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Pfeiffer AF, Chang N, Zarudskaya O, Cheng C, Berkus MD, Boyd AR, Byrne JJ, Doyle NM. IV iron supplementation, dosage, and timing in pregnancy: A single-institution review on a maternal transfusion reduction bundle. Eur J Obstet Gynecol Reprod Biol 2025; 309:42-47. [PMID: 40107172 DOI: 10.1016/j.ejogrb.2025.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2025] [Revised: 03/14/2025] [Accepted: 03/16/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND Little is known about the effects of intravenous iron (IVFe) supplementation on maternal hemoglobin (Hb) by timing of infusion and dosage. OBJECTIVE To identify the association of IVFe timing and dose on pre-delivery Hb. STUDY DESIGN A retrospective cohort study of pregnant patients with iron deficiency anemia (IDA) who received iron sucrose (Venofer®) at our Level IV maternity care center following the implementation of a quality improvement (QI) transfusion reduction bundle from January 2020 to December 2023. The primary outcome was the association between IVFe timing and pre-delivery Hb. Secondary outcomes included the impact of IVFe dosage and infusion-to-delivery interval on Hb. Statistical analyses included paired t-tests, Mann-Whitney U tests, χ2 tests, ANOVA, and post-hoc Tukey multiple comparisons (significance set at p < 0.05). RESULTS 295 patients were included. Mean age, BMI, and ferritin were 26.6 ± 6.3 years, 28.1, and 7.2 ± 7.8 μg/L, respectively. Mean GA for IVFe administration was 34 weeks. Two patients required intrapartum/postpartum red blood cell transfusions. A greater mean Hb difference (2.5 g/dL vs 1.3 g/dL), was observed with IVFe at <34 weeks compared to ≥34 weeks (p < 0.001). Higher IVFe doses were associated with increased pre-delivery Hb levels (p = 0.002) and a longer infusion-to-delivery interval (p = 0.049). The strongest Hb improvement was seen with latency from ≥6-8 weeks with doses >800 mg versus <2 weeks at doses ≤ 800 mg (increase of 2.6 - 3.1 g/dL, p < 0.0001). CONCLUSION Substantial benefit is seen when IVFe is given in the early third trimester, especially with ≥6 weeks of latency and doses ≥800 mg.
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Affiliation(s)
- Alixandria F Pfeiffer
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States.
| | - Nathalie Chang
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Oxana Zarudskaya
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Cece Cheng
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, WA, United States
| | - Michael D Berkus
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Angela R Boyd
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Nora M Doyle
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Fatima N, Yaqoob S, Rana L, Imtiaz A, Iqbal MJ, Bashir Z, Shaukat A, Naveed H, Sultan W, Afzal M, Kashif Z, Al-Asmari F, Shen Q, Ma Y. Micro-nutrient sufficiency in mothers and babies: management of deficiencies while avoiding overload during pregnancy. Front Nutr 2025; 12:1476672. [PMID: 40236637 PMCID: PMC11996651 DOI: 10.3389/fnut.2025.1476672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 01/13/2025] [Indexed: 04/17/2025] Open
Abstract
Pregnancy is a period characterized by extensive physiological changes in both the mother and fetus. During this period, the nutritional status of the mother has a profound and irreversible impact on her health and the growth and development of the fetus. The fetus depends exclusively on the mother and drives nutrients through the placenta. Therefore, mothers must be provided with a well-balanced diet that is adequate in both macro- and micronutrients. Most pregnant women generally manage to get adequate macronutrients; however, many women fail to get micronutrients up to the recommended dietary allowance. Micronutrients such as vitamins and minerals are necessary for preventing congenital abnormalities and the optimal development of the brain and body of the fetus. Their inadequacy can lead to complications like anemia, hypertension, pre-eclampsia, maternal and fetal hypothyroidism, premature infants, intrauterine growth restriction, stillbirth, and other negative pregnancy outcomes. New studies recommend the use of prenatal micronutrient supplements to prevent birth defects and health issues caused by deficiencies in folic acid, iron, iodine, and calcium during pregnancy. This is especially important in developing nations where deficiencies are prevalent. Also while using these supplements, their upper limits (UL) must be considered to avoid overload. In this review, we provide an overview of the four most critical micronutrients during pregnancy: iron, folic acid, iodine, and calcium. We provide insight into their sources, RDAs, deficiency consequences, and the need for supplementation while considering the risk of micronutrient overload. To maximize the potential benefits while minimizing the risk of nutrient overload, although knowledge gaps remain.
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Affiliation(s)
- Noor Fatima
- NIFSAT - National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - Sanabil Yaqoob
- Laboratory of Food Nutrition and Clinical Research, Institute of Seafood, Zhejiang Gongshang University, Hangzhou, China
- Department of Food Science and Technology, Faculty of Science and Technology, University of Central Punjab, Lahore, Pakistan
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
| | - Laraib Rana
- NIFSAT - National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - Aysha Imtiaz
- School of Food Science and Engineering, Yangzhou University, Yangzhou, China
| | | | - Zahid Bashir
- Department of Food Science and Technology, Faculty of Science and Technology, University of Central Punjab, Lahore, Pakistan
| | - Amal Shaukat
- Department of Food Science and Technology, Faculty of Science and Technology, University of Central Punjab, Lahore, Pakistan
| | - Hiba Naveed
- Department of Food Science and Technology, Faculty of Science and Technology, University of Central Punjab, Lahore, Pakistan
| | - Waleed Sultan
- Department of Food Science and Technology, Faculty of Science and Technology, University of Central Punjab, Lahore, Pakistan
| | - Muneeba Afzal
- NIFSAT - National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - Zara Kashif
- NIFSAT - National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - Fahad Al-Asmari
- Department of Food and Nutrition Sciences, College of Agriculture and Food Sciences, King Faisal University, Hofuf, Saudi Arabia
| | - Qing Shen
- NIFSAT - National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan
| | - Yongkun Ma
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
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Patel PB, Patel N, Hedges MA, Benson AE, Tomer A, Lo JO, Shatzel JJ. Hematologic Complications of Pregnancy. Eur J Haematol 2025; 114:596-614. [PMID: 39790057 PMCID: PMC11882378 DOI: 10.1111/ejh.14372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Revised: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 01/12/2025]
Abstract
Hematologic complications are common in pregnancy and can significantly impact both maternal and fetal health. Recognizing and treating these complications can be challenging due to the limited evidence available to guide clinical consultants. Iron deficiency anemia is the most prevalent hematologic issue in pregnancy and often occurs due to increased maternal blood volume and the nutritional demands of the growing fetus. Thrombocytopenia is the second most commonly occurring hematologic issue in pregnancy and can be associated with increased blood loss and complications during childbirth. However, the most common type of thrombocytopenia in pregnancy is gestational thrombocytopenia, which does not typically require clinical management. Thus, it is important to distinguish gestational thrombocytopenia from other etiologies of thrombocytopenia in pregnancy that require immediate treatment, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, preeclampsia, and HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels) syndrome. Other important hematologic conditions in pregnancy include non-inherited anemias, such as autoimmune hemolytic anemia and aplastic anemia, as well as inherited anemias, such as sickle cell disease and thalassemia, which may require specialized management to optimize maternal and fetal outcomes. Additionally, bleeding disorders, such as von Willebrand disease and hemophilia, pose unique challenges in pregnancy, especially around the time of delivery, due to the risk of excessive bleeding. Lastly, thromboembolic disorders, such as venous thromboembolism (VTE), remain the leading cause of mortality in pregnancy in developed countries. Pregnancy-related hormonal changes, venous stasis, and hypercoagulability contribute to an increased thromboembolic risk, further exacerbated by additional risk factors such as obesity or a prior personal or family history of VTE. This review aims to summarize current guidelines and management of the most common hematologic disorders in pregnancy.
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Affiliation(s)
| | - Nidhi Patel
- Department of Medicine, Providence Medical Center, Portland, Oregon, USA
| | - Madeline A Hedges
- Department of Pediatrics, Division of Neonatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ashley E Benson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Arjun Tomer
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamie O Lo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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Al-Taiar A, Ziyab AH, Hammoud MS, Al-Sabah R, Akhtar S. Anemia in pregnant women: findings from Kuwait birth cohort study. BMC Pregnancy Childbirth 2025; 25:326. [PMID: 40114090 PMCID: PMC11927135 DOI: 10.1186/s12884-025-07439-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 03/06/2025] [Indexed: 03/22/2025] Open
Abstract
BACKGROUND Anemia is the most common hematologic disorder in pregnancy, affecting over one-third of pregnant women globally. This study aimed to assess the prevalence of anemia in pregnant women and its associated factors in the Kuwait Birth Cohort study. METHODS The Kuwait birth cohort (n = 1,108) was a prospective study in which pregnant women were recruited during their second or third trimester. Data were collected through personal interviews during antenatal care visits, including data on sociodemographic and lifestyle factors. Blood samples were analyzed under strict quality control to measure various laboratory indicators. Anemia was defined as hemoglobin (Hb) < 110 g/L. Predictors of anemia were categorized as underlying or direct factors, and logistic regression models were used to investigate their association with anemia. RESULTS The prevalence of anemia was 28.16% (95% CI:25.53-30.91%), with 8.75% of women experiencing moderate anemia and 19.40% mild anemia. No cases of severe anemia were observed. Multivariable analysis identified current iron supplement use, (Adjusted Odds Ratio [AOR] 0.52, 95%CI:0.28-0.99; p = 0.049), vitamin D status (sufficient vs. insufficient/deficient), (AOR 0.63, 95%CI:0.43-0.92; p = 0.018), iron levels (p < 0.001), and ferritin levels (p < 0.001) as factors significantly associated with anemia. CONCLUSION Anemia in pregnant women in Kuwait represents a mild to moderate public health concern, primarily driven by iron deficiency. The estimated prevalence of anemia is influenced by the Hb threshold used to define anemia, a topic currently subject to vigorous debate. Our findings suggest that improved screening for iron deficiency during pregnancy may further reduce anemia in pregnant women in Kuwait.
