UK guidelines on the management of iron deficiency in pregnancy

Perinatal Outcomes Following Intravenous Iron for Treatment of Iron Deficiency With and Without Anemia

OBJECTIVE

To determine maternal and neonatal outcomes in individuals with iron deficiency receiving antepartum intravenous (IV) iron supplementation, stratified by the degree of anemia.

STUDY DESIGN

Retrospective cohort study of iron-deficient pregnant patients who received at least one IV infusion of iron (iron sucrose, low molecular weight iron dextran [LMWID], or ferric carboxymaltose) during their pregnancy from January 1, 2011 through June 16, 2022. Our primary outcomes included both neonatal composite morbidity and maternal composite morbidity in the context of maternal anemia.

RESULTS

Patients who received LMWID had fewer infusion visits, received higher total doses of iron and had a more substantial correction of hemoglobin compared to those who received iron sucrose (p < 0.01). Maternal anemia at the time of admission was not associated with neonatal composite morbidity. However, there was a significant association between anemia status and maternal composite outcome (p = 0.05). Anemia at time of delivery was associated with the likelihood of requiring a blood transfusion (p = 0.01).

CONCLUSION

This study reinforces previous findings emphasizing the adverse effects of iron deficiency on maternal health and the role of IV iron in reducing these risks.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

The Effects of Prenatal Iron Supplementation on Offspring Neurodevelopment in Upper Middle- or High-Income Countries: A Systematic Review

Iron supplementation is commonly recommended for the prevention and treatment of maternal iron deficiency (ID) or iron deficiency anemia (IDA). However, the impacts of prophylactic of therapeutic prenatal iron supplementation on child neurodevelopment in upper middle-income (UMI) and high-income countries (HICs), where broad nutritional deficiencies are less common, are unclear. To investigate this, we conducted a systematic review, searching four databases (Medline, CINAHL, EMBASE, Cochrane Library) through 1 May 2023. Randomized controlled trials (RCTs) assessing oral or intravenous iron supplementation in pregnant women reporting on child neurodevelopment (primary outcome: age-standardized cognitive scores) were eligible. We included three RCTs (five publications) from two HICs (Spain and Australia) (N = 935 children; N = 1397 mothers). Due to clinical heterogeneity of the RCTs, meta-analyses were not appropriate; findings were narratively synthesized. In non-anemic pregnant women, prenatal iron for prevention of IDA resulted in little to no difference in cognition at 40 days post-partum (1 RCT, 503 infants; very low certainty evidence). Similarly, the effect on the intelligence quotient at four years was very uncertain (2 RCTs, 509 children, very low certainty evidence). No RCTs for treatment of ID assessed offspring cognition. The effects on secondary outcomes related to language and motor development, or other measures of cognitive function, were unclear, except for one prevention-focused RCT (302 children), which reported possible harm for children's behavioral and emotional functioning at four years. There is no evidence from UMI countries and insufficient evidence from HICs to support or refute benefits or harms of prophylactic or therapeutic prenatal iron supplementation on child neurodevelopment.

Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach

BACKGROUND AND OBJECTIVE

It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan.

METHODS

A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus.

RESULTS

Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion.

CONCLUSION

These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.

Age and sex-based impacts of maternal iron deficiency on offspring's cognitive function and anemia: A systematic review

Iron deficiency is a recognized global health concern, particularly impactful during pregnancy where the mother serves as the primary source of iron for the developing fetus. Adequate maternal iron levels are crucial for fetal growth and cognitive development. This review investigates the correlation between maternal iron deficiency and cognitive impairment and anemia in offspring, considering age and gender differentials. PubMed, ScienceDirect, and Google Scholar databases were queried using keywords "maternal," "iron," "gender/sex," and "cognition." The review included studies on human and animal subjects where maternal iron deficiency was the exposure and offspring cognitive function and anemia were outcomes. Out of 1139 articles screened, fourteen met inclusion criteria. Twelve studies highlighted cognitive deficits in offspring of iron-deficient mothers, with females generally exhibiting milder impairment compared to males. Additionally, two studies noted increased anemia prevalence in offspring of iron-deficient mothers, particularly affecting males and younger individuals. The findings suggest that male offspring are at higher risk of both anemia and cognitive dysfunction during youth, while females face increased risks in adulthood. Thus, maternal iron deficiency elevates the likelihood of anemia and cognitive impairments in offspring, underscoring the importance of addressing maternal iron status for optimal child health.

Association between maternal hemoglobin concentration and educational attainment in mid-childhood in a high-resource obstetric setting: a prospective cohort study

BACKGROUND

Although maternal hemoglobin levels during pregnancy are commonly associated with perinatal outcomes, their link to childhood neurodevelopment remains uncertain.

OBJECTIVE

This study aimed to examine the associations between maternal hemoglobin in early and late pregnancy and the educational attainment of offspring mid-childhood in a high-resource obstetric setting.

STUDY DESIGN

Pregnancy data from a prospective birth cohort (Pregnancy Outcome Prediction Study, Cambridge, United Kingdom, 2008-2012, N=3285) were linked to mid-childhood educational outcomes (Department for Education, United Kingdom). Regression models adjusted for maternal, child, and socioeconomic factors were used to determine associations between maternal hemoglobin, pregnancy complications, and offspring educational outcomes (aged 5-7 years).

RESULTS

No association was observed between maternal hemoglobin at 12 weeks and the likelihood of either adverse pregnancy outcomes or children meeting expected educational standards between ages 5-7 years. Higher maternal hemoglobin at 28 weeks was associated with an increased risk of small-for-gestational-age infants (adjusted odds ratio, 1.26 [95% confidence interval, 1.11-1.59]; P=.002) and preterm birth (adjusted odds ratio, 1.38 [95% confidence interval, 1.11-1.81]; P=.005). There were no adverse birth outcomes associated with anemia. However, children of mothers who were anemic at 28 weeks had ∼40% increased risk of not attaining expected educational standards at age 5 (adjusted odds ratio, 1.42 [95% confidence interval, 1.03-1.95]; P=.03). There was no association between maternal anemia at 28 weeks and educational performance at ages 6-7. No associations were found between high maternal hemoglobin concentrations (top decile) or change in hemoglobin concentrations between 12 and 28 weeks and childhood educational attainment.

CONCLUSION

Maternal anemia at 28 weeks of pregnancy is associated with reduced educational attainment at 5 years old but not at older ages (6-7 years old). A proactive approach to increasing maternal hemoglobin in high-resource settings is unlikely to impact long-term childhood educational attainment.

Immediate postpartum anemia and associated factors at shewarobit health facilities, Amhara, Ethiopia, 2022: a cross sectional study

BACKGROUND

Immediate postpartum anemia occurs when the amount of red blood cell count is reduced or hemoglobin concentration is below 10 g/dl in the immediate postpartum. It occurs primarily due to inadequate iron intake before and during pregnancy and blood loss during delivery. The aim of this study is to assess the proportion of immediate postpartum anemia and associated factors among mothers who gave birth at Shewarobit health facilities; in Amhara, Ethiopia.

METHODS

Institutional-based cross-sectional study was conducted from June to September 2022. A systematic random sampling method was employed to select the study participants. The data were collected through interviewer-assisted questions. Data were entered into Epi Data software version 4.6.0.4 and exported to SPSS 21 for analysis, and descriptive statistics were computed. Logistic regression was applied, and P-values less than 0.05 were considered statistically significant.

RESULTS

This study was conducted among 307 study participants and, the proportion of immediate postpartum anemia was 41.4% [95% CI: 36.7-46.6]. Having postpartum hemorrhage [AOR = 4.76, 95% CI: 2.44-9.28], not taking iron and folic acid supplementation [AOR = 6.19, 95% CI: 2.69, 14.22], having a prolonged second stage of labor [AOR = 2.52, 95% CI: 1.16-5.44], and mid-upper arm circumference < 23 cm [AOR = 2.02, 95% CI: 1.11-3.68] were factors significantly associated with immediate postpartum anemia.

