The Prevalence and Risk Factors of Iron Deficiency Anemia Among Pregnant Women in Malaysia: A Systematic Review

Association Between the Anemia During Pregnancy and Maternal Intensive Care Unit Admissions: A Systematic Review and Meta-Analysis

Anemia during pregnancy is one of the most common conditions that may have adverse consequences on maternal and fetal health. Current evidence is inconsistent with regards to the effects of anemia on maternal ICU admissions. This meta-analysis aimed to examine the overall effect of anemia during pregnancy on maternal ICU admissions. We searched PubMed, Embase, Cochrane Library, and Web of Science for observational studies that compared the risk of ICU admission between anemic and non-anemic pregnant women. We pooled the odds ratios (ORs) for ICU admission using a random-effects model. Heterogeneity among studies was assessed using prediction intervals (PIs), Tau2 and I2 statistics. Sensitivity analysis by excluding outlier studies, meta-regression by sample size and age, and publication bias detection by LFK index and Doi plot was undertaken. Eight studies with a total of 21,997,574 participants in both anemic and non-anemic groups were included. Of them, meta-analysis was conducted in seven studies which yielded a pooled OR for anemia and ICU admission as 1.32 (95% CI 0.62-2.81). There was also a very high level of heterogeneity among studies (PI: 0.10-18.16, I2 = 100%). When an influential study was omitted, the pooled OR 1.16 (95% CI - 1.13; 1.20) for ICU admission was significant. The LFK index was - 3.64, indicating publication bias. Anemia in pregnant women might be associated with a higher risk of ICU admission, but it is essential to interpret this cautiously due to significant heterogeneity and potential publication bias. Registration : PROSPERO database (CRD42023466529).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-024-01849-0.

Fetal bradycardia and acidosis during maternal parenteral iron: Case reports and literature review

Iron deficiency anemia is an important problem among pregnant women, and intravenous (IV) iron infusions have been increasingly used. Whether fetal monitoring is required during infusion has been debated, with a recent guideline by Hematologists recommending against such. We report two cases of fetal bradycardia after iron isomaltoside (IIM), in women with otherwise good maternal and fetal health. Both developed dyspnea with desaturation minutes from infusion, followed by persistent fetal bradycardia. Both underwent category 1 CS, with cord arterial pH of 7.08 and 6.94 respectively. Upon literature review, only three case reports on fetal bradycardia in IV iron were identified. For older IV iron formulations, a case was reported after IV dextran test dose, while two cases after ferric gluconate were reported. For the new formulation IIM, only one case was reported so far, but in a woman with Crohn's disease and intrauterine growth restriction. IV iron in pregnancy carries risk of anaphylactic or hypersensitivity reactions, even with the newest formulations and in women with good maternal and fetal health. While rarely reported so far, fetal bradycardia is a possible consequence, commonly preceded by respiratory symptoms. Fetal monitoring should therefore be considered during infusion.

Non-adherence to antenatal iron supplementation and its determinants among pregnant women in 35 sub-saharan African countries: a generalized linear mixed-effects modeling with robust Poisson regression analysis

BACKGROUND

Despite the integration of iron supplementation into routine antenatal care programs as a nutritional intervention to prevent anemia in pregnant women, the use of this supplement for the recommended duration remains low in sub-Saharan Africa (SSA). Evidence on maternal compliance with iron supplementation at the SSA level is lacking and most of the previous studies have been limited to specific geographic areas. Therefore, the current study used large population survey data from 35 SSA countries to estimate the pooled prevalence of non-adherence and its determinants.

METHODS

A secondary analysis was conducted using data from the demographic and health surveys across 35 SSA countries. After excluding women with missing data on the outcome variable, a weighted sample of 158,941 women who received iron supplementation during their recent pregnancy was included in the analysis. Forest plot was used to present the pooled and country-level rates of non-adherence to antenatal iron supplementation. A multilevel mixed-effects Poisson regression with robust variance was done to identify determinants of non-adherence.

RESULTS

The pooled prevalence of non-compliance to iron supplementation in SSA was 65.1% [95% CI: 64.9 - 65.3%], with the lowest level in Zambia (18%) and the highest in Burundi (97%). The analysis revealed that living in rural areas (aPR: 1.16, 95% CI: 1.13-1.19), lack of access to mass media (aPR: 1.10, 95% CI: 1.09-1.12), low household wealth (aPR: 1.11, 95% CI: 1.09-1.14), late (aPR: 1.19, 95% CI: 1.17-1.20) and frequent ANC visit (aPR: 1.28, 95% CI: 1.26, 1.29), women's employment status (aPR: 1.05, 95% CI: 1.03-1.06), husband illiteracy (aPR: 1.12, 95% CI: 1.10-1.13), and distance to a health facilities (aPR: 1.03, 95% CI: 1.01-1.05) were associated higher prevalence of non-adherence. Conversely, older maternal age was associated lower prevalence of non-compliance (aPR: 0.96, 95% CI: 0.94-0.97).

