Iron status and iron balance during pregnancy. A critical reappraisal of iron supplementation

Spatial distribution and identifying biochemical factors affecting haemoglobin levels among women of reproductive age for each province in Indonesia: A geospatial analysis

Anaemia is still a public health problem in Indonesia. The iron supplement program, known as Tablet Tambah Darah (Blood Add Tablet) has not yet produced optimal results. This study aimed to identify the cause of anaemia and the factors that influence it. Biochemical indicator data are haemoglobin (Hb), C-reactive protein (CRP), ferritin and serum transferrin receptor (sTfR) from 9,463 women of reproduction age. Data from the Basic Health Research (Riskesdas) project of 2013 were used for the study. ANOVA as well as global and local regression approaches (classical regression and geo-weighted regression) were used to compare the mean Hb and CRP values between provinces and to determine the factors that influence Hb concentrations. The results showed that the distribution of anaemia in Indonesia is uneven and not always caused by iron deficiency. The lowest Hb mean coupled with the highest iron deficiency was found in Papua, where there are high rates of parasitic infections. In contrast, the highest mean Hb coupled with low iron deficiency, and also low infection rates, was found in North Sulawesi. The Hb concentrations were significantly associated by ferritin, CRP and sTfR and there were varying magnitudes between provinces. Although anaemia is mainly influenced by the iron concentration, CRP, ferritin and sTfR can also affect it through their association with inflammatory reactions. Identification of all causes of anaemia in each province needs to be done in the future, while blanket iron supplementation should be reviewed.

Iron Status in Pregnant Women in Latvia: An Epidemiological, Cross-Sectional, Multicenter Study According to WHO and UK Criteria

Background and Objectives: During pregnancy, iron deficiency anaemia is a common problem associated with health risks for both the mother and her foetus/infant. This study aimed to investigate the prevalence of iron deficiency, iron deficiency anaemia, and related dietary patterns in pregnant women in Latvia. Materials and Methods: This cross-sectional, multicentre study included pregnancy data from 974 women. The sample selection was based on the stratification principle (population of women of childbearing age in regions of Latvia). Maternal demographic details, anthropometric measurements, iron status, dietary patterns, and supplementation information were obtained from maternal files and during interviews held in eight outpatient departments of medical institutions and maternity departments. The prevalence was assessed. Chi-square tests and logistic regression were used to identify associations between iron deficiency and sociodemographic characteristics, dietary patterns, and iron supplement intake during pregnancy. The criterion used for the diagnosis of iron deficiency anaemia is a Hb level <110 g/L in the 1st and 3rd trimesters and <105 g/L during the 2nd trimester as recommended by the WHO. However, the UK guideline was used for borderline iron deficiency, which is an SF level <30 μg/L in all trimesters. Results: The observed prevalence of anaemia was 2.8% in the first trimester, 7.9% in the second trimester, and 27.0% in the third trimester. The prevalence of iron deficiency was 46.7% in the first trimester, 78.1% in the second trimester, and 91.7% in the third trimester. No associations with dietary patterns were found. Single women had 1.85 times the odds (95% CI 1.07 to 3.18) of being anaemic than married women. Conclusions: Iron deficiency affects a large proportion of pregnant women in Latvia in all trimesters, with iron deficiency anaemia affecting pregnant women in the third trimester. Monitoring and intervention should be performed in a timely and more targeted manner.

Iron Deficiency and Iron Deficiency Anemia: Implications and Impact in Pregnancy, Fetal Development, and Early Childhood Parameters

A normal pregnancy consumes 500–800 mg of iron from the mother. Premenopausal women have a high incidence of marginal iron stores or iron deficiency (ID), with or without anemia, particularly in the less developed world. Although pregnancy is associated with a “physiologic” anemia largely related to maternal volume expansion; it is paradoxically associated with an increase in erythrocyte production and erythrocyte mass/kg. ID is a limiting factor for this erythrocyte mass expansion and can contribute to adverse pregnancy outcomes. This review summarizes erythrocyte and iron balance observed in pregnancy; its implications and impact on mother and child; and provides an overview of approaches to the recognition of ID in pregnancy and its management, including clinically relevant questions for further investigation.

REGAIN STUDY: Retrospective Study to Assess the Effectiveness, Tolerability, and Safety of Ferric Carboxymaltose in the Management of Iron Deficiency Anemia in Pregnant Women

