the impact of suboptimal iron levels during pregnancy not only on the mother but also on the developing fetus and hence might lead to a more informed timing of iron supplementation during pregnancy.

Early life nutrition and metabolic programming

Research investigating the early programming of adult metabolic disease has in recent years provided much mechanistic insight into how the early environment impacts on long-term health. It includes studies addressing the roles of intrauterine nutrient availability, which is determined by maternal nutrition, maternal exposure to oxygen, toxic events, and infection; the placental interface; and also the early postnatal environment. This review will explore the epidemiological evidence for programming of metabolic disease and provide an overview of the various studies using animals to model metabolic phenotypic outcome. It will also discuss evidence for the proposed molecular mechanisms and the potential for intervention.

Causes and mechanisms of intrauterine hypoxia and its impact on the fetal cardiovascular system: a review

Until today the role of oxygen in the development of the fetus remains controversially discussed. It is still believed that lack of oxygen in utero might be responsible for some of the known congenital cardiovascular malformations. Over the last two decades detailed research has given us new insights and a better understanding of embryogenesis and fetal growth. But most importantly it has repeatedly demonstrated that oxygen only plays a minor role in the early intrauterine development. After organogenesis has taken place hypoxia becomes more important during the second and third trimester of pregnancy when fetal growth occurs. This review will briefly adress causes and mechanisms leading to intrauterine hypoxia and their impact on the fetal cardiovascular system.

Uterine and umbilical artery Doppler velocimetry as a predictor for adverse pregnancy outcomes in pregnant women with anemia

AIMS

The aim of this study was to investigate the significance of Doppler ultrasound as a predictor for adverse pregnancy outcomes in Korean women with anemia during the third trimester of pregnancy.

METHODS

A retrospective study comparing women with (n=377) and without (n=3183) anemia was performed. Maternal anemia was defined as hemoglobin concentration <10 g/dL. Umbilical artery Doppler (UmA) and uterine artery Doppler (UtA) velocimetry was performed before delivery.

RESULTS

There were higher rates of small for gestational age, cesareans for fetal distress, and preterm birth among the anemic compared to non-anemic women. When maternal anemia was combined with abnormal Doppler, the odds ratio (OR) of adverse pregnancy outcome was further increased. Both abnormal UtA and UmA to predict adverse pregnancy outcome showed sensitivity, specificity, positive and negative predictive values of 41.2%, 97.4%, 85.9%, and 51.2%, respectively (OR 2.0; 95% confidence interval 1.2-2.3).

CONCLUSIONS

Doppler ultrasound examination could be used as a predictor for adverse pregnancy outcomes in women with anemia during the third trimester.

HFE gene variants modify the association between maternal lead burden and infant birthweight: a prospective birth cohort study in Mexico City, Mexico

BACKGROUND

Neonatal growth is a complex process involving genetic and environmental factors. Polymorphisms in the hemochromatosis (HFE) iron regulatory genes have been shown to modify transport and toxicity of lead which is known to affect birth weight.

METHODS

We investigated the role of HFE C282Y, HFE H63 D, and transferrin (TF) P570 S gene variants in modifying the association of lead and infant birthweight in a cohort of Mexican mother-infant pairs. Subjects were initially recruited between 1994-1995 from three maternity hospitals in Mexico City and 411 infants/565 mothers had archived blood available for genotyping. Multiple linear regression models, stratified by either maternal/infant HFE or TF genotype and then combined with interaction terms, were constructed examining the association of lead and birthweight after controlling for covariates.

RESULTS

3.1%, 16.8% and 17.5% of infants (N=390) and 1.9%, 14.5% and 18.9% of mothers (N=533) carried the HFE C282Y, HFE H63D, and TF P570 S variants, respectively. The presence of infant HFE H63 D variants predicted 110.3 g (95% CI -216.1, -4.6) decreases in birthweight while maternal HFE H63 D variants predicted reductions of 52.0 g (95% CI -147.3 to 43.2). Interaction models suggest that both maternal and infant HFE H63 D genotype may modify tibia lead's effect on infant birthweight in opposing ways. In our interaction models, maternal HFE H63 D variant carriers had a negative association between tibia lead and birthweight.