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Affiliation(s)
- Abdullah Al-Taiar
- Joint School of Public Health, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, VA, USA.
| | - Ali H Ziyab
- Department of Community Medicine and Behavioral Sciences, College of Medicine, Kuwait University, P. O. Box 24923, Safat, 13110, Kuwait.
| | - Majeda S Hammoud
- Department of Pediatrics, College of Medicine, Kuwait University, Safat, Kuwait
| | - Reem Al-Sabah
- Department of Community Medicine and Behavioral Sciences, College of Medicine, Kuwait University, P. O. Box 24923, Safat, 13110, Kuwait
| | - Saeed Akhtar
- Department of Community Medicine and Behavioral Sciences, College of Medicine, Kuwait University, P. O. Box 24923, Safat, 13110, Kuwait
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Arias-Gastélum M, Lindberg NM, Leo MC, Gille S, Vaughn K, Shuster E, LeBlanc ES, Stevens VJ, Vega-López S. A better diet quality based on the Healthy Eating Index-2020 is associated with lower energy intake and age but not with a pre-diabetes/T2DM diagnosis among Hispanic women with overweight/obesity. Nutr Res 2025; 134:88-98. [PMID: 39874721 PMCID: PMC11830551 DOI: 10.1016/j.nutres.2025.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 01/03/2025] [Accepted: 01/04/2025] [Indexed: 01/30/2025]
Abstract
Low diet quality is related to obesity and type 2 diabetes mellitus (T2DM) risk among Hispanic women. This cross-sectional study compared diet quality among Hispanic women with overweight/obesity based on their T2DM diagnosis (pre-diabetes/T2DM group, n = 104 vs no diagnosis, at-risk group, n = 84). It was hypothesized that having a pre-diabetes or T2DM diagnosis would be associated with better diet quality based on the Healthy Eating Index (HEI)-2020 score. Means were compared using a 2-sample t-test for parametric and Kruskal-Wallis for non-parametric variables. Women with pre-diabetes/T2DM reported a lower intake of total energy (1378 ± 557 vs 1644 ± 703 kcal; P = .004) and cholesterol (228 ± 140 vs 299 ± 216 mg; P = .007). Total HEI score was higher for pre-diabetes/T2DM than the at-risk group (64 ± 8 vs 62 ± 9; P = .027). Among all participants, adequacy subscores were excellent for whole fruits, greens & beans, total proteins, and seafood and plant proteins, good for total fruits (77%); fair for total vegetables and fatty acids (64% for both); and poor for whole grains, and dairy (20% and 53%, respectively). Moderation subscores were very good for added sugars (89%), good for saturated fats (78%), and poor for refined grains, and sodium (44% and 33%, respectively). Compared to the at-risk group, women with pre-diabetes/T2DM had higher fatty acid ratio scores (7 ± 2 vs 6 ± 3, P = .039). Multiple linear regression revealed that pre-diabetes/T2DM did not significantly impact diet quality, but energy intake and age did. Overall, HEI subscores underscore the need to improve diet quality through key food groups in Hispanic women with overweight/obesity, regardless of T2DM status.
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Affiliation(s)
- Mayra Arias-Gastélum
- School of Nutrition, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México; College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Sara Gille
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Katie Vaughn
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | - Erin S LeBlanc
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | - Sonia Vega-López
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA; Southwest Interdisciplinary Research Center, Arizona State University, Phoenix, AZ, USA.
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6
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Ryan KS, Martens KL, Garg B, Chobrutskiy BI, Hedges MA, Hagen OL, Sabile JMG, Lewkowitz AK, Tuuli MG, Deloughery TG, Shatzel JJ, Lo JO, Benson AE. Perinatal Outcomes Following Intravenous Iron for Treatment of Iron Deficiency With and Without Anemia. Eur J Haematol 2024; 113:842-851. [PMID: 39223998 PMCID: PMC11632358 DOI: 10.1111/ejh.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 08/10/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To determine maternal and neonatal outcomes in individuals with iron deficiency receiving antepartum intravenous (IV) iron supplementation, stratified by the degree of anemia. STUDY DESIGN Retrospective cohort study of iron-deficient pregnant patients who received at least one IV infusion of iron (iron sucrose, low molecular weight iron dextran [LMWID], or ferric carboxymaltose) during their pregnancy from January 1, 2011 through June 16, 2022. Our primary outcomes included both neonatal composite morbidity and maternal composite morbidity in the context of maternal anemia. RESULTS Patients who received LMWID had fewer infusion visits, received higher total doses of iron and had a more substantial correction of hemoglobin compared to those who received iron sucrose (p < 0.01). Maternal anemia at the time of admission was not associated with neonatal composite morbidity. However, there was a significant association between anemia status and maternal composite outcome (p = 0.05). Anemia at time of delivery was associated with the likelihood of requiring a blood transfusion (p = 0.01). CONCLUSION This study reinforces previous findings emphasizing the adverse effects of iron deficiency on maternal health and the role of IV iron in reducing these risks.
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Affiliation(s)
- Kimberly S Ryan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kylee L Martens
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Bharti Garg
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Boris I Chobrutskiy
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Madeline A Hedges
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Olivia L Hagen
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Jean M G Sabile
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Adam K Lewkowitz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Methodius G Tuuli
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Thomas G Deloughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamie O Lo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Ashley E Benson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Obianeli C, Afifi K, Stanworth S, Churchill D. Iron Deficiency Anaemia in Pregnancy: A Narrative Review from a Clinical Perspective. Diagnostics (Basel) 2024; 14:2306. [PMID: 39451629 PMCID: PMC11506382 DOI: 10.3390/diagnostics14202306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 09/24/2024] [Accepted: 10/14/2024] [Indexed: 10/26/2024] Open
Abstract
Anaemia in pregnancy is a global problem of significance in all settings. The most common cause is iron deficiency. Large numbers of women are affected, ranging up to 25-30% antenatally and 20-40% postnatally. It is associated with serious adverse outcomes for both the mother and her baby. The risk of low birth weight, preterm birth, postpartum haemorrhage, stillbirth, and neonatal death are all increased in the presence of anaemia. For the infants of affected pregnancies, complications may include neurocognitive impairment. Making an accurate diagnosis during pregnancy has its challenges, which include the choice of thresholds of haemoglobin below which a diagnosis of anaemia in each trimester of pregnancy can be made and, aligned with this question, which are the most appropriate biomarkers to use to define iron deficiency. Treatment with oral iron supplements increases the haemoglobin concentration and corrects iron deficiency. But high numbers of women fail to respond, probably due to poor adherence to medication, resulting from side effects. This has resulted in an increased use of more expensive intravenous iron. Doubts remain about the optimal regimen to of oral iron for use (daily, alternate days, or some other frequency) and the cost-effectiveness of intravenous iron. There is interest in strategies for prevention but these have yet to be proven clinically safe and effective.
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Affiliation(s)
- Chidi Obianeli
- The Royal Wolverhampton NHS Trust, New Cross Hospital, Wednesfield, Wolverhampton WV10 0QP, UK; (C.O.); (K.A.)
| | - Khaled Afifi
- The Royal Wolverhampton NHS Trust, New Cross Hospital, Wednesfield, Wolverhampton WV10 0QP, UK; (C.O.); (K.A.)
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford OX3 9DU, UK;
- Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - David Churchill
- The Royal Wolverhampton NHS Trust, New Cross Hospital, Wednesfield, Wolverhampton WV10 0QP, UK; (C.O.); (K.A.)
- Research Institute of Healthcare Science, University of Wolverhampton, Wulfruna Street, Wolverhampton WV1 1LY, UK
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Cabalar I, Le TH, Silber A, O'Hara M, Abdallah B, Parikh M, Busch R. The role of blood testing in prevention, diagnosis, and management of chronic diseases: A review. Am J Med Sci 2024; 368:274-286. [PMID: 38636653 DOI: 10.1016/j.amjms.2024.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
Blood tests are vital to prevention, diagnosis, and management of chronic diseases. Despite this, it can be challenging to construct a comprehensive view of the clinical importance of blood testing because relevant literature is typically fragmented across different disease areas and patient populations. This lack of collated evidence can also make it difficult for primary care providers to adhere to best practices for blood testing across different diseases and guidelines. Thus, this review article synthesizes the recommendations for, and importance of, blood testing across several common chronic conditions encountered in primary care and internal medicine, including cardiovascular diseases, diabetes mellitus, chronic kidney disease, vitamin D deficiency, iron deficiency, and rheumatoid arthritis. Future research is needed to continue improving chronic disease management through clearer dissemination and awareness of clinical guidelines among providers, and better access to blood testing for patients (e.g., via pre-visit laboratory testing).
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Affiliation(s)
- Imelda Cabalar
- Division of Rheumatology, Department of Medicine, Adventist HealthCare Fort Washington Medical Center, Fort Washington, MD, USA
| | - Thu H Le
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | | | - Robert Busch
- Division of Community Endocrinology, Department of Medicine, Albany Medical Center, Albany, NY, USA.
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Nicholson WK, Silverstein M, Wong JB, Chelmow D, Coker TR, Davis EM, Jaén CR, Krousel-Wood M, Lee S, Li L, Rao G, Ruiz JM, Stevermer J, Tsevat J, Underwood SM, Wiehe S. Screening and Supplementation for Iron Deficiency and Iron Deficiency Anemia During Pregnancy: US Preventive Services Task Force Recommendation Statement. JAMA 2024; 332:906-913. [PMID: 39163015 DOI: 10.1001/jama.2024.15196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
Importance Iron deficiency is the leading cause of anemia during pregnancy. According to survey data from 1999 to 2006, overall estimated prevalence of iron deficiency during pregnancy is near 18% and increases across the 3 trimesters of pregnancy (from 6.9% to 14.3% to 28.4%). An estimated 5% of pregnant persons have iron deficiency anemia. Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on the benefits and harms of screening and supplementation for iron deficiency with and without anemia on maternal and infant health outcomes in asymptomatic pregnant persons. Population Asymptomatic pregnant adolescents and adults. Evidence Assessment The USPSTF concludes that the current evidence is insufficient, and the balance of benefits and harms of screening for iron deficiency and iron deficiency anemia in asymptomatic pregnant persons on maternal and infant health outcomes cannot be determined. The USPSTF also concludes that the current evidence is insufficient, and the balance of benefits and harms of iron supplementation in asymptomatic pregnant persons on maternal and infant health outcomes cannot be determined. Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency and iron deficiency anemia in pregnant persons to prevent adverse maternal and infant health outcomes. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine supplementation for iron deficiency and iron deficiency anemia in pregnant persons to prevent adverse maternal and infant health outcomes. (I statement).