CONCLUSIONS

The proportion of immediate postpartum anemia was public problem in Shewarobit health facilities. Following the progress of labor using a partograph, closely monitoring and immediate intervention of PPH, and prevent undernutrition during antenatal care is recommended.

Retrospective Study Comparing Treatment Outcomes in Obstetric Patients With Iron Deficiency Anemia Treated With and Without Intravenous Ferric Carboxymaltose

Introduction Iron deficiency anemia is associated with an increased risk of adverse maternal and perinatal outcomes. Intravenous iron preparation containing ferric carboxymaltose has been shown to be a safe and effective way of increasing hemoglobin (Hb) and mean corpuscular volume (MCV) levels and reducing the need for blood transfusion. In our center, it used to be given as an inpatient procedure because of the risks of potential drug reactions. In 2021, we initiated the administration of intravenous ferric carboxymaltose as an outpatient procedure. We compared the outcomes of patients between 2021 and 2023 after the initiation of outpatient administration of intravenous ferric carboxymaltose in 127 obstetric patients with iron deficiency anemia in the second and third trimesters. Methods In this study conducted in a large maternity unit in Singapore between 2021 to 2023, we compared the changes in maternal hematological parameters among obstetric patients with iron deficiency anemia presenting to the day care unit in the second or third trimester with a Hb level of <8 g/dl treated with a single dose of ferric carboxymaltose injection (Ferinject) against a control group who were referred for treatment but defaulted on and declined treatment. Results Ferric carboxymaltose significantly increased the Hb and MCV levels at delivery in obstetric patients with iron deficiency. The mean Hb at delivery was 10.8 g/dL in the case group compared to 8.8 g/dL in the control group. The percentage of patients with Hb ≥10.0 g/dL was 73.4% in the case group compared to 27.8% in the control group. The incidence of adverse side effects was low and mild (2/127; 1.6%). None of the patients received were hospitalized because of ferric carboxymaltose. Conclusion A single injection dose of ferric carboxymaltose as an outpatient antenatal procedure was easily administered and well tolerated. Obstetric patients with iron deficiency anemia who received intravenous ferric carboxymaltose had a significantly higher level of Hb than those who did not.

Role of mineral nutrients other than iron in pregnancy: under recognized opportunities to improve maternal/fetal outcomes: a literature review

BACKGROUND

Anemia during pregnancy is an important global health concern, affecting 40% of women worldwide, and iron deficiency shares a significant proportion of the burden. From conception to birth, pregnancy is a period when women undergo metabolic and physiological changes. The nutritional needs are higher during pregnancy; thus, adequate nutrition is essential to maintain fetal growth and development. However, adverse effects due to deficiency in nutrition during pregnancy can result in maternal, fetal and neonatal complications. Despite the multifactorial etiology of anemia, iron deficiency is assumed as the primary cause of anemia during pregnancy and hence, mitigation strategy pivots around it for anemia management. Therefore, excluding other contributors, a single-micronutrient approach with iron supplements remains a myopic approach and this can exacerbate iron deficiency anemia. Micronutrient deficiencies are of particular concern as they may pose a silent threat to the survival and well-being of reproductive-age women and their infants.

AIM

Micronutrients, especially trace minerals, play a myriad of roles in pregnancy, and the lack of each one causes adverse complications to both the mother and the fetus. In this review paper, we attempt to piece together available information regarding the adverse effects of abnormal trace mineral levels along with iron deficiency on the mother and the fetus.

METHOD

A non-systematic literature search in PubMed, Google Scholar, and the Cochrane databases, for publications on minerals and vitamins during pregnancy and the possible influence of supplements on pregnancy outcomes.

CONCLUSION

Micronutrient deficiency exacerbates the pregnancy-induced anemia and other adverse birth outcomes. Micronutrient supplementation during pregnancy can combat anemia as well as reduce a number of adverse pregnancy outcomes in a comprehensive manner.

Mining the Gap: Deriving Pregnancy Reference Intervals for Hematology Parameters Using Clinical Datasets

BACKGROUND

Physiological changes during pregnancy invalidate use of general population reference intervals (RIs) for pregnant people. The complete blood count (CBC) is commonly ordered during pregnancy, but few studies have established pregnancy RIs suitable for contemporary Canadian mothers. Prospective RI studies are challenging to perform during pregnancy while retrospective techniques fall short as pregnancy and health status are not readily available in the laboratory information system (LIS). This study derived pregnancy RIs retrospectively using LIS data linked to provincial perinatal registry data.

METHODS

A 5-year healthy pregnancy cohort was defined from the British Columbia Perinatal Data Registry and linked to laboratory data from two laboratories. CBC and differential RIs were calculated using direct and indirect approaches. Impacts of maternal and pregnancy characteristics, such as age, body mass index, and ethnicity, on laboratory values were also assessed.

RESULTS

The cohort contained 143 106 unique term singleton pregnancies, linked to >972 000 CBC results. RIs were calculated by trimester and gestational week. Result trends throughout gestation aligned with previous reports in the literature, although differences in exact RI limits were seen for many tests. Trimester-specific bins may not be appropriate for several CBC parameters that change rapidly within trimesters, including red blood cells (RBCs), some leukocyte parameters, and platelet counts.

CONCLUSIONS

Combining information from comprehensive clinical databases with LIS data provides a robust and reliable means for deriving pregnancy RIs. The present analysis also illustrates limitations of using conventional trimester bins during pregnancy, supporting use of gestational age or empirically derived bins for defining CBC normal values during pregnancy.

Patient blood management to minimize transfusions during the postpartum period

Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.

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.

Iron deficiency and sexual dysfunction in women

INTRODUCTION

Sexual dysfunction negatively affects approximately 40% to 50% of adult women across various stages of life. Common risk factors include sexual traumas, relationship problems, chronic conditions, medication side effects, and poor physical health, including iron deficiency.

OBJECTIVES

This review summarizes a presentation from a symposium that discussed the types and causes of sexual dysfunction at key times in women's lives, focusing on the relationship between iron deficiency and sexual dysfunction.

METHODS

The symposium was held at the XV Annual European Urogynaecological Association Congress, Antibes, France, in October 2022. Symposium content was identified through literature searches of PubMed. Original research, review articles, and Cochrane analyses discussing sexual dysfunction in association with iron deficiency/anemia were included.

RESULTS

Iron deficiency in women is commonly caused by abnormal uterine bleeding, but women may develop iron deficiency anemia (IDA) because of increased iron needs or reduced iron intake/absorption. Treatment with oral iron supplementation has been shown to improve sexual function in women with IDA. Ferrous sulphate is considered as a standard of care for oral iron treatment; prolonged-release iron formulations have improved tolerability, enabling lower doses and better tolerability.

CONCLUSION

IDA and sexual dysfunction are related, so the identification of sexual dysfunction or iron deficiency in a woman should prompt an investigation of the other condition. Testing for iron deficiency is an inexpensive and simple step that can be routinely included in the workup of women with sexual dysfunction. Once identified, IDA and sexual dysfunction in women should be treated and followed to optimize quality of life.

Comprehensive management of Jehovah's Witness in pregnancy

Jehovah's Witness (JW) is a denomination of Christianity which has many-fold higher morbidity and mortality compared to the general population as they refuse blood transfusion. Information is scanty regarding guidelines on the optimal approach to pregnant ladies of JW faith. In this review we have attempted to analyse the ways and techniques available which can be used to reduce the morbidity and mortality of these women. In antenatal care, haematological status can be optimised to reduce modifiable risk factors, namely anaemia by parenteral iron therapy from the second trimester onwards especially in patients who do not respond to oral iron therapy. In severe cases, erythropoietin serves as an effective alternative to blood transfusion. During the intrapartum period, using antifibrinolytics, cell salvage, bloodless surgical techniques, and uterine cooling for patients undergoing caesarean delivery have been proven effective. To conclude, complications of pregnant JW patients may be reduced if they comply with the preventives and targeted monitoring during the various phases of pregnancy. Further studies are warranted as this population exists as a minor group but is growing worldwide.