CONCLUSION

More than six out of ten pregnant women in SSA do not take iron supplements for the recommended period, with substantial variations across the countries. The level of non-adherence was significantly varied by women's sociodemographic and reproductive characteristics. This urges the need for strengthening community health interventions and other existing programs to reach women in rural and economically disadvantaged settings. Furthermore, promoting antenatal care services through mass media and community-based health education strategies is key for scaling up the utilization of the supplement. Our results also suggest the importance of establishing the community-based distribution of iron supplements to address women with limited access to the healthcare system.

The effect of quail egg supplements enriched with marine macroalgae Eucheuma spinosum on the physiological condition of Sprague Dawley rats during pregnancy

Objective

To investigate the effect of quail egg supplements enriched with marine macroalgae Eucheuma spinosum on body weight and physiological conditions of Sprague Dawley rats during pregnancy.

Materials and Methods

This study used a completely randomized experimental design. The test animals were 25 pregnant white rats aged 3 months and weighed ± 200 gm. Pregnant rats were divided into five treatments and five repetitions; each repetition contained one pregnant rat. T0: control treatment; T1: treatment group consuming quail eggs from quail fed commercial feed; T2: treatment group consuming quail eggs from quail fed with 3% E. spinosum; T3: treatment group consuming quail eggs from quail fed with 4% E. spinosum; T4: treatment group consuming quail eggs from quail fed with 5% E. spinosum. The parameters measured were egg proximate, egg iron, egg cholesterol, red blood cell (RBC), hemoglobin (Hb), hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular Hb (MCH), mean corpuscular Hb concentration (MCHC), white blood cell (WBC), lymphocytes (LYM), neutrophils (NEUT), RBC distribution width (RDW), platelet distribution width (PDW), mean platelet volume (MPV), cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), glucose, superoxide dismutase (SOD), and malondialdehyde (MDA).

Results

The addition of E. spinosum into quail feed at concentrations of 3%, 4%, and 5% did not show statistically significant differences (p > 0.05) in the proximate levels (water, ash, fat, protein, and carbohydrates) compared to the control. However, the analysis of iron in quail eggs indicated a significant increase (p < 0.05) in comparison to the control treatment. In addition, the supplementation of E. spinosum in the quail feed resulted in significantly reduced (p < 0.05) quail egg cholesterol levels when compared to the control treatment. Furthermore, the supplementation of quail egg produced by quail fed with E. spinosum did not significantly affect the birth weight of the pups, RBC, MCV, MCH, MCHC, WBC, LYM, NEUT, RDW, PDW, MPV, MDA, and SOD when compared to the control treatment (p > 0.05). Meanwhile, the mother weight, Hb, HCT, cholesterol, HDL, LDL, and glucose levels significantly increased (p < 0.05) compared to the control.

Conclusion

The administration of E. spinosum with concentrations of 3%, 4%, and 5% can increase iron levels and decrease cholesterol levels in quail eggs. The administration of quail egg supplements produced by quail-fed additional macroalgae E. spinosum can increase body weight, Hb, and HCT in pregnant rats. The addition of marine macroalgae with concentrations of 4% and 5% can decrease the levels of cholesterol, LDL, and glucose and increase serum HDL levels in pregnant rats.

Uncovering the hidden health burden: a systematic review and meta-analysis of iron deficiency anemia among adolescents, and pregnant women in Pakistan

INTRODUCTION

Iron deficiency anemia (IDA) is the most prevalent diet-related disorder and mainly affects women and children. To determine the trend of anemia incidence in Pakistan, a current review was carried out. This review aimed to estimate the prevalence of anemia among pregnant women and adult/adolescent nonpregnant women in Pakistan and to provide a 15-year trend analysis.

MATERIALS AND METHODS

Studies were identified by searching PubMed, Google Scholar, Scopus, and Science Direct, complementing this digital exploration, and a manual review of reference lists from previously published prevalence studies was performed to enhance the scope of relevant articles. A total of twenty-seven population-based anemia studies on adolescent/adult females and pregnant women published in Pakistan from January 1st-2007 until December 2021 were included. Systematic data extraction was facilitated through the implementation of a standardized and rigorously pretested data extraction checklist. For the subsequent analysis, the sophisticated capabilities of R statistical software were harnessed. The I2 test was used to assess heterogeneity among studies, and the pooled prevalence of anemia was calculated.

