Hemoglobin distributions and prevalence of anemia in a multiethnic United States pregnant population

BACKGROUND

Few normative longitudinal hemoglobin data are available to estimate the prevalence and risk factors for anemia among a multiethnic United States pregnant population.

OBJECTIVES

The aim of this study was to characterize hemoglobin distributions and prevalence of anemia in a pregnant population receiving care at a large urban medical center.

METHODS

A retrospective medical chart review was undertaken in 41,226 uncomplicated pregnancies of 30,603 pregnant individuals who received prenatal care between 2011 and 2020. Mean hemoglobin concentrations and anemia prevalence in each trimester and incidence of anemia during pregnancy in a subset of 4821 women with data in each trimester were evaluated in relation to self-reported race and ethnicity and other possible risk factors. Risk ratios (RRs) of anemia were determined using generalized linear mixed-effects models. Smoothed curves describing changes in hemoglobin across pregnancy were created using generalized additive models.

RESULTS

The overall prevalence of anemia was 26.7%. The observed fifth percentiles of the hemoglobin distributions were significantly lower than the United States CDC anemia cutoffs in the second and third trimesters (T3). The RR (95% CI) of anemia were 3.23 (3.03, 3.45), 6.18 (5.09, 7.52), and 2.59 (2.48, 2.70) times higher in Black women than that in White women in each trimester, respectively. Asian women recorded the lowest risk of anemia compared with other racial groups in T3 (compared with White womenRR: 0.84; 95% CI: 0.74, 0.96). Hispanic women presented a higher risk of anemia in T3 than non-Hispanic women (RR: 1.36; 95% CI: 1.28, 1.45). In addition, adolescents, individuals with higher parity, and those carrying multiple fetuses experienced a higher risk of developing anemia in late gestation.

CONCLUSIONS

Anemia was evident in more than one-quarter of a multiethnic United States pregnant population despite current universal prenatal iron supplementation recommendations. Prevalence of anemia was higher among Black women and lowest among Asian and White women.

Luteoma of Pregnancy Masquerading as a Granulosa Cell Tumor

Pregnancy luteomas are rare, nonmalignant lesions thought to be caused by hormonal changes during pregnancy. Granulosa cell tumor is a rare type of ovarian cancer; 10% occur during pregnancy and typically present with elevated inhibin levels. Herein, we present a case of a pregnant female with a pelvic mass and elevated inhibin B suggestive of a granulosa cell tumor, yet with final pathology consistent with a pregnancy luteoma.

Placental Ferroportin Protein Abundance Is Associated With Neonatal Rather Than Maternal Iron Status in Women at High Risk for Gestational Iron Insufficiency

Objectives

Murine data suggest that the placenta prioritizes iron (Fe) for its own needs when Fe is limited by upregulating transferrin receptor 1 (TFR1) and downregulating the Fe exporter ferroportin (FPN). Human data on the impact of maternal and neonatal Fe status on placental FPN are conflicting. The study aims were to identify determinants of placental FPN protein abundance in women at risk of Fe insufficiency and to assess the utility of the placental Fe deficiency index (PIDI), which is the FPN/TFR1 ratio, as a measure of maternal/fetal Fe insufficiency.

Methods

FPN and TFR1 protein abundance was measured by semi-quantitative western blots in placentae collected from 43 neonates born to teens (17.4 ± 1.1 y) carrying singletons (39.9 ± 1.3 weeks of gestation at birth) and from 57 neonates born to 26 women (31.3 ± 6.3 y) carrying multiples (35.5 ± 2.7 weeks of gestation at birth). Fe status biomarkers (Hb, SF, sTfR, TBI) and hormones (hepcidin, EPO, ERFE) were assessed in maternal and cord blood.

Results

FPN and TFR1 were detected in all samples analyzed between 30.4–41.7 weeks of gestation. In both cohorts, FPN protein abundance was associated with neonatal but not maternal factors. Higher FPN was associated with lower cord Hb (p = 0.03) in the multiples cohort and with higher cord EPO (p = 0.002) in the teens. In contrast, TFR1 was inversely associated with maternal Fe status; multiples cohort (SF, p = 0.01; sTfR, p = 0.01; TBI, p = 0.003; hepcidin p = 0.01), teens (SF, p = 0.01). The PIDI was predicted by maternal and neonatal Fe status but in opposite directions. In the multiples cohort, Fe deficient women (mid-gestation sTfR > 8.5 mg/L, delivery SF < 12 μg/L or TBI < 0 mg/kg) had a lower PIDI (p = 0.02, p = 0.003, p = 0.04) but lower cord Hb was associated with a higher PIDI (p = 0.004). In the teens, lower mid-gestation hepcidin was associated with a lower PIDI (p = 0.009) but higher cord EPO was associated with a higher PIDI (p = 0.006).

Conclusions

Placental FPN protein was inversely associated with neonatal Fe status. The PIDI captures fetal and maternal regulation of placental Fe trafficking as it reflects Fe export to the fetus relative to Fe import from maternal circulation. More data are needed to assess the utility of the PIDI as an indicator of Fe insufficiency during pregnancy and how it relates to neonatal outcomes that are driven by placental health.

