Screening, Treatment, and Monitoring of Iron Deficiency Anemia in Pregnancy and Postpartum.

Iron deficiency anemia is the most prevalent form of anemia worldwide. In the United States, clinicians routinely screen for iron deficiency anemia upon initiation of prenatal care, at the start of the third trimester, and prior to birth. Treatment of iron deficiency anemia generally begins with oral supplementation of elemental iron, which is associated with adverse gastrointestinal effects. These adverse effects can decrease adherence, leading to subtherapeutic treatment. Newer evidence highlights the benefits of early screening for iron deficiency before the onset of anemia, as well as the use of intravenous iron to expedite the treatment of iron deficiency anemia. More research is needed on the potential consequences of over-supplementation and iron deficiency without anemia to guide treatment. This article reviews the evidence for best practices for screening, treatment, and continued monitoring of iron deficiency anemia during pregnancy and postpartum. Maternal, fetal, and neonatal implications are reviewed, as well as the risks and benefits of treatment options. Finally, an evidence-based algorithm is proposed to guide clinicians on continued monitoring after treatment.

Iron parameters in pregnant women with beta-thalassaemia minor combined with iron deficiency anaemia compared to pregnant women with iron deficiency anaemia alone demonstrate the safety of iron supplementation in beta-thalassaemia minor during pregnancy.

In patients with beta-thalassaemia intermedia or major, hepcidin induces iron overload by continuously promoting iron absorption. There have been no studies in pregnant women with beta-thalassaemia minor combined with iron deficiency anaemia (IDA), examining whether hepcidin is inhibited by GDF15, as may occur in patients with beta-thalassaemia intermedia or major, or whether the iron metabolism characteristics and the effect of iron supplementation are consistent with simple IDA in pregnancy. We compared and analysed routine blood parameters, iron metabolism parameters, the GDF15 levels, and the hepcidin levels among four groups, namely the beta-thalassaemia (ß) + IDA, ß, IDA, and normal groups. In addition, the ß + IDA and IDA groups received iron supplementation for four weeks. We found no statistically significant correlation between hepcidin and GDF15 in any group, but a positive correlation was observed between hepcidin and ferritin. After iron supplementation, the routine blood parameters and iron metabolism parameters in the ß + IDA group were improved, and the hepcidin content was significantly increased. These results suggest that in pregnant women with beta-thalassaemia minor, hepcidin functions normally to maintain iron homeostasis, and that iron supplementation is effective and safe.

Laboratory approach to investigation of anemia in pregnancy.

Anemia is a global health problem in all age groups. According to World Health Organization (WHO), approximately 40% of pregnant women are anemic. Iron deficiency anemia (IDA) due to nutritional deficiency is the most common cause. The incidence of IDA varies worldwide depending on the socioeconomic status, but it remains the leading cause even in developed countries. Physiologic anemia of pregnancy due to relatively higher expansion of blood volume in comparison with elevated red blood cell mass also occurs frequently. Complete blood count (CBC) in the first trimester is recommended for all pregnant women to screen for anemia. The screening of pregnant women for IDA in absence of anemia is still debatable. If IDA is suspected, ferritin level of <30 ng/ml is diagnostic. Iron supplementation is recommended for all pregnant women to compensate the increased demand.

Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections.

OBJECTIVES: Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation. METHODS: We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation. RESULTS: Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected. CONCLUSIONS: Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.

The use of intravenous iron in pregnancy: for whom and when? A survey of Australian and New Zealand obstetricians.