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Affiliation(s)
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
| | | | | | - Esa M Davis
- University of Maryland School of Medicine, Baltimore
| | | | | | - Sei Lee
- University of California, San Francisco
| | - Li Li
- University of Virginia, Charlottesville
| | - Goutham Rao
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Joel Tsevat
- University of Texas Health Science Center, San Antonio
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Cantor AG, Holmes R, Bougatsos C, Atchison C, DeLoughery T, Chou R. Screening and Supplementation for Iron Deficiency and Iron Deficiency Anemia During Pregnancy: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2024; 332:914-928. [PMID: 39163033 DOI: 10.1001/jama.2024.13546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
Importance In 2015 the US Preventive Services Task Force (USPSTF) found insufficient evidence to assess the balance of benefits and harms of routine screening and supplementation for iron deficiency anemia during pregnancy. Objective To update the 2015 review on screening for iron deficiency anemia, in addition to iron deficiency during pregnancy, to inform the USPSTF. Data Sources Ovid MEDLINE and Cochrane databases through May 24, 2023; surveillance through May 24, 2024. Study Selection Randomized clinical trials of iron supplementation, screening effectiveness, treatment, and harms; observational studies of screening. Data Extraction and Synthesis Dual review of abstracts, full-text articles, study quality, and data abstraction. Data were pooled using a random-effects model. Main Outcomes and Measures Maternal and infant clinical outcomes, hematologic indices, and harms. Results Seventeen trials (N = 24 023) on maternal iron supplementation were included. Iron supplementation was associated with decreased risk of maternal iron deficiency anemia at term (4 trials, n = 2230; 8.6% vs 19.8%; relative risk, 0.40 [95% CI, 0.26-0.61]; I2 = 20.5%) and maternal iron deficiency at term (6 trials, n = 2361; 46% vs 70%; relative risk, 0.47 [95% CI, 0.33-0.67]; I2 = 81.9%) compared with placebo or no iron supplement. There were no statistically significant differences in maternal quality of life, rates of gestational diabetes, maternal hemorrhage, hypertensive disorders of pregnancy, cesarean delivery, preterm birth, infant low birth weight, or infants small for gestational age for maternal iron supplementation compared with placebo or no supplementation. Harms of iron supplementation included transient gastrointestinal adverse effects. No studies evaluated the benefits or harms of screening for iron deficiency or iron deficiency anemia during pregnancy. Data on the association between iron status and health outcomes, such as hypertensive disorders of pregnancy and preterm birth, were very limited. Conclusions and Relevance Routine prenatal iron supplementation reduces the incidence of iron deficiency and iron deficiency anemia during pregnancy, but evidence on health outcomes is limited or indicates no benefit. No studies addressed screening for iron deficiency or iron deficiency anemia during pregnancy. Research is needed to understand the association between changes in maternal iron status measures and health outcomes.
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Affiliation(s)
- Amy G Cantor
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Rebecca Holmes
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Chandler Atchison
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Thomas DeLoughery
- Department of Hematology/Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Roger Chou
- The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of General Internal Medicine, Oregon Health & Science University, Portland
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Moumin NA, Shepherd E, Liu K, Makrides M, Gould JF, Green TJ, Grzeskowiak LE. The Effects of Prenatal Iron Supplementation on Offspring Neurodevelopment in Upper Middle- or High-Income Countries: A Systematic Review. Nutrients 2024; 16:2499. [PMID: 39125379 PMCID: PMC11314290 DOI: 10.3390/nu16152499] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Iron supplementation is commonly recommended for the prevention and treatment of maternal iron deficiency (ID) or iron deficiency anemia (IDA). However, the impacts of prophylactic of therapeutic prenatal iron supplementation on child neurodevelopment in upper middle-income (UMI) and high-income countries (HICs), where broad nutritional deficiencies are less common, are unclear. To investigate this, we conducted a systematic review, searching four databases (Medline, CINAHL, EMBASE, Cochrane Library) through 1 May 2023. Randomized controlled trials (RCTs) assessing oral or intravenous iron supplementation in pregnant women reporting on child neurodevelopment (primary outcome: age-standardized cognitive scores) were eligible. We included three RCTs (five publications) from two HICs (Spain and Australia) (N = 935 children; N = 1397 mothers). Due to clinical heterogeneity of the RCTs, meta-analyses were not appropriate; findings were narratively synthesized. In non-anemic pregnant women, prenatal iron for prevention of IDA resulted in little to no difference in cognition at 40 days post-partum (1 RCT, 503 infants; very low certainty evidence). Similarly, the effect on the intelligence quotient at four years was very uncertain (2 RCTs, 509 children, very low certainty evidence). No RCTs for treatment of ID assessed offspring cognition. The effects on secondary outcomes related to language and motor development, or other measures of cognitive function, were unclear, except for one prevention-focused RCT (302 children), which reported possible harm for children's behavioral and emotional functioning at four years. There is no evidence from UMI countries and insufficient evidence from HICs to support or refute benefits or harms of prophylactic or therapeutic prenatal iron supplementation on child neurodevelopment.
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Affiliation(s)
- Najma A. Moumin
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- Discipline of Pediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Emily Shepherd
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- Discipline of Obstetrics and Gynecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Kai Liu
- Discipline of Obstetrics and Gynecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5005, Australia;
- Lifelong Health, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
| | - Maria Makrides
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- Discipline of Pediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Jacqueline F. Gould
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- Discipline of Pediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Tim J. Green
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- College of Nursing and Allied Health, Caring Futures Institute, Flinders University, Adelaide, SA 5042, Australia
| | - Luke E. Grzeskowiak
- Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (N.A.M.); (E.S.); (M.M.); (J.F.G.); (T.J.G.)
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA 5042, Australia
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12
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O'Toole F, Sheane R, Reynaud N, McAuliffe FM, Walsh JM. Screening and treatment of iron deficiency anemia in pregnancy: A review and appraisal of current international guidelines. Int J Gynaecol Obstet 2024; 166:214-227. [PMID: 38069617 DOI: 10.1002/ijgo.15270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 06/27/2024]
Abstract
Iron deficiency anemia (IDA) in pregnancy is a common diagnosis that is associated with adverse obstetric and neonatal outcomes. There remains uncertainty regarding how best to screen for, prevent, and treat established IDA in pregnancy. There is no consensus on the benefits of routine iron supplementation in pregnancy, with concerns regarding potential harmful effects of routine iron supplementation in women who are iron replete. Fourteen international guidelines were selected and appraised and compared by a multidisciplinary team. The AGREE II GRS tool was used. Each reviewer independently made their own assessment, and the scores from 1 to 7 were also collated and averaged for an overall score incorporating seven domains: process of development, clarity of presentation, completeness of reporting, clinical validity, and overall quality. The reviewers' scores were also individually compared according to discipline. The mean score across all the guidelines was 4.4 (range 3.5-6.5). Only half of the guidelines recommend routine iron in pregnancy. In terms of screening recommendations, five guidelines recommend screening with ferritin in addition to a full blood count in pregnancy, two recommend selective screening with ferritin for at risk groups only, and one guideline suggests using ferritin where feasible. Although many of the guidelines recommend similar doses of oral elemental iron of 100-200 mg daily for the treatment of established IDA in pregnancy, two recommend twice or three times daily dosing. Only five guidelines give hemoglobin rises to expect within specific timeframes. There remains a need to clarify the optimal screening method, dosing regimen, timing, and route of iron supplementation in pregnancy. Robust randomized controlled data are needed to guide appropriate prevention and management.
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Affiliation(s)
- Fiona O'Toole
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Rachel Sheane
- Department of Dietetics, National Maternity Hospital, Dublin, Ireland
| | - Niamh Reynaud
- Department of Hematology, St Vincent's University Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Jennifer M Walsh
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
- Obstetrics & Gynecology, National Maternity Hospital, Dublin, Ireland
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13
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Neef V, Choorapoikayil S, Hof L, Meybohm P, Zacharowski K. Current concepts in postpartum anemia management. Curr Opin Anaesthesiol 2024; 37:234-238. [PMID: 38390913 PMCID: PMC11062600 DOI: 10.1097/aco.0000000000001338] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Postpartum anemia (PPA) is common in women after childbirth and affects about 50-80% of all women worldwide. Iron deficiency (ID) is the main cause for anemia and constitutes a potentially preventable condition with great impact on the mother's physical and mental condition after delivery. In most cases, PPA is associated with antenatal ID and peripartum blood losses. Numerous published studies confirmed the positive effect of PPA diagnosis and treatment. RECENT FINDINGS Iron deficiency as well as iron deficiency anemia (IDA) are common in the postpartum period and represent significant health problems in women of reproductive age. SUMMARY Important movements towards early detection and therapy of postpartum anemia have been observed. However, postpartum anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Diagnosis and therapy of PPA, particularly iron supplementation in ID and IDA, has proven to be highly effective with a tremendous effect on women's wellbeing and outcome.
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Affiliation(s)
- Vanessa Neef
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Suma Choorapoikayil
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Lotta Hof
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
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14
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Tang GH, Sholzberg M. Iron deficiency anemia among women: An issue of health equity. Blood Rev 2024; 64:101159. [PMID: 38042684 DOI: 10.1016/j.blre.2023.101159] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
Iron deficiency is the most common and widespread nutritional deficiency in the world. For women, the risk of iron deficiency and iron deficiency anemia increases due to iron demands during pregnancy and regular iron losses due to menstruation during reproductive years. These interrelated conditions are of public health concern as they are highly prevalent, and the negative consequences such as chronic fatigue, cognitive impairment and poor quality of life are broad and multifaceted. People of low socioeconomic status are at higher risk of iron deficiency due to low intake of expensive iron-rich foods, and decreased access to healthcare. In this review, we applied a health equity lens to describe the current state of care for women with iron deficiency with or without anemia. We have highlighted several structural challenges that span from the laboratory diagnosis, inconsistent screening guidelines, and stigma associated with heavy menstrual bleeding, to treatment barriers.
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Affiliation(s)
- Grace H Tang
- Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine, and Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Canada.
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15
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Mintsopoulos V, Tannenbaum E, Malinowski AK, Shehata N, Walker M. Identification and treatment of iron-deficiency anemia in pregnancy and postpartum: A systematic review and quality appraisal of guidelines using AGREE II. Int J Gynaecol Obstet 2024; 164:460-475. [PMID: 37424100 DOI: 10.1002/ijgo.14978] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/10/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Several international guidelines provide recommendations for the optimal management of iron-deficiency anemia (IDA) in the pregnant and postpartum populations. OBJECTIVES To review the quality of guidelines containing recommendations for the identification and treatment of IDA in pregnancy and postpartum using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and to summarize their recommendations. SEARCH STRATEGY PubMed, Medline, and Embase databases were searched from inception to August 2, 2021. A web engine search was also performed. SELECTION CRITERIA Clinical practice guidelines that focused on the management of IDA in pregnancy and/or postpartum populations were included. DATA COLLECTION AND ANALYSIS Included guidelines were appraised using AGREE II independently by two reviewers. Domain scores greater than 70% were considered high-quality. Overall scores of six or seven (out of a possible seven) were considered high-quality guidelines. Recommendations on IDA management were extracted and summarized. MAIN RESULTS Of 2887 citations, 16 guidelines were included. Only six (37.5%) guidelines were deemed high-quality and were recommended by the reviewers. All 16 (100%) guidelines discussed the management of IDA in pregnancy, and 10 (62.5%) also included information on the management of IDA in the postpartum period. CONCLUSIONS The complex interplay of racial, ethnic, and socioeconomic disparities was rarely addressed, which limits the generalizability of the recommendations. In addition, many guidelines failed to identify barriers to implementation, strategies to improve uptake or iron treatment, and resource and cost implications of clinical recommendations. These findings highlight important areas to target future work.