Iron deficiency anemia (IDA) during pregnancy arises because of preexisting inadequate stores or complex physiological changes and can lead to serious maternal and fetal complications. Oral iron, either as iron sulfate or fumarate, with or without folic acid, is the most commonly used treatment for IDA in pregnancy. Intravenous (IV) iron has a role in the treatment of IDA in pregnancy, particularly in women who present late, display severe anemia (Hb ≤ 9 g/dL), or risk factors, and are intolerant/noncompliant of oral iron. Previously, administration of IV iron was minimal, owing to potentially serious anaphylactic reactions. Recently, new IV iron products have been developed, offering better compliance, tolerability, efficacy, and a good safety profile. Our study aimed to assess the effectiveness, safety, and tolerability of IV ferric carboxymaltose (FCM) in the treatment of IDA in pregnant women in the UAE. Data from 1001 pregnant women who received at least one administration of FCM (500, 1000, or 1500 mg) during their second or third trimester of pregnancy (2 years backward from study initiation) were collected retrospectively from electronic medical records at Corniche Hospital, Abu Dhabi, UAE. Results showed that 41.4% of the women were able to achieve an increase of ≥2 g/dL in blood hemoglobin overall. A change of ≥2 g/dL was achieved by 27.5% of women administered a dose of 500 mg, 39.2% of women administered a dose of 1000 mg, and 63.9% of women administered a dose of 1500 mg of IV FCM. This indicates a directly proportional relationship between increasing IV FCM dose and the increase of ≥2 g/dL in blood hemoglobin. A total of 7 (0.7%) women reported mild, nonserious adverse events during the study. Within the limits of this retrospective study, IV FCM therapy was safe and effective in increasing the mean hemoglobin of pregnant women with IDA.

Prenatal Intervention with Partial Meal Replacement Improves Micronutrient Intake of Pregnant Women with Obesity

A behavioral lifestyle intervention with partial meal replacement reduced excess gestational weight gain in ethnically diverse women with overweight/obesity, but the effects on micronutrient intake remained unknown. A secondary analysis of a randomized, controlled trial tested whether the intervention improved micronutrient intake relative to usual care. Pregnant women (n = 211; 30.5 years of age, body mass index, BMI, of 32.0 kg/m²) were enrolled and randomized within site and ethnicity (40% were Hispanic) into intervention (n = 102) or usual care (n = 109) groups. Two 24 h dietary recalls were conducted on random days at study entry and late pregnancy (35–36 weeks gestation). Nutrient adequacy was defined using the Estimated Average Requirement cut-point method. At study entry and including prenatal vitamins, ≥90% of participants reported inadequate intake of vitamins D and E and iron; 40–50% reported inadequate intake of calcium, protein, vitamins A, C, B₆, folate, magnesium, and zinc. From study entry to late pregnancy, the behavioral intervention with partial meal replacement increased the overall intake of vitamins A, E, and D and copper and reduced the odds of inadequate intake of calcium (odds ratio (OR) = 0.37 (0.18, 0.76)), vitamins A (OR = 0.39 (0.21, 0.72)) and E (OR = 0.17 (0.06, 0.48)), and magnesium (OR = 0.36 (0.20, 0.65)). A behavioral intervention with partial meal replacement during pregnancy improved the intake of several micronutrients in Hispanic and non-Hispanic women with overweight/obesity.

Risk factors for peripartum blood transfusion in South Africa: a case-control study

BACKGROUND

Obstetric hemorrhage (OH) and access to peripartum blood transfusion remains a global health challenge. The rates of peripartum transfusion in South Africa exceed those in high-income countries despite comparable rates of OH. We sought to evaluate factors associated with peripartum transfusion.

STUDY DESIGN AND METHODS

A case-control study was conducted at four large South African hospitals. Transfused peripartum women (cases) and nontransfused controls were stratum matched 1:2 by hospital and delivery date. Data on obstetric, transfusion, and human immunodeficiency virus (HIV) history were abstracted from medical records. Blood was obtained for laboratory evaluation. We calculated unadjusted and adjusted odds ratios (ORs) for transfusion using logistic regression.

RESULTS

A total of 1200 transfused cases and 2434 controls were evaluated. Antepartum hemorrhage (OR, 197.95; 95% confidence interval [CI], 104.27-375.78), hemorrhage with vaginal delivery (OR, 136.46; 95% CI, 75.87-245.18), prenatal anemia (OR, 22.76; 95% CI, 12.34-41.93 for prenatal hemoglobin level < 7 g/dL), and failed access to prenatal care (OR, 6.71; 95% CI, 4.32-10.42) were the major risk factors for transfusion. Platelet (PLT) count (ORs, 4.10, 2.66, and 1.77 for ≤50 × 10⁹ , 51 × 10⁹ -100 × 10⁹ , and 101 × 10⁹ -150 × 10⁹ cells/L, respectively), HIV infection (OR, 1.29; 95% CI, 1.02-1.62), and admitting hospital (twofold variation) were also associated with transfusion. Mode of delivery, race, age category, gravidity, parity, gestational age, and birthweight were not independently associated with transfusion.

CONCLUSION

Major risk factors of peripartum transfusion in South Africa, namely, prenatal anemia and access to prenatal care, may be amenable to intervention. HIV infection and moderately low PLT count are novel risk factors that merit further investigation.

Efficacy and safety of adjuvant recombinant human erythropoietin and ferrous sulfate as treatment for iron deficiency anemia during the third trimester of pregnancy

PURPOSE

Gestational anemia increases the incidence of maternal and fetal complications. Adjuvant recombinant human erythropoietin (rHuEPO) has been used in patients who refuse blood transfusions, have a low response to treatment with iron sulfate, have limited time before birth, or have other illnesses that complicate the anemia. We demonstrated that the use of adjuvant rHuEPO with iron sulfate reduces the anemia time period and is innocuous to the fetus.