RESULTS

The final analysis included 27 research articles as well as two extensive National Nutrition survey reports, NNS 2011 and NNS 2018. The forest plot of sixteen studies on pregnant women revealed that the overall pooled prevalence of anemia among pregnant females in Pakistan was 70.4% (95% CI: 0.619, 0.789), and the forest plot of eleven studies on non-pregnant adolescent and adult females reported the pooled prevalence was 54.6% (95% CI: 0.422, 0.669). Subgroup analysis among pregnant women based on region, trimester and socioeconomic status revealed that the highest anemia incidence was observed in Punjab (77.4%). Similarly, females in the second trimester reported a higher prevalence of anemia 78% (95% CI, 0.556 1.015), and the status-wise group with a mixed background reported a higher prevalence 72.8% (95% CI, 0.620 0.835). According to the subgroup analysis, eleven studies of adult nonpregnant groups of mixed socioeconomic status reported a higher prevalence of 56.9% (95% CI, 0.292 0.845).

CONCLUSION

In Pakistan, anemia, is widespread among pregnant women and nonpregnant adolescent/adult females. A deeper understanding of anemia in Pakistani women is necessary for targeted interventions and policy decisions to predict demographic shifts.

Effects of Oral Folic Acid and Iron Tablets Intake on the Prevalence and Severity of Anemia in Pregnant Women in a Public Sector Hospital in Delhi

OBJECTIVE

To study the effects of oral folic acid, iron tablets, and tea consumption on the prevalence and severity of anemia in pregnancy.

METHODS

This cross-sectional study was conducted on 430 women who fulfilled the eligibility criteria in the second and third trimesters of pregnancy attending the antenatal clinic of a public sector hospital in Delhi.

RESULTS

The mean age, parity, BMI, and gestation were 26.2 ± 4.5 years, 1.8 ± 1.2, 22.5 ± 4.5 kg/m2, and 32.2 ± 3.4 weeks, respectively. Out of 430 patients, the prevalence of anemia was found in 210 (48.84%) patients, with mild anemia in 111 (25.81%), moderate in 68 (15.81%), severe in 30 (6.98%), and very severe in one (0.24%) patient. Significantly more women (97, 46.19%) in the anemia group did not take oral folic acid tablets as compared to the normal hemoglobin (Hb) group (83, 37.72%) (p = 0.04). Similarly, significantly more (103, 49.04%) women in the anemia group did not take oral iron tablets as compared to the normal Hb group (19, 8.63%) (p = 0.02) with even more patients being in the severe anemia group (29, 93.55%) (p = 0.001). Intake of two or more cups of tea per day was a significant risk factor for anemia, with 147 (70%) anemic vs. 134 (60.9%) with normal Hb (p = 0.05).

CONCLUSION

The prevalence of anemia during pregnancy was found to be high in 210 (48.84%) patients. Non-intake of oral folic acid and iron tablets and consumption of two or more cups of tea were significant risk factors for anemia in pregnancy.

Burden and Predictors of Anemia Among Pregnant and Lactating Females in a Rural Area in India With a High Tribal Population

Introduction Nutritional anemia is a silent emergency particularly rampant in developing countries, especially among women of reproductive age group. This study was done with the objective to determine the prevalence and predictors of anemia among pregnant and lactating females in the Ormanjhi block of Ranchi district, Jharkhand. Methodology A community-based cross-sectional study was done on 388 pregnant and lactating females from July 2022 to June 2024 using a multi-stage cluster sampling technique. A pre-designed, pre-tested, semi-structured, interviewer-administered questionnaire containing different sections namely socio-demographic details, dietary history, menstrual history, obstetric history, antenatal history, medical history, behavioral history, and personal history was used. House-to-house visits were done for the collection of data. To estimate the prevalence, hemoglobin levels were analyzed using a digital hemoglobinometer. Results The overall prevalence of anemia among pregnant and lactating females was found to be 361 (93%) among 388 participants. Prevalence among pregnant females was 295 (92.76%) out of 318, and among lactating females, it was 66(94.28%) out of 70. The prevalence of anemia in the first trimester was 80 (80.45%) out of 87, 112 (94.91%) in the second trimester among 118, and 103 (91.15%) among 113 females in the third trimester. Conclusion There are concerns about stagnancy in the prevalence of anemia in pregnancy despite strong political commitments. A baseline data is generated from this study giving a clear picture of the exact prevalence and the predictors of anemia among pregnant and lactating females. This would help the policymakers to make warranted modifications imperative to improve the nutritional status of pregnant and lactating women and hence the children.