CONCLUSIONS

These results suggest that the HFE H63 D genotype modifies lead's effects on infant birthweight in a complex fashion that may reflect maternal-fetal interactions with respect to the metabolism and transport of metals.

Maternal iron deficiency alters essential fatty acid and eicosanoid metabolism and increases locomotion in adult guinea pig offspring

Iron deficiency (ID) is the most prevalent worldwide nutritional deficiency. Groups at risk of developing ID anemia are infants and pregnant women, even in industrialized countries. Our goal in this study was to evaluate the long-term consequences of maternal ID on the offspring's fatty acid and eicosanoid metabolism, behavior, and spatial memory. Female guinea pigs consumed iron-sufficient (IS) and -deficient (ID) diets for 14 d before mating and throughout pregnancy and lactation. Dietary iron restriction resulted in ID in pregnant females. On postnatal d 9, all offspring (ID and IS) were weaned to the IS diet and at 42 d, all offspring were iron replete. Locomotion was tested in pups on postnatal d 24 and 40 and spatial memory from d 25 to 40. Pups from the ID group were significantly more active in the open field at both times of testing, whereas spatial memory, tested in a Morris water maze, was comparable in both groups. On postnatal d 42, liver, RBC, and brain fatty acid composition were measured. Dihomogammalinolenic [20:3(n-6)], docosapentaenoic [22:5(n-3)], and docosahexaenoic [22:6(n-3)] acid contents were significantly higher in brain phospholipids of offspring born to ID dams. Prostaglandin E(2) and F(2alpha) concentrations were also significantly higher in brains of offspring born to ID dams. This demonstrates that moderate ID during gestation and lactation results in alterations of brain fatty acid and eicosanoid metabolism and perturbation in behavior in adult offspring.

Maternal iron deficiency and its effect on essential fatty acid and eicosanoid metabolism and spatial memory in the guinea pig offspring

Iron deficiency is prevalent among infants and pregnant women in industrialized country. The goal of this study was to evaluate the impact of moderate maternal iron deficiency on the offspring's fatty acid and eicosanoid metabolism and spatial memory in guinea pigs. An iron-sufficient (IS) or iron-deficient (ID) diet was fed 14 days before mating and throughout pregnancy and lactation. The pups were tested for spatial memory on post-natal days 4-7. On post-natal day 9, the biochemical analysis included the pup's brain fatty acid profiles, prostaglandin (PGE(2) and PGF(2alpha)) concentrations and cyclooxygenase II protein levels. Spatial memory and indices of eicosanoid metabolism were comparable in both dietary groups. However, n-3 fatty acids were significantly higher (p<0.05) in brain of pups from the ID group. The data suggest that maternal iron deficiency results in a modification of the fatty acid profile of the offspring's brain that is not associated with any spatial memory deficits during early development.

Nutritional anaemia dysregulates endocrine control of fetal growth

Severe anaemia is associated with increased low birth weight and Barker's hypothesis of ‘fetal origins’ proposes that a nutritional insult during critical periods of development results in adaptations that predispose individuals to adult onset diseases. We hypothesize that endocrine alterations may occur in the maternal–fetal milieu as a consequence of nutritional anaemia during pregnancy. We examined the quantitative variations in hormonal profiles in paired maternal and cord blood samples obtained from mothers and their neonates who were classified based on maternal anaemia status. Our results show that: (1) 74·6 % of the mothers enrolled in the study were anaemic, of which 85·2 % had moderate anaemia and 14·7 % had severe anaemia; (2) anthropometric parameters measured in the mothers indicate that severely anaemic mothers had a significantly low pre- and post-pregnancy weight, a significantly decreased maternal fundal height and abdominal circumference; (3) anthropometric measures in the neonates born to severely anaemic mothers show a significant reduction in ponderal index, birth weight and placental weight; (4) significant increase in both maternal, fetal insulin-like growth factor 1, ferritin levels and increased maternal erythropoietin levels were observed with an increase in severity of anaemia; (5) decreased T3and increased prolactin levels were observed in the maternal blood of severely anaemic mothers as compared with the control group. An insight into the endocrine modulation to overcome a growth disadvantage due to nutritional anaemia in pregnancy may lead to a better understanding of fetal adaptations invoked when the maternal-placental nutrient supply fails to meet the fetal nutrient demand.