BACKGROUND: Iron deficiency anaemia in pregnancy (IDAP) affects 11-18% of Australian pregnancies and is associated with adverse perinatal outcomes. National prescribing data suggests the use of intravenous iron in pregnancy is increasingly common. This study aimed to: 1) Establish the current patterns of intravenous iron use by Fellows of the Royal Australian and New Zealand College of Obstetricians (FRANZCOG) when treating iron deficiency and IDAP including immediately postpartum and; 2) Assess FRANZCOG opinions regarding potential trial of intravenous iron for first-line treatment of IDAP. METHODS: An online survey of RANZCOG Fellows practicing obstetrics was distributed in September 2018. Results were analysed descriptively and responses compared by clinician demographics using Chi-squared testing. RESULTS: Of 484 respondents (21% of FRANZCOG), 457 were currently practicing obstetrics. Most prescribed intravenous iron in pregnancy (96%) and/or postpartum (85%). Most intravenous iron was prescribed for IDAP (98%) rather than iron deficiency without anaemia (53%), and for IDAP most commonly second-line to failed oral iron supplementation and first-line in special circumstances (59%). Intravenous iron prescribing was associated with shorter time since FRANZCOG completion (p = 0.01), public hospital practice (p = 0.008) and higher hospital birth numbers (p = 0.01). Most respondents (90%) would consider a randomised controlled trial of first-line intravenous iron for IDAP, although views on appropriate thresholds differed. CONCLUSIONS: Almost all respondents prescribed intravenous iron for IDAP, and while mostly used for second-line treatment over half sometimes used it first-line. With accelerating intravenous iron use, further research is required into its optimal use in pregnancy, recognizing important clinical outcomes and cost effectiveness.

Iron stores in pregnant women with sickle cell disease: a systematic review.

BACKGROUND: Gradual improvements in the management of sickle cell disease (SCD), have led to an increase in the number of women with SCD who reach the age of procreation. However, evidence on the iron status of pregnant women with sickle cell disease (PWSCD) remains inconclusive. We conducted the first systematic review on the prevalence, determinants and maternal/foetal outcomes of iron deficiency anaemia among PWSCD. METHODS: We searched MEDLINE, EMBASE, Global Health, Africa Index Medicus, the Cochrane library databases and reference lists of retrieved publications for studies describing the iron status of PWSCD. The literature search was done over a period of 1 month, with no language or date restrictions applied. Data were extracted on a Microsoft excel sheet. Two authors assessed all included studies for methodological quality and risk of bias. RESULTS: A total of 710 reports were identified for title and article screening. Five retained studies were conducted before or during the 90s and included 67 participants. After quality assessment, the observational studies were designated to have a "fair" quality assessment while the randomised control trial had an "unclear" quality assessment. The prevalence of iron deficiency anaemia among PWSCD varied by study design and diagnostic method. The overall prevalence ranged from 6.67-83.33%. None of the studies provided evidence on factors associated with iron deficiency anaemia and the randomized trial reported no difference in outcomes between PWSCD who had iron supplementation and those who did not. CONCLUSION: Evidence on factors associated with iron deficiency anaemia among PWSCD and maternal/foetal outcomes in PWSCD who have iron deficiency anaemia is poor. The studies included in this review suggests that iron deficiency anaemia may be highly prevalent in PWSCD but due to the very small sample sizes and varied study designs, this evidence is inconclusive. The review shows that there is a need for more studies with robust designs and adequate sample sizes to assess the disease burden of iron deficiency anaemia in PWSCD.

Hemoglobin and hepcidin have good validity and utility for diagnosing iron deficiency anemia among pregnant women.

BACKGROUND/OBJECTIVES: Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. SUBJECTS/METHODS: We pooled data from an iron supplementation trial of 1500 iron-replete pregnant woman and a prospective cohort of 600 iron-deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age <27 weeks) and IDA at delivery. RESULTS: Hemoglobin had the largest AUC for crude ID (0.96), while hepcidin had the largest AUC for corrected ID (0.80). The optimal hepcidin cutoff for the diagnosis of corrected IDA based on maximal sensitivity and specificity was ≤1.6 µg/L. An hepcidin cutoff of <4.3 µg/L had a sensitivity of 95% for regression-corrected ID. Among iron-replete women who did not receive iron, the association of baseline hemoglobin >110 g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin >1.6 µg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). CONCLUSIONS: Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin's high costs may limit its use.

Iron status and risk factors of iron deficiency among pregnant women in Singapore: a cross-sectional study.