Funding Sources

USDA, Gerber Foundation, NIH NICHD.

Science, healthcare system, and government effectiveness perception and COVID-19 vaccination acceptance and hesitancy in a global sample: an analytical cross-sectional analysis

BACKGROUND

Determinants of COVID-19 vaccine acceptance are complex; how perceptions of the effectiveness of science, healthcare and government impact personal COVID-19 vaccine acceptance is unclear, despite all three domains providing critical roles in development, funding and provision, and distribution of COVID-19 vaccine.

OBJECTIVE

To estimate impact of perception of science, healthcare systems, and government along with sociodemographic, psychosocial, and cultural characteristics on vaccine acceptance.

DESIGN

We conducted a global nested analytical cross-sectional study of how the perceptions of healthcare, government and science systems have impacted COVID-19 on vaccine acceptance.

SETTING

Global Facebook, Instagram and Amazon Mechanical Turk (mTurk) users from 173 countries.

PARTICIPANTS

7411 people aged 18 years or over, and able to read English, Spanish, Italian, or French.

MEASUREMENTS

We used Χ2 analysis and logistic regression-derived adjusted Odds Ratios (aORs) and 95% CIs to evaluate the relationship between effectiveness perceptions and vaccine acceptance controlling for other factors. We used natural language processing and thematic analysis to analyse the role of vaccine-related narratives in open-ended explanations of effectiveness.

RESULTS

After controlling for confounding, attitude toward science was a strong predictor of vaccine acceptance, more so than other attitudes, demographic, psychosocial or COVID-19-related variables (aOR: 2.1; 95% CI: 1.8 to 2.5). The rationale for science effectiveness was dominated by vaccine narratives, which were uncommon in other domains.

LIMITATIONS

This study did not include participants from countries where Facebook and Amazon mTurk are not available, and vaccine acceptance reflected intention rather than actual behaviour.

CONCLUSIONS

As our findings show, vaccine-related issues dominate public perception of science's impact around COVID-19, and this perception of science relates strongly to the decision to obtain vaccination once available.

Placental Iron Content Is Lower Than Previously Estimated and Is Associated With Maternal Iron Status

Objectives

It has been estimated that 90 mg of iron (Fe) is retained by a ∼600 g term placenta to support placental needs, but this value is based on limited data. While there has been an increase in studies evaluating placental Fe content (p[Fe]), there is also substantial variability in published values. Our aims were to characterize p[Fe] in pregnant women at risk of Fe deficiency and to identify determinants of p[Fe].

Methods

Placentae were collected at 39.8 ± 1.2 weeks of gestation from 132 neonates born to teens carrying singletons (≤18 y) and at 35.3 ± 2.4 weeks of gestation from 101 neonates born to 48 women carrying multiples (20–46 y). Maternal and cord blood samples were collected and maternal and neonatal Fe status indicators (hemoglobin, serum ferritin (SF), transferrin receptor (sTfR), serum Fe, total body Fe (TBI)) and regulatory hormones (erythropoietin (EPO), hepcidin) were measured. Inductively coupled plasma-mass spectrometry was used to measure p[Fe].

Results

Mean placental weight per fetus was 290 ± 74 g in the multiples and 619 ± 149 g in the teens (p &lt; 0.001). Mean p[Fe] was 23 mg per placenta [95%CI 15–33] in the multiples and 40 mg per placenta [95%CI 31–51] in the teens (p = 0.03). Mean μg of Fe per g of placental wet tissue did not differ between the two cohorts. Maternal anemia had opposite effects on p[Fe] in the two cohorts. In women carrying multiples, mean μg of Fe per g of placenta was higher in anemic compared to non-anemic women (p = 0.02). In contrast, mean μg of Fe per g of placenta was lower in anemic compared to non-anemic teens (p = 0.04). These divergent observations were supported by observed associations between p[Fe] and maternal Fe status markers at delivery. In women carrying multiples, low maternal Fe status [lower SF (p = 0.002) and lower TBI (p = 0.01)] was associated with higher μg of Fe per g of placenta, while in teens, improved Fe status [lower sTfR (p = 0.03) and higher TBI (p = 0.03)] was associated with higher μg of Fe per g of placenta.

Conclusions

These human data show that p[Fe] is significantly associated with maternal Fe status but determinants of p[Fe] differ between adult women and teens who may still be growing. Using current methodology, the average p[Fe] was found to be ∼50% lower than previously estimated. More data are needed to characterize p[Fe] and understand maternal and neonatal determinants of p[Fe].

Funding Sources

The USDA and Gerber Foundation.

Placental EPO mRNA Expression Is Measurable in Very Preterm to Term Placentae

Objectives

Our objective was to evaluate placental EPO mRNA expression in term and preterm placentae and explore maternal/neonatal/placental determinants of EPO expression.