KEY MESSAGES

CURRENT RESEARCH QUESTIONS

Reducing unnecessary premedication prior to parenteral iron therapy: A quality improvement project

BACKGROUND

Intravenous (IV) iron carries risks of mild, self-limiting, tryptase-negative Fishbane and complement activation-related pseudo-allergy reactions, with rare reports of anaphylaxis. Historically, high-molecular-weight iron dextran (HMWID) was associated with a higher incidence of anaphylaxis and empiric premedication with antihistamines/corticosteroids have been used to mitigate this risk. HMWID is no longer available and the risk of hypersensitivity reactions with newer IV iron formulations is low. Therefore, the use of routine prophylactic premedication in all patients is not justified but should be considered in high-risk patients.

STUDY DESIGN AND METHODS

Our primary aim was to reduce inappropriate premedication before IV iron administration by 50% so that our institution's hematology providers only prescribe premedications to patients at high risk of having a severe reaction. Interventions included a multidisciplinary education initiative to highlight current evidence against universal administration of premedications and revision of the IV iron informed consent form and electronic order set.

RESULTS

We measured the success of our intervention by comparing data collected during a 6-month pre-intervention period (837 infusions) to a 6-month post-intervention period (947 infusions). Inappropriate administration of premedications decreased from 79% in the pre-intervention period compared to 65% in the post-intervention period. We found no significant difference in the number of Fishbane reactions, severe reactions, and emergency room admissions, despite this reduction in premedication use.

DISCUSSION

Although we did not reach our goal of a 50% reduction in inappropriate premedication use, opportunities for process improvements were uncovered and are being explored in the next cycle of this quality improvement project.

The Effect of Fresh Moringa Leaf Consumption During Pregnancy on Maternal Hemoglobin Level in Southern Ethiopia: Multilevel Analysis of a Comparative Cross-Sectional Study

Purpose

Anemia, especially iron-deficiency anemia during pregnancy, significantly impacts maternal health, fetal growth, and development. Moringa leaf is an iron-rich food that can overcome anemia, but there is a lack of evidence on the association between fresh moringa leaf consumption and maternal hemoglobin level during pregnancy. The aim of this study is to test the effect of fresh moringa leaf consumption during pregnancy on maternal hemoglobin levels in southern Ethiopia.

Methods

A community-based comparative cross-sectional study was conducted from May to June 2022 among 230 fresh moringa leaf consumers and 230 non-consumers pregnant women. Data were collected using an interviewer-administered structured questionnaire and hemoglobin level was determined by HemoCue Hb 301. Multivariate multilevel linear regression models were fitted using Statistical Software for Data Science (STATA) version 14.

Results

The overall mean hemoglobin level among pregnant women was 11.76 g/dl ± 1.47 [12.06 g/dl ± 1.22 among fresh moringa leaf consumers and 11.45 g/dl ± 1.64 among non-consumers] with a significant coefficient of association (β) of 0.90 g/dl [β = 0.90 g/dl, 95% CI: 0.54, 1.27]. A number of under-five children, bleeding during the current pregnancy, male-headed household, and current antenatal care visit were the individual-level factors. Distance from the nearest health facility and urban dweller was identified as the community-level factor associated with maternal hemoglobin level during pregnancy.

Conclusion

This study showed that the consumption of fresh moringa leaf during pregnancy increases the level of hemoglobin. So policymakers and maternal and child health program managers need to target moringa tree scale-up and encourage fresh moringa leaf consumption during pregnancy, but its use needs additional rigorous clinical trials. In addition to this, mark the above factors in their efforts to increase maternal hemoglobin levels during pregnancy.

Wellbeing Forecasting in Postpartum Anemia Patients

Postpartum anemia is a very common maternal health problem and remains a persistent public health issue globally. It negatively affects maternal mood and could lead to depression, increased fatigue, and decreased cognitive abilities. It can and should be treated by restoring iron stores. However, in most health systems, there is typically a six-week gap between birth and the follow-up postpartum visit. Risks of postpartum maternal complications are usually assessed shortly after birth by clinicians intuitively, taking into account psychosocial and physical factors, such as the presence of anemia and the type of iron supplementation. In this paper, we investigate the possibility of using machine-learning algorithms to more reliably forecast three parameters related to patient wellbeing, namely depression (measured by Edinburgh Postnatal Depression Scale-EPDS), overall tiredness, and physical tiredness (both measured by Multidimensional Fatigue Inventory-MFI). Data from 261 patients were used to train the forecasting models for each of the three parameters, and they outperformed the baseline models that always predicted the mean values of the training data. The mean average error of the elastic net regression model for predicting the EPDS score (with values ranging from 0 to 19) was 2.3 and outperformed the baseline, which already hints at the clinical usefulness of using such a model. We further investigated what features are the most important for this prediction, where the EDPS score and both tiredness indexes at birth turned out to be by far the most prominent prediction features. Our study indicates that the machine-learning model approach has the potential for use in clinical practice to predict the onset of depression and severe fatigue in anemic patients postpartum and potentially improve the detection and management of postpartum depression and fatigue.

The prevalence of trimester-specific dietary supplements and associated factors during pregnancy: An observational study

Objectives: This study aimed to assess the prevalence of trimester-specific dietary supplements (DS)s use and their possible correlates during pregnancy.

Method: Pregnant women were convenience sampled and recruited from a comprehensive obstetric care center in Shanghai, China. Data relating to the use of DS during pregnancy, social support and other social-demographic and obstetric data were collected. Trimester-specific DS use and factors related DS were explored.

Results: Of the 2803 women participating in this study, 94.8%, 96.2%, 93.8%, and 94.4% reported the use of at least one DS during pregnancy (all trimesters) and in the first, second, and third trimesters of pregnancy, respectively. Significant differences were noted in the use of DS containing folic acid, calcium, iron, vitamins, and docosahexaenoic acid (DHA), during the three trimesters of pregnancy. A higher proportion of DS use was negatively associated with certain categories of pregnant woman, including unemployed/housewife, low education level, obese, and low social support. A positive association was identified with gestational age.

Conclusion for practice: Considering the high prevalence of DS use during pregnancy, future studies are needed to evaluate the accuracy and suitability of DS usage during pregnancy.

Obstetrical and neonatal complications in hereditary haemorrhagic telangiectasia: A retrospective study

OBJECTIVE

To retrospectively describe a large series of pregnancies in women with hereditary haemorrhagic telangiectasia followed in our reference centre, plus neonatal outcomes, to better understand the risks of complications and to improve their prevention.

DESIGN

A retrospective descriptive study conducted through a phone questionnaire.

SETTING

Reference centre for hereditary haemorrhagic telangiectasia in Lyon, France.

POPULATION

Women meeting the following criteria: (1) alive and aged ≥18 years; (2) with a definite clinical and/or genetic diagnosis of hereditary haemorrhagic telangiectasia; and (3) with at least one full-term pregnancy.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes of pregnancies in women with hereditary haemorrhagic telangiectasia.

RESULTS

Five hundred and sixty-two pregnancies were reported in 207 women with hereditary haemorrhagic telangiectasia. A total of 271 complications (48.2%) were registered. Of these, 149 (55%) non-specific complications, 110 (40.6%) non-severe specific complications and 12 (4.4%) severe specific complications were registered. There were four cases of haemoptysis and two cases of transient ischaemic attack related to pulmonary arteriovenous malformations. Four patients had severe decompensated dyspnoea, related to pulmonary arteriovenous malformations in three cases and to pulmonary arteriovenous malformations associated with severe hepatic arteriovenous malformations in one case. Hepatobiliary necrosis occurred in one case. Epidural or spinal anaesthesia was performed in 139 of 452 deliveries (31%), without complications. There were 12 reports of congenital anomalies in 461 live births (3%).

CONCLUSIONS

Most pregnancies in hereditary haemorrhagic telangiectasia women are uneventful; complications are rare but can be severe. Women thus need to be educated about screening and possible pregnancy-related risks before becoming pregnant.

Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use

Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.