Maternal iron intake and iron status during pregnancy and child blood pressure at age 3 years

BACKGROUND

Animal data suggest that maternal iron deficiency during pregnancy leads to lower birth weight and sustained blood pressure elevation in the offspring. In humans, iron deficiency during pregnancy is common and is associated with adverse birth outcomes such as low birth weight. Data are lacking, however, regarding the effects of maternal iron intake and iron status during pregnancy on offspring blood pressure. Our aim was to examine the extent to which lower maternal iron intake, haemoglobin level and mean cell volume (MCV) during pregnancy are associated with higher child systolic blood pressure (SBP) at age 3 years.

METHODS

We studied 1167 participants in Project Viva, a longitudinal cohort study of pregnant women and their children. We estimated first and second trimester maternal iron intake from food frequency questionnaires. We used an electronic laboratory database to identify haemoglobin and MCV levels in pregnancy. We measured child BP up to five times with a Dinamap and used mixed-effects regression models in our analysis.

RESULTS

Mean (SD) child SBP at 3 years was 92.0 (9.9) mmHg. Adjusting for confounders, for each 10 mg increase in first trimester iron intake, child SBP was not lower, but was in fact 0.4 mmHg higher (95% CI 0.1, 0.7). For second trimester iron intake, and for first or second trimester haemoglobin and MCV levels, we did not find any appreciable association with 3 year SBP.

CONCLUSIONS

In contrast to animal studies, we did not find that lower maternal iron status during pregnancy was associated with higher offspring BP.

Relationship between the iron status of pregnant women and their newborns

OBJECTIVE: To determine the relationship between iron nutritional status of pregnant women and their newborns using a combination of hematological and biochemical parameters for the diagnosis of iron deficiency. METHODS: A cross-sectional study was conducted in Jundiaí, Southeastern Brazil, in 2000. Venous blood samples collected from 95 pregnant women and from their umbilical cord and used for the determination of complete blood count, serum iron, total iron-binding capacity, serum ferritin, zinc protoporphyrin, and transferrin saturation. Women were classified into three groups: anemic, iron deficient and non-iron deficient. Statistical analysis included the Tukey-HSD test, Pearson's correlation coefficient and multiple linear regression analysis. RESULTS: Among pregnant women, 19% were anemic (97.9% mildly anemic and 2.1% moderately anemic) and 30.5% were iron deficient. No significant difference was seen in mean values of any parameter studied between newborns in the three groups (p>0.05). Multiple linear regression analysis showed weak association between neonatal and maternal parameters. CONCLUSIONS: The iron nutritional status of pregnant women with iron deficiency or mild anemia does not seem to have a significant impact on the iron levels of their children.

Iron, copper and fetal development

Pregnancy is a period of rapid growth and cell differentiation for both the mother and fetus. Consequently, it is a period when both are vulnerable to changes in dietary supply, especially of those nutrients that are marginal under normal circumstances. In developed countries this vulnerability applies mainly to micronutrients. Even now, Fe deficiency is a common disorder, especially in pregnancy. Similarly, Cu intake in the UK population is rarely above adequate levels, which is a matter of some concern, both in terms of public health and possible clinical consequences. In early studies it was shown that lambs born to mothers on Cu-deficient pastures develop ‘swayback,’ with neurological and muscular symptoms that cannot be reversed by postnatal supplementation. More recently, rat studies have shown that responses such as the ‘startle’ response are lost in offspring of Cu-deficient mothers. Data have shown that prenatal Fe deficiency results in increased postnatal blood pressure, even though the offspring have normal dietary Fe levels from birth. These observations emphasise the importance of Fe and Cu in growth and development. In the present review the importance of these metals and the consequences, both short term and long term, of deficiency will be discussed and some possible mechanisms whereby these effects may be generated will be considered.

A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru

OBJECTIVE

To assess the effect on birthweight of antenatal mebendazole plus iron vs. placebo plus iron in a highly hookworm-endemic area.

METHODS

Double-blind, randomized controlled trial set in rural and peri-urban communities in the Peruvian Amazon region. A total of 1042 second trimester pregnant women between the ages of 18 and 44 years were recruited from April to November 2003, and followed to July 2004. Women were randomly assigned to receive either mebendazole (500 mg single dose) plus iron supplements (60 mg elemental iron daily) or placebo plus iron supplements. The primary outcome was mean infant birthweight and secondary measures included proportion of low birthweight babies and maternal anaemia.