Methods

Placental tissue was collected from pregnant adolescents (n = 82, &lt; 19 y of age) and from women (n = 62) carrying multiple fetuses (twins = 23, triplets = 39). Placental mRNA expression was evaluated using qPCR. Hemoglobin and iron status biomarkers (SF, TBI, sTfR, Hepcidin) were measured in maternal blood at delivery and in cord blood.

Results

In this population, women delivered between 30–42 weeks of gestation. Of the 144 women, 30% delivered prematurely (&lt; 37 weeks, n = 44) and 69% delivered at term (≥37 weeks, n = 100). As expected, preterm placentae weighed significantly less than term placenta (293 ± 93 g vs. 544 ± 143 g, p &lt; 0.0001). Placental EPO mRNA expression was detected in all samples collected. Placental EPO mRNA expression did not significantly differ between anemic (Hb &lt; 13 g/dL) (n = 23) and non-anemic (n = 84) neonates (p = 0.69), nor was it significantly associated with maternal anemia at delivery (p = 0.44). Placental EPO mRNA expression was also not significantly associated with maternal (p = 0.56) or neonatal (p = 0.61) Hb concentrations, placental weight (p = 0.46) or gestational age at delivery (p = 0.39).

Conclusions

While placental EPO mRNA was detected in all placental tissue collected between 30–42 weeks of gestation none of the iron biomarkers evaluated were significantly related to placental EPO mRNA expression. Further studies are needed to understand determinants of placental EPO mRNA and protein expression.

Funding Sources

The U.S. National Institutes of Health (NIH) National Institute of Child Health and Development (NICHD) Grant 1R21HD098864, The Gerber Foundation and USDA grants 2005–35,200-15,218 and 2009–35,200-05,171.

Prevalence of Anemia Across Trimesters in Multiethnic Pregnant Women

Objectives

This study aimed to characterize prevalence and determinants of anemia in a multiethnic cohort of pregnant women.

Methods

A retrospective medical chart review was undertaken of all deliveries occurring from 2011 to 2020 at Strong Memorial Hospital and Highland Hospital in Rochester, NY. Among a total of 53,642 deliveries, 42,289 occurred to women with no underlying health complications. Anemia was defined using the CDC criteria as &lt; 11g/dL in the first (T1) and third trimesters (T3) and &lt; 10.5 g/dL in the second trimester (T2). Mean Hb concentration was compared between trimesters and racial groups by ANOVA and post-hoc pairwise comparisons. Relationships between prevalence of anemia by trimesters, racial groups, and BMI were examined by chi-square or t-tests. Logistic regression models were conducted to estimate the risk factors associated with anemia.

Results

Pregnant women had a mean age of 29.8 ± 5.5 y (range: 13−52 y) at delivery. The majority of women (66.8%) self-identified as white, 20.0% as black, 3.8% as Asian, and 9.4% as Other. Mean Hb concentrations significantly differed by trimester [12.6 ± 1.0, 11.5 ± 1.1, and 11.8 ± 1.3 g/dL in T1, T2 and T3, respectively, p &lt; 0.001]. Mean Hb was significantly lower in black women in each trimester by -0.8 (T1), -0.7 (T2), and -1.0 g/dL (T3) compared to white women. White women had the highest Hb concentrations in T1 and T2 (12.8 ± 0.9, 11.8 ± 1.0 g/dL) while Asian women had the highest Hb concentrations in T3 (12.2 ± 1.2 g/dL, n = 1577, p &lt; 0.001). The overall prevalence of anemia was 17.1%, which significantly increased across pregnancy [4.5% (T1), 16.4% (T2) and 25.2% (T3), p &lt; 0.001]. Observed rates of anemia were higher than the estimated NHANES (1999–2006) prevalence in pregnant women. After stratifying by racial groups, higher BMI was significantly associated with a lower prevalence of anemia in T2 and T3 only in black women and in those whose race was categorized as Other.

Conclusions

The prevalence of anemia was highest in black pregnant women in all trimesters, while it was lowest in white pregnant women in T1 and T2, and in Asians in T3. Risk factors associated with anemia included late gestation or self-reported race as black or Other.

Funding Sources

None.

The Biopsychosocial Model and Perinatal Health Care: Determinants of Perinatal Care in a Community Sample

Insufficient care in the perinatal period is associated with poorer maternal health, poorer perinatal outcomes, infant mortality, and health inequalities. Identifying the sources of and reducing the rates of insufficient care is therefore a major clinical and public health objective. We propose a specific application of the biopsychosocial model that conceptualizes prenatal and postpartum care quality as health markers that are influenced by psychological factors and family and social context. Clinic attendance data were abstracted from the electronic medical records of N = 291 participants enrolled in a longitudinal pregnancy cohort study of healthy women who have been followed since the first trimester; the Kotelchuck Index (KI) was calculated as an index of perinatal care utilization. Detailed prenatal psychological, social, and sociodemographic data were collected from self-report questionnaire and interview. Bivariate analyses indicated socio-demographic (e.g., race), psychological (e.g., response to perceived racism, affective symptoms, trauma experience), and social and family context (e.g., social support, family size) significantly influenced pre- and post-natal care utilization. Multivariate logistic regression analyses, adjusting for medical complications, identified social and family context as robust predictors of perinatal care utilization. The findings underscore the need for biopsychosocial models of health care and highlight several potential strategies for improving health care utilization.