The Effects of Iron Deficiency on the Gut Microbiota in Women of Childbearing Age

Iron deficiency anemia (IDA) is the most prevalent and common nutritional deficiency worldwide and is a global health problem with significant risk, particularly among women of reproductive age. Oral iron supplementation is the most widely used and cost-effective treatment for iron deficiency and IDA. However, there are limitations regarding side effects such as enteritis, treatment compliance, and bioavailability. Intestinal microbiome characteristic research has been recently conducted to overcome these issues, but more is needed. Against this background, a metagenomics study on the 16S gene in the feces of young women vulnerable to IDA was conducted. As a result of analyzing 16 normal subjects and 15 IDA patients, significant differences in bacterial community distribution were identified. In particular, a significant decrease in Faecalibacterium was characteristic in IDA patients compared with normal subjects. Furthermore, in the case of patients who recovered from IDA following iron supplementation treatment, it was confirmed that Faecalibacterium significantly recovered to normal levels. However, no significance in beta diversity was seen compared with before treatment. There were also no differences in the beta diversity results between the recovered and normal subjects. Therefore, intestinal dysbiosis during the disease state was considered to be restored as IDA improved. Although the results were derived from a limited number of subjects and additional research is needed, the results of this study are expected to be the basis for developing treatment and prevention strategies based on host-microbiome crosstalk in IDA.

Efficacy and safety of Mojeaga remedy in combination with conventional oral iron therapy for correcting anemia in obstetric population: A phase II randomized pilot clinical trial

BACKGROUND

To our knowledge, there is no prior randomized trial on the efficacy of Mojeaga remedy (a special blend of Alchornea cordifolia, Pennisetum glaucum and Sorghum bicolor extracts) when co-administered with standard-of-care for correction of anemia in obstetrics practice. This study determined the efficacy, safety and tolerability of Mojeaga as adjunct to conventional oral iron therapy for correction of anemia in obstetric population.

METHODS

A pilot open-label randomized clinical trial. Participants with confirmed diagnosis of anemia in three tertiary hospitals in Nigeria were studied. Eligible participants were randomized 1:1 to either Mojeaga syrups 50 mls (200mg/50mls) administered three times daily in conjunction with conventional iron therapy (Mojeaga group) for 2 weeks or conventional iron therapy alone without Mojeaga (standard-of-care group) for 2 weeks. Repeat hematocrit level were done 2 weeks post-initial therapy. Primary outcome measures were changes in hematocrit level and median hematocrit level at two weeks post therapy. Maternal adverse events and neonatal outcomes (birth anomalies, low birthweight, preterm rupture of membranes and preterm labor) were considered the safety outcome measures. Analysis was by intention-to-treat.

RESULTS

Ninety five participants were enrolled and randomly assigned to the Mojeaga group (n = 48) or standard-of-care group (n = 47). The baseline socio-demographic and clinical characteristics of the study participants were similar. At two weeks follow-up the median rise in hematocrit values from baseline (10.00±7.00% vs 6.00±4.00%;p<0.001) and median hematocrit values (31.00±2.00% vs 27.00±3.00%;p<0.001) were significantly higher in the Mojeaga group. There were no treatment-related serious adverse events, congenital anomalies or deaths in the Mojeaga group and incidence of other neonatal outcomes were similar (p>0.05).

CONCLUSION

Mojeaga represents a new adjuvants for standard-of-care option for patients with anemia. Mojeaga remedy is safe for treating anemia during pregnancy and puerperium without increasing the incidence of congenital anomalies, or adverse neonatal outcomes.

CLINICAL TRIAL REGISTRATION

www.pactr.samrc.ac.za: PACTR201901852059636 (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5822).

Evaluation of RET-He values as an early indicator of iron deficiency anemia in pregnant women

INTRODUCTION

During pregnancy, women are at an increased risk of developing iron-deficiency anemia.

OBJECTIVE

The objective of this study was to assess the diagnostic performance of the reticulocyte hemoglobin equivalent (RET-He) in the early detection of iron-deficiency anemia in a group of pregnant women and to establish a reference range for this parameter in a group of control individuals.

METHOD

A total of 60 patients and 130 control subjects were included in the study. Blood samples collected from the subjects were submitted to a complete blood count and a serum ferritin test and the data were analyzed by comparing the groups and ROC curves.

RESULTS

The reference range found for the RET-He was between 29.75pg and 38.24pg, with a median of 35pg. The receiver operating characteristic (ROC) curve analysis for the ferritin parameter showed an area under the curve of 0.732 for the RET-He, 0.586 for hemoglobin, 0.551 for the mean corpuscular hemoglobin concentration and 0.482 for the mean corpuscular volume.

CONCLUSION

Early diagnosis of iron deficiency anemia in pregnancy is essential to prevent damage to both maternal and fetal health. The RET-He presents an excellent potential as an auxiliary tool for the diagnosis of iron deficiency in pregnant women.

Thrombocytopenia in pregnancy

Hematologists are often consulted for thrombocytopenia in pregnancy, especially when there is a concern for a non-pregnancy-specific etiology or an insufficient platelet count for the hemostatic challenges of delivery. The severity of thrombocytopenia and trimester of onset can help guide the differential diagnosis. Hematologists need to be aware of the typical signs of preeclampsia with severe features and other hypertensive disorders of pregnancy to help distinguish these conditions, which typically resolve with delivery, from other thrombotic microangiopathies (TMAs) (eg, thrombotic thrombocytopenic purpura or complement-mediated TMA). Patients with chronic thrombocytopenic conditions, such as immune thrombocytopenia, should receive counseling on the safety and efficacy of various medications during pregnancy. The management of pregnant patients with chronic immune thrombocytopenia who are refractory to first-line treatments is an area that warrants further research. This review uses a case-based approach to discuss recent updates in diagnosing and managing thrombocytopenia in pregnancy.

Study of Relationship Between Iron Deficiency and Thyroid Function in Pregnant Females

BACKGROUND

Iron is essential for the normal functioning of thyroid peroxidase and iron deficiency is very commonly encountered during pregnancy. Thyroid disorders and iron deficiency are associated with obstetrical and fetal complications. The aim of the study was to find out the relationship between iron deficiency and thyroid function in pregnant females during first trimester.

METHODOLOGY

 The present cross-sectional observational study was conducted among first trimester pregnant females at the Department of Medicine, Obstetrics and Gynecology, and Biochemistry at Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi. Hundred pregnant women were included in this study. On the basis of serum ferritin value, the study population was divided into two groups namely iron deficient and non-iron deficient. Serum thyroid-stimulating hormone (TSH), FT4, and anti-thyroid peroxidase (TPO) values were then compared between the two groups.

RESULTS

In the present study, 68% of the females were iron deficient. In the Iron deficient group, serum TSH and anti-TPO levels were significantly higher as compared to that in the non-iron deficient group (35.29% vs. 6.25% and 22.06% vs. 3.13%; p=0.001 and 0.018, respectively). A positive correlation was obtained between FT4 and ferritin with correlation coefficient of 0.907 and p-value of 0.0001. Serum TSH levels and serum anti-TPO levels were inversely correlated with ferritin. Univariate logistic regression analysis revealed that iron deficiency was associated with an increased risk of subclinical hypothyroidism with odds ratio (OR) 8.182 (95% CI: 1.798-37.234, p=0.007) and raised anti-TPO with OR 8.77 (95% CI: 1.105-69.681; p=0.040).

CONCLUSIONS

Iron deficiency is frequent during the first trimester of pregnancy and is associated with an increased risk of subclinical hypothyroidism and thyroid autoimmunity.

Trends in prevalence and treatment rate of anemia in the U.S. population: cross-sectional study using data from NHANES 2005-2018

OBJECTIVES

To determine the trends in anemia prevalence, treatment rates, and their associated demographic and socioeconomic status factors in the U.S. nationally representative population.

METHODS

We extracted data from individuals ≥20-year-old from the NHANES from 2005 to 2018. The trends of anemia prevalence and treatment were assessed by Cochran-Armitage test. The association between two dependent variables (anemia status and treatment) and demographic were examined by multiple logistic regression.