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Affiliation(s)
| | - Evan Tannenbaum
- University of Toronto, Toronto, Ontario, Canada
- General Division, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - A Kinga Malinowski
- University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nadine Shehata
- University of Toronto, Toronto, Ontario, Canada
- Laboratory Medicine and Pathobiology, Departments of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Hematology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Melissa Walker
- University of Toronto, Toronto, Ontario, Canada
- General Division, Department of Obstetrics & Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
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16
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Lewkowitz AK. Identifying and treating iron deficiency anemia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:223-228. [PMID: 38066889 PMCID: PMC10727057 DOI: 10.1182/hematology.2023000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Anemia is common during pregnancy, and while most anemia is physiologic, the most common pathologic cause is iron deficiency. The American College of Obstetricians and Gynecologists (ACOG) recommends confirmation of iron deficiency anemia with iron studies when anemia is diagnosed during pregnancy but acknowledges that presumptive treatment for suspected iron deficiency anemia is common in practice. Currently ACOG does not recommend treating iron deficiency without anemia during pregnancy. Though the benefits of treating iron deficiency anemia during pregnancy are clear, the optimal route of iron repletion remains uncertain. Results of ongoing large, randomized trials will help define the optimal route of iron treatment for pregnant patients diagnosed with iron deficiency anemia.
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Affiliation(s)
- Adam K. Lewkowitz
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, Providence, RI
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17
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Williams AM, Brown KH, Allen LH, Dary O, Moorthy D, Suchdev PS. Improving Anemia Assessment in Clinical and Public Health Settings. J Nutr 2023; 153 Suppl 1:S29-S41. [PMID: 37778891 PMCID: PMC11002965 DOI: 10.1016/j.tjnut.2023.05.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 10/03/2023] Open
Abstract
We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.
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Affiliation(s)
- Anne M Williams
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand; Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States.
| | - Kenneth H Brown
- Department of Nutrition and Institute for Global Nutrition, University of California, Davis, CA, United States
| | - Lindsay H Allen
- United States Department of Agriculture, Agricultural Research Service Western Human Nutrition Research Center, Davis, CA, United States
| | - Omar Dary
- Division of Nutrition and Environmental Health, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | | | - Parminder S Suchdev
- Nutrition Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States; Emory University, Atlanta, GA, United States
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18
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Mujica-Coopman MF, Garmendia ML, Corvalán C. Iron, folic acid, and vitamin D supplementation during pregnancy: Did pregnant Chilean women meet the recommendations during the COVID pandemic? PLoS One 2023; 18:e0293745. [PMID: 37917771 PMCID: PMC10621940 DOI: 10.1371/journal.pone.0293745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Antenatal micronutrient supplementation has been defined as a priority for Low-and Middle-income Countries (LMICs). However, it is also relevant to assess its performance in middle-high income countries, such as Chile, particularly given the post-pandemic food insecurity context. AIM To assess the use (frequency and doses) of daily recommended supplementation (iron (15-30 mg), folic acid (FA) (400-800 μg/day), and vitamin (VD) (400 IU)) in a sample of Chilean pregnant women. METHODS In 1, 507 pregnant women selected from public health care registries of the Southeast area of Santiago-Chile, we collected maternal, supplement use, sociodemographic, and nutritional information at the first (<15 weeks), second (24-28 weeks), and third trimesters (32-36 weeks) of gestation by using a researcher administer online questionnaire. RESULTS The median (IQR) age of women was 29 (25-33) years. Pre-conceptional supplementation was rare (24%), but it reached >93% in the first trimester; thereafter supplement use decreased to 79% in the second and 84% in the third trimesters, particularly in women with lower income (p<0.05), lower education (p<0.05), and with excess weight (p<0.05). Use of iron supplements in the first trimester was rare (<21%) as well as the use of VD supplements across pregnancy (<31%). Most FA (70%) and iron (80%) supplement users, exceeded the recommended daily dose while ~40% of VD users took less than the recommended dose. CONCLUSIONS In this sample of Chilean women, timely initiation of FA, iron, and VD supplementation was low and doses were not aligned with the recommendations. Strengthening adherence and quality of micronutrient supplementation programs delivered through public primary care could benefit particularly the most vulnerable women.
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Affiliation(s)
| | - María Luisa Garmendia
- Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile
| | - Camila Corvalán
- Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile
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19
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Igbinosa II, Leonard SA, Noelette F, Davies-Balch S, Carmichael SL, Main E, Lyell DJ. Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity. Obstet Gynecol 2023; 142:845-854. [PMID: 37678935 PMCID: PMC10510811 DOI: 10.1097/aog.0000000000005325] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity. METHODS We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity. RESULTS In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%. CONCLUSION Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.
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Affiliation(s)
- Irogue I Igbinosa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, and the Department of Pediatrics, School of Medicine, Stanford University, Stanford, and the BLACK Wellness & Prosperity Center, Fresno, California
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20
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Merz LE, Achebe MO. Iron Deficiency in Pregnancy: A Health Inequity. Am J Clin Nutr 2023; 117:1059-1060. [PMID: 37088229 DOI: 10.1016/j.ajcnut.2023.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/25/2023] Open
Affiliation(s)
- Lauren E Merz
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Maureen Okam Achebe
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States.
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21
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Kang W, Irvine C, Wang Y, Clark A, Gu Z, Pressman E, O'Brien KO. Hemoglobin distributions and prevalence of anemia in a multiethnic United States pregnant population. Am J Clin Nutr 2023; 117:1320-1330. [PMID: 37270292 PMCID: PMC10447485 DOI: 10.1016/j.ajcnut.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 01/10/2023] [Accepted: 01/23/2023] [Indexed: 06/05/2023] Open
Abstract
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.
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Affiliation(s)
- Wanhui Kang
- Division of Nutritional Sciences, Cornell University Ithaca, NY, United States
| | - Carrie Irvine
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY, United States
| | - Yiqin Wang
- Division of Nutritional Sciences, Cornell University Ithaca, NY, United States
| | - Andrew Clark
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, United States; Department of Computational Biology, Cornell University, Ithaca, NY, United States
| | - Zhenglong Gu
- Division of Nutritional Sciences, Cornell University Ithaca, NY, United States
| | - Eva Pressman
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY, United States
| | - Kimberly O O'Brien
- Division of Nutritional Sciences, Cornell University Ithaca, NY, United States.
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22
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Liu Y, Guo N, Feng H, Jiang H. The prevalence of trimester-specific dietary supplements and associated factors during pregnancy: An observational study. Front Pharmacol 2023; 14:1135736. [PMID: 37089956 PMCID: PMC10116053 DOI: 10.3389/fphar.2023.1135736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Objectives: This study aimed to assess the prevalence of trimester-specific dietary supplements (DS)s use and their possible correlates during pregnancy.Method: Pregnant women were convenience sampled and recruited from a comprehensive obstetric care center in Shanghai, China. Data relating to the use of DS during pregnancy, social support and other social-demographic and obstetric data were collected. Trimester-specific DS use and factors related DS were explored.Results: Of the 2803 women participating in this study, 94.8%, 96.2%, 93.8%, and 94.4% reported the use of at least one DS during pregnancy (all trimesters) and in the first, second, and third trimesters of pregnancy, respectively. Significant differences were noted in the use of DS containing folic acid, calcium, iron, vitamins, and docosahexaenoic acid (DHA), during the three trimesters of pregnancy. A higher proportion of DS use was negatively associated with certain categories of pregnant woman, including unemployed/housewife, low education level, obese, and low social support. A positive association was identified with gestational age.Conclusion for practice: Considering the high prevalence of DS use during pregnancy, future studies are needed to evaluate the accuracy and suitability of DS usage during pregnancy.
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23
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Liu L, Yan F, Yan H, Wang Z. Impact of iron supplementation on gestational diabetes mellitus: A literature review. Diabetes Obes Metab 2023; 25:342-353. [PMID: 36200449 DOI: 10.1111/dom.14886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/23/2022] [Accepted: 10/03/2022] [Indexed: 02/02/2023]
Abstract
Gestational diabetes mellitus (GDM) is a common complication of pregnancy, affecting 14% of pregnancies worldwide, and the prevention of pathological hyperglycaemia during pregnancy is meaningful for global public health. The role of iron supplementation in the progression of GDM has been of significant interest in recent years. Iron is a micronutrient that is vital during pregnancy; however, given the toxic properties of excess iron, it is probable that prophylactic iron supplementation will increase the risk of adverse pregnancy outcomes, including GDM. It is critical to clarify the effect of iron supplementation on the risk of GDM. Therefore, in this review, we comprehensively assess the role of iron in pregnancy. This review aimed to analyse the necessity of iron supplementation and maintenance of iron homeostasis during pregnancy, particularly reviewing the role and function of iron in beta cells and examining the mechanisms of excess iron contributing to the pathogenesis of GDM. Moreover, we aimed to discuss the association of haemoglobin and ferritin with GDM and identify priority areas for research.
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Affiliation(s)
- Lulu Liu
- Key Laboratory of Public Health Safety of Hebei Province, School of Public Health, Hebei University, Baoding, China
| | - Feng Yan
- Department of Gynecology, Baoding Maternal and Child Health Hospital, Baoding, China
| | - Hongyuan Yan
- Key Laboratory of Public Health Safety of Hebei Province, School of Public Health, Hebei University, Baoding, China
- Key Laboratory of Medicinal Chemistry and Molecular Diagnosis of Ministry of Education, College of Pharmaceutical Sciences, Hebei University, Baoding, China
| | - Zhiqiang Wang
- Key Laboratory of Public Health Safety of Hebei Province, School of Public Health, Hebei University, Baoding, China
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24
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Lagadinou M, Markantes G, Amerali M, Mulita F, Marangos M, Michalaki M. A Retrospective Study of Various Iron Preparations Oral Administration in Pregnant Women with Iron Deficiency Anemia. Mater Sociomed 2023; 35:157-164. [PMID: 37701349 PMCID: PMC10495134 DOI: 10.5455/msm.2023.35.157-164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/06/2023] [Indexed: 09/14/2023] Open
Abstract
During pregnancy anemia is a common medical condition, with iron deficiency and megaloblastic anemia being the most common. The symptoms range from very mild to severe and if left without proper medical treatment, there can be serious consequences for both mother and fetus. The most frequent pregnancy problem is anemia. The term "Iron Deficiency Anemia" refers to erythropoiesis under conditions of absolute iron deficiency. This presupposes the depletion of iron stores in the body. Iron deficiency anemia or Sideropenic anemia is the most common form of anemia worldwide. Special attention must be given to nutrition during pregnancy. In the current retrospective study, it was evaluated the contribution of various iron preparations substitution during the pregnancy and puerperium.