Risk of COVID-19-related bullying, harassment and stigma among healthcare workers: an analytical cross-sectional global study

OBJECTIVES

Essential healthcare workers (HCW) uniquely serve as both COVID-19 healers and, potentially, as carriers of SARS-CoV-2. We assessed COVID-19-related stigma and bullying against HCW controlling for social, psychological, medical and community variables.

DESIGN

We nested an analytical cross-sectional study of COVID-19-related stigma and bullying among HCW within a larger mixed-methods effort assessing COVID-19-related lived experience and impact. Adjusted OR (aOR) and 95% CIs evaluated the association between working in healthcare settings and experience of COVID-19-related bullying and stigma, controlling for confounders. Thematic qualitative analysis provided insight into lived experience of COVID-19-related bullying.

SETTING

We recruited potential participants in four languages (English, Spanish, French, Italian) through Amazon Mechanical Turk's online workforce and Facebook.

PARTICIPANTS

Our sample included 7411 people from 173 countries who were aged 18 years or over.

FINDINGS

HCW significantly experienced more COVID-19-related bullying after controlling for the confounding effects of job-related, personal, geographic and sociocultural variables (aOR: 1.5; 95% CI 1.2 to 2.0). HCW more frequently believed that people gossip about others with COVID-19 (OR: 2.2; 95% CI 1.9 to 2.6) and that people with COVID-19 lose respect in the community (OR: 2.3; 95% CI 2.0 to 2.7), both which elevate bullying risk (OR: 2.7; 95% CI 2.3 to 3.2, and OR: 3.5; 95% CI 2.9 to 4.2, respectively). The lived experience of COVID-19-related bullying relates frequently to public identities as HCW traverse through the community, intersecting with other domains (eg, police, racism, violence).

INTERPRETATION

After controlling for a range of confounding factors, HCW are significantly more likely to experience COVID-19-related stigma and bullying, often in the intersectional context of racism, violence and police involvement in community settings.

Erythroferrone Is Associated with Maternal Erythropoietic Drive During Pregnancy

Objectives

Iron (Fe) homeostasis must be tightly regulated during pregnancy to meet both maternal and fetal Fe demands. Several hormones are known to impact Fe homeostasis including hepcidin, erythropoietin and erythroferrone (ERFE). Few data are available on determinants of ERFE in pregnant women or in their newborns at birth. The objective of this study was to characterize concentrations of ERFE across gestation and evaluate this hormone in relation to other Fe status biomarkers and regulatory hormones in mothers across pregnancy.

Methods

ERFE was measured in serum from pregnant adolescents (n = 166, age 14–19) or women carrying multiple fetuses (n = 61, age 20–46). ERFE concentrations across gestation (wks 8 – 42.1) were compared to Fe status and nutritional indicators (hemoglobin (Hb), serum ferritin (SF), soluble transferrin receptor (sTfR), total body Fe (TBI), TR-F index (sTfR/log(SF)), folate and vitamin B-12), as well as regulatory hormones (erythropoietin (EPO), hepcidin) and inflammatory markers (IL-6, C-reactive protein (CRP)).

Results

ERFE concentrations increased significantly across pregnancy in women carrying multiple fetuses (P &lt; 0.01), but did not change across pregnancy in the adolescents (P = 0.3). In both populations, 16% (n = 30) of women were anemic at midgestation (MG) and 24% (n = 75) at delivery. ERFE concentrations were significantly increased in anemic women at both MG (P = 0.02) and at delivery (P = 0.02). At MG (median 26 wks), ERFE was significantly positively associated with TfR (P &lt; 0.001) and EPO (P = 0.002). Maternal TfR, IL-6 and serum Fe were the strongest determinants of maternal MG ERFE, and explained 29% of variance in ERFE. At delivery (median 38 wks), ERFE was significantly positively associated with TfR (P &lt; 0.001) and EPO (P &lt; 0.001), which together explained 18% of variance in ERFE at delivery. ERFE was not significantly associated with hepcidin at either MG (P = 0.87) or delivery (P = 0.52).

Conclusions

ERFE was significantly higher in anemic women across pregnancy and, as expected, was positively associated with indicators of erythropoietic drive. ERFE however, was not significantly associated with hepcidin, possibly because hepcidin is regulated by multiple competing signals. More research is needed to understand the relationship between maternal ERFE and neonatal Fe status at birth.

Funding Sources

Funded by the NIH (NIDDK/NICHD).

Maternal Red Blood Cell Catabolism as a Source of Fetal Iron

Objectives

The developing fetus is reliant on maternal iron (Fe) supply across gestation. Fetal Fe may be obtained from maternal red blood cell (RBC) catabolism, dietary sources or maternal stores. Relative use of these Fe pools has not been explored in humans. The objective of this study was to label the maternal RBC pool in early gestation and evaluate determinants of RBC enrichment across. A second objective was to compare fetal uptake of Fe from RBC catabolism vs recent maternal diet.