Risk Factors for Anemia in Adolescent Pregnancies: Evidence From the Lembah Pantai Urban Health District in Malaysia

Introduction Adolescent pregnant mothers are at higher risk of acquiring anemia during pregnancy, which has detrimental consequences for the mother and baby. Untreated and prolonged anemia can lead to perinatal morbidity and mortality and antepartum, intrapartum, and postpartum maternal morbidity. Anemia among adolescent pregnant mothers can be attributed to many factors, such as poor nutrition and the physiological demands of pregnancy. Hence, this study aimed to determine the prevalence and characteristics of anemia among adolescent pregnancies in Lembah Pantai Health District in an urban setting. Materials and methods This cross-sectional study utilized secondary data from registry records of adolescent pregnant mothers in the Lembah Pantai District Health Office in Kuala Lumpur, Malaysia from 2019 to 2022. All adolescent pregnancies aged 10 to 19 years were included in this study. Those with a prior diagnosis of thalassemia or other hematological disorders, as indicated in their medical records, were excluded from the study. The chi-square (χ2) test was applied to elicit the association at a univariate level, and those variables with a p-value of <0.25 were included in a multiple logistic regression model. Results A total of 307 records were reviewed, and 272 pregnant adolescent cases were eligible for the analyses. The prevalence of anemia among teenage pregnancies from 2019 to 2022 was 28.7% (95% CI: 23.0-33.6). This prevalence was lower than in many lower-income countries and developing countries. Factors that were significant on using multiple logistic regression analysis included marital status (unmarried) (AOR: 1.87, 95% CI: 1.01-3.45, p=0.046), residing area Seputeh (AOR: 0.29, 95% CI: 0.14-0.61, p=0.001), and third trimester of first antenatal visit/booking (AOR: 5.08, 95% CI: 2.02-12.70, p<0.001). The population in the Seputeh area has a higher overall household income in comparison to Lembah Pantai. Conclusions  According to the WHO classification, the prevalence of anemia among adolescent pregnant women at the Lembah Pantai District Health Office reflects a moderate public health issue. Consequently, anemia may exacerbate the impact of other health conditions in this population. Hence, local health authorities should ensure that anemia is adequately addressed without ignoring other crucial health issues. A multidisciplinary, comprehensive, holistic strategy involving healthcare providers, school health teams, and community assets offers a potential solution. Strategies that can be employed include providing targeted health and nutrition education in schools through school health teams. Additionally, establishing adolescent-friendly health clinics tailored to the specific needs of pregnant adolescents and enhancing antenatal services to ensure comprehensive screening and management of anemia should also be implemented. Hence, this will ensure achieving safe motherhood goals through an effective healthcare response.

Management of iron deficiency anemia during pregnancy: a midwife-led continuity of care model

Background

Globally, 36.5% of pregnancies are affected by anemia, particularly in low-and middle-income countries, posing significant risks to maternal and perinatal health. In rural Pakistan, 44.3% of pregnant women suffer from iron deficiency, contributing to the high prevalence of anemia. Limited accessibility to antenatal care exacerbates the challenge, necessitating innovative solutions. This study assessed a midwife-led continuity of care model, utilizing intravenous (IV) iron therapy for the management of anemia in Karachi, Pakistan.

Methods

We performed a retrospective analysis of data from a prospective cohort study conducted in two primary healthcare facilities, which employed a community midwife (CMW)-led continuity of care model for antenatal care, including IV iron therapy. We extracted data from February 2021 to March 2022 for women who were diagnosed with anemia based on hemoglobin (Hb) levels, categorized as mild (10.0 to 10.9 g/dL), moderate (7.0 to 9.9 g/dL), or severe (less than 7.0 g/dL). Assessment occurred at the initial antenatal care (ANC) visit to establish baseline anemia severity, and approximately 2 weeks after intravenous (IV) iron therapy administration to evaluate post-treatment changes were considered.

Results

We enrolled 114 pregnant women, where the majority presented with moderate (88.6%) anemia. After IV iron treatment, 48.5% improved to normal-mild levels, while 50% remained unchanged. Severe anemia affected 10.5% at baseline; 42% shifted to moderate and 50% to normal-mild post-treatment, with one remaining unchanged (p < 0.001). Among women enrolled in the first and second trimesters, severe anemia improved to normal-mild (50%) and moderate levels (50%) (pre-treatment: n = 10, post-treatment: n = 0), and moderate anemia decreased by 48% (pre-treatment: n = 92, post-treatment: n = 47).

Conclusion

Our midwife-led model of care demonstrated an improvement in iron levels among pregnant women. The model addressed the challenges of anemia prevalence in Pakistan and underscored the significance of empowering front-line healthcare providers, such as community midwives (CMWs) for managing these common conditions.

