First Trimester Ferritin Is Superior over Soluble Transferrin Receptor and Hepcidin in Predicting Anemia in the Third Trimester: Result from a Cohort Study in Indonesia.

INTRODUCTION: Anemia in the third trimester has been identified as a risk factor for maternal and fetal morbidity that might lead to mortality. Due to its high cost, finding the best marker to predict anemia became more important to allow early prevention. Only one of ferritin, hepcidin, or soluble transferrin receptors can be picked for the prediction of anemia in the third trimester especially in low-resource setting. OBJECTIVE: This study aimed at defining the best marker among ferritin, hepcidin, or soluble transferrin receptor (sTfR) in the first trimester for prediction of anemia in the third trimester. Materials, Methods, and Setting. This diagnostic study was nested on the cohort study of vitamin D and its impact during pregnancy in Indonesia. Singleton pregnant mothers with normal fetus were recruited in the first trimester from four cities in West Java, Indonesia. The 304 pregnant women were screened for hepcidin, ferritin, and sTfR level in the sera. All biomarkers were measured by ELISA. Complete blood count (CBC) was done by impedance method measurement (SysmexR). Only subjects with complete data were included in analysis for diagnostic study to compare the three markers by finding the best receiver operating curve (RoC), likelihood ratio (LR), and risk estimate (RR). RESULT: One-hundred and eighty-one pregnant women were eligible for analysis. The result of this study showed that the serum ferritin level in the first trimester was the best marker to predict anemia in the third trimester of pregnancy. Hepcidin and sTfR performed poorly. A new cutoff point of ferritin level ≤27.23 ng/ml yielded the best ROC with 67% area under curve (95% CI 60%-75%, p < 0.0001, Youden index J 0.28), specificity 86.29% (95% CI 79.0%-91.8%), LR (+) 3.07 (95% CI 1.8-5.3), and RR 2.48 (95% CI 1.67-3.68). These last figures were better than the previously used cutoff point of ferritin level below 30 ng/ml. CONCLUSION: This study provided evidence that the serum ferritin level ≤27.23 ng/ml in the first trimester was the best marker to predict anemia in the third trimester. It was valuably useful for secondary screening of anemia in pregnancy, targeting subjects who may need rigorous approach for iron deficiency treatment in the prevention of anemia in pregnancy.

Optimizing ultraviolet B radiation exposure to prevent vitamin D deficiency among pregnant women in the tropical zone: report from cohort study on vitamin D status and its impact during pregnancy in Indonesia.

BACKGROUND: Vitamin D deficiency during pregnancy carries potential threat to fetal well being. Natural conversion of vitamin D in the skin can be facilitated by direct ultra violet B (UVB) radiation, but the effect is reduced by wearing umbrellas, clothes, or sunblock cream. Muslim women wear hijab that allows only face and hands to be seen. With increasing proportion of muslim women wearing hijab and the lack of vitamin D fortification and fish consumption in Indonesia, it poses a problem for vitamin D deficiency among pregnant women. This study aimed at finding the best timing of UVB exposure and the duration of exposure which can be suggested to prevent vitamin D deficiency among pregnant women, for those wearing hijab or not. METHODS: This study recruited 304 pregnant women in the first trimester, 75-76 women from 4 cities of the most populated province, West Java, Indonesia which represented 70-80% percent of pregnancy per year. A 3-day notes on duration, time and type of outdoor activity and the clothing wore by the women were collected. UVB intensity radiation were obtained. Calculation on body surface area exposed to direct UVB radiation and UVB radiation intensity were done. Measurement of vitamin D level in sera were done on the same week. RESULTS: The median of maternal sera vitamin D level was 13.6 ng/mL and the mean exposed area was around 0.48 m2 or 18.59% of total body surface area. Radiation intensity reached its peak around 10.00 and 13.00, but the mean duration of exposure to UVB during this window was lower than expected. Significant correlation was found between maternal sera vitamin D level and exposed body surface area (r = 0.36, p < 0.002) or percentage of exposed body surface (r = 0.39, p < 0.001) and radiation intensity (r = 0.15, p = 0.029). Further analysis showed that duration of exposure to UVB should be longer for pregnant women wearing hijab as compared to women without hijab. CONCLUSION: This study suggested that the best timing to get UVB exposure was between 10.00-13.00, with longer duration for women wearing hijab (64.5 vs 37.5 min) of continuous exposure per day.

Association of Colecalciferol, Ferritin, and Anemia among Pregnant Women: Result from Cohort Study on Vitamin D Status and Its Impact during Pregnancy and Childhood in Indonesia.

Studies had shown that iron-cycling was disturbed by inflammatory process through the role of hepcidin. Pregnancy is characterized by shifts of interleukin. Our objective was to determine if 25(OH) vitamin D (colecalciferol) status was associated with ferritin, anemia, and its changes during pregnancy. Method. A cohort study was done in 4 cities in West Java, Indonesia, beginning in July 2016. Subjects were followed up until third trimester. Examinations included were maternal ferritin, colecalciferol, and haemoglobin level. Result. 191 (95.5%) subjects had low colecalciferol, and 151 (75.5%) among them were at deficient state. Anemia is found in 15 (7.5%) subjects, much lower than previous report. Proportion of anemia increased by trimester among women with colecalciferol deficiency. Ferritin status and prepregnancy body mass index in the first trimester were correlated with anemia (r = 0.147, p = 0.038 and r = -0.56, p = 0.03). Anemia in the second trimester was strongly correlated with anemia in the third trimester (r = 0.676, p < 0.01). Conclusion. Our study showed that the state of colecalciferol was not associated with either ferritin state or anemia, but proportion of anemia tends to increase by trimester in the colecalciferol deficient subjects.