Methods

Fifteen women (age 17–34 y) were dosed with an oral stable ,57Fe isotope during the early second trimester of pregnancy (wk 15 ± 0.7) to label the maternal RBC pool. Enrichment of ,57Fe in maternal RBCs was monitored at regular intervals across pregnancy and in neonatal RBC's at birth. All women ingested an additional stable isotope (,58Fe) in late gestation (wk 34 ± 0.7) to quantify rapid transfer of dietary Fe to the fetus. The net amounts of each isotope in the mother and neonate were calculated using hemoglobin (Hb) concentration, body weight and estimated blood volumes. Hb, serum ferritin (SF), soluble transferrin receptor (sTfR), hepcidin and erythroferrone (ERFE) were assessed in maternal and cord blood.

Results

In this population, 25% of women were anemic at delivery (Hb &lt; 11 g/dL), and 36% of the newborns were anemic at birth (wk 39 ± 1.8) (Hb &lt; 13 g/dL). During the third trimester of pregnancy, 25% of women were Fe deficient (SF &lt; 12 mg/L). In the group as a whole, RBC ,57Fe enrichment decreased (b = −0.2, P = 0.06) on average by 2% across the 22 wk study interval (from 13.1% to 9.6%). Of the net amount of ,57Fe released from RBC catabolism, 25.4% [95% CI: 10.0%–64.4%] was transferred to the neonate. Neonatal RBC ,57Fe enrichment was significantly inversely associated with maternal and neonatal SF, which captured 87% of the variance in neonatal RBC ,57Fe enrichment (P &lt; 0.01). Maternal SF was significantly inversely associated with neonatal RBC ,58Fe enrichment from the dietary source in late gestation. Maternal SF captured 55% of the variance in neonatal RBC ,58Fe enrichment (P = 0.01).

Conclusions

Women with low Fe stores exhibited a greater loss of RBC enrichment across gestation and a higher transfer of Fe from both catabolized RBC's and dietary sources to the fetus. More research on the determinants of placental Fe trafficking of different sources of maternal Fe is needed.

Funding Sources

Work funded by the NIH/NIDDK.

Active immunization with tau epitope in a mouse model of tauopathy induced strong antibody response together with improvement in short memory and pSer396-tau pathology

Abnormal tau hyperphosphorylation and its aggregation into neurofibrillary tangles are a hallmark of tauopathies, neurodegenerative disorders that include Alzheimer's disease (AD). Active and passive Tau-immunotherapy has been proposed as a therapeutic approach to AD with mixed results. One of the limitations of active immunotherapy may be associated with the mediocre immunogenicity of vaccines that are not inducing therapeutically potent titers of antibodies. The aim of this study was to test the efficacy of an anti-tau vaccine, AV-1980R/A composed of N terminal peptide of this molecule fused with an immunogenic MultiTEP platform and formulated in a strong adjuvant, Advax^CpG in a Tg4510 mouse model of tauopathy. Experimental mice were immunized with AV-1980R/A and a control group of mice were injected with adjuvant only. Nontransgenic and tetracycline transactivator (tTA) transgenic littermates were included as baseline controls to contrast with the tau phenotype. Active immunization with AV-1980R/A induced very strong anti-tau humoral immune responses in both nontransgenic and transgenic mice with evidence of IgG in brains of AV-1980R/A vaccinated mice. These experimental animals displayed an improvement in short-term memory during a novel object recognition test. However, impairments in other behavioral tasks were not prevented by AV-1980R/A vaccinations. At the same time, high titers of anti-tau antibodies reduced hyperphosphorylated pSer396 tau but did not lower the level of other phosphorylated tau species in the brains of AV-1980R/A vaccinated mice. These data indicate that active immunotherapy with an N-terminal Tau epitope was only partially effective in improving cognition and reducing pathology in the stringent Tg4510 mouse model of tauopathy.

Iron Absorption and Partitioning During Pregnancy (OR35-03-19)

Objectives

Iron (Fe) homeostasis must be tightly regulated during pregnancy to supply sufficient Fe to both the mother and her developing fetus. Stable isotopes have been utilized to understand Fe absorption during pregnancy by measuring maternal red blood cell incorporation. This measure, however, underestimates the true amount of Fe absorbed, as dietary Fe is transferred to the fetus and may be retained by the placenta. The objective of this study was to obtain a more accurate estimation of Fe absorption during pregnancy and determine factors associated with Fe partitioning between the mom, baby and placenta.

Methods

Sixty-eight women (6 carrying multiple fetuses (age 27–33), 20 carrying singletons from Rochester NY (age 16–32), and 42 carrying singletons from Peru (age 18–30)) were dosed with an oral stable Fe isotope during late pregnancy. Iron absorption was calculated as the sum of tracer recovered in maternal and umbilical cord red blood cells (RBC) and for isotope retained in placental tissue. The net amount of Fe in each compartment was calculated based on Hb concentration, body (or placental) weight and estimated blood volume. Hemoglobin (Hb), serum ferritin (SF), soluble transferrin receptor (sTfR), folate and vitamin B-12 were assessed in maternal and cord blood.