Iron deficiency anemia status in Iranian pregnant women and children: an umbrella systematic review and meta-analysis

BACKGROUND

Iron deficiency anemia (IDA) is a global health challenge, especially affecting females and children. We aimed to conduct an umbrella systematic review of available evidence on IDA's prevalence in Iranian pregnant women and children.

METHODS

We searched the Web of Science, Science Direct, PubMed, Scopus, and Google Scholar databases for articles published by April 2023. Meta-analyses investigating the status of IDA in Iran were included. The findings of seven meta-analyses comprising 189,627 pregnant women with a mean age of 26 and 5,890 children under six years old were included in this study. The methodological quality of each study was evaluated with the Assessment of Multiple Systematic Reviews (AMSTAR2) instrument.

RESULTS

We estimated the prevalence of IDA at 15.71% in pregnant women and 19.91% in young children. According to our subgroup analysis of pregnant women, IDA's prevalence in urban and rural regions was 16.32% and 12.75%; in the eastern, western, central, southern, and northern regions of Iran, it was estimated at 17.8%, 7.97%, 19.97%, 13.45%, and 17.82%, respectively.

CONCLUSION

IDA is common in young children and pregnant females and is a significant public health concern in Iran. The present umbrella review results estimated that Iran is in the mild level of IDA prevalence based on WHO classification. However, due to sanctions and high inflation in Iran, the prevalence of anemia is expected to increase in recent years. Multi-sectoral efforts are required to improve the iron status of these populations and reduce the burden of IDA in the country.

Prevalence and determinants of moderate-to-severe anaemia in the third trimester of pregnancy: a multicenter cross-sectional study in Lagos, Nigeria

The high burden of anaemia during pregnancy underscores the urgent need to gain a comprehensive understanding of the factors contributing to its widespread occurrence. Our study assessed the prevalence and the trends of moderate-to-severe anaemia (MSA) in late pregnancy (28 to 36 weeks) and then investigated the key determinants driving this prevalence among women in Lagos, Nigeria. We conducted a secondary data analysis involving 1216 women enrolled in the Predict-PPH study between January and March 2023. We employed a multivariate binary logistic regression model with a backward stepwise selection approach to identify significant predictors of MSA. The study revealed a 14.5% prevalence of MSA during pregnancy. Independent predictors of MSA included having given birth to two or more children (adjusted odds ratio = 1.46, 95% confidence interval: 1.03-2.07), having a maternal body mass index (BMI) of 28 kg/m2 or higher (adjusted odds ratio = 1.84, 95% confidence interval: 1.29-2.61), having less than tertiary education (adjusted odds ratio = 1.51, 95% confidence interval: 1.08-2.11), and being unemployed (adjusted odds ratio = 1.97, 95% confidence interval: 1.19-3.26). It is crucial for pregnant women, particularly those with higher parities and elevated BMI, to be monitored regularly for anaemia and its consequences during their antenatal care. Additionally, addressing the link between low education, unemployment, and anaemia necessitates comprehensive strategies that empower women in terms of education and economic status to enhance the overall well-being of individuals and communities, ultimately reducing the prevalence of anaemia and associated health issues in pregnancy.

Association between Iron-Folic Acid Supplementation during Pregnancy and Maternal and Infant Anemia in West Java, Indonesia: A Mixed-Method Prospective Cohort Study

The Indonesian government has provided iron-folic acid (IFA) supplementation in response to maternal pregnancy iron-deficiency anemia. However, community-based cohorts on IFA's effects on maternal and infant anemia are limited. A mixed-method study design with a primary longitudinal cohort was used to observe the association between IFA and anemia in mothers and infants. Iron-folic acid supplementation was observed throughout pregnancy. Anemia status was based on a single hemoglobin assessment using HemoCue Hb 201 + in the second or third trimester of pregnancy for the mother and at birth for the infant. Qualitative data were collected via in-depth interviews (IDIs) and a forum group discussion (FGD). Iron-folic acid supplementation with > 180 tablets throughout pregnancy was associated with lower pregnancy anemia (adjusted relative risk [aRR] = 0.25, 95% CI: 0.092-0.664, P = 0.006) after adjusting for potential confounding variables. Supplementation with IFA was not associated with infant anemia (RR = 1.033, 95% CI: 0.70-1.54, P = 0.873 for 90-180 tablets and RR = 1.07, 95% CI 0.70-1.63, P = 0.774 for > 180 tablets). The IDIs and FGD suggested that IFA and multivitamin content knowledge, IFA consumption monitoring, and paternal involvement were important in IFA supplementation and effectiveness in reducing anemia. Iron-folic acid supplementation was associated with reduced maternal but not infant anemia. Because maternal anemia is associated with infant anemia, an anemia monitoring program for women in early pregnancy is vital in addressing infant health. Paternal involvement was also identified as a major factor in maternal and child health.