BACKGROUND: Iron deficiency is the most prevalent nutrient deficiency and the most common cause of anaemia worldwide. Because of the increased iron requirements during pregnancy, iron deficiency can lead to maternal anaemia and reduced newborn iron stores. We examined the proportion and risk factors of iron deficiency among pregnant women in a developed Asian country. METHODS: Within a prospective cohort in Singapore, 985 Asian women were assessed for iron status at 26-28 weeks' gestation, with plasma ferritin and soluble transferrin receptor (sTfR) measurements. Iron status was determined according to plasma ferritin concentrations at ≥30 µg/L (iron sufficiency), 15 to < 30 µg/L (modest iron depletion) and < 15 µg/L (severe iron depletion). Multivariable ordinal logistic regression was used to analyze risk factors for modest and severe iron depletion. RESULTS: The median (25-75th percentile) plasma ferritin concentration was 24.2 (19.9-30.6) µg/L. Overall, 660 (67.0%) and 67 (6.8%) women had modest and severe iron depletion, respectively. Higher plasma sTfR was observed in women with severe iron depletion than among those with iron sufficiency (median 17.6 versus 15.5 nmol/L; p < 0.001). Age < 25 years (odds ratio 2.36; 95% confidence interval 1.15-4.84), Malay (2.05; 1.30-3.24) and Indian (1.98; 1.14-3.44) ethnicities (versus Chinese), university qualification (1.64; 1.13-2.38), multiparity (1.73; 1.23-2.44) and lack of iron-containing supplementation (3.37; 1.25-8.53) were associated with increased odds of modest and severe iron depletion. CONCLUSIONS: Nearly three-quarters of Singaporean women were iron deficient in the early third trimester of pregnancy. These results suggest universal screening and supplementation of at-risk pregnancies may be evaluated as a preventive strategy. TRIAL REGISTRATION: NCT01174875 . Registered 1 July 2010 (retrospectively registered).

Iron supplementation during pregnancy - a cross-sectional study undertaken in four German states.

BACKGROUND: Iron deficiency but also iron overload during pregnancy has been associated with unwanted health effects. In Germany, iron supplements are only recommended for pregnant women with diagnosed iron deficiency/anaemia. Prevalence of anaemia among pregnant women was reported at 24.4% in 2011. However, limited data suggest that more than 60% of women in Germany use iron supplements during gestation. Against this background, we investigated the prevalence of iron supplement intake among pregnant women and explored determining factors in order to assess whether women are following the advice to only supplement iron in case of a diagnosed iron deficiency/anaemia. METHODS: A cross-sectional study was carried out in four German states in 2015 where, with the help of midwives, women in childbed were asked to retrospectively answer a questionnaire about iron intake from various sources and reasons for supplementing iron during their recent pregnancy. We used Chi-square-tests and logistic regression analysis to evaluate associations between iron supplementation and other nutritional, sociodemographic and maternal variables and to assess attitudes of women meeting versus not meeting the official recommendation on iron supplement intake during pregnancy. RESULTS: Of 207 participants, 65.2% had supplemented iron. 84.4% reported to have done this because of a diagnosed iron deficiency/anaemia. Iron intake ranged from 5 to 200 mg/day, and duration of supplementation varied between two weeks and throughout gestation. Of women who reported to have been diagnosed with iron deficiency/anaemia, 47.5% had supplemented ≥80 mg/day iron, while 26.2% had taken iron in lower amounts ≤40 mg/day. Six percent of the participating women had not supplemented iron in spite of a diagnosed iron deficiency/anaemia, whereas 19.7% of women without iron deficiency/anaemia still had supplemented iron (range: 7 to 80 mg/day). CONCLUSION: The majority of pregnant women used iron supplements in case of a diagnosed iron deficiency/anaemia. However, not all women with iron deficiency/anaemia supplemented (sufficient amounts of) iron, while there was also indiscriminate use of iron supplements in women without iron deficiency/anaemia. Further research is warranted to confirm these findings in representative samples.

[Diagnostics and treatment of iron deficiency in pregnancy].

Iron deficiency and iron deficiency anaemia are frequent complications to pregnancy and especially iron deficiency is underdiagnosed because of scarce symptoms. Due to the increased need for iron and the variation in iron storage in healthy pregnant women, iron supplementation should be individualised based on the level of haemoglobin and ferritin. First choice of treatment is oral iron supplementation, unless there is a failure of treatment, a known condition with malabsorption, or severe iron deficiency anaemia very close to due date. In these cases, intravenous iron may be considered.

Integrated point-of-care testing (POCT) of HIV, syphilis, malaria and anaemia in antenatal clinics in western Kenya: A longitudinal implementation study.