Results

The amount of maternally absorbed Fe was significantly greater when neonatal and placental uptake of tracer was accounted for (Table 1). While the majority (> 85%) of absorbed Fe tracer was utilized by the mother for RBC production, neglecting net Fe tracer transferred to the placenta and neonatal compartment underestimated true Fe absorption by 4%-20%. There was a significant positive association between the net amounts of Fe tracer recovered in the fetal compartment and the maternal compartment (R2 = 0.63, P < 0.001). Net Fe tracer retained in placental tissue was significantly positively associated with the net amount of Fe tracer present in the neonatal RBC pool at birth (P = 0.04).

Conclusions

Iron absorption was underestimated by up to 20% when absorbed Fe that was transferred to the fetus or retained by the placenta was not measured. More research on determinants of iron partitioning in pregnant women is needed to fully evaluate maternal Fe demands and absorption.

Funding Sources

National Institutes of Health, United States Department of Agriculture, Nestle Foundation.

Supporting Tables, Images and/or Graphs

Umbilical Cord Coiling in High-risk Pregnancies: Associations With Determinants of Adverse Birth Outcomes and Iron Status

Abnormal umbilical cord coiling has been associated with adverse neonatal outcomes, but the etiology of these findings remains poorly characterized. This study was undertaken to examine associations between cord coiling and maternal iron (Fe) status and to identify potential determinants of hypo- and hypercoiling in 2 higher risk obstetric groups: pregnant adolescents (≤18 years, n = 92) and adult women carrying twins (n = 49), triplets (n = 11), or quadruplets (n = 1). Umbilical cords were classified as hypo-, normo-, or hypercoiled using digital photographs to assess gross appearance. Hypocoiling and hypercoiling were observed in 44% (n = 86/195) and 13% (n = 26/195) of the combined study population. The prevalence of hypocoiling among women carrying multiples was over 3-fold higher than the prevalence in singleton pregnancies based on the published data. Within the entire study population, hypocoiling was associated with a lower gestational age at birth when compared to normocoiling and hypercoiling (36.3 ± 3.6 weeks [n = 86] vs 37.8 ± 2.7 [n = 83], P < .01, and 38.2 ± 2.6 [n = 26], P < .01, respectively), whereas hypercoiling was associated with significantly lower serum ferritin when compared to normocoiling ( P < .01) and hypocoiling ( P < .001). In the multiples cohort only, hypercoiling was significantly associated with multiparity ( P < .01) and lower birth weight ( P < .05). Further studies are needed to identify the determinants and consequences of cord coiling.

Prevalence of anemia and associations between neonatal iron status, hepcidin, and maternal iron status among neonates born to pregnant adolescents

BACKGROUND

Little is known about anemia and iron status in US newborns because screening for anemia is typically not undertaken until 1 y of age. This study was undertaken to characterize and identify determinants of iron status in newborns born to pregnant adolescents.

METHODS

Pregnant adolescents (≤ 18 y, n = 193) were followed from ≥ 12 wk gestation until delivery. Hemoglobin, ferritin, soluble transferrin receptor, serum iron, hepcidin, erythropoietin (EPO), IL-6, and C-reactive protein were assessed in maternal and cord blood.

RESULTS

At birth, 21% of the neonates were anemic (Hb < 13.0 g/dl) and 25% had low iron stores (ferritin < 76 µg/l). Cord serum ferritin concentrations were not significantly associated with gestational age (GA) at birth across the range of 37-42 wk. Neonates born to mothers with ferritin < 12 µg/l had significantly lower ferritin (P = 0.003) compared to their counterparts. Hepcidin and IL-6 were significantly (P < 0.05) higher in neonates born to mothers with longer durations of active labor.

CONCLUSION

Given the importance of the iron stores at birth on maintenance of iron homeostasis over early infancy, additional screening of iron status at birth is warranted among those born to this high risk obstetric population.

Timing of induction of labor

Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.