Efficacy and Safety of Microsomal Ferric Pyrophosphate Supplement for Iron Deficiency Anemia in Pregnancy

Introduction Anemia during pregnancy is characterized by decreased hemoglobin levels. Iron deficiency poses a significant global health concern, especially in pregnant women, where increased iron demands are crucial for both maternal and fetal well-being. Method In the current study, we investigated the effectiveness and safety of 30 mg SunActiveTM Fe (Taiyo GmbH, Yokkaichi, Japan), emulsified microsomalTM ferric pyrophosphate (EMFP) tablets in treating iron deficiency anemia in 27 second-trimester singleton pregnant women. Results Our study results demonstrated that hemoglobin levels increased significantly within 30 days of treatment and continued to remain higher than baseline throughout the study. Serum ferritin levels exhibited a 6.61-fold increase, maintaining elevated levels consistently. Serum iron also increased significantly by 46.9%. Additionally, symptoms such as nausea, breathlessness, dizziness, irritability, and heartburn were notably reduced, leading to improved quality of life. Subjects reported decreased overall fatigue, indicating an enhanced quality of life. Babies born during the study showed healthy birth weights, with uncomplicated deliveries. High treatment compliance of 99.5% underscored patient commitment to the study. Furthermore, the investigational product demonstrated a favorable safety profile, with only two mild adverse events observed, unrelated to the treatment. Conclusion These findings suggest that EMFP could be a valuable therapeutic option for managing iron deficiency anemia in pregnant women, promoting better maternal and fetal outcomes. Further research with an increased sample size is warranted to delve into the underlying mechanisms behind these positive outcomes, nonetheless, our study provides a promising foundation for addressing this critical health issue.

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.

Iron overload in anaemia with underlying haemoglobin constant spring in an antenatal mother in primary care

This is the case of a gravida 3 para 1 woman in her late 20s with underlying haemoglobin constant spring who visited a healthcare clinic for an antenatal check-up. Towards the end of her second trimester, she experienced lethargy. During her antenatal booking, she was diagnosed with mild asymptomatic anaemia, high serum ferritin, T saturation of 88% and abnormal liver function tests. She was referred to a hospital where an MRI scan revealed over 2 g of iron deposits in her liver, leading to a revised diagnosis of iron overload. Treatment included deferoxamine and expectant management throughout her antenatal period, and her delivery was uncomplicated. While iron deficiency anaemia is common in pregnancy, it is crucial not to overlook iron deposition and the distinction from acute fatty liver during pregnancy to prevent treatment delays.

Iron deficiency in healthy, term infants aged five months, in a pediatric outpatient clinic: a prospective study

BACKGROUND

Iron deficiency (ID) is prevalent in Malaysian children. The incidence of ID in infants under 6 months of age is unknown. Our aim was to determine the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) in healthy, term infants aged below 6 months in our hospital population.

METHODS

A prospective longitudinal pilot study of mother-infant pairs was conducted on infants receiving routine immunizations in a mother and child clinic at a university hospital, in Kuala Lumpur, Malaysia. Mothers completed standardized questionnaires at 3- and 5-month postnatal visits. Maternal and infant full blood count, ferritin, and C-reactive protein (CRP) levels were measured at 3 months and for the infants repeated at 5 months. Infant anthropometric measurements were obtained at both visits. We conducted a univariate analysis to identify factors associated with ID and IDA.

RESULTS

Altogether, 91 mother-infant pairs were enrolled, with 88 completing the study. No infant had ID or IDA at 3 months; the lowest ferritin level was 16.6 µg/L. At 5 months, 5.9% (5/85) of infants had ID, and 2.4% (2/85) had IDA. Median (interquartile range) infant ferritin levels significantly declined from 113.4 (65.0-183.6) µg/L at 3 months to 50.9 (29.2-70.4) µg/L at 5 months, p < 0.001. Exclusive breastfeeding until 3 or 5 months was significantly associated with ID at 5 months (p = 0.020, and p = 0.008, respectively) on univariate analysis. The drop in ferritin between 3-5 months was significantly associated with weight and length gains between 0-3 months (p = 0.018, p = 0.009, respectively). Altogether, 14.3% of infants exclusively breastfed until 5 months developed ID. At 5 months, 3.4% of infants were underweight, 1.1% stunted, and 10.2% wasted.

CONCLUSIONS

In exclusively breastfed term infants, ID occurred by 5 months. Early introduction of iron-rich foods should be considered in exclusively breastfed babies. A high prevalence of wasting suggests a calorie deficit in this population and will lead to stunting if not addressed.