BACKGROUND: In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women. METHODS: A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence. FINDINGS: For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin-piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses. CONCLUSIONS: Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.

Magnitude and associated factors of anemia among pregnant women in Dera District: a cross-sectional study in northwest Ethiopia.

BACKGROUND: Anemia is associated with adverse health and socio-economic consequences among pregnant women. Particularly, severe anemia increases the risk of maternal mortality by 20%. However, literatures are scarce in the northwest Ethiopia. Therefore, this study aimed to determine the magnitude and associated factors of anemia among pregnant women attending antenatal care in Dera District, South Gondar Zone, northwest Ethiopia. METHODS: A facility-based cross-sectional study was conducted in Dera District health centers from June 27 to September 2, 2015. Capillary blood samples were taken from 348 pregnant women. The raw measured values of hemoglobin were obtained using the portable Hb301 instrument and adjusted for altitude. Besides, nutritional status of the women was assessed by the mid upper arm circumference (MUAC) taken on non-dominant upper limb, mostly of the left hand. Socio-demographic factors, obstetric history, environmental related factors and dietary intake were collected by interviewing the pregnant women. A multivariate logistic regression analysis was employed to identify factors associated with anemia. Adjusted odds ratio (AOR) with corresponding 95% confidence interval (CI) was computed to show the strength of association. In multivariable analysis, a P value of <0.05 was used to declare statistical significance. RESULTS: The overall prevalence of anemia among pregnant women was 30.5% [95% CI 21.0, 40.0]. The result of multivariable analysis revealed that the likelihood of anemia was higher among pregnant women living in rural areas [AOR = 3.03, 95% CI 1.17, 7.82], had no latrine [AOR = 4.75, 95% CI 1.15, 16.60], low monthly income:

Serum ferritin thresholds for the diagnosis of iron deficiency in pregnancy: a systematic review.

The aim of this review was to understand the landscape of serum ferritin in diagnosing iron deficiency in the aetiology of anaemia in pregnancy. Iron deficiency in pregnancy is a major public health problem leading to the development of anaemia. Reducing the global prevalence of anaemia in women of reproductive age is a 2025 global nutrition target. Bone marrow aspiration is the gold standard test for iron deficiency but requires an invasive procedure; therefore, serum ferritin is the most clinically useful test. We undertook a systematic search of electronic databases and trial registers from inception to January 2016. Studies of iron or micronutrient supplementation in pregnancy with pre-defined serum ferritin thresholds were included. Two independent reviewers selected studies, extracted data and assessed quality. There were 76 relevant studies mainly of observational study design (57%). The most commonly used thresholds of serum ferritin for the diagnosis of iron deficiency were <12 and <15 ng mL-1 (68%). Most primary studies provided no justification for the choice of serum ferritin threshold used, but 25 studies (33%) used thresholds defined by expert consensus in a guideline development process. There were five studies (7%) using a serum ferritin threshold defining iron deficiency derived from primary studies of bone marrow aspiration. Unified international thresholds of iron deficiency for women throughout pregnancy are required for accurate assessments of the global disease burden and for evaluating effectiveness of interventions addressing this problem.

Strategies to reduce blood product utilization in obstetric practice.

PURPOSE OF REVIEW: Patient blood management (PBM) aims to improve patient outcome and safety by reducing the number of unnecessary RBC transfusions and vitalizing patient-specific anemia reserves. Although PBM is increasingly recognized as best clinical practice in elective surgery, implementation of PBM is restrained in the setting of obstetrics. This review summarizes recent findings to reduce blood product utilization in obstetric practice. RECENT FINDINGS: PBM-related evidence-based benefits should be urgently adopted in the field of obstetric medicine. Intravenous iron can be considered a safe, effective strategy to replenish iron stores and to correct both pregnancy-related and hemorrhage-related iron deficiency anemia. In addition to surgical techniques and the use of uterotonics, recent findings support early administration of tranexamic acid, fibrinogen and a coagulation factor concentrate-based, viscoelastically guided practice in case of peripartum hemorrhage to manage coagulopathy. In patients with cesarean section, autologous red cell blood salvage may reduce blood product utilization, although its use in this setting is controversial. SUMMARY: Implementation of PBM in obstetric practice offers large potential to reduce blood loss and transfusion requirements of allogeneic blood products, even though large clinical trials are lacking in this specific field. Intravenous iron supplementation may be suggested to increase peripartum hemoglobin levels. Additionally, tranexamic acid and point-of-care-guided supplementation of coagulation factors are potent methods to reduce unnecessary blood loss and blood transfusions in obstetrics.