Maternal inflammation at delivery affects assessment of maternal iron status

Pregnant adolescents (aged ≤ 18 y, n = 253) were followed from ≥ 12 wk of gestation to delivery to assess longitudinal changes in anemia and iron status and to explore associations between iron status indicators, hepcidin, and inflammatory markers. Hemoglobin, soluble transferrin receptor (sTfR), ferritin, serum iron, erythropoietin (EPO), hepcidin, C-reactive protein, interleukin-6 (IL-6), folate, and vitamin B-12 were measured, and total body iron (TBI) (milligrams per kilogram) was calculated using sTfR and ferritin values. Anemia prevalence increased from trimesters 1 and 2 (3-5%, <28 wk) to trimester 3 (25%, 33.2 ± 3.7 wk, P < 0.0001). The prevalence of iron deficiency (sTfR > 8.5 mg/L) doubled from pregnancy to delivery (7% to 14%, P = 0.04). Ferritin and hepcidin concentrations at delivery may have been elevated as a consequence of inflammation because IL-6 concentrations at delivery were 1.6-fold higher than those obtained at 26.1 ± 3.3 wk of gestation (P < 0.0001), and a positive association was found between IL-6 and both hepcidin and ferritin at delivery (P < 0.01). EPO was consistently correlated with hemoglobin (r = -0.36 and -0.43, P < 0.001), ferritin (r = -0.37 and -0.32, P < 0.0001), sTfR (r = 0.35 and 0.25, P < 0.001), TBI (r = -0.44 and -0.37, P < 0.0001), and serum iron (r = -0.22 and -0.16, P < 0.05) at mid-gestation and at delivery, respectively. EPO alone explained the largest proportion of variance in hemoglobin at 26.0 ± 3.3 wk of gestation (R(2) = 0.13, P = 0.0001, n = 113) and at delivery (R(2) = 0.19, P < 0.0001, n = 192). Pregnant adolescents are at high risk of anemia. EPO is a sensitive indicator of iron status across gestation, is not affected by systemic inflammation, and may better predict risk of anemia at term. The trial was registered at clinicaltrials.gov as NCT01019902.

Gestational iron deficiency is associated with pica behaviors in adolescents

A relation between pica (the craving and purposive consumption of nonfood items) during pregnancy and anemia is observed frequently. However, few studies related pica behaviors to biomarkers of iron status, and little is known about pica prevalence in U.S. pregnant adolescents. To address this, we undertook a longitudinal study examining iron status and pica behaviors among a group of 158 pregnant adolescents (aged ≤18 y). Approximately two-thirds of the participants were African American and 25% were Hispanic. Maternal iron status indicators [hemoglobin, soluble transferrin receptor, serum ferritin (SF), total body iron (TBI), and serum hepcidin] were assessed during pregnancy (18.5-37.3 wk) and at delivery. Pica behavior was assessed up to 3 times across gestation. Among the 158 adolescents, 46% reported engaging in pica behavior. Substances ingested included ice (37%), starches (8%), powders (4%), and soap (3%). During pregnancy, mean SF [geometric mean: 13.6 μg/L (95% CI: 11.0, 17.0 μg/L)], TBI (mean ± SD: 2.5 ± 4.2 mg/kg), and hepcidin [geometric mean: 19.1 μg/L (95% CI: 16.3, 22.2 μg/L)] concentrations were significantly lower (P < 0.05) in the pica group (n = 72) than values observed among the non-pica group [SF, geometric mean: 21.1 μg/L (95% CI: 18.0, 25.0 μg/L); TBI, mean ± SD: 4.3 ± 3.5 mg/kg; hepcidin, geometric mean: 27.1 μg/L (95%: 23.1, 32.1 μg/L); n = 86]. Although additional studies must address the etiology of these relations, this practice should be screened for, given its association with low iron status and because many of the substances ingested may be harmful. This trial was registered at clinicaltrials.gov as NCT01019902.

Nutrient Inadequacy Is Prevalent in Pregnant Adolescents, and Prenatal Supplement Use May Not Fully Compensate for Dietary Deficiencies

A longitudinal study was undertaken in 156 pregnant adolescents (≤18 years old) to characterize dietary intake and to determine the degree to which prenatal supplement use compensates for dietary deficits. The adequacy of dietary intake was assessed by comparing self-reported intake from up to three 24-hour dietary recalls with the dietary reference intakes. The majority of teens did not meet the estimated average requirements (EAR) for vitamin D (93%), vitamin E (94%), Mg (90%), Fe (76%), and Ca (74%). More than half of the adolescents in each gestational window (<23 weeks; 23-30 weeks; and ≥31 weeks of gestation) self-reported daily use of prenatal supplements, but the additional supplement contributions were not sufficient to meet the EAR for Mg (90%) or Ca (54%). Pregnant adolescents are at risk for insufficient intake of several essential nutrients from diet alone in spite of adequate or excessive energy intakes. Daily use of prenatal supplements reduces the prevalence of dietary inadequacy for many nutrients but may not be sufficient to meet the requirements for Mg and Ca. Practitioners should identify motivators and barriers to adequate diet and prenatal supplement use in order to address key nutrients of concern.

Women's preferences for testing and management of sexually transmitted infections among low-income New York City family planning clients

Summary

High prevalence of chlamydia in the USA persists despite efforts to annually screen women under the age of 26. Tailoring sexually transmitted infection (STI) services to client preferences may strengthen existing programmes. We report women's preferences for STI services from a family planning clinic in New York City serving low-income women. Seventy-eight percent (995/1275) of eligible women participated, with a mean age of 26 (SD±7). Ninety-one percent self-identified as Latina. Nineteen percent reported a past STI. Women preferred self-collection (65%) for testing to a speculum exam (20%); 15% had no preference. Women with a previous STI were more likely to prefer a pelvic exam to women with no previous STI (50% versus 32%, P < 0.01). Nearly all women (94%) preferred informing a sex partner about a positive STI test themselves, but 88% were willing to bring expedited partner therapy to a partner. Women were more likely to prefer third party partner notification if their last partner was casual rather than a main partner (14% versus 3%, respectively, P < 0.01). Forty-four percent of participants worried about physical violence after partner notification. Self-collecting specimens for screening was widely acceptable. Partner notification strategies should be based on understanding partnership status, including fears of violence.