METHOD

An experimental longitudinal prospective study; 100 pregnant women in their third trimester were included. Group 1 (n=50) was set as control for prevalence of anemia and establish hematological maternal and fetal parameters at delivery for our population; 50 women diagnosed with iron deficiency anemia were randomly assigned to treatment groups. Group 2 (n=25) third trimester women with a hemoglobin of <11g/dL were treated with iron sulfate, 600mg administered orally daily for 4 weeks, evaluating the hematologic response for the mother weekly and for both mother and fetus at birth; Group 3 (n=25) women similar to group 2, treated in addition with adjuvant rHuEPO, 4000 units subcutaneously, three times a week, for 4 weeks evaluating the same parameters.

RESULTS

Group 2 and 3 showed a corrected anemia before delivery (mean 11.1 vs 11.4g/dL), but Group 3 showed a statistically broader and more rapid increase in hemoglobin (1.22 vs 1.92g/dL, p value 0.013) with an rHuEPO dose of 4000 units, three times a week for 1 month. No clinical or hematologic difference or changes in growth were observed in the fetus.

CONCLUSIONS

Erythropoietin is safe and effective for both mother and fetus, although an ideal pregnancy dose has not yet been established.

Supplementation during pregnancy: beliefs and science

Pregnancy represents a challenge from a nutritional perspective, because micronutrient intake during the periconceptional period and in pregnancy affects fetal organ development and the mother's health. Inappropriate diet/nutrition in pregnancy can lead to numerous deficiencies including iron deficiency and may impair placental function and play a role in miscarriage, intrauterine growth restriction, preterm delivery, and preeclampsia. This article reviews the risks associated with nutrient deficiencies in pregnant women and presents an overview of recommendations for dietary supplementation in pregnancy, focusing on oral iron supplementation. Risk factor detection, including dietary patterns and comorbidities, is paramount in optimal pregnancy management. Dietary habits, which can lead to deficiencies (e.g., iron, folate, vitamin D, and calcium) and result in negative health consequences for the mother and fetus/newborn, need to be investigated. Prenatal care should be personalized, accounting for ethnicity, culture, education, information level about pregnancy, and dietary and physical habits. Clinicians should make a plan for appropriate supplementation and prophylaxis/treatment of nutritional and other needs, and consider adequate intake of calcium, iodine, vitamin D, folate, and iron. Among the available oral iron supplements, prolonged-released ferrous sulfate (ferrous sulfate-polymeric complex) presents the lowest incidence of overall and gastrointestinal adverse events, with positive implications for compliance.

Safety and Efficacy of Ferric Carboxymaltose in Anemic Pregnant Women: A Retrospective Case Control Study

Background. Anemia during pregnancy is commonly caused by iron deficiency and can have severe consequences for both the mother and the developing fetus. The aim of this retrospective study was to assess the safety and efficacy of intravenous ferric carboxymaltose (FCM) in pregnant women. Methods. All women treated with FCM for anemia during pregnancy between 2010 and 2012 at our institution were included. A matched control group was selected, including women who either were nonanemic or had anemia but were not considered for intravenous iron. Main outcome measures were maternal safety and pregnancy outcomes. Results. The study included 128 patients (FCM: 64; control: 64). Median FCM dose was 1000 mg and median gestational age at the time of first treatment was 34 weeks and 6 days. Median Hb increased from 8.4 g/dL (interquartile range 7.7; 8.9 g/dL) at the first FCM administration to 10.7 g/dL (9.8; 11.5 g/dL; n = 46 with available Hb at delivery) at the time of delivery, achieving levels similar to those in the control group (10.8 g/dL [9.8; 11.8 g/dL; n = 48]). No treatment-related adverse events were reported and no statistically significant differences in pregnancy outcomes were observed between groups. Conclusions. Within the limitations of this case control study, FCM was a safe and efficient treatment of anemia during pregnancy.

Association of genetic variants with response to iron supplements in pregnancy

The incidence of iron deficiency anemia in pregnancy is high in India where iron supplementation is a regular practice. The response to oral iron is influenced by several factors such as age, body mass index, gravida, socioeconomic status, food, vitamin deficiency and compliance to supplements. The major challenge is to understand the various modulators of iron status in this high-risk group so that we can improve the diagnosis and the management of these patients. The current study was designed to evaluate the iron status during pregnancy and to identify factors which might be influencing their response to oral iron. We investigated a total of 181 pregnant women with anemia (Hb < 11 g/dl) and evaluated the impact of probable factors on anemia and their iron status. Assessment of the response was based on hemoglobin and serum ferritin or transferrin saturation level after 8 and 20 weeks of iron supplementation. Socioeconomic, clinical, hematological, biochemical and genetic factors were all evaluated. Molecular analysis revealed that HFE variant allele (G) (rs1799945) was significantly associated with an adequate response to iron supplementation. We identified five subjects with a sustained poor response, and targeted re-sequencing of eleven iron-related genes was performed in them. We have identified seven novel variants in them, and in silico analysis suggested that these variants may have an iron regulatory effect. Taken together, our findings underscore the association of genetic variants with response to supplements in pregnancy, and they can be extended to other diseases where anemia and iron deficiency coexist.

Tacrolimus placental transfer at delivery and neonatal exposure through breast milk

AIM(S)

The current investigation aims to provide new insights into fetal exposure to tacrolimus in utero by evaluating maternal and umbilical cord blood (venous and arterial), plasma and unbound concentrations at delivery. This study also presents a case report of tacrolimus excretion via breast milk.