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Affiliation(s)
- Maria Lagadinou
- Department of Internal medicine, University Hospital of
Patras, Patras Greece
| | - Georgios Markantes
- Division of Endocrinology, University Hospital of Patras,
Patras, Greece
| | - Marina Amerali
- Department of Internal medicine, University Hospital of
Patras, Patras Greece
| | - Francesk Mulita
- Department of General Surgery, University Hospital of
Patras, Patras, Greece
| | - Markos Marangos
- Department of Internal medicine, University Hospital of
Patras, Patras Greece
| | - Marina Michalaki
- Division of Endocrinology, University Hospital of Patras,
Patras, Greece
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25
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Quality Appraisal of Nutritional Guidelines to Prevent, Diagnose, and Treat Malnutrition in All Its Forms during Pregnancy. Nutrients 2022; 14:nu14214579. [PMID: 36364841 PMCID: PMC9659219 DOI: 10.3390/nu14214579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
This work aimed to identify clinical practice guidelines (CPGs) that include recommendations for the prevention, diagnosis, and treatment of women’s malnutrition during pregnancy and to evaluate the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. We conducted a literature review using PubMed and different websites from January 2009 to February 2021. The quality of the CPGs was independently assessed by reviewers using the AGREE II instrument, which defines guidelines scoring >70% in the overall assessment as “high quality”. The analysis included 43 guidelines. Among the main findings, we identified that only half of the CPGs (51.1%) obtained a final “high quality” evaluation. AGREE II results varied widely across domains and categories. The two domains that obtained the highest scores were scope and purpose with 88.3% (range 39 to 100%) and clarity of presentation with 87.2% (range 25 to 100%). Among the “high quality” CPGs, the best scores were achieved by the three guidelines published by the National Institute of Health and Care Excellence (NICE) and the World Health Organization (WHO). Due to the importance of maternal nutrition in pregnancy, it is essential to join forces to improve the quality of the guidelines, especially in CPGs that do not meet the reference standards for quality.
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26
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Cochrane KM, Hutcheon JA, Karakochuk CD. Iron-Deficiency Prevalence and Supplementation Practices Among Pregnant Women: A Secondary Data Analysis From a Clinical Trial in Vancouver, Canada. J Nutr 2022; 152:2238-2244. [PMID: 35687377 PMCID: PMC9535446 DOI: 10.1093/jn/nxac135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND North American public health guidelines recommend supplementation with an iron-containing prenatal multivitamin throughout pregnancy to meet the RDA of 27 mg of elemental iron daily. However, whether supplementation with standard prenatal multivitamins is sufficient to prevent maternal iron deficiency is unclear, as needs increase substantially with advancing gestation. OBJECTIVES This study aimed to assess iron status in early and late pregnancy among 60 pregnant women receiving 27 mg/day of elemental iron as part of a randomized trial in Vancouver, Canada. METHODS Study visits were conducted at 8-21 (baseline) and 24-38 (endline) weeks of gestation. Venous blood specimens were collected for a complete blood count and measurement of iron and inflammatory biomarkers. Supplementation with any additional iron (beyond 27 mg/day) was reported by participants (treatment with additional iron is recommended if ferritin is <30 μg/L). Quantile regression was used to explore predictors of endline ferritin concentrations, including ethnicity, education, income, and baseline ferritin measurement. RESULTS Overall, 60 and 54 women participated in baseline and endline visits, respectively. Rates of probable iron deficiency (ferritin <30 μg/L) at baseline and endline were 17 (28%) and 44 (81%), respectively. Less than half (n = 18; 41%) of participants with probable iron deficiency at endline reported supplementation with additional iron. Ethnicity was the only significant modifier of endline ferritin, with higher concentrations in those of South, East, and Southeast Asian ethnicity compared to those of European ethnicity (β: 10.4 μg/L; 95% CI: 0.3-20.5). CONCLUSIONS Pregnant individuals may require additional supplemental iron beyond 27 mg to meet requirements in later pregnancy, given the high rates of iron deficiency observed in this clinical trial, despite consumption meeting 100% of the RDA. This trial was registered at clinicaltrials.gov as NCT04022135.
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Affiliation(s)
- Kelsey M Cochrane
- Food Nutrition and Health Faculty of Land and Food Systems University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute University of British Columbia, Vancouver, Canada
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute University of British Columbia, Vancouver, Canada
- Obstetrics and Gynaecology Faculty of Medicine University of British Columbia, Vancouver, Canada
| | - Crystal D Karakochuk
- Food Nutrition and Health Faculty of Land and Food Systems University of British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute University of British Columbia, Vancouver, Canada
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27
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Jefferds MED, Mei Z, Addo Y, Hamner HC, Perrine CG, Flores-Ayala R, Pfeiffer CM, Sharma AJ. Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities. Am J Public Health 2022; 112:S826-S835. [PMID: 36288529 PMCID: PMC9612197 DOI: 10.2105/ajph.2022.306998] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 11/04/2022]
Abstract
Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).
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Affiliation(s)
- Maria Elena D Jefferds
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Zuguo Mei
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Yaw Addo
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Heather C Hamner
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Cria G Perrine
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Rafael Flores-Ayala
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Christine M Pfeiffer
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
| | - Andrea J Sharma
- At the time of writing, Maria Elena D. Jefferds, Zuguo Mei, Yaw Addo, Heather C. Hamner, Cria G. Perrine, Rafael Flores-Ayala, and Andrea J. Sharma were with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Christine M. Pfeiffer was with the Nutritional Biomarkers Branch, National Center for Environmental Health, CDC, Atlanta
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28
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Xu S, Zheng H, Tang Z, Gu Z, Wang M, Tang C, Xie Y, Kong M, Jing J, Su Y, Zhu Y. Antenatal Iron-Rich Food Intervention Prevents Iron-Deficiency Anemia but Does Not Affect Serum Hepcidin in Pregnant Women. J Nutr 2022; 152:1450-1458. [PMID: 35285912 DOI: 10.1093/jn/nxac065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/29/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Limited evidence supports the efficacy of iron-rich foods (IRFs) in improving iron status during pregnancy. OBJECTIVES The study aims to evaluate the effect of IRFs on iron status and biomarkers of iron metabolism in the third trimester of pregnancy. METHODS A total of 240 pregnant women at 11-13 wk of gestation without iron-deficiency anemia (IDA) in South China were recruited to this single-blind clinical trial [non-IDA referred to both hemoglobin (Hb) ≥110g/L and serum ferritin (SF) ≥15ng/mL], randomly assigned to 1) control, 2) IRFs containing 20 mg iron/d (IRF-20), or 3) IRFs containing 40 mg iron/d (IRF-40). The IRFs were consumed 3 days a week, including pork liver, chicken/duck blood, soybean, and agaric. The IRFs started at recruitment and ended in the predelivery room. Primary outcome included anemia (Hb <110 g/L), iron deficiency (ID, definition 1: SF <15 ng/mL; definition 2: SF <12 ng/mL), and IDA (ID and Hb <110 g/L). Secondary outcome was plasma Hb and iron indices, including SF, serum hepcidin, and iron. RESULTS All participants who completed the trial with full data (n = 170) were included in the analysis. At the endline, both intervention groups showed lower ID and IDA rates than control. Specifically, IRF-40 showed a lower ID (SF <12 ng/mL) rate than control (9.0% compared with 22.8%, P = 0.022). For IDA by definition 1, the incidence in IRF-40 was lower than that in control (1.9% compared with 8.9%, P = 0.045). For IDA by definition 2, the incidence in IRF-20 was lower than that in control (3.9% compared with 17.9%, P = 0.049). Moreover, IRF-20 showed higher SF concentrations than control (P = 0.039). No effects of IRFs on anemia (P = 0.856), plasma Hb (P = 0.697), serum hepcidin (P = 0.311), and iron (P = 0.253) concentrations were observed. The assessed iron intakes were 22.2 mg/d in IRF-20 and 25.0 mg/d in IRF-40, respectively. CONCLUSIONS Antenatal IRFs reduce the risk of ID and IDA in late pregnancy, although the present results are inadequate to confirm an ideal dosage (No. ChiCTR1800017574).
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Affiliation(s)
- Suhua Xu
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hao Zheng
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Zhaoxie Tang
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Zhuohe Gu
- Maoming Maternal and Child Health Care Hospital, Maoming, China
| | - Min Wang
- Maoming Maternal and Child Health Care Hospital, Maoming, China
| | - Cuilan Tang
- Maoming Maternal and Child Health Care Hospital, Maoming, China
| | - Yanqi Xie
- Maoming Maternal and Child Health Care Hospital, Maoming, China
| | - Minli Kong
- Maoming Maternal and Child Health Care Hospital, Maoming, China
| | - Jiajia Jing
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yanbin Su
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yanna Zhu
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China.,Department of Maternal and Child Health, and Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
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29
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Elmore C, Ellis J. Screening, Treatment, and Monitoring of Iron Deficiency Anemia in Pregnancy and Postpartum. J Midwifery Womens Health 2022; 67:321-331. [PMID: 35642737 DOI: 10.1111/jmwh.13370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Christina Elmore
- Birthcare Healthcare, University of Utah College of Nursing, Salt Lake City, Utah
| | - Jessica Ellis
- Birthcare Healthcare, University of Utah College of Nursing, Salt Lake City, Utah
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30
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Fischer T, Helmer H, Klaritsch P, Fazelnia C, Bogner G, Hillerer KM, Wohlmuth C, Jaksch-Bogensperger H. Diagnosis and Therapy of Iron Deficiency Anemia During Pregnancy: Recommendation of the Austrian Society for Gynecology and Obstetrics (OEGGG). Geburtshilfe Frauenheilkd 2022; 82:392-399. [PMID: 35392071 PMCID: PMC8983107 DOI: 10.1055/a-1710-3387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 10/25/2022] Open
Abstract
This overview analyzes the data on the controversial therapy of iron substitution during pregnancy, the diagnosis of iron deficiency anemia and the indication-related therapy, and is the first recommendation issued by the OEGGG on the appropriate therapy. The effects of anemia during pregnancy on postnatal outcomes have been intensively investigated with heterogeneous results. A final scientific conclusion with regards to the "optimal" maternal hemoglobin level is limited by the heterogeneous results of various studies, many of which were conducted in emerging nations (with different dietary habits and structural differences in the respective healthcare systems). The current literature even suggests that there may be a connection between both decreased and increased maternal serum hemoglobin concentrations and unfavorable short-term and long-term neonatal outcomes. In Austria, 67 percent of pregnant women take pharmacological supplements or use a variety of dietary supplements. Clinically, the prevalence of maternal anemia is often overestimated, leading to overtreatment of pregnant women (iron substitution without a medical indication). To obtain a differential diagnosis, a workup of the indications for treatment should be carried out prior to initiating any form of iron substitution during pregnancy. If treatment is medically indicated, oral iron substitution is usually sufficient. Because of the restricted approval and potential side effects, medical indications for intravenous iron substitution should be limited. Intravenous iron substitution without a prior detailed diagnostic workup is an off-label use and should only be used in very limited cases, and women should be advised accordingly.