RESULTS

The general anemia prevalence has a significant increasing trend from 5.71% to 6.86% (P trend<.001) from 2005 to 2018, whereas the trend in general anemia treatment rate was not significant (p = .148). Logistic regression showed that age groups (OR: 2.15for 60 or older vs. 20-39 years old), sex (0.47 for male vs. female), race (0.22 for NHW vs. NHB), education (0.80for some college or AA degree vs. less than high school), PIR (0.60 for ≥3.5 vs.≤1.3), and birthplace (0.88 for U.S. vs. other) were significantly associated with anemia. The factors significantly associated with anemia treatment were age group (1.51 for 60 years and older vs. 20-39 years old), sex (0.53 male vs. female), birthplace (1.88 U.S. vs. other), and insurance (1.80 for Yes vs. No).

CONCLUSION

While there was no significant increase in anemia treatment between 2005 and 2018, the anemia prevalence increased significantly, particularly among individuals with lower income, less education, and born outside the U.S. Moreover, the high anemia prevalence among NHB compared to other races indicated that more resources are needed to reduce disparities.

Patient Blood Management programs for post-partum hemorrhage

Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.

Quality Appraisal of Nutritional Guidelines to Prevent, Diagnose, and Treat Malnutrition in All Its Forms during Pregnancy

This work aimed to identify clinical practice guidelines (CPGs) that include recommendations for the prevention, diagnosis, and treatment of women’s malnutrition during pregnancy and to evaluate the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. We conducted a literature review using PubMed and different websites from January 2009 to February 2021. The quality of the CPGs was independently assessed by reviewers using the AGREE II instrument, which defines guidelines scoring >70% in the overall assessment as “high quality”. The analysis included 43 guidelines. Among the main findings, we identified that only half of the CPGs (51.1%) obtained a final “high quality” evaluation. AGREE II results varied widely across domains and categories. The two domains that obtained the highest scores were scope and purpose with 88.3% (range 39 to 100%) and clarity of presentation with 87.2% (range 25 to 100%). Among the “high quality” CPGs, the best scores were achieved by the three guidelines published by the National Institute of Health and Care Excellence (NICE) and the World Health Organization (WHO). Due to the importance of maternal nutrition in pregnancy, it is essential to join forces to improve the quality of the guidelines, especially in CPGs that do not meet the reference standards for quality.

Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.

Beyond hemoglobin: uncovering iron deficiency and iron deficiency anemia using serum ferritin concentration among pregnant women in eastern Ethiopia: a community-based study

BACKGROUND

Although the high burden of anemia among pregnant women in low-resource settings like Ethiopia is well documented, evidence is scarce on the underlying causes using biochemical tests. Therefore, this study assessed the iron status and factors associated with iron deficiency (ID) using serum ferritin concentration among pregnant women in Haramaya district, eastern Ethiopia.

METHODS

A community-based cross-sectional study was conducted among randomly selected pregnant women in Haramaya district, eastern Ethiopia. The serum ferritin (SF) concentration was measured in the National Biochemical Laboratory of Ethiopia on a fully automated Cobas e411 (German, Japan Cobas 4000 analyzer series) immunoassay analyzer using the electro-chemiluminescence (ECL) method and standard procedures. A log-binomial regression analysis identified variables associated with iron deficiency, and defined as serum ferritin concentration < 15 μg/L (per the World Health Organization recommendation in developing countries). An adjusted risk ratio (aRR), and a 95% confidence interval (CI), were used to report associations. Finally, the p-value < 0.05 was the cut-off point for the significant association.

RESULTS

A total of 446 pregnant women with a mean age of 24.78 (+ 5.20) were included in the study. A total of 236 (52.91%; 95% CI: 48.16-57.63) had iron deficiency. The overall prevalence of anemia and iron deficiency anemia (IDA) was 45.96% (95% CI: 41.32-50.71) and 28.03% (95% CI: 21.27-32.44), respectively. The risk of iron deficiency was more likely among women with low dietary diversity (aRR = 1.36; 95% CI = 1.07-1.72) and those who skipped meals (aRR = 1.29; 95% CI = 1.05-1.57), but less among women who had antenatal care (aRR = 0.73 (95% CI = 0.61-0.88).

CONCLUSION

More than half of the pregnant women in eastern Ethiopia had iron deficiency. Improving dietary diversity, meal frequency, and prenatal follow-up is essential to improve the high burden of ID and the adverse effect on pregnant women and the fetus. Moreover, a prospective study comparing maternal and perinatal outcomes among these spectra-iron depletion, ID, and IDA-is crucial for understanding their impact on maternal and perinatal mortality and morbidity.

Maternal iron deficiency anaemia in pregnancy: Lessons from a national audit

We describe the management and the prevalence of iron deficiency anaemia (IDA) during pregnancy by comparison to standards. A cross-sectional national cohort study of women who had given birth six weeks prior to data collection was conducted at maternity units in the UK and Ireland. Participating centres collected data from 10 consecutive pregnant women. Analysis was descriptive to define the prevalence of IDA in pregnancy and the puerperium, and to compare the outcomes in women who had IDA with women who did not have anaemia anytime during pregnancy. Eighty-six maternity units contributed data on 860 pregnancies and births. The overall prevalence of IDA during pregnancy was 30.4% and in the puerperium 20%. Anaemic women were more likely to be from ethnic minorities, odds ratio 2.23 (1.50, 3.32). Adherence to national guidance was suboptimal, and the prevalence of anaemia in pregnancy remains very high. There is pressing need to explore barriers to early identification and effective management of iron deficiency. IDA should be considered a major public health problem in the UK.

Maternal Iron Deficiency Programs Rat Offspring Hypertension in Relation to Renin—Angiotensin System and Oxidative Stress

Hypertension is an important public health challenge, affecting up to 30–50% of adults worldwide. Several epidemiological studies indicate that high blood pressure originates in fetal life—the so-called programming effect or developmental origin of hypertension. Iron-deficiency anemia has become one of the most prevalent nutritional problems globally. Previous animal experiments have shown that prenatal iron-deficiency anemia adversely affects offspring hypertension. However, the underlying mechanism remains unclear. We used a maternal low-iron diet Sprague Dawley rat model to study changes in blood pressure, the renal renin-angiotensin system, oxidative stress, inflammation, and sodium transporters in adult male offspring. Our study revealed that 16-week-old male offspring born to mothers with low dietary iron throughout pregnancy and the lactation period had (1) higher blood pressure, (2) increased renal cortex angiotensin II receptor type 1 and angiotensin-converting enzyme abundance, (3) decreased renal cortex angiotensin II receptor type 2 and MAS abundance, and (4) increased renal 8-hydroxy-2′-deoxyguanosine and interleukin-6 abundance. Improving the iron status of pregnant mothers could influence the development of hypertension in their offspring.

Effects of Moringa oleifera leaves on hemoglobin and serum retinol levels and underweight status among adolescent girls in rural Bangladesh

Objectives

Moringa oleifera has been used for centuries due to its medicinal properties and health benefits. The plant has antifungal, anti-viral, and anti-inflammatory properties. We aimed to evaluate the effect of consumption of Moringa leaves, along with a regular diet on serum hemoglobin and retinol and underweight status among rural Bangladeshi adolescent girls.

Methods

This school-based quasi-experimental study involved 226 adolescent girls (12–14 years-old). Intervention group (n = 113) received a meal comprising rice, concentrated dal, and fried potato with Moringa pakora (oil-fried snack); the control group (at a different school in an adjacent area with similar population demographics) received calorie-matched meal without Moringa pakora for 6 months. We used generalized liner regression (GLM) analysis, to explore the effect of the intervention among the groups between baseline and endline.

Results

Mean age of the intervention and control groups were 12.7 ± 0.7 and 13.3 ± 0.8 years, respectively. After adjusting for maternal education, absenteeism, asset index, BMI-for-age Z-score, GLM regression showed significant positive changes in hemoglobin (intervention vs. control: coef = 0.41, P = 0.010) and serum retinol (coef = 0.27, P = 0.00). No significant changes in weight was observed between groups.