METHODS

Maternal and umbilical cord (venous and arterial) samples were obtained at delivery from eight solid organ allograft recipients to measure tacrolimus and metabolite bound and unbound concentrations in blood and plasma. Tacrolimus pharmacokinetics in breast milk were assessed in one subject.

RESULTS

Mean (±SD) tacrolimus concentrations at the time of delivery in umbilical cord venous blood (6.6 ± 1.8 ng ml(-1)) were 71 ± 18% (range 45-99%) of maternal concentrations (9.0 ± 3.4 ng ml(-1)). The mean umbilical cord venous plasma (0.09 ± 0.04 ng ml(-1)) and unbound drug concentrations (0.003 ± 0.001 ng ml(-1)) were approximately one fifth of the respective maternal concentrations. Arterial umbilical cord blood concentrations of tacrolimus were 100 ± 12% of umbilical venous concentrations. In addition, infant exposure to tacrolimus through the breast milk was less than 0.3% of the mother's weight-adjusted dose.

CONCLUSIONS

Differences between maternal and umbilical cord tacrolimus concentrations may be explained in part by placental P-gp function, greater red blood cell partitioning and higher haematocrit levels in venous cord blood. The neonatal drug exposure to tacrolimus via breast milk is very low and likely does not represent a health risk to the breastfeeding infant.

Intravenous ferric carboxymaltose for anaemia in pregnancy

BACKGROUND

Iron deficiency is a common nutritional deficiency amongst women of childbearing age. Peri-partum iron deficiency anaemia (IDA) is associated with significant maternal, fetal and infant morbidity. Current options for treatment are limited: these include oral iron supplementation, which can be ineffective and poorly tolerated, and red blood cell transfusions, which carry an inherent risk and should be avoided. Ferric carboxymaltose is a new treatment option that may be better tolerated.The study was designed to assess the safety and efficacy of iron deficiency anaemia (IDA) correction with intravenous ferric carboxymaltose in pregnant women with mild, moderate and severe anaemia in the second and third trimester.

METHODS

Prospective observational study; 65 anaemic pregnant women received ferric carboxymaltose up to 15 mg/kg between 24 and 40 weeks of pregnancy (median 35 weeks gestational age, SD 3.6). Treatment effectiveness was assessed by repeat haemoglobin (Hb) measurements and patient report of well-being in the postpartum period. Safety was assessed by analysis of adverse drug reactions and fetal heart rate monitoring during the infusion.

RESULTS

Intravenous ferric carboxymaltose infusion significantly increased Hb values (p < 0.01) above baseline levels in all women. Increased Hb values were observed at 3 and 6 weeks post infusion and up to 8 weeks post-infusion. Ferritin values increased significantly after the infusion. Only 4 women had repeat ferritin values post-partum which remained above baseline levels. Fetal heart rate monitoring did not indicate a drug related negative impact on the fetus. Of the 29 (44.6%) women interviewed, 19 (65.5%) women reported an improvement in their well-being and 9 (31%) felt no different after the infusion. None of the women felt worse. No serious adverse effects were found and minor side effects occurred in 13 (20%) patients.

CONCLUSIONS

Our prospective data is consistent with existing observational reports of the safe and effective use of ferric carboxymaltose in the treatment of iron deficiency anaemia in pregnancy.

Ferrous bisglycinate 25 mg iron is as effective as ferrous sulfate 50 mg iron in the prophylaxis of iron deficiency and anemia during pregnancy in a randomized trial

OBJECTIVE

To compare the effects of oral ferrous bisglycinate 25 mg iron/day vs. ferrous sulfate 50 mg iron/day in the prevention of iron deficiency (ID) and iron deficiency anemia (IDA) in pregnant women.

DESIGN

Randomized, double-blind, intention-to-treat study.

SETTING

Antenatal care clinic.

SAMPLE

80 healthy ethnic Danish pregnant women.

METHODS

Women were allocated to ferrous bisglycinate 25 mg elemental iron (Aminojern®) (n=40) or ferrous sulfate 50 mg elemental iron (n=40) from 15 to 19 weeks of gestation to delivery. Hematological status (hemoglobin, red blood cell indices) and iron status (plasma iron, plasma transferrin, plasma transferrin saturation, plasma ferritin) were measured at 15-19 weeks (baseline), 27-28 weeks and 36-37 weeks of gestation.

MAIN OUTCOME MEASURES

Occurrence of ID (ferritin <15 μg/L) and IDA (ferritin <12 μg/L and hemoglobin <110 g/L).

RESULTS

At inclusion, there were no significant differences between the bisglycinate and sulfate group concerning hematological status and iron status. The frequencies of ID and IDA were low and not significantly different in the two iron groups. The frequency of gastrointestinal complaints was lower in the bisglycinate than in the sulfate group (P=0.001). Newborns weight was slightly higher in the bisglycinate vs. the sulfate group (3601±517 g vs. 3395±426 g, P=0.09).

CONCLUSIONS

In the prevention of ID and IDA, ferrous bisglycinate was not inferior to ferrous sulfate. Ferrous bisglycinate in a low dose of 25 mg iron/day appears to be adequate to prevent IDA in more than 95% of Danish women during pregnancy and postpartum.