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Affiliation(s)
- Thorsten Fischer
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
| | - Hanns Helmer
- Leitliniengruppe der Österreichischen Gesellschaft für Gynäkologie und Geburtshilfe, Univ.-Klinik f. Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Philipp Klaritsch
- Abteilung für Geburtshilfe, Universitätsklinik für Frauenheilkunde und Geburtshilfe, Medizinische Universität Graz, Graz, Austria
| | - Claudius Fazelnia
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
| | - Gerhard Bogner
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
| | - Katharina M Hillerer
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
| | - Christoph Wohlmuth
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
| | - Heidi Jaksch-Bogensperger
- Universitätsklinik für Frauenheilkunde und Geburtshilfe, Paracelsus Medizinische Universität Salzburg (PMU), Salzburg, Austria
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31
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Wierzejska RE. Review of Dietary Recommendations for Twin Pregnancy: Does Nutrition Science Keep Up with the Growing Incidence of Multiple Gestations? Nutrients 2022; 14:1143. [PMID: 35334799 PMCID: PMC8953105 DOI: 10.3390/nu14061143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023] Open
Abstract
Recommendations for nutrition and the use of dietary supplements for pregnant women are updated on regular basis but it remains to be seen to what extent they may be applicable in twin pregnancies. The aim of this narrative review is to present the current state of knowledge about the energy and nutrient demand in twin pregnancy. There is general consensus in literature that the energy demand is higher than in a singleton pregnancy, but there is a lack of position statements from scientific societies on specific energy intake that is required. In turn, recommended maternal weight gain, which favors the normal weight of the neonate, has been determined. There is even a larger knowledge gap when it comes to vitamins and minerals, the body stores of which are theoretically used up faster. The greatest number of studies so far focused on vitamin D, and most of them concluded that its concentration in maternal blood is lower in twin as compared to singleton pregnancy. Few randomized studies focus on iron supplementation and there are no other studies that would assess dietary interventions. In light of a growing incidence of multiple pregnancies, more studies are necessary to establish the nutritional demands of the mother and the course of action for adequate supplementation.
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Affiliation(s)
- Regina Ewa Wierzejska
- Department of Nutrition and Nutritional Value of Food, National Institute of Public Health NIH-National Research Institute, Chocimska St. 24, 00-791 Warsaw, Poland
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Shin DW, Cho J, Park JH, Cho B. National General Health Screening Program in Korea: history, current status, and future direction: A scoping review. PRECISION AND FUTURE MEDICINE 2022. [DOI: 10.23838/pfm.2021.00135] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Meyerovitch J, Carmi D, Aviner S, Sherf M, Comaneshter D, Laks Y, Key C, Gabbay U, Cohen AD. Reducing infantile anemia: insight on patterns of process and outcome indicators by ethnicity and socioeconomic class during a 10-year intervention program and 5 years after. Isr J Health Policy Res 2022; 11:2. [PMID: 34986880 PMCID: PMC8734336 DOI: 10.1186/s13584-021-00510-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022] Open
Abstract
Background In 2005, Clalit Health Services (CHS), the largest health maintenance organization in Israel, initiated an intervention program aimed at reducing the prevalence rate of infantile anemia (IA). This study evaluated the progress made during the intervention (2005–2014) and its yield 5 years after it ended (2019). Methods The CHS database was retrospectively reviewed twice yearly from 2005 to 2014 for repetitive samples of children aged 9 to 18 months regarding the previous half-year interval, and a single sample in 2019. Data were collected on gender, ethnicity (Jewish/non-Jewish), socioeconomic class (SEC; low/intermediate/high), hemoglobin testing (yes/no), and hemoglobin level (if tested). Excluded were infants with documented or suspected hemoglobinopathy. Results At study initiation, the rate of performance of hemoglobin testing was 54.7%, and the IA prevalence rate was 7.8%. The performance rate was lower in the Jewish than the non-Jewish subpopulation. The low-SEC subpopulation had a similar hemoglobin testing rate to the high-SEC subpopulation but double the IA prevalence rate. Overall, by the end of the intervention (2014), the performance rate increased to 87.5%, and the AI prevalence rate decreased to 3.4%. In 2019, there was little change in the performance rate from the end of the intervention (88%) and the IA prevalence was further reduced to 2.7%. The non-Jewish and low-SEC subpopulations showed the most improvement which was maintained and even bettered 5 years after the intervention ended. Conclusions The 10-year IA intervention program introduced by CHS in 2005 led to a reduction in IA prevalence rate to about 3.5% in all sub-populations evaluated. By program end, the results in the weaker subpopulations, which had the highest prevalence of IA at baseline, were not inferior to those in the stronger subpopulations. We recommended to the Israel Ministry of Health to adopt the intervention countrywide, and we challenge other countries to consider similar interventions.
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Affiliation(s)
- Joseph Meyerovitch
- Medicine Wing, Community Division, Clalit Health Services, Tel Aviv, Israel.,The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Ramat Aviv, Tel-Aviv, Israel
| | - Doron Carmi
- Shoham Ambulatory Center, Clalit Health Services, Shoham, Israel
| | - Shraga Aviner
- Department of Pediatrics, Faculty of Health Sciences, Barzilai University Medical Center, Ashkelon, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | | | | | - Yoseph Laks
- Pediatric Ambulatory Center, Clalit Health Services, Tel Aviv, Israel
| | - Calanit Key
- Nursing Medicine Wing, Community Division, Clalit Health Services, Tel Aviv, Israel
| | - Uri Gabbay
- Sackler Faculty of Medicine, Tel Aviv University, 6997801, Ramat Aviv, Tel-Aviv, Israel. .,Quality Unit, Rabin Medical Center, Petach Tikva, Israel.
| | - Arnon D Cohen
- Department of Pediatrics, Faculty of Health Sciences, Barzilai University Medical Center, Ashkelon, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Siaal Research Center for Family Medicine and Primary Care Faculty of Health Sciences, Ben Gurion University of Negev, Beer Sheva, Israel
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Ouazzani HE, Rouillon S, Venisse N, Sifer-Rivière L, Dupuis A, Cambien G, Ayraud-Thevenot S, Gourgues AS, Pierre-Eugène P, Pierre F, Rabouan S, DisProSE Group, Migeot V, Albouy-Llaty M. Impact of perinatal environmental health education intervention on exposure to endocrine disruptors during pregnancy-PREVED study: study protocol for a randomized controlled trial. Trials 2021; 22:876. [PMID: 34863252 PMCID: PMC8642981 DOI: 10.1186/s13063-021-05813-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/10/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The suspected or actual effects on health of endocrine-disrupting chemicals (EDC) and their ubiquitous presence in everyday life justify the implementation of health promotion interventions. These interventions should ideally be applied during critical windows like pregnancy. Perinatal environmental health education interventions may help to reduce EDC exposure during pregnancy. METHODS/DESIGN PREVED (Pregnancy, PreVention, Endocrine Disruptors) is an open-label randomized controlled trial assessing the impact of environmental health education intervention on EDC exposure during pregnancy. Inclusion, consent, and randomization take place during the first trimester. The participants are randomly allocated into three groups: (i) control group (information leaflet on EDCs), (ii) intervention group in neutral location (information leaflet and workshops in a meeting room), and (iii) intervention group in contextualized location (information leaflet and workshops in a real apartment). Workshops are organized between the second and third trimesters of pregnancy. Main outcome is the percentage of participants who reported consuming manufactured/industrial food. Secondary outcomes are as follows: (i) psycho-social dimensions, (ii) EDC concentrations in urine, (iii) EDC concentration in colostrum, and (iv) percentage of participants who reported consuming paraben-free personal care products. DISCUSSION PREVED is a ground-breaking intervention research project dedicated to perinatal environmental health education that aims to identify pollutant sources in daily life and to offer accessible and realistic alternative solutions, by promoting the sharing of know-how and experience in a positive and non-alarmist approach. TRIAL REGISTRATION ClinicalTrials.gov : NCT03233984 (current status: ongoing). Retrospectively registered on 31 July 2017 ( https://clinicaltrials.gov/ct2/show/NCT03233984 ) because when the first participant was enrolled in this non-drug intervention, ClinicalTrials.gov was centered in therapeutic trials. The World Health Organization Trial Registration Data Set is in Additional file 1.
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Affiliation(s)
- Houria El. Ouazzani
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Steeve Rouillon
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- UMR CNRS 7285, IC2MP, Poitiers, France
| | - Nicolas Venisse
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Lynda Sifer-Rivière
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Research Center of Medicine, Sciences, Health and Society (Cermes 3), EHESS, University of Paris Descartes, Villejuif, France
| | - Antoine Dupuis
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Guillaume Cambien
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
| | - Sarah Ayraud-Thevenot
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
| | - Anne-Sophie Gourgues
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Pascale Pierre-Eugène
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Fabrice Pierre
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Department of Obstetrics and Gynecology and Reproductive Medicine, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Sylvie Rabouan
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
| | - DisProSE Group
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- UMR CNRS 7285, IC2MP, Poitiers, France
- Research Center of Medicine, Sciences, Health and Society (Cermes 3), EHESS, University of Paris Descartes, Villejuif, France
- Department of Obstetrics and Gynecology and Reproductive Medicine, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Virginie Migeot
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
| | - Marion Albouy-Llaty
- Health-Endocrine Disruptors-EXposome (HEDEX), INSERM-CIC1402, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
- Faculty of Medicine and Pharmacy, University of Poitiers, 6 rue de la Milétrie, 86000 Poitiers, France
- BioSPharm Pole, University Hospital of Poitiers, 2 rue de la Milétrie, 86021 Poitiers CEDEX, France
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Suboptimal iron deficiency screening in pregnancy and the impact of socioeconomic status in a high-resource setting. Blood Adv 2021; 5:4666-4673. [PMID: 34459878 PMCID: PMC8759118 DOI: 10.1182/bloodadvances.2021004352] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/31/2021] [Indexed: 12/16/2022] Open
Abstract
Iron deficiency (ID) anemia in pregnancy is associated with poor maternal and childhood outcomes, yet ferritin testing, the standard test for ID, is not considered part of routine prenatal bloodwork in Canada. We conducted a retrospective cohort study of 44 552 pregnant patients with prenatal testing at community laboratories in Ontario, Canada, to determine the prevalence of ferritin testing over 5 years. Secondary objectives were to determine the prevalence and severity of ID and to identify clinical and demographic variables that influence the likelihood of ID screening. A total of 59.4% of patients had a ferritin checked during pregnancy; 71.4% were ordered in the first trimester, when the risk of ID is lowest. Excluding patients with abnormally elevated ferritins, 25.2% were iron insufficient (30-44 µg/L) and 52.8% were iron deficient (≤29 µg/L) at least once in pregnancy. A total of 8.3% were anemic (hemoglobin <105 g/L). The proportion of anemic patients with a subsequent ferritin test in pregnancy ranged from 22% to 67% in the lowest and highest anemia severity categories, respectively. Lower annual household income was negatively associated with the odds of a ferritin test; compared with those in the fifth (ie, highest) income quintile, the odds of ferritin testing for patients in the first, second, and fourth quintiles were 0.83 (95% confidence interval [CI], 0.74-0.91), 0.82 (95% CI, 0.74-0.91), and 0.86 (95% CI, 0.77-0.97), respectively. These data highlight gaps in prenatal care and issues of health equity that warrant harmonization of obstetrical guidelines to recommend routine ferritin testing in pregnancy.