RESULTS

The prevalence of hookworm infection was 47.5%. There were no differences between intervention groups in mean birthweight (3104 g vs. 3090 g, P = 0.629), proportion of low birthweight (<2500 g; 8.1%vs. 8.7%, P = 0.755) or maternal anaemia in the third trimester [33.0% (158/479) vs. 32.3% (152/471), P = 0.815]. However, the proportion of very low birthweight (<1500 g) was significantly lower in the mebendazole group [0% (0/479) vs. 1.5% (7/471), P = 0.007].

CONCLUSIONS

This trial provides additional evidence for the use of anthelmintics, over and above iron supplementation, within antenatal care programmes in hookworm-endemic areas. Benefits of de-worming may be higher in countries not having an antenatal iron supplementation programme or where intensity of hookworm infections is higher.

Maternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery

OBJECTIVE

The present study was designed to investigate the outcome of pregnancy and delivery in patients with anemia.

METHODS

A retrospective population-based study comparing all singleton pregnancies of patients with and without anemia was performed. Deliveries occurred during the years 1988-2002 in the Soroka University Medical Center. Maternal anemia was defined as hemoglobin concentration lower than 10 g/dl during pregnancy. Patients with hemoglobinopathies such as thalassemia were excluded from the analysis. Multiple logistic regression models were performed to control for confounders.

RESULTS

During the study period there were 153,396 deliveries, of which 13,204 (8.6%) occurred in patients with anemia. In a multivariable analysis, the following conditions were significantly associated with maternal anemia: placental abruption, placenta previa, labor induction, previous cesarean section (CS), non-vertex presentation and Bedouin ethnicity. Higher rates of preterm deliveries (<37 weeks gestation) and low birthweight (<2500 g) were found among patients with anemia as compared to the non-anemic women (10.7% versus 9.0%, p < 0.001 and 10.5% versus 9.4%, p < 0.001; respectively). Higher rates of CS were found among anemic women (20.4% versus 10.3%; p < 0.001). The significant association between anemia and low birthweight persisted after adjusting for gender, ethnicity and gestational age, using a multivariable analysis (OR = 1.1; 95% CI 1.0-1.2, p = 0.02). Two multivariable logistic regression models, with preterm delivery (<37 weeks gestation) and low birthweight (<2500 g) as the outcome variables, were constructed in order to control for possible confounders such as ethnicity, maternal age, placental problems, mode of delivery and non-vertex presentation. Maternal anemia was an independent risk factor for both, preterm delivery (OR = 1.2; 95% CI 1.1-1.2, p < 0.001) and low birthweight (OR = 1.1; 95% CI 1.1-1.2, p = 0.001).

CONCLUSION

Maternal anemia influences birthweight and preterm delivery, but in our population, is not associated with adverse perinatal outcome.

Behavioral consequences of developmental iron deficiency in infant rhesus monkeys

Human studies have shown that iron deficiency and iron deficiency anemia in infants are associated with behavioral impairment, but the periods of brain development most susceptible to iron deficiency have not been established. In the present study, rhesus monkeys were deprived of iron by dietary iron restriction during prenatal (n=14, 10 microg Fe/g diet) or early postnatal (n=12, 1.5 mg Fe/L formula) brain development and compared to controls (n=12, 100 microg Fe/g diet, 12 mg Fe/L formula) in behavioral evaluations conducted during the first four months of life in the nonhuman primate nursery. Iron deficiency anemia was detected in the pregnant dams in the third trimester and compromised iron status was seen in the prenatally iron-deprived infants at birth, but no iron deficiency was seen in either the prenatally or postnatally iron-deprived infants during the period of behavioral evaluation. Neither prenatal nor postnatal iron deprivation led to significant delays in growth, or gross or fine motor development. Prenatally deprived infants demonstrated a 20% reduced spontaneous activity level, lower inhibitory response to novel environments, and more changes from one behavior to another in weekly observation sessions. Postnatally deprived infants demonstrated poorer performance of an object concept task, and greater emotionality relative to controls. This study indicates that different syndromes of behavioral effects are associated with prenatal and postnatal iron deprivation in rhesus monkey infants and that these effects can occur in the absence of concurrent iron deficiency as reflected in hematological measures.