Conclusion

Consumption of Moringa leaves has the potential to improving hemoglobin and serum retinol level and should be encouraged as regular diet.

Antenatal Iron-Rich Food Intervention Prevents Iron-Deficiency Anemia but Does Not Affect Serum Hepcidin in Pregnant Women

BACKGROUND

Limited evidence supports the efficacy of iron-rich foods (IRFs) in improving iron status during pregnancy.

OBJECTIVES

The study aims to evaluate the effect of IRFs on iron status and biomarkers of iron metabolism in the third trimester of pregnancy.

METHODS

A total of 240 pregnant women at 11-13 wk of gestation without iron-deficiency anemia (IDA) in South China were recruited to this single-blind clinical trial [non-IDA referred to both hemoglobin (Hb) ≥110g/L and serum ferritin (SF) ≥15ng/mL],  randomly assigned to 1) control, 2) IRFs containing 20 mg iron/d (IRF-20), or 3) IRFs containing 40 mg iron/d (IRF-40). The IRFs were consumed 3 days a week, including pork liver, chicken/duck blood, soybean, and agaric. The IRFs started at recruitment and ended in the predelivery room. Primary outcome included anemia (Hb <110 g/L), iron deficiency (ID, definition 1: SF <15 ng/mL; definition 2: SF <12 ng/mL), and IDA (ID and Hb <110 g/L). Secondary outcome was plasma Hb and iron indices, including SF, serum hepcidin, and iron.

RESULTS

All participants who completed the trial with full data (n = 170) were included in the analysis. At the endline, both intervention groups showed lower ID and IDA rates than control. Specifically, IRF-40 showed a lower ID (SF <12 ng/mL) rate than control (9.0% compared with 22.8%, P = 0.022). For IDA by definition 1, the incidence in IRF-40 was lower than that in control (1.9% compared with 8.9%, P = 0.045). For IDA by definition 2, the incidence in IRF-20 was lower than that in control (3.9% compared with 17.9%, P = 0.049). Moreover, IRF-20 showed higher SF concentrations than control (P = 0.039). No effects of IRFs on anemia (P = 0.856), plasma Hb (P = 0.697), serum hepcidin (P = 0.311), and iron (P = 0.253) concentrations were observed. The assessed iron intakes were 22.2 mg/d in IRF-20 and 25.0 mg/d in IRF-40, respectively.

CONCLUSIONS

Antenatal IRFs reduce the risk of ID and IDA in late pregnancy, although the present results are inadequate to confirm an ideal dosage (No. ChiCTR1800017574).

Intravenous versus Oral Iron for Iron-Deficiency Anemia in Pregnancy (IVIDA): A Randomized Controlled Trial

OBJECTIVE

Iron-deficiency anemia (IDA) can have serious consequences for mothers and babies. Iron supplementation is recommended, but the administration route is controversial. We sought to conduct a randomized controlled trial (RCT) testing the effectiveness and safety of intravenous (IV) iron compared with oral iron on perinatal outcomes in pregnant women with IDA.

STUDY DESIGN

This open-label RCT randomized patients with IDA (hemoglobin [hgb] <10 g/dL and ferritin <30 ng/mL) at 24 to 34 weeks' to oral iron or single 1,000-mg dose of IV low-molecular weight iron dextran over one hour. The primary outcome was maternal anemia at delivery (hgb < 11 g/dL). Secondary outcomes were mild/moderate or severe adverse reactions, maternal hgb and ferritin at delivery, blood transfusion, gestational age at delivery, birth weight, neonatal hgb and ferritin, and composite neonatal morbidity. Analysis was as per protocol.

RESULTS

The trial was stopped early for logistical reasons, and the data analyzed as preliminary data to inform a larger, potentially externally funded, definitive trial. Of 55 patients approached, 38 consented. Of these, 15 were withdrawn: 5 received IV iron from their primary obstetrician after being randomized to oral iron and 10 declined to receive IV iron. Of the remaining 23 patients, who were included in the analytic population, 13 received oral iron and 10 received IV iron. The rate of maternal anemia at delivery (hgb < 11 g/dL) was high overall but significantly reduced with IV iron (40 vs. 85%, p = 0.039). Rates of maternal hgb < 10 g/dL were significantly lower in the IV iron group (10 vs. 54%, p = 0.029). There were no severe adverse reactions and similar rates of mild/moderate reactions between groups.

CONCLUSION

IV iron reduces rates of anemia at the time of admission for delivery, supporting a larger RCT comparing IV versus oral iron for the treatment of IDA of pregnancy powered for definitive clinical outcomes. However, issues uncovered in this RCT suggest that patient, clinician, and systems-level barriers associated with different IDA treatment modalities must be considered prior to conducting a larger RCT. This study is registered with clinicaltrials.gov with identifier no.: NCT03438227.

KEY POINTS

· IV iron decreases rates of anemia on admission for delivery compared with oral iron.. · In an unblinded randomized trial, a significant proportion of patients preferred alternate therapy.. · Future RCTs should incorporate double-blinded technique to reduce risk of patient crossover.. · Results from feasibility trial support a larger RCT comparing IV to oral iron for IDA in pregnancy..

Diagnosis and Therapy of Iron Deficiency Anemia During Pregnancy: Recommendation of the Austrian Society for Gynecology and Obstetrics (OEGGG)

This overview analyzes the data on the controversial therapy of iron substitution during pregnancy, the diagnosis of iron deficiency anemia and the indication-related therapy, and is the first recommendation issued by the OEGGG on the appropriate therapy. The effects of anemia during pregnancy on postnatal outcomes have been intensively investigated with heterogeneous results. A final scientific conclusion with regards to the "optimal" maternal hemoglobin level is limited by the heterogeneous results of various studies, many of which were conducted in emerging nations (with different dietary habits and structural differences in the respective healthcare systems). The current literature even suggests that there may be a connection between both decreased and increased maternal serum hemoglobin concentrations and unfavorable short-term and long-term neonatal outcomes. In Austria, 67 percent of pregnant women take pharmacological supplements or use a variety of dietary supplements. Clinically, the prevalence of maternal anemia is often overestimated, leading to overtreatment of pregnant women (iron substitution without a medical indication). To obtain a differential diagnosis, a workup of the indications for treatment should be carried out prior to initiating any form of iron substitution during pregnancy. If treatment is medically indicated, oral iron substitution is usually sufficient. Because of the restricted approval and potential side effects, medical indications for intravenous iron substitution should be limited. Intravenous iron substitution without a prior detailed diagnostic workup is an off-label use and should only be used in very limited cases, and women should be advised accordingly.

A Retrospective Study Using Mentzer Index for Prevalence of Iron Deficiency Anemia among Infants Visiting Maternal Centers at the Age of One Year

Anemia, defined as a hemoglobin level two standard deviations below the mean for age, is prevalent in infants and children worldwide. Characterizing anemia as microcytic and normocytic depends on the mean corpuscular volume (MCV), which is an important parameter in differentiating many types of anemia. Microcytic anemia due to iron deficiency is the most common type of anemia in children. In this study, we aimed to assess the Mentzer index used by the Ministry of Health (MOH) in Palestine as a useful tool in differentiating between iron deficiency anemia (IDA) and thalassemia. We assessed for the prevalence of IDA among infants at the age of one year visiting the mother centers from seven West Bank provinces in Palestine. Medical records and hematology laboratory data of 3262 infants were retrospectively analyzed from the years of 2018 to 2020. The Mentzer index applied to all population by dividing mean corpuscular volume (MCV, in fL) by the red blood cell count (RBC, in millions per microliter). A corrected Mentzer index was further calculated among anemic infants to include only microcytic (MCV with less than 72 fl) and hypochromic (mean corpuscular hemoglobin concentration (MCHC) with less than 32 g/L) indices. Mentzer index calculations for the whole population showed that 29.1% were anemic (hemoglobin (HGB) less than 11 g/dl): 21.1% had mild anemia, 7.6% had moderate anemia, while 0.2% had severe anemia. The corrected Mentzer index calculations showed a prevalence of 5.9% and 3.2% among IDA and thalassemia infants, respectively. Severity of anemia was correlated with low body weight and infants born through cesarean mother birth with no interference with gender influence. CBC indices of RBC count, HGB, MCV, and mean corpuscular hemoglobin (MCH) showed a significant difference (p values < 0.05) between IDA and thalassemia infants' populations following the corrected Mentzer index. With the corrected Mentzer index, we introduced a new CBC index among infants at the age of 1 year in Palestine. These lab references could aid in differentiating IDA and thalassemia among the population and improve initial diagnosis screenings. The Mentzer index calculation for the whole population did not necessarily include cases of IDA, and therefore, it is recommended to comprise microcytic and hypochromic anemia indices prior to performing the Mentzer index.