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Duarte AFM, Carneiro ACSV, Peixoto ATBMM, Montenegro DFP, Campos DSC, Alves APR, Costa ARMM, Fino APM. Oral Iron Supplementation in Pregnancy: Current Recommendations and Evidence-Based Medicine. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:782-788. [PMID: 34784635 PMCID: PMC10183862 DOI: 10.1055/s-0041-1736144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To review the evidence about universal iron supplementation in pregnancy to prevent maternal anemia. METHODS Bibliographic research of randomized and controlled clinical trials, meta-analyses, systematic reviews, and clinical guidelines, published between August 2009 and August 2019, using the MeSH terms: iron; therapeutic use; pregnancy; anemia, prevention and control. RESULTS We included six clinical guidelines, three meta-analyses and one randomized controlled clinical trial. DISCUSSION Most articles point to the improvement of hematological parameters and reduction of maternal anemia risk, with supplementary iron. However, they do not correlate this improvement in pregnant women without previous anemia with the eventual improvement of clinical parameters. CONCLUSION Universal iron supplementation in pregnancy is controversial, so we attribute a SORT C recommendation strength.
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Caughey AB, Krist AH, Wolff TA, Barry MJ, Henderson JT, Owens DK, Davidson KW, Simon MA, Mangione CM. USPSTF Approach to Addressing Sex and Gender When Making Recommendations for Clinical Preventive Services. JAMA 2021; 326:1953-1961. [PMID: 34694343 DOI: 10.1001/jama.2021.15731] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diversity that are not often considered in studies of clinical preventive services that inform the recommendations, resulting in challenges when evaluating the evidence and communicating recommendations for persons in specific gender identification categories (man/woman/gender nonbinary/gender nonconforming/transgender). To advance its methods, the USPSTF reviewed its past recommendations that included the use of sex and gender terms, reviewed the approaches of other guideline-making bodies, and pilot tested strategies to address sex and gender diversity. Based on the findings, the USPSTF intends to use an inclusive approach to identify issues related to sex and gender at the start of the guideline development process; assess the applicability, variability, and quality of evidence as a function of sex and gender; ensure clarity in the use of language regarding sex and gender; and identify evidence gaps related to sex and gender. Evidence reviews will identify the limitations of applying findings to diverse groups from underlying studies that used unclear terminology regarding sex and gender. The USPSTF will use gender-neutral language when appropriate to communicate that recommendations are inclusive of people of any gender and will clearly state when recommendations apply to individuals with specific anatomy associated with biological sex (male/female) or to specific categories of gender identity. The USPSTF recognizes limited evidence to inform the preventive care of populations based on gender identity.
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Affiliation(s)
- Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
| | - Tracy A Wolff
- Center for Evidence and Practice Improvement (CEPI), Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Michael J Barry
- Informed Medical Decisions Program, Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Jillian T Henderson
- Kaiser Permanente, Northwest, Center for Health Research, Kaiser Permanente Evidence-based Practice Center, Portland, Oregon
| | - Douglas K Owens
- Stanford Health Policy, Department of Medicine and Freeman Spogli Institute for International Studies, Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institutes for Medical Research at Northwell Health, New York, New York
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carol M Mangione
- Departments of Medicine and Health Policy and Management, University of California at Los Angeles
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Sharma AJ, Ford ND, Bulkley JE, Jenkins LM, Vesco KK, Williams AM. Use of the Electronic Health Record to Assess Prevalence of Anemia and Iron Deficiency in Pregnancy. J Nutr 2021; 151:3588-3595. [PMID: 34386820 PMCID: PMC9550311 DOI: 10.1093/jn/nxab254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/06/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the United States, the prevalence of anemia, iron deficiency (ID), and iron-deficiency anemia (IDA) during pregnancy remains largely unknown as data at the national or state level are limited or nonexistent, respectively. OBJECTIVES In an effort to identify opportunities to improve maternal health surveillance, we assessed the feasibility of anemia, ID, and IDA surveillance among first-trimester pregnancies using electronic health records (EHRs). METHODS We identified pregnancies among Kaiser Permanente Northwest members aged ≥18 y during 2005-2016 with first-trimester prenatal care (n = 41,991). Earliest laboratory test results for hemoglobin or hematocrit and ferritin were selected. We describe the proportion of pregnancies screened for and the prevalence of anemia, ID, and IDA; the concordance of anemia status by hemoglobin compared with hematocrit; and the proportion of pregnancies with laboratory-confirmed anemia that also had an International Classification of Diseases diagnostic code related to anemia. RESULTS Identified pregnancies included women who were 73.1% non-Hispanic (NH) white, 11.5% Hispanic, 8.5% NH Asian/Pacific Islander, and 2.9% NH black. Hemoglobin and hematocrit results were available for 92.7% (n = 38,923) pregnancies. Anemia prevalence was 2.7% (n = 1045) based on hemoglobin <11.0 g/dL or hematocrit <33%; 45.2% of anemia cases had both low hemoglobin and low hematocrit. Among pregnancies with anemia, 18.9% (n = 197) had a ferritin result; of those, 48.2% had ID (ferritin <15 μg/L). In pregnancies without anemia, 3.4% (n = 1275) had a ferritin result; of those, 23.5% had ID. Based on 1472 pregnancies with both anemia and ID assessed, prevalence of ID and IDA was 26.8% and 6.5%, respectively; estimates likely represent selective screening. CONCLUSIONS EHR data have potential to monitor anemia prevalence and trends in health systems where prenatal anemia screening is nearly universal. However, if iron assessment is not routine, then representative estimates of ID or IDA are unattainable.
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Affiliation(s)
- Andrea J Sharma
- Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA,US Public Health Service Commissioned Corps, Atlanta, GA, USA
| | - Nicole D Ford
- Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA,McKing Consulting Corporation, Fairfax, VA, USA
| | | | | | - Kimberly K Vesco
- Kaiser Permanente Center for Health Research, Portland, OR, USA,Department of Obstetrics & Gynecology, Kaiser Permanente Northwest, Portland, OR, USA
| | - Anne M Williams
- Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA,McKing Consulting Corporation, Fairfax, VA, USA
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Under-recognition of measurement and management of serum ferritin among populations at high risk of iron deficiency - Authors' reply. LANCET HAEMATOLOGY 2021; 8:e787-e788. [PMID: 34715042 PMCID: PMC10174049 DOI: 10.1016/s2352-3026(21)00299-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/21/2022]
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Franco B, Mota DS, Daubian-Nosé P, Rodrigues NDA, Simino LADP, de Fante T, Bezerra RMN, Manchado Gobatto FDB, Manconi M, Torsoni AS, Esteves AM. Iron deficiency in pregnancy: Influence on sleep, behavior, and molecular markers of adult male offspring. J Neurosci Res 2021; 99:3325-3338. [PMID: 34651324 DOI: 10.1002/jnr.24968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 08/17/2021] [Accepted: 08/31/2021] [Indexed: 12/14/2022]
Abstract
Iron restriction during pregnancy can lead to iron deficiency and changes in the dopaminergic system in the adulthood of offspring, and restless legs syndrome (RLS) is closely related to these changes. Objectives: Analyze whether iron restriction during pregnancy would cause changes in the behavior, sleep, and dopaminergic system of the male offspring. In addition, we aimed to assess whether exercise would be able to modulate these variables. The pregnant rats (Wistar) were divided into four groups with different concentrations of iron in the diet: standard (St), supplementation (Su), restriction since weaning (R1), and restriction only during pregnancy (R2). After birth, the offspring were assigned to their respective groups according to the dams diet (St, Su, R1, and R2) and distributed into sedentary (SD) and exercised (EX) (for 8 weeks of training), reaching eight groups of offspring (O): OSt SD, OSt EX, OSu SD, OSu EX, OR1 SD, OR1 EX, OR2 SD, and OR2 EX. Sleep, behavior, and analysis of key genes of dopaminergic system (D2, DAT) were performed after 8 weeks. The results for trained offspring that the mother received supplementation diet were the most expressive, with increased freezing and the OR1 SD group showed an increase in DAT protein content. These changes may have been due to the association between the dams diet during pregnancy and the practice of exercise by the offspring. The different concentrations of iron during pregnancy caused changes in the offspring, however, they were not associated with fetal programming in the context of RLS.
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Affiliation(s)
- Beatriz Franco
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Campinas, Brazil
| | - Diego Silva Mota
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | - Paulo Daubian-Nosé
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | | | | | - Thaís de Fante
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | | | - Fúlvia de Barros Manchado Gobatto
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Campinas, Brazil.,Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Lugano, Switzerland
| | | | - Andrea Maculano Esteves
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Campinas, Brazil.,Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
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Read AJ, Waljee AK, Sussman JB, Singh H, Chen GY, Vijan S, Saini SD. Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians. JAMA Netw Open 2021; 4:e2127827. [PMID: 34596670 PMCID: PMC8486982 DOI: 10.1001/jamanetworkopen.2021.27827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. OBJECTIVE To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. DESIGN, SETTING, AND PARTICIPANTS This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. MAIN OUTCOMES AND MEASURES Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. RESULTS Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. CONCLUSIONS AND RELEVANCE In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.
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Affiliation(s)
- Andrew J. Read
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jeremy B. Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Grace Y. Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
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Abstract
Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester (depending on the guideline used) is considered anemia. Anemia is the most common hematologic abnormality in pregnancy. Maternal anemia is associated with adverse fetal, neonatal and childhood outcomes, but causality is not established. Maternal anemia increases the likelihood of transfusion at delivery. Besides hemodilution, iron deficiency is the most common cause of anemia in pregnancy. The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation. Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia. A trial of oral iron can be both diagnostic and therapeutic. Mild anemia with a very low MCV, macrocytic anemia, moderate anemia (hemoglobin 7.0-9.9 g/dL) or severe anemia (hemoglobin 4.0-6.9 g/dL) requires further investigation. Once a diagnosis of iron deficiency anemia is confirmed, first-line treatment is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred. With contemporary formulations, allergic reactions are rare.
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Sun Y, Shen ZZ, Huang FL, Jiang Y, Wang YW, Zhang SH, Ma S, Liu JT, Zhan YL, Lin H, Chen YL, Shi YJ, Ma LK. Association of gestational anemia with pregnancy conditions and outcomes: A nested case-control study. World J Clin Cases 2021; 9:8008-8019. [PMID: 34621857 PMCID: PMC8462208 DOI: 10.12998/wjcc.v9.i27.8008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/01/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gestational anemia is a serious public health problem that affects pregnant women worldwide. Pregnancy conditions and outcomes might be associated with the presence of gestational anemia. This study investigated the association of pregnancy characteristics with anemia, exploring the potential etiology of the disease.