[Severe maternal anemia and pregnancy outcome]

OBJECTIVES

The aim of this study was to determine the effects of severe antenatal maternal anemia on pregnancy outcome.

MATERIAL

and methods. A retrospective study comparing 2 groups of pregnant women: 111 (pregnant women) with anemia (Hb < 8 g/dl), 111 non- anemic pregnant women (Hb >10 g/dl). Clinical and biological characteristics for both groups were compared. Data on the newborn babies were collected.

RESULTS

In the anemic group: iron deficiency was the most common cause of anemia (92.7%). There was no significant difference between the 2 groups with respect to age or parity. Maternal anemia was found to be significantly associated with more frequent preterm birth (29.2% vs 9.2%) and increased low birth weight (2933 g vs 3159 g).

DISCUSSION

The literature is not conclusive on the influence of anemia in pregnant women. More frequent preterm birth and low birth weight have been reported in the majority of studies considering mild to moderate maternal anemia (in contrast to our study where the mothers had severe anemia). Many studies indicated that routine iron supplementation during pregnancy may have beneficial effects on pregnancy outcome. Severe anemia in pregnancy may have adverse effects for the newborn and should be treated or prevented early in pregnancy.

Preconception hemoglobin and ferritin concentrations are associated with pregnancy outcome in a prospective cohort of Chinese women

Prenatal anemia and iron deficiency are associated with adverse birth outcomes, but no previous studies have examined the relation between preconception anemia, iron deficiency, and pregnancy outcome in healthy women. We measured hemoglobin (Hb), ferritin, transferrin receptor (TfR), and vitamins B-6, B-12, and folate concentrations before pregnancy in 405 Chinese women (median time from sample collection to gestation end = 316 d). Both mild (95 </= Hb < 120 g/L) and moderate (Hb < 95 g/L) anemia were significantly associated with lower birthweight (139 and 192 g, respectively); iron-deficiency anemia alone (Hb < 120 g, ferritin < 12 microg/L, no B-vitamin deficiency) was associated with a 242-g decrease in birthweight. Both low (<12 microg/L) and high (>/=60 microg/L) ferritin were also significantly associated with lower birthweight (106 and 123 g, respectively). The risks of low birthweight (LBW) and fetal growth restriction (FGR) were significantly greater among women with moderate anemia compared with nonanemic controls [odds ratio (OR): 6.5; 95% CI: 1.6, 26.7; P = 0.009 and OR: 4.6; 95% CI: 1.5, 13.5; P = 0.006, respectively]. TfR and low ferritin were not associated with adverse birth outcome, but elevated ferritin, which could be a marker of inflammation, was associated with increased risk of LBW (OR: 2.2; 95% CI: 0.9, 5.7; P = 0.09) and FGR (OR: 2.7; 95% CI: 1.3, 5.6; P = 0.008). Preconception anemia, particularly iron-deficiency anemia, was associated with reduced infant growth and increased risk of adverse pregnancy outcome in Chinese women.

Maternal and perinatal outcome in varying degrees of anemia

OBJECTIVES

To analyze the maternal and perinatal outcome in varying degrees of anemia.

METHODS

A total of 447 pregnant women were divided into group I (Hb>11 g%, n=123 women), group II (Hb 9-10.9 g%, n=214 women), group III (Hb 7-8.9 g%, n=79 women) group IV (Hb<7 g%, n=31 women). Their maternal and perinatal outcome, mode of delivery, duration of labor and postpartum complications were noted and analyzed using multiple logistic regression to calculate odds ratios (95% CI) for duration of labor, mode of delivery and low birth babies. Chi square or Fisher's exact test was employed for difference in proportions and Student's t-test for testing difference between means.

RESULTS

Mean age (27+/-4.25 years) and number of women with parity >3 were highest in group IV. The patients with Hb<8.9 g% had a 4-6-fold higher risk of prolonged labor compared to Hb>11 g%. The odds ratios for abnormal delivery (cesarean and operative vaginal deliveries) showed a 4.8-fold higher risk (95% CI 1.82, 12.7) in patients with Hb </=7.5 g%. The mean birth weight was maximum in the 9.6-10.5 g% category that fell with both increasing and decreasing hemoglobin values, being lowest in Group IV. Women in Group II had lowest number of low birth weight and IUGR babies, no stillbirths and neonatal deaths, lowest induction and operative delivery rates.