Review of Dietary Recommendations for Twin Pregnancy: Does Nutrition Science Keep Up with the Growing Incidence of Multiple Gestations?

Recommendations for nutrition and the use of dietary supplements for pregnant women are updated on regular basis but it remains to be seen to what extent they may be applicable in twin pregnancies. The aim of this narrative review is to present the current state of knowledge about the energy and nutrient demand in twin pregnancy. There is general consensus in literature that the energy demand is higher than in a singleton pregnancy, but there is a lack of position statements from scientific societies on specific energy intake that is required. In turn, recommended maternal weight gain, which favors the normal weight of the neonate, has been determined. There is even a larger knowledge gap when it comes to vitamins and minerals, the body stores of which are theoretically used up faster. The greatest number of studies so far focused on vitamin D, and most of them concluded that its concentration in maternal blood is lower in twin as compared to singleton pregnancy. Few randomized studies focus on iron supplementation and there are no other studies that would assess dietary interventions. In light of a growing incidence of multiple pregnancies, more studies are necessary to establish the nutritional demands of the mother and the course of action for adequate supplementation.

Desiderosmia: a manifestation of iron deficiency in pregnancy

A pregnant woman in her 20s presented with an excessive desire to smell a specific household cleaning product. She was found to have severe iron deficiency anaemia and her symptoms resolved following intravenous iron supplementation. She described symptoms of fatigue, shortness of breath and olfactory cravings. The specific scent could not be replicated with other smells and the woman had to significantly modify her lifestyle to accommodate the excessive desire. She had a similar experience during her prior pregnancy which resolved after the correction of severe iron deficiency anaemia. This unique symptom has been described as desiderosmia: iron deficiency manifesting as olfactory cravings. This underappreciated but useful symptom is defined as a separate entity to pica, as there is an absence of desire to ingest the product. Desiderosmia can harm mother and baby through inhalation of potentially harmful fumes; hence, women who describe this symptom should be assessed for iron deficiency anaemia.

Iron supplementation during the first trimester of pregnancy after a national change of recommendation: a Danish cross-sectional study

In 2013, the Danish Health Authorities recommended a change in prophylactic iron supplementation to 40–50 mg/d from gestational week 10. Hence, the aims of the present study were (1) to estimate the prevalence of women who follow the Danish recommendation on iron supplementation during the last 3 weeks of the first trimester of pregnancy and (2) to identify potential sociodemographic, reproductive and health-related pre-pregnancy predictors for iron supplementation during the first trimester. We conducted a cross-sectional study with data from the hospital-based Copenhagen Pregnancy Cohort. Characteristics were analysed by descriptive statistics and multivariable logistic regression analysis was performed to examine the associations between predictors and iron supplementation during the last 3 weeks of the first trimester. The study population consisted of 23 533 pregnant women attending antenatal care at Copenhagen University Hospital - Rigshospitalet from October 2013 to May 2019. The prevalence of iron supplementation according to recommendations was 49⋅1 %. The pre-pregnancy factors of ≥40 years of age, the educational level below a higher degree and a vegetarian or vegan diet were identified as predictors for iron supplementation during the first trimester of pregnancy. Approximately half of the women were supplemented with the recommended dose of iron during the first trimester of pregnancy. We identified pre-pregnancy predictors associated with iron supplementation. Interventions that target women of reproductive age are needed. An enhanced focus on iron supplementation during pregnancy should be incorporated in pre-pregnancy and interpregnancy counselling.

The Influence of Nutritional Supplementation for Iron Deficiency Anemia on Pregnancies Associated with SARS-CoV-2 Infection

Anemia is a very common occurrence during pregnancy, with important variations during each trimester. Anemia was also considered as a risk factor for severity and negative outcomes in patients with SARS-CoV-2 infection. As the COVID-19 pandemic poses a significant threat for pregnant women in terms of infection risk and access to care, we developed a study to determine the impact of nutritional supplementation for iron deficiency anemia in correlation with the status of SARS-CoV-2 infection. In a case-control design, we identified 446 pregnancies that matched our inclusion criteria from the hospital database. The cases and controls were stratified by SARS-CoV-2 infection history to observe the association between exposure and outcomes in both the mother and the newborn. A total of 95 pregnant women were diagnosed with COVID-19, having a significantly higher proportion of iron deficiency anemia. Low birth weight, prematurity, and lower APGAR scores were statistically more often occurring in the COVID-19 group. Birth weight showed a wide variation by nutritional supplementation during pregnancy. A daily combination of iron and folate was the optimal choice to normalize the weight at birth. The complete blood count and laboratory studies for iron deficiency showed significantly decreased levels in association with SARS-CoV-2 exposure. Puerperal infection, emergency c-section, and small for gestational age were strongly associated with anemia in patients with COVID-19. It is imperative to screen for iron and folate deficiency in pregnancies at risk for complications, and it is recommended to supplement the nutritional intake of these two to promote the normal development and growth of the newborn and avoid multiple complications during pregnancy in the COVID-19 pandemic setting.

Iron Metabolism in Normal and Pathological Pregnancies and Fetal Consequences

Iron is required for energy production, DNA synthesis, and cell proliferation, mainly as a component of the prosthetic group in hemoproteins and as part of iron-sulfur clusters. Iron is also a critical component of hemoglobin and plays an important role in oxygen delivery. Imbalances in iron metabolism negatively affect these vital functions. As the crucial barrier between the fetus and the mother, the placenta plays a pivotal role in iron metabolism during pregnancy. Iron deficiency affects 1.2 billion individuals worldwide. Pregnant women are at high risk of developing or worsening iron deficiency. On the contrary, in frequent hemoglobin diseases, such as sickle-cell disease and thalassemia, iron overload is observed. Both iron deficiency and iron overload can affect neonatal development. This review aims to provide an update on our current knowledge on iron and heme metabolism in normal and pathological pregnancies. The main molecular actors in human placental iron metabolism are described, focusing on the impact of iron deficiency and hemoglobin diseases on the placenta, together with normal metabolism. Then, we discuss data concerning iron metabolism in frequent pathological pregnancies to complete the picture, focusing on the most frequent diseases.

The Etiology of Anemia Among Pregnant Women in the Hill State of Himachal Pradesh in North India: A Cross-Sectional Study

Background and objective

Anemia during pregnancy is a major cause of maternal and fetal complications including mortality. A study of the etiology of anemia is required to formulate guidelines for the prevention and treatment of the condition. To this end, we conducted a study among anemic women in northern India.

Materials and methods

A cross-sectional study was conducted among anemic antenatal women attending the outpatient department at a tertiary care hospital in Himachal Pradesh, India, involving 172 participants. Complete blood count, serum ferritin level, serum B12, serum folate levels, high-performance liquid chromatography (HPLC), liver function tests, and renal function tests were performed.