Embarazo en la paciente con drepanocitosis: atención integral en el Instituto de Hematología e Inmunología / Pregnancy in patients with sickle cell disease: comprehensive care at the Institute of Hematology and Immunology

Desde la fundación del Instituto de Hematología e Inmunología (IHI) en el año 1966, como centro rector para el diagnóstico y tratamiento de las enfermedades hematológicas, la atención a los pacientes con drepanocitosis ha mostrado cambios importantes. A partir de 1973 se han estudiado aspectos clínicos, hematológicos y de laboratorio de esta enfermedad. En 1983 se inició en el IHI el diagnóstico prenatal,proceder que en 1986 se trasladó al Centro Nacional de Genética Médica, donde se realiza en la actualidad. Posteriormente se creó el Programa Nacional de Atención Integral al paciente con drepanocitosis 1,2. Un aspecto muy importante de este programa es el diagnóstico y seguimiento del embarazo en la paciente con drepanocitosis, teniendo en cuenta el alto riesgo que presenta en relación con la morbilidad y la mortalidad durante la gestación, el parto y el puerperio; así como el empeoramiento de su cuadro clínico posterior a estos periodos...

Iron deficiency anaemia.

Anaemia affects roughly a third of the world's population; half the cases are due to iron deficiency. It is a major and global public health problem that affects maternal and child mortality, physical performance, and referral to health-care professionals. Children aged 0-5 years, women of childbearing age, and pregnant women are particularly at risk. Several chronic diseases are frequently associated with iron deficiency anaemia--notably chronic kidney disease, chronic heart failure, cancer, and inflammatory bowel disease. Measurement of serum ferritin, transferrin saturation, serum soluble transferrin receptors, and the serum soluble transferrin receptors-ferritin index are more accurate than classic red cell indices in the diagnosis of iron deficiency anaemia. In addition to the search for and treatment of the cause of iron deficiency, treatment strategies encompass prevention, including food fortification and iron supplementation. Oral iron is usually recommended as first-line therapy, but the most recent intravenous iron formulations, which have been available for nearly a decade, seem to replenish iron stores safely and effectively. Hepcidin has a key role in iron homoeostasis and could be a future diagnostic and therapeutic target. In this Seminar, we discuss the clinical presentation, epidemiology, pathophysiology, diagnosis, and acute management of iron deficiency anaemia, and outstanding research questions for treatment.

Iron deficiency anemia in pregnancy.

Anemia is the most frequent derailment of physiology in the world throughout the life of a woman. It is a serious condition in countries that are industrialized and in countries with poor resources. The main purpose of this manuscript is to give the right concern of anemia in pregnancy. The most common causes of anemia are poor nutrition, iron deficiencies, micronutrients deficiencies including folic acid, vitamin A and vitamin B12, diseases like malaria, hookworm infestation and schistosomiasis, HIV infection and genetically inherited hemoglobinopathies such as thalassemia. Depending on the severity and duration of anemia and the stage of gestation, there could be different adverse effects including low birth weight and preterm delivery. Treatment of mild anemia prevents more severe forms of anemia, strictly associated with increased risk of fetal-maternal mortality and morbidity.

Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women to Improve Maternal Health and Birth Outcomes: U.S. Preventive Services Task Force Recommendation Statement.

DESCRIPTION: Update of the 2006 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for iron deficiency anemia. METHODS: The USPSTF reviewed the evidence on the association between change in iron status as a result of intervention (oral supplementation or treatment) in pregnant women and adolescents and improvement in maternal and infant health outcomes. POPULATION: This recommendation applies to pregnant women and adolescents living in the United States who do not have symptoms of iron deficiency anemia. It does not address pregnant women who are malnourished, have symptoms of iron deficiency anemia, or have special hematologic conditions or nutritional needs that may increase their need for iron. RECOMMENDATIONS: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes. (I statement). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine iron supplementation for pregnant women to prevent adverse maternal health and birth outcomes. (I statement).