Clinical and haematological characteristics of 38 individuals with Hb G-Makassar in Malaysia

Haemoglobin (Hb) G-Makassar is a rare Hb variant. It presents a diagnostic challenge as it imitates sickle Hb (Hb S) in standard electrophoresis and high-performance liquid chromatography assays requiring DNA analysis to confirm diagnosis. Both have point mutations in codon 6, exon 1 in the β-globin (HBB) gene with different pathogenicities. This study describes the clinical phenotype, haematology and genotype of Hb G-Makassar. Clinical and laboratory data of 38 cases of Hb G-Makassar over 8 years were analysed. Hb G-Makassar was confirmed by a direct sequencing of HBB gene and co-inheritance of α-thalassaemia determined through multiplex gap-PCR and multiplex Amplification Refractory Mutation System polymerase chain reaction. All cases were Malays, predominantly from Terengganu (n = 20, 52.6%). There were 14 (36.8%) males and 24 (63.2%) females with median age of 25 years. Majority (n = 33, 86.8%) had features of thalassaemia trait with mean ± SD for Hb, mean cell volume (MCV) and mean cell haemoglobin (MCH) as 13.21 g/dL ± 1.69, 73.06 ± 4.48 fL and 24.71 ± 1.82 pg, respectively. None had evidence of haemolysis or thromboembolic complications. Six genotypes were identified; ßG-Makassar/ß,αα/αα (n = 19, 50.0%), ßG-Makassar/ßE,αα/αα (n = 4, 10.5%), ßG-Makassar/ßNewYork,αα/αα (n = 1, 2.6%), ßG-Makassar/ß,αα/-α (n = 11, 28.9%), ßG-Makassar/ß,αα/αAdanaα (n = 2, 5.3%) and ßG-Makassar/ß,αα/-SEA (n = 1, 2.6%). The ßG-Makassar/ß,αα/αα showed that features of thalassaemia trait with mean ± SD for Hb, MCV and MCH were 13.74 g/dL ± 2.40, 76.18 ± 6.02 fL and 25.79 ± 2.41 pg, respectively. This is the largest study reporting a significant number of Hb G-Makassar in Malaysia. Although the mutation is similar to Hb S, the phenotype is benign.

Anemia in pregnancy and sleep of 6-month-old infants: A prospective cohort study

Objective

Anemia has been reported to adversely influence sleep in infants. However, the association between anemia in pregnancy and infant sleep remains unclear. We aimed to examine the association between maternal anemia in pregnancy and sleep parameters of 6-month-old infants.

Methods

We enrolled 2,410 mother-infant pairs between 2018 and 2021 in Hefei. Data on maternal hemoglobin concentration were collected at 24–28 gestational weeks from the electronic medical records of the hospitals. Nocturnal and daytime sleep duration, number of night awakenings, nocturnal wakefulness, and sleep latency of infants aged 6 months were measured using the Brief Infant Sleep Questionnaire with five items. A restricted cubic spline model was used to examine the relationship between maternal hemoglobin concentration and infant nocturnal sleep duration after adjusting for potential confounders.

Results

In our study, 807 (33.5%) mothers had anemia during pregnancy. Compared to infants born to mothers without anemia, infants born to mothers with anemia in pregnancy had shorter nocturnal sleep duration [mean (SD), 560.29 (79.57) mins vs. 574.27 (75.36) mins] at the age of 6 months. Subgroup analysis showed consistent significant differences in nocturnal sleep duration between infant born to anemic and non-anemic mothers, except in case of stratification by preterm birth [mean difference (mins), 2.03 (95% CI, −20.01, −24.07)] and pre-pregnancy obesity [mean difference (mins), −0.85 (95% CI, −16.86, −15.16)]. A J-shaped nonlinear correlation curve was observed between maternal hemoglobin concentration and infant nocturnal sleep duration. Compared with mothers without daily iron supplementation, mothers who had daily iron supplementation had higher hemoglobin concentrations [mean (SD), 112.39 (11.33) g/L vs. 110.66 (10.65) g/L] at delivery and their infants had longer nocturnal sleep duration [mean (SD), 565.99 (82.46) mins vs. 553.66 (76.03) mins].

Conclusion

Anemia in pregnancy may have an adverse influence on the sleep of 6-mon-old infants, and the relationship between maternal hemoglobin concentration and nocturnal sleep duration is nonlinear.

How can pharmacists contribute to anaemia management? A review of literature and exploratory study on pharmacists' role in anaemia

Background

Iron deficiency anaemia (IDA) is the leading cause of anaemia globally, most frequently found in children and pregnant women. With their increasing role in the healthcare system, pharmacists may contribute to the management of anaemia. Through the International Pharmaceutical Federation (FIP) Multinational Needs Assessment Programme, the FIP explored the contribution of pharmacists in anaemia, specifically IDA, focusing on five countries: India, Indonesia, Malaysia, Philippines and Singapore.