Results

The mean hemoglobin level among the subjects was 8.87 g/dl with a standard deviation of 0.79; 50% of women had serum ferritin levels of less than 15 ng/ml, 48.8% had serum B12 levels of less than 150 pg/ml. and 33.72% of women had serum folate levels of less than 3 ng/ml. Of note, 13.37% of women had either low or deficient levels for all three parameters; 14 women had abnormal results on HPLC. All nutrient deficiencies (ferritin, folate, and vitamin B12) were found in all morphological types of anemia. Significantly, 73.26% of iron-deficient anemic women had additional folate or vitamin B12 deficiencies, suggesting that additional methods would be required to decrease the prevalence of anemia. Two-thirds of the women in our study were vegetarians, a contributing factor towards a high percentage of vitamin B12 deficiency among women. ß-thalassemia trait was the most common abnormality found, consistent with the high prevalence of ß-thalassemia in north India.

Conclusion

Multiple deficiencies should be treated simultaneously in anemic women. Vitamin B12 deficiency is an important contributor to anemia, in addition to iron and folate deficiency.

Prevalence and aetiologies of anaemia among first trimester pregnant women in Sri Lanka; the need for revisiting the current control strategies

BACKGROUND

The Sustainable development goals, which focus strongly on equity, aim to end all forms of malnutrition by 2030. However, a significant cause of intergenerational transfer of malnutrition, anaemia in pregnancy, is still a challenge. It is especially so in the low- and middle-income settings where possible context-specific aetiologies leading to anaemia have been poorly explored. This study explores the prevalence of etiological factors significantly contributing to anaemia in pregnancy in Sri Lanka, a lower-middle-income country with a high prevalence of malnutrition albeit robust public health infrastructure.

METHODS

All first-trimester pregnant women registered in the public maternal care programme in the Anuradhapura district from July to September 2019 were invited to participate in Rajarata Pregnancy Cohort (RaPCo). After a full blood count analysis, high-performance liquid chromatography, peripheral blood film examination, serum B12 and folate levels were performed in anaemic participants, guided by an algorithm based on the red cell indices in the full blood count. In addition, serum ferritin was tested in a random subsample of 213 participants. Anaemic women in this subsample underwent B12 and folate testing.

RESULTS

Among 3127 participants, 14.4% (95%CI 13.2-15.7, n = 451) were anaemic. Haemoglobin ranged between 7.4 to 19.6 g/dl. 331(10.6%) had mild anaemia. Haemoglobin ≥13 g/dl was observed in 39(12.7%). Microcytic, normochromic-normocytic, hypochromic-normocytic and macrocytic anaemia was observed in 243(54%), 114(25.3%), 80(17.8%) and two (0.4%) of full blood counts in anaemic women, respectively. Microcytic anaemia with a red cell count ≥5 * 106 /μl demonstrated a 100% positive predictive value for minor haemoglobinopathies. Minor hemoglobinopathies were present in at least 23.3%(n = 105) of anaemic pregnant women. Prevalence of iron deficiency, B12 deficiency and Southeast Asian ovalocytosis among the anaemic was 41.9% (95%CI 26.4-59.2), 23.8% (95%CI 10.6-45.1) and 0.9% (95%CI 0.3-2.3%), respectively. Folate deficiency was not observed.

CONCLUSION

Even though iron deficiency remains the primary cause, minor hemoglobinopathies, B 12 deficiency and other aetiologies substantially contribute to anaemia in pregnancy in this study population. Public health interventions, including screening for minor hemoglobinopathies and multiple micronutrient supplementation in pregnancy, should be considered in the national programme for areas where these problems have been identified.

Reference intervals for reticulocyte parameters (reticulocyte haemoglobin equivalent and immature reticulocyte fraction) in first-trimester pregnancy

Reticulocyte parameters including reticulocyte haemoglobin equivalent (Ret-He) and immature reticulocyte fraction (IRF) are newly recognised hematological parameters that are being used for diagnosis and follow-up of anaemic patients. Reference intervals of these parameters have been established in different populations, however, the data relating to pregnancy are still lacking. One hundred and fifty-five first-trimester pregnant females were screened and the reference interval was calculated after selecting the patient with fixed criteria. R statistical software was used for statistical calculations. We tried to establish a reference interval of Ret-He content and IRF in first-trimester pregnancy in our study.IMPACT STATEMENTWhat is already known on this subject? Ret-He and IRF have been established as the marker of iron deficiency and iron-deficiency anaemia in different age groups and as a marker of response to iron therapy. However, literature is scarce regarding the reference intervals of these parameters, especially in pregnancy.What do the results of this study add? This study establishes the reference interval of newer reticulocyte parameters in first-trimester pregnancy which is not yet established in the literature. Establishing a reference interval is required for any laboratory parameters to be used in the clinical context.What are the implications of these findings for clinical practice and further research? The results of this study may help in making a clinical decision regarding iron deficiency in early pregnancy which is one of the common clinical problems in pregnancy. This study also serves as a baseline study for further studies of reference intervals for newer reticulocyte parameters in pregnancy. A similar study with a larger study population and follow-up with iron therapy may establish these parameters as one of the important markers of iron deficiency in pregnancy and help institute iron therapy on case-to-case basis.

Addition of oral iron bisglycinate to intravenous iron sucrose for the treatment of postpartum anemia-randomized controlled trial

BACKGROUND

Studies that have compared the effectiveness of oral with intravenous iron supplements to treat postpartum anemia have shown mixed results. The superiority of one mode of treatment vs the other has yet to be demonstrated. Therefore, despite guidelines and standards of care, treatment approaches vary across practices. A single 500 mg dose of iron sucrose, which is higher than what is usually administered, has not been evaluated to treat postpartum moderate to severe anemia.

OBJECTIVE

This study aimed to compare the efficacy of intravenous iron sucrose alone with intravenous iron sucrose in combination with oral iron bisglycinate supplementation in treating moderate to severe postpartum anemia.

STUDY DESIGN

A randomized controlled trial was conducted between February 2015 and June 2020. Women with postpartum hemoglobin level of ≤9.5 g/dL were treated with 500 mg intravenous iron sucrose after an anemia workup, which ruled out other causes for anemia. In addition to receiving intravenous iron, women were randomly allocated to receive either 60 mg of oral iron bisglycinate for 45 days or no further iron supplementation. The primary outcome was hemoglobin level at 6 weeks after delivery. Secondary outcomes were iron storage parameters and quality of life.

RESULTS

Of 158 patients who participated, 63 women receiving intravenous and oral iron, and 44 women receiving intravenous iron-only, completed the study and were included in the analysis. Baseline and obstetrical characteristics were similar between the study cohorts. Although statistically significant, postpartum hemoglobin levels were only 0.4 g/dL higher in the intravenous and oral iron than intravenous iron-only cohort (12.4 g/dL vs 12.0 g/dL, respectively; P=.03), with a respective increase from baseline of 4.2 g/dL vs 3.7 g/dL (P=.03). There was no difference in the rate of women with hemoglobin level of <12.0 or 11.0 g/dL. Iron storage and health quality were not different between the cohorts. Oral iron treatment was associated with 29% rate of adverse effects. Compliance and satisfaction from treatment protocol were high in both cohorts.

CONCLUSION

Intravenous 500 mg iron sucrose treatment alone is sufficient to treat postpartum anemia without the necessity of adding oral iron treatment.

Community Pharmacist-Led Interventions to Improve Preconception and Pregnancy Health: A Systematic Review

Background: Community pharmacist-led interventions are effective in improving health outcomes; however, their impact in improving preconception and pregnancy health is not clear. This study evaluated the effectiveness of community pharmacist-led interventions which aimed to improve health outcomes of preconception and pregnant women. Methods: A systematic review of the literature, consistent with PRISMA guidelines, was performed. Five electronic databases were searched up to February 2021. Results: Four studies, three in pregnant women and one in preconception women, were identified. The studies focused on improving micronutrient status and smoking cessation. The studies increased knowledge about, and use of, iron supplements, and improved iron status and smoking cessation rates in pregnant women, while improving knowledge regarding, and increasing the use of, preconception folic acid. The studies were ranked as weak to moderate quality. Conclusion: This review provides preliminary evidence for the potential benefit of community pharmacist-led interventions to improve the health of women before and during pregnancy.