Helicobacter pylori and pregnancy-related disorders

Helicobacter pylori (H. pylori) infection is investigated in gastric diseases even during pregnancy. In particular, this Gram-negative bacterium seems to be associated with hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy. During the last decade, the relationship among H. pylori and several extra-gastric diseases strongly emerged in literature. The correlation among H. pylori infection and pregnancy-related disorders was mainly focused on iron deficiency anemia, thrombocytopenia, fetal malformations, miscarriage, pre-eclampsia and fetal growth restriction. H. pylori infection may have a role in the pathogenesis of various pregnancy-related disorders through different mechanisms: depletion of micronutrients (iron and vitamin B₁₂) in maternal anemia and fetal neural tube defects; local or systemic induction of pro-inflammatory cytokines release and oxidative stress in gastrointestinal disorders and pre-eclampsia; cross-reaction between specific anti-H. pylori antibodies and antigens localized in placental tissue and endothelial cells (pre-eclampsia, fetal growth restriction, miscarriage). Since H. pylori infection is most likely acquired before pregnancy, it is widely believed that hormonal and immunological changes occurring during pregnancy could activate latent H. pylori with a negative impact not only on maternal health (nutritional deficiency, organ injury, death), but also on the fetus (insufficient growth, malformation, death) and sometime consequences can be observed later in life. Another important issue addressed by investigators was to determine whether it is possible to transmit H. pylori infection from mother to child and whether maternal anti-H. pylori antibodies could prevent infant’s infection. Studies on novel diagnostic and therapeutic methods for H. pylori are no less important, since these are particularly sensitive topics in pregnancy conditions. It could be interesting to study the possible correlation between H. pylori infection and other pregnancy-related diseases of unknown etiology, such as gestational diabetes mellitus, obstetric cholestasis and spontaneous preterm delivery. Since H. pylori infection is treatable, the demonstration of its causative role in pregnancy-related disorders will have important social-economic implications.

Development of PBPK models for PFOA and PFOS for human pregnancy and lactation life stages

Perfluoroalkyl acid carboxylates and sulfonates (PFAA) have many consumer and industrial applications. Developmental toxicity studies in animals have raised concern about potential reproductive/developmental effects of perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS); however, in humans conflicting results have been reported for associations between maternal PFAA levels and these outcomes. Risk assessments and interpretation of available human data during gestation and lactation are hindered due to lack of a framework for understanding and estimating maternal, fetal, and neonatal pharmacokinetics (PK). Physiologically based pharmacokinetic (PBPK) models were developed for PFOA and PFOS for the gestation and lactation life stages in humans to understand how the physiological changes associated with development affect pharmacokinetics of these compounds in the mother, fetus, and infant. These models were derived from PBPK models for PFOA/PFOS that were previously developed for adult humans and rats during gestation and lactation and from existing human pregnancy and lactation models developed for other chemicals. The models simulated PFOA and PFOS concentrations in fetal, infant, and maternal plasma and milk, were compared to available data in humans, and also were used to estimate maternal exposure. The models reported here identified several research needs, which include (1) the identification of transporters involved in renal resorption to explain the multiyear half-lives of these compounds in humans, (2) factors affecting clearance of PFOA/PFOS during gestation and lactation, and (3) data to estimate clearance of PFOA/PFOS in infants. These models may help address concerns regarding possible adverse health effects due to PFOA/PFOS exposure in the fetus and infant and may be useful in comparing pharmacokinetics across life stages.

Intravenous iron sucrose versus oral iron ferrous sulfate for antenatal and postpartum iron deficiency anemia: a randomized trial

OBJECTIVE

To compare oral iron to intravenous iron administration to women in late pregnancy and/or after labor to correct iron deficiency.

METHODS

271 anemic women (148 pregnant women and 123 women post lower segment caesarean section) with hemoglobin (Hb) levels below 110 g/L were enrolled over a two-year period and randomized to receive either two tablets FGF (ferrous sulfate with folic acid) or 400 mg of intravenous iron sucrose plus folic acid 600 µg. Treatment effectiveness was assessed by measuring Hb and ferritin postpartum on day 1, day 14 and day 42. Transfusions of red blood cells and adverse drug reactions were recorded.

RESULTS

Data of 214 women were available for analysis. Both forms of iron replacement therapy led to increased hemoglobin and ferritin levels over the testing period. Ferritin was significantly higher in the i.v. iron treatment group compared to the oral iron treatment group (p = 0.004) two weeks after delivery, while Hb values did not differ between the groups. No serious adverse drug reactions were observed. Red blood cell transfusion rate was low (1.9%), with equal rates observed in both treatment groups.

CONCLUSION

Intravenous and oral irons were both effective in correcting peripartum anemia, although intravenous iron restored stores faster than oral iron.

Gaps in the evidence for prevention and treatment of maternal anaemia: a review of systematic reviews

BACKGROUND

Anaemia, in particular due to iron deficiency, is common in pregnancy with associated negative outcomes for mother and infant. However, there is evidence of significant variation in management. The objectives of this review of systematic reviews were to analyse and summarise the evidence base, identify gaps in the evidence and develop a research agenda for this important component of maternity care.