Objective

To explore information on pharmacists' roles in a variety of settings related to 1) IDA management; 2) education and training needed to support the roles; and 3) barriers and enablers to expanding or developing the roles.

Methods

This study involved a literature review and a focus group discussion with twelve participants selected purposively and nominated by national professional leadership bodies across five countries. A literature search was conducted using PubMed Database. A focus group discussion explored pharmacists' roles, education and training needs, as well as barriers and enablers to support their roles in anaemia management, specifically in IDA. A codebook thematic analysis approach was conducted according to the study objectives.

Results

Sixteen articles were included in the analysis. The pharmacists' roles in anaemia identified from literature ranged from patient management and monitoring, collaboration with other healthcare professionals and involvement in guideline development, in which the roles vary according to the workplace. Twelve participants attended the focus group discussion. Participants highlighted pharmacists' roles in screening and detection, medication therapeutic management, patient counselling and patient monitoring. Participants emphasised a need for guidelines or toolkits with subsequent training or workshops to support their competency development in anaemia. Monitoring the success of pharmacist delivered anaemia programmes was recommended to support advocating for active pharmacist roles.

Conclusion

Pharmacists have a growing opportunity to contribute to achieving the global targets on anaemia through their involvement in screening and managing anaemia and increasing anaemia awareness among the patients and community.

Prevalence, maternal characteristics, and birth outcomes of preeclampsia: A cross-sectional study in a single tertiary healthcare center in greater Kuala Lumpur Malaysia

Background

Preeclampsia is associated with an increased risk of adverse maternal and perinatal outcomes. This study aimed to assess preeclampsia prevalence in a Malaysian referral maternity hospital and the association between preeclampsia and maternal characteristics and outcomes.

Methods

A cross-sectional study was conducted between January 2010 and December 2020 using secondary data from a single tertiary healthcare center in Greater Kuala Lumpur, Malaysia. A total of 40,212 deliveries were included for analysis to investigate the association between conditions (maternal characteristics and adverse birth outcomes) and preeclampsia. Multivariable logistic regression was conducted to assess the association between multiple independent variables and the outcome variable (preeclampsia).

Results

The reported prevalence of preeclampsia was 1.6%. Pregnant women with preeclampsia had a higher risk of preterm delivery (67.7%), instrumental and cesarean delivery (74.7%), neonatal low birth weight (48.5%), neonatal 5-min Apgar score <7 (18.1%), and neonatal intensive care unit (NICU) admission (19.8%). There were significantly higher odds of developing preeclampsia among nullipara [adjusted odd ratio (adjOR) 1.792, 95% CI: 1.518-2.115], women with a previous history of preeclampsia (adjOR 5.345, 95% CI: 2.670-10.698) and women with multiple pregnancies (adjOR 1.658, 95% CI: 1.071-2.566). However, there is a significant association between maternal characteristic variables. There was a significant association when a combination of variables for risk assessment: the presence of anemia and gestational hypertension effect on preeclampsia (OR 26.344, 95% CI: 9.775-70.993, p < 0.002) and gestational hypertension without anemia on preeclampsia (OR 3.084, 95% CI: 2.240-4.245, p < 0.001). Similarly, an association was seen between chronic hypertension and younger age (<35 years old) on preeclampsia (OR 14.490, 95% CI: 9.988-21.021, p < 0.001), and having chronic hypertension with advanced maternal age (≥35 years old) on preeclampsia (OR 5.174, 95% CI: 3.267-8.195, p < 0.001). Both conditions had increased odds of preeclampsia, in varying magnitudes. Overall, the significant interaction effects suggest that a history of chronic or gestational hypertension has a different relationship to the incidence of preeclampsia depending on the maternal age and anemia status. Pregnant women with preeclampsia had significantly higher odds for preterm delivery (adjOR 6.214, 95% CI: 5.244-7.364), instrumental and cesarean delivery (adjOR 4.320, 95% CI: 3.587-5.202), neonatal low birth weight (adjOR 7.873, 95% CI: 6.687-9.271), 5-min Apgar score <7 (adjOR 3.158, 95% CI: 2.130-4.683), and NICU admission (adjOR 8.778, 95% CI: 7.115-10.830).

Conclusions

Nulliparity, previous history of preeclampsia, and multiple pregnancies were associated with an increased risk of preeclampsia. The presence of different underlying conditions, such as chronic hypertension, anemia, and extremes of maternal age played an important role in increasing preeclampsia risk in the considered study. Larger samples are needed to validate such findings.