CONCLUSIONS

Mild anemia fared best in maternal and perinatal outcome. Severe anemia was associated with increased low birth weight babies, induction rates, operative deliveries and prolonged labor.

Impact of maternal anemia on the infant's iron status at 9 months of age

BACKGROUND

Iron-deficiency anemia during pregnancy is still common in developed countries. The aim of this study was to evaluate the influence of maternal anemia on the infant's iron status at 9 months of age in Moncton, NB.

METHODS

Mothers giving birth between April 1998 and February 1999 were selected from medical records. A letter was sent to invite them to participate. In total, 75 mothers with their infants were examined.

RESULTS

The proportion of iron-deficiency anemia was higher (p = 0.055) in the group born to anemic compared to non-anemic mothers. A positive association between the mother's haemoglobin and haematocrit during her 3rd trimester and her infant's haemoglobin and haematocrit was found at 9 months of age. These results are not explained by differences in feeding practices and socio-economic status between groups.

INTERPRETATION

Infants born to mildly anemic mothers may be at risk of developing anemia.

Screening for severe anaemia in pregnancy in Kenya, using pallor examination and self-reported morbidity

Severe anaemia in pregnancy is an important preventable cause of maternal and perinatal morbidity and mortality. Different methods of screening for severe anaemia in pregnancy were evaluated in a 2-phased study conducted in Kilifi, Kenya. In phase 1 (in 1994/95), pallor testing was evaluated alone and in addition to raised respiratory/pulse rates: 1787 pregnant women were examined by one of 2 midwives. Sensitivities for detecting severe anaemia (haemoglobin < 7 g/dL) were 62% and 69% and specificities 87% and 77%, respectively for each of the midwives. Addition of high pulse rate increased sensitivity to 77% and 81%, but specificity reduced to 60% and 51%, respectively. In phase 2, following qualitative in-depth work, a screening questionnaire was developed. An algorithm based on screening questions had 80% sensitivity and 40% specificity. Midwife pallor-assessment was conducted following the screening questionnaire. In this phase (conducted in 1997), the midwife performed very highly in detecting severe anaemia, achieving sensitivity of 84% and specificity of 92%. Spending a few minutes asking women questions may have improved the ability to interpret pallor findings. This study demonstrates the value of pallor testing and raises alternative approaches to improving it.

Effects of maternal iron restriction in the rat on hypoxia-induced gene expression and fetal metabolite levels

The mechanism by which maternal Fe deficiency in the rat causes fetal growth retardation has not been clearly established. This study compared the effects on the fetuses from dams fed a control diet with two groups of dams fed Fe-restricted diets. One Fe-restricted group was fed the Fe-restricted diet for 1 week prior to mating and throughout gestation and the second Fe-restricted group was fed the Fe-restricted diet for 2 weeks prior to mating and throughout gestation. On day 21 of gestation Fe-restricted dams, and their fetuses, were anaemic. Fetal weight was reduced in both Fe-restricted groups compared with controls. Expression of hypoxia-inducible factor (HIF)-1alpha and vascular endothelial growth factor (VEGF) are induced by hypoxia. The levels of HIF-1alpha mRNA were highest in placenta, then in kidney, heart and liver but were not different between the groups. Levels of plasma VEGF were not different between the groups. Maternal plasma triacylglycerol was decreased in the 1-week Fe-restricted dams compared with controls. Maternal plasma cholesterol and free fatty acid levels were not different between the groups. In fetal plasma, levels of triacylglycerol and cholesterol were decreased in both Fe-restricted groups. In maternal plasma, levels of a number of amino acids were elevated in both Fe-restricted groups. In contrast, levels of a number of amino acids in fetal plasma were lower in both Fe-restricted groups. Fetal plasma lactate was increased in Fe-restricted fetuses but fetal plasma glucose and beta-hydroxybutyrate were not affected. These changes in fetal metabolism may contribute to fetal growth retardation in this model. This study does not support the hypothesis that the Fe-restricted fetus is hypoxic.