Maternal choline intake modulates maternal and fetal biomarkers of choline metabolism in humans

BACKGROUND

In 1998 choline Adequate Intakes of 425 and 450 mg/d were established for nonpregnant and pregnant women, respectively. However, to our knowledge, no dose-response studies have been conducted to evaluate the effects of pregnancy or maternal choline intake on biomarkers of choline metabolism.

OBJECTIVE

We sought to quantify the effects of pregnancy and maternal choline intake on maternal and fetal indicators of choline metabolism.

DESIGN

Healthy pregnant (n = 26; 27 wk gestation) and nonpregnant (n = 21) women were randomly assigned to receive 480 or 930 mg choline/d for 12 wk. Fasting blood samples and placental tissue and umbilical cord venous blood were collected and analyzed for choline and its metabolites.

RESULTS

Regardless of the choline intake, pregnant women had higher circulating concentrations of choline (30%; P < 0.001) but lower concentrations of betaine, dimethylglycine, sarcosine, and methionine (13-55%; P < 0.001). Obligatory losses of urinary choline and betaine in pregnant women were ∼2-4 times as high (P ≤ 0.02) as those in nonpregnant women. A higher choline intake yielded higher concentrations of choline, betaine, dimethylglycine, and sarcosine (12-46%; P ≤ 0.08) in both pregnant and nonpregnant women without affecting urinary choline excretion. The higher maternal choline intake also led to a doubling of dimethylglycine in cord plasma (P = 0.002).

CONCLUSION

These data suggest that an increment of 25 mg choline/d to meet the demands of pregnancy is insufficient and show that a higher maternal choline intake increases the use of choline as a methyl donor in both maternal and fetal compartments. This trial was registered at clinicaltrials.gov as NCT01127022.

Maternal choline intake alters the epigenetic state of fetal cortisol-regulating genes in humans

The in utero availability of methyl donors, such as choline, may modify fetal epigenetic marks and lead to sustainable functional alterations throughout the life course. The hypothalamic-pituitary-adrenal (HPA) axis regulates cortisol production and is sensitive to perinatal epigenetic programming. As an extension of a 12-wk dose-response choline feeding study conducted in third-trimester pregnant women, we investigated the effect of maternal choline intake (930 vs. 480 mg/d) on the epigenetic state of cortisol-regulating genes, and their expression, in placenta and cord venous blood. The higher maternal choline intake yielded higher placental promoter methylation of the cortisol-regulating genes, corticotropin releasing hormone (CRH; P=0.05) and glucocorticoid receptor (NR3C1; P=0.002); lower placental CRH transcript abundance (P=0.04); lower cord blood leukocyte promoter methylation of CRH (P=0.05) and NR3C1 (P=0.04); and 33% lower (P=0.07) cord plasma cortisol. In addition, placental global DNA methylation and dimethylated histone H3 at lysine 9 (H3K9me2) were higher (P=0.02) in the 930 mg choline/d group, as was the expression of select placental methyltransferases. These data collectively suggest that maternal choline intake in humans modulates the epigenetic state of genes that regulate fetal HPA axis reactivity as well as the epigenomic status of fetal derived tissues.

Maternal hepcidin is associated with placental transfer of iron derived from dietary heme and nonheme sources

The determinants of placental transport of dietary iron remain largely uncharacterized. The objective of this research was to elucidate determinants of fetal Fe transfer from maternally ingested dietary heme and non-heme Fe. The study was undertaken in 19 pregnant females (16-32 y) who ingested intrinsically labeled (58)Fe-heme and a nonheme Fe source ((57)FeSO(4)) during the third trimester of pregnancy. At delivery, maternal and cord blood was obtained to assess neonatal (57)Fe and (58)Fe enrichment as a function of maternal/neonatal Fe status [serum ferritin (SF), transferrin receptor, hemoglobin (Hb), total body Fe, and hepcidin]. There was a greater percentage of maternally absorbed (58)Fe tracer present in the neonates compared to the (57)Fe tracer (5.4 ± 2.4 vs. 4.0 ± 1.6; P < 0.0001). Net dietary nonheme Fe (mg) and heme Fe (mg) transferred to the fetus were both inversely correlated with measures of maternal serum hepcidin (P = 0.002, r(2) = 0.43; P = 0.004, r(2) = 0.39) and SF (P = 0.0008, r(2) = 0.49; P = 0.003, r(2) = 0.41) and directly associated with neonatal Hb (P = 0.004, r(2) = 0.39; P = 0.008, r(2) = 0.35). The results of this study suggest that during pregnancy there appears to be preferential fetal use of maternally ingested Fe derived from a dietary, animal-based heme source compared to Fe ingested as ferrous sulfate. Maternal serum hepcidin and maternal/neonatal Fe status may play a role in placental uptake of dietary heme and nonheme Fe.