METHODS

Multiple databases were searched, including MEDLINE, EMBASE and The Cochrane Library. All systematic reviews relating to interventions to prevent and treat anaemia in the antenatal and postnatal period were eligible. Two reviewers independently assessed data inclusion, extraction and quality of methodology.

RESULTS

27 reviews were included, all reporting on the prevention and treatment of anaemia in the antenatal (n = 24) and postnatal periods (n = 3). Using AMSTAR as the assessment tool for methodological quality, only 12 of the 27 were rated as high quality reviews. The greatest number of reviews covered antenatal nutritional supplementation for the prevention of anaemia (n = 19). Iron supplementation was the most extensively researched, but with ongoing uncertainty about optimal dose and regimen. Few identified reviews addressed anaemia management post-partum or correlations between laboratory and clinical outcomes, and no reviews reported on clinical symptoms of anaemia.

CONCLUSIONS

The review highlights evidence gaps including the management of anaemia in the postnatal period, screening for anaemia, and optimal interventions for treatment. Research priorities include developing standardised approaches to reporting of laboratory outcomes, and information on clinical outcomes relevant to the experiences of pregnant women.

The effect of high doses of folic acid and iron supplementation in early-to-mid pregnancy on prematurity and fetal growth retardation: the mother-child cohort study in Crete, Greece (Rhea study)

PURPOSE

We examined whether high doses of folic acid and iron supplementation in early-to-mid pregnancy affect the risk of preterm birth, low birth weight, and small for gestational age neonates, in the mother-child cohort in Crete, Greece (Rhea study).

METHODS

We included 1,279 women with singleton pregnancies with complete data on supplements use in early-to-mid pregnancy and birth outcomes. Anthropometric measurements at birth were obtained from medical records. Red blood cell folate concentrations in cord blood were measured in a subsample of the study population (n = 58).

RESULTS

Sixty-six percent of the study participants reported high doses of supplemental folic acid use (5 mg/day), while 21 % reported excessive doses of folic acid use (>5 mg/day) in early-to-mid pregnancy. Daily intake of 5-mg supplemental folic acid was associated with a 31 % decrease in the risk of preterm birth (RR, 0.69; 95 % CI, 0.44, 0.99), 60 % decrease in the risk of delivering a low birth weight neonate (RR, 0.40; 95 % CI, 0.21, 0.76), and 66 % decrease in the risk of delivering a small for gestational age (SGA) neonate (RR, 0.34; 95 % CI, 0.16, 0.73). Daily doses of iron supplementation more than 100 mg were associated with a twofold increased risk for SGA neonates (RR, 2.14; 95 % CI, 0.99, 5.97).

CONCLUSION

These findings suggest that high daily doses of supplementary folic acid in early-to-mid pregnancy may be protective for preterm birth, low birth weight, and small for gestational age neonates, while high daily doses of supplementary iron may be harmful for fetal growth.

The effect of maternal multiple micronutrient supplementation on cognition and mood during pregnancy and postpartum in Indonesia: a randomized trial

Maternal caregiving capacity, which is affected in part by cognition and mood, is crucial for the health of mothers and infants. Few interventions aim to improve maternal and infant health through improving such capacity. Multiple micronutrient (MMN) supplementation may improve maternal cognition and mood, since micronutrients are essential for brain function. We assessed mothers who participated in the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT), a double-blind cluster-randomized trial in Indonesia comparing MMN supplementation to iron and folic acid (IFA) during pregnancy and until three months postpartum. We adapted a set of well-studied tests of cognition, motor dexterity, and mood to the local context and administered them to a random sample of 640 SUMMIT participants after an average of 25 weeks (SD = 9) of supplementation. Analysis was by intention to treat. Controlling for maternal age, education, and socio-economic status, MMN resulted in a benefit of 0.12 SD on overall cognition, compared to IFA (95%CI 0.03–0.22, p = .010), and a benefit of 0.18 SD on reading efficiency (95%CI 0.02–0.35, p = .031). Both effects were found particularly in anemic (hemoglobin<110 g/L; overall cognition: B = 0.20, 0.00–0.41, p = .055; reading: B = 0.40, 0.02–0.77, p = .039) and undernourished (mid-upper arm circumference<23.5 cm; overall cognition: B = 0.33, 0.07–0.59, p = .020; reading: B = 0.65, 0.19–1.12, p = .007) mothers. The benefit of MMN on overall cognition was equivalent to the benefit of one year of education for all mothers, to two years of education for anemic mothers, and to three years of education for undernourished mothers. No effects were found on maternal motor dexterity or mood. This is the first study demonstrating an improvement in maternal cognition with MMN supplementation. This improvement may increase the quality of care mothers provide for their infants, potentially partly mediating effects of maternal MMN supplementation on infant health and survival. The study is registered as an International Standard Randomized Controlled Trial, number ISRCTN34151616. http://www.controlled-trials.com/ISRCTN34151616

[Association between iron supplementation during pregnancy and prematurity, low birth weight, and very low birth weight]