Is There a Causal Relationship between Iron Deficiency or Iron-Deficiency Anemia and Weight at Birth, Length of Gestation and Perinatal Mortality?

An extensive literature review was conducted to identify whether iron deficiency, iron-deficiency anemia and anemia from any cause are causally related to low birth weight, preterm birth or perinatal mortality. Strong evidence exists for an association between maternal hemoglobin concentration and birth weight as well as between maternal hemoglobin concentration and preterm birth. It was not possible to determine how much of this association is attributable to iron-deficiency anemia in particular. Minimal values for both low birth weight and preterm birth occurred at maternal hemoglobin concentrations below the current cut-off value for anemia during pregnancy (110 g/L) in a number of studies, particularly those in which maternal hemoglobin values were not controlled for the duration of gestation. Supplementation of anemic or nonanemic pregnant women with iron, folic acid or both does not appear to increase either birth weight or the duration of gestation. However, these studies must be interpreted cautiously because most are subject to a bias toward false-negative findings. Thus, although there may be other reasons to offer women supplemental iron during pregnancy, the currently available evidence from studies with designs appropriate to establish a causal relationship is insufficient to support or reject this practice for the specific purposes of raising birth weight or lowering the rate of preterm birth.

Angiogenesis during implantation, and placental and early embryonic development

Angiogenesis, the development of new capillaries from pre-existing vessels, is induced by inflammation, wound healing, immune reactions and neoplasia, and is required for tumour growth and progression. Angiogenesis participates in a wide range of ovulatory-related and non-ovulatory-related reproductive processes. We present a review of current data pertaining to angiogenesis of pregnancy, with specific emphasis on implantation and placental and embryonic development in both normal physiology processes and various pathological conditions. To this goal, MEDLINE, Current Contents and Index Medicus were searched for studies published between 1966 and August 1999. Pertinent studies (including human and animal models) pertaining to angiogenesis of implantation and placental and embryonic development were reviewed. Current literature supports that angiogenesis is an essential physiological component of implantation, and placental and embryonic development. Angiogenesis also actively participates in abnormal implantation, and various pathological processes of the placenta including those observed in association with pre-eclampsia, growth restriction, maternal anaemia in the first-trimester and other hypoxia-related conditions during pregnancy. Finally, administration of an angiogenesis inhibitor (AGM-1470) in mice has been shown to result in complete failure of embryonic growth due to interference with decidualization, placental and yolk sac formation, and embryonic vascular development.

Anemia and deficiencies of folate and vitamin B-6 are common and vary with season in Chinese women of childbearing age

Little is known about the micronutrient status of Chinese women of childbearing age. We assessed nonfasting plasma concentrations of folic acid, vitamin B-12, vitamin B-6 (as pyridoxal-5'-phosphate), hemoglobin (Hb), ferritin and transferrin receptor (TfR) in 563 nonpregnant textile workers aged 21-34 y from Anqing, China. All women had obtained permission to become pregnant and were participating in a prospective study of pregnancy outcomes. Mean (SD) plasma concentrations were 9.7 (4.1) nmol/L folic acid, 367 (128) pmol/L vitamin B-12, 40.2 (15.8) nmol/L vitamin B-6, 108 (12. 9) g/L Hb, 42.6 (34.2) microgram/L ferritin and 5.2 (2.7) mg/L TfR. Twenty-three percent of women had biochemical evidence of folic acid deficiency, 26% were deficient in vitamin B-6 and 10% had low vitamin B-12. Overall, 44% of women were deficient in at least one B vitamin. Although anemia (Hb < 120 g/L) was detected in 80% of women, only 17% had depleted iron stores (ferritin < 12 microgram/L); 11% had elevated TfR concentrations. Distinct seasonal trends were observed in the prevalence of moderate anemia (Hb < 100 g/L) and deficiencies of folic acid and vitamin B-6, with significantly lower concentrations of folate and Hb occurring in summer and lower concentrations of vitamin B-6 occurring in winter and spring than in other seasons. We conclude that deficiencies of folic acid, vitamin B-6 and iron were relatively common in this sample of Chinese women of childbearing age and were contributing to the high prevalence of anemia. Without appropriate supplementation, these deficiencies could jeopardize the women's health and increase their risk of adverse pregnancy outcomes.