The objective was to evaluate the association between prophylactic iron supplementation and prematurity and low birth weight. Pregnant women 20 years and older with 21 to 28 weeks of gestational age were enrolled consecutively in prenatal services in the Unified National Health System in six Brazilian State capitals between 1991 and 1995. Socio-demographic data and information on iron supplementation up until the 28th gestational week were obtained by means of an interview. Outcomes and other variables were collected from medical records. Anemia was present in 31.3% of the 3,865 women. Among anemic women (hemoglobin < 11.0g/dL), 29.8% were taking iron supplements, as compared to 16.7% among non-anemic women (hemoglobin > or = 11.0g/dL). After adjusting for potential confounders, iron was not associated with prematurity (OR = 0.88; 95%CI: 0.73-1.07), low birth weight (OR = 0.99; 95%CI: 0.75-1.31), or very low birth weight (OR = 0.58; 95%CI: 0.29-1.13). The results suggest that iron supplementation up to the 28th gestational week does not reduce the risk of prematurity, low birth weight, or very low birth weight.

The clinical content of preconception care: nutrition and dietary supplements

Women of child-bearing age should achieve and maintain good nutritional status prior to conception to help minimize health risks to both mothers and infants. Many women may not be aware of the importance of preconception nutrition and supplementation or have access to nutrition information. Health care providers should be knowledgeable about preconception/pregnancy-related nutrition and take the initiative to discuss this information during preconception counseling. Women of reproductive age should be counseled to consume a well-balanced diet including fruits and vegetables, iron and calcium-rich foods, and protein-containing foods as well as 400 microg of folic acid daily. More research is critically needed on the efficacy and safety of dietary supplements and the role of obesity in birth outcomes. Preconception counseling is the perfect opportunity for the health care provider to discuss a healthy eating guideline, dietary supplement intake, and maintaining a healthy weight status.

Body iron and individual iron prophylaxis in pregnancy--should the iron dose be adjusted according to serum ferritin?

This study aims to evaluate iron prophylaxis in pregnant women from the individual aspect, i.e. according to serum ferritin levels at the beginning of pregnancy, and to assess which dose of iron would be adequate to prevent iron deficiency (ID) and iron deficiency anaemia (IDA) during pregnancy and postpartum. A randomised, double-blind study comprising 301 healthy Danish pregnant women allocated into four groups taking ferrous iron (as fumarate) in doses of 20 mg (n=74), 40 mg (n=76), 60 mg (n=77) and 80 mg (n=75) from 18 weeks gestation (inclusion) to 8 weeks postpartum. Iron status markers [serum ferritin, serum soluble transferrin receptor (sTfR), haemoglobin] were recorded at 18, 32 and 39 weeks gestation and 8 weeks postpartum. Body iron was calculated using the serum sTfR/serum ferritin ratio. ID was defined by serum ferritin <12 microg/l in pregnancy and <15 microg/l postpartum; IDA as serum ferritin <12 microg/l and haemoglobin <5th percentile in iron-replete pregnant women. Women in the iron supplement groups were stratified according to serum ferritin levels at inclusion; 50.7% had ferritin <or=30 microg/l, 37.7% ferritin 30-70 microg/l and 11.6% ferritin >70 microg/l. At 32 weeks, women with ferritin <or=30 microg/l had an ID frequency of: 20-mg group 54.1%, 40 mg 29.7%, 60 mg 24.4%, 80 mg 20.6% (p<0.001); women with ferritin >30 microg/l had an ID frequency of: 20-mg group 20.0%, 40 mg 13.9%, 60 mg 5.7%, 80 mg 5.1% (p<0.001). Women with ferritin >70 microg/l had no ID. Postpartum, ID was found in 4.7% in 20-mg group, 2.9% in group 40 mg and 0% in group 60 and 80 mg. IDA: At 32 weeks, women with ferritin <or=30 microg/l had an IDA frequency of: 20-mg group 2.7%, 40 mg 2.7%, 60 and 80 mg 0%; none of the women with ferritin >30 microg/l displayed IDA. Body iron at 18 weeks was 10.4 mg/kg, similar in the four iron groups. Later in pregnancy body iron declined significantly, being lower the 20 mg group, and similar in the 40, 60 and 80-mg groups. Postpartum body iron rose to inclusion levels being 9.3 mg/kg in the 20-mg group and 10.5 mg/kg in the 40-, 60- and 80-mg groups. This study gives an estimate of iron dosage in individual iron prophylaxis adjusted to serum ferritin levels in early pregnancy. In the prevention of ID, we suggest 80-100 mg ferrous iron/day to women having ferritin <or=30 microg/l and 40 mg ferrous iron/day to women having ferritin 31-70 mug/l. In the prevention of IDA, we suggest 40 mg ferrous iron/day to women having ferritin <or=70 microg/l. Women with ferritin >70 microg/l have no need for iron supplement.

Multiple micronutrients in pregnancy and lactation: an overview

This overview of multiple micronutrients during pregnancy and lactation emphasizes 2 relatively neglected issues. The first is that maternal micronutrient status in the periconceptional period, and throughout pregnancy and lactation, should be viewed as a continuum; too often these 3 stages are treated and discussed separately from both a scientific and a public health perspective. Iron and vitamin B-12 are included as examples to stress how status at conception affects maternal, fetal, and infant status and health until the child is weaned. The second issue is that while most attention has been focused on a few micronutrients, for example iron and folate as discussed elsewhere in this Supplement, multiple micronutrient deficiencies occur simultaneously when diets are poor. Some of these deserve more attention as causes of poor pregnancy outcome, including other B vitamin deficiencies that result in homocysteinemia, antioxidants, vitamin D, and iodine. In lactation, maternal status or intake of the B vitamins (except folate), vitamin A, selenium and iodine strongly affect the amount of these nutrients secreted in breast milk. This can result in the infant consuming substantially less than the recommended amounts and further depleting stores that were low at birth. While the optimal mode of meeting recommended micronutrient intakes is an adequate diet, in some situations supplementation is also important. Unfortunately, information is lacking on the optimal formulation of micronutrient supplements for pregnant women, and the need to continue these supplements during lactation is not recognized in many situations where maternal and infant health could benefit.

Role of Helicobacter pylori infection in iron deficiency during pregnancy

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Anemia during pregnancy and treatment with intravenous iron: review of the literature

Anemia, the decrease of the hemoglobin concentration with a consequent decrease in the hematocrit level, is a common disorder complicating pregnancies and is mostly due to iron deficiency. The increase of iron requirements, plasma volume, and the poor intake of iron constitute the principal causes of this deficiency. The present review summarizes the current literature regarding anemia during pregnancy and the parenteral iron therapy options.

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

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

Nutritional assessment and support during pregnancy

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

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

OBJECTIVE

We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.

DESIGN

Cross-sectional study.

SETTING

Four antenatal clinics in rural northern Tanzania.

SUBJECTS/METHODS

A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70-89 g/l (n=61), Hb=90-109 g/l (n=86), Hb=110-149 g/l (n=105) and Hb> or =150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.

MAIN OUTCOME MEASURES

Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l.

RESULTS

Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90-109 g/l) were similar, but weaker.

CONCLUSIONS

Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.

SPONSORSHIP

The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Serum Ferritin is a Reliable, Non-invasive Test for Iron Status in Pregnancy: Comparison of Ferritin with Other Iron Status Markers in a Longitudinal Study on Healthy Pregnant Women; Erythropoiesis

Background and Aims: To assess the true positive and false positive rates of the iron status markers (serum iron, serum transferrin, transferrin saturation, haemoglobin, haematocrit, mean corpuscular volume (MCV), mean cell haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), erythrocyte count) in the diagnosis of depleted iron stores (iron depletion) during normal pregnancy and postpartum. Methods: Among 120 pregnant women, 58 were randomised to placebo-treatment and 62 to iron-treatment (66 mg ferrous iron daily from 14 weeks of gestation). Iron status markers were measured every 4th week during pregnancy and 8 weeks postpartum. Iron depletion was defined by a serum ferritin concentration < 16 &mgr;g/L. The 5th percentiles for the other iron status markers in the group of iron-treated women were used as cut-off values. Calculations were made in the 2nd and 3rd trimester, praepartum and postpartum. Results: In general, the true positive rates of other iron status markers in the diagnosis of iron depletion (serum ferritin < 16 &mgr;g/L) were low ranging from 0% to 52% during pregnancy and from 9% to 64% postpartum. Transferrin saturation and MCH displayed the highest true positive rates. The false positive rates ranged from 0% to 13% during pregnancy and from 4% to 17% postpartum. Haemoglobin and MCH displayed the highest false positive rates. Conclusions: The sensitivities of the other iron status markers were too low and the false positive rates too high to be of clinical value in the diagnosis of iron depletion. Despite physiologic variations due to haemodilution, the serum ferritin concentration is currently the most reliable non-invasive marker of iron status in pregnancy and postpartum.

A "conservative" approach to iron supplementation during pregnancy

A review of current knowledge about iron metabolism during pregnancy and the evidence from various studies on the effects of iron supplementation in pregnancy on maternal, fetal, and infant outcomes suggest that the implicit goal of current recommendations regarding iron supplementation may be to achieve the highest hemoglobin concentration possible. This goal is only weakly related to improved maternal and infant outcomes in the current pregnancy or to improved maternal iron stores long-term. Indeed, the claim that iron supplementation is universally innocuous is shown to be controversial. For women in developed countries who are generally clinically healthy and have access to adequate nutrition, the benefits of iron supplementation are unclear, and there may be risks. Thus, a better "conservative" approach may be that such women do not require routine iron supplementation during pregnancy. The midwifery philosophy of individualizing care based on a woman's history and health status is one that should be taken in approaching the issue of iron supplementation in pregnancy.

Iron deficiency in pregnancy, obstetrics, and gynecology

Iron deficiency remains a major health risk in the United States, despite the apparent availability of a high-quality diet. In the United States, at least 7.8 million adolescent girls and premenopausal women are iron-deficient. Worldwide, the challenge of identifying and treating iron deficiency is enormous. Physicians involved in the primary care and in the obstetric and gynecologic care of women of all ages must be aware of the nature of the problem and the correct approach to screening, diagnosis, and treatment. The potential benefit to newborns and infants and to their mothers is substantial. Furthermore, a thorough diagnostic evaluation has considerable potential for uncovering a potentially lethal disease, such as gastrointestinal malignancy, in a curable phase.