AIM To assess the association of pregnancy parameters with gestational anemia.
METHODS A nested case-control study was conducted based on the Chinese Pregnant Women Cohort Study-Peking Union Medical College Project (CPWCS-PUMC). A total of 3172 women were included. Patient characteristics and gestational anemia occurrence were extracted, and univariable and multivariable logistic regression models were used to analyze the association of pregnancy parameters with gestational anemia.
RESULTS Among the 3172 women, 14.0% were anemic, 46.4% were 25-30 years of age, 21.9% resided in eastern, 15.7% in middle, 12.4% in western 18.0% in southern and 32.0% in northern regions of China. Most women (65.0%) had a normal prepregnancy body mass index. Multivariable analysis found that the occurrence of gestational anemia was lower in the middle and western regions than that in the eastern region [odds ratio (OR) = 0.406, 95% confidence interval (CI): 0.309-0.533, P < 0.001)], higher in the northern than in the southern region (OR = 7.169, 95%CI: 5.139-10.003, P < 0.001), lower in full-term than in premature births (OR = 0.491, 95%CI: 0.316-0.763, P = 0.002), and higher in cases with premature membrane rupture (OR=1.404, 95%CI: 1.051-1.876, P = 0.02).
CONCLUSION Gestational anemia continues to be a health problem in China, and geographical factors may contribute to the situation. Premature birth and premature membrane rupture may be associated with gestational anemia. Therefore, we should vigorously promote local policy reformation to adapt to the demographic characteristics of at-risk pregnant women, which would potentially reduce the occurrence of gestational anemia.
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Affiliation(s)
- Yin Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
| | - Zhong-Zhou Shen
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fei-Ling Huang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ya-Wen Wang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Su-Han Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
| | - Shuai Ma
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jun-Tao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
| | - Yong-Le Zhan
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hang Lin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
| | - Yun-Li Chen
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ying-Jie Shi
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Liang-Kun Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing 100730, China
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Iron deficiency during the first 1000 days of life: are we doing enough to protect the developing brain? Proc Nutr Soc 2021; 81:108-118. [PMID: 34548120 DOI: 10.1017/s0029665121002858] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Iron is essential for the functioning of all cells and organs, most critically for the developing brain in the fundamental neuronal processes of myelination, energy and neurotransmitter metabolism. Iron deficiency, especially in the first 1000 days of life, can result in long-lasting, irreversible deficits in cognition, motor function and behaviour. Pregnant women, infants and young children are most vulnerable to iron deficiency, due to their high requirements to support growth and development, coupled with a frequently inadequate dietary supply. An unrecognised problem is that even if iron intake is adequate, common pregnancy-related and lifestyle factors can affect maternal-fetal iron supply in utero, resulting in an increased risk of deficiency for the mother and her fetus. Although preterm birth, gestational diabetes mellitus and intrauterine growth restriction are known risk factors, more recent evidence suggests that maternal obesity and delivery by caesarean section further increase the risk of iron deficiency in the newborn infant, which can persist into early childhood. Despite the considerable threat that early-life iron deficiency poses to long-term neurological development, life chances and a country's overall social and economic progress, strategies to tackle the issue are non-existent, too limited or totally inappropriate. Prevention strategies, focused on improving the health and nutritional status of women of reproductive age are required. Delayed cord clamping should be considered a priority. Better screening strategies to enable the early detection of iron deficiency during pregnancy and early-life should be prioritised, with intervention strategies to protect maternal health and the developing brain.
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Santander Ballestín S, Giménez Campos MI, Ballestín Ballestín J, Luesma Bartolomé MJ. Is Supplementation with Micronutrients Still Necessary during Pregnancy? A Review. Nutrients 2021; 13:3134. [PMID: 34579011 PMCID: PMC8469293 DOI: 10.3390/nu13093134] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Proper nutrition during pregnancy is important to prevent nutritional imbalances that interfere with pregnancy. Micronutrients play critical roles in embryogenesis, fetal growth, and maternal health, as energy, protein, vitamin, and mineral needs can increase during pregnancy. Increased needs can be met by increasing the intake of dietary micronutrients. Severe micronutrient deficiency or excess during pregnancy can have negative effects on fetal growth (intrauterine growth retardation, low birth weight, or congenital malformations) and pregnancy development (pre-eclampsia or gestational diabetes). We investigate whether it is necessary to continue micronutrient supplementation during pregnancy to improve women's health in this stage and whether this supplementation could prevent and control pathologies associated with pregnancy. AIM The present review aims to summarize evidence on the effects of nutritional deficiencies on maternal and newborn morbidity. METHODS This aim is addressed by critically reviewing results from published studies on supplementation with different nutrients during pregnancy. For this, major scientific databases, scientific texts, and official webpages have been consulted. PubMed searches using the terms "pregnancy" OR "maternal-fetal health" AND "vitamins" OR "minerals" OR "supplementation" AND "requirement" OR "deficiency nutrients" were performed. RESULTS There are accepted interventions during pregnancy, such as folic acid supplementation to prevent congenital neural tube defects, potassium iodide supplementation to correct neurodevelopment, and oral iron supplementation during the second half of pregnancy to reduce the risk of maternal anemia and iron deficiency. A number of micronutrients have also been associated with pre-eclampsia, gestational diabetes mellitus, and nausea and vomiting in pregnancy. In general, experimental studies are necessary to demonstrate the benefits of supplementation with different micronutrients and to adjust the recommended daily doses and the recommended periconceptional nutrition for mothers. CONCLUSIONS Presently, there is evidence of the benefits of micronutrient supplementation in perinatal results, but indiscriminate use is discouraged due to the fact that the side effects of excessive doses are not known. Evidence supports the idea that micronutrient deficiencies negatively affect maternal health and the outcome of pregnancy. No single micronutrient is responsible for the adverse effects; thus, supplementing or correcting one deficiency will not be very effective while other deficiencies exist.
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Affiliation(s)
- Sonia Santander Ballestín
- Department of Pharmacology, Physiology and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | | | | | - María José Luesma Bartolomé
- Department of Human Anatomy and Histology, Faculty of Science, University of Zaragoza, 50009 Zaragoza, Spain;
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Harrison RK, Lauhon SR, Colvin ZA, McIntosh JJ. Maternal anemia and severe maternal morbidity in a US cohort. Am J Obstet Gynecol MFM 2021; 3:100395. [PMID: 33992832 PMCID: PMC8435012 DOI: 10.1016/j.ajogmf.2021.100395] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Maternal anemia is a common pregnancy complication and often leads to a requirement for additional treatments and interventions. Identifying the frequency at which women with antenatally diagnosed anemia experience severe morbidity at the time of admission to the labor and delivery unit will guide future recommendations regarding screening and interventions for anemia during pregnancy. OBJECTIVE The objective of this study was to evaluate the association between antenatally diagnosed anemia and severe maternal morbidity as defined by the Centers for Disease Control and Prevention in a large, contemporary, US cohort. Neonatal outcomes were also examined. STUDY DESIGN This was a secondary analysis of the Consortium on Safe Labor database from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, which collected data on 228,438 deliveries in 19 United States hospitals from 2002 to 2008. This analysis included women with viable, singleton gestations and excluded stillbirths and gestations with severe congenital anomalies. Women with a diagnosis of antenatal anemia were compared with those without. Identification of diagnoses of antenatal anemia was obtained via electronic medical record abstraction and International Classification of Diseases coding according to each hospital protocol within the Consortium on Safe Labor. The primary maternal outcome consisted of a composite of severe maternal morbidity as defined by the Centers for Disease Control and Prevention and included maternal death, eclampsia, thrombosis, transfusion, hysterectomy, and maternal intensive care unit admission. The primary neonatal outcome was a composite that included a 5-minute Apgar score of <7, hypoxic ischemic encephalopathy, respiratory distress syndrome, necrotizing enterocolitis, seizures, intracranial hemorrhage, periventricular or intraventricular hemorrhage, neonatal sepsis, neonatal intensive care unit admission, and neonatal death. Each outcome within the composites was assessed individually along with other additional secondary outcomes, including a composite of severe maternal morbidity not including transfusion morbidity. All statistical analyses were performed with Stata version 14.2 (StataCorp LLC, College Station, TX) using Student's t test, chi-square test, Fisher's exact test, and Wilcoxon rank-sum (Mann-Whitney U) test, as appropriate. A multivariable logistic regression was performed with potential confounding variables entered into the regression equation if they differed between groups at a significance level of P<.05. RESULTS A total of 166,566 women met the inclusion criteria. From the original cohort, 56,734 women could not be included because of an unknown diagnosis of anemia. Of those included, 10,217 (6.1%) were diagnosed with anemia during the pregnancy. Women with anemia were more likely to be younger, non-Hispanic Black, single, multiparous, and have a higher prepregnancy body mass index than those without anemia. The frequency of the primary maternal composite outcome, the neonatal composite outcome, and other secondary outcomes including the severe maternal morbidity composite not including transfusion, maternal death, transfusion during labor and the postpartum period, hysterectomy, postpartum hemorrhage, infectious morbidity, cesarean delivery, and preterm delivery were more common in women with anemia (P<.05). After multivariable logistic regression analysis adjusting for confounders, higher rates of severe maternal morbidity remained persistently associated with anemia (adjusted odds ratio, 2.04; 95% confidence interval, 1.86-2.23) in addition to the association of anemia with the severe maternal morbidity composite not including transfusion, maternal death, thrombosis, transfusion, hysterectomy, intensive care unit admission, postpartum hemorrhage, hypertensive disorders of pregnancy, cesarean delivery, and infectious morbidity. The composite neonatal outcome also remained associated with anemia after adjusting for confounders (adjusted odds ratio, 1.14; 95% confidence interval, 1.06-1.23). CONCLUSION Women with antepartum anemia experienced increased rates of severe maternal morbidity and other serious adverse outcomes. Diagnosis and treatment of anemia during the antepartum period may lead to the identification and treatment of women at higher risk for maternal morbidity and mortality.
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Affiliation(s)
- Rachel K Harrison
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Drs Harrison, Colvin, and McIntosh); Maternal Fetal Medicine, Advocate Medical Group, Chicago, IL (Dr Harrison).
| | | | - Zachary A Colvin
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Drs Harrison, Colvin, and McIntosh)
| | - Jennifer J McIntosh
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Drs Harrison, Colvin, and McIntosh)
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47
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Abstract
Anemia, the most common hematologic abnormality, is a reduction in the concentration of erythrocytes or hemoglobin in blood. The two most common causes of anemia in pregnancy and the puerperium are iron deficiency and acute blood loss. Iron requirements increase during pregnancy, and a failure to maintain sufficient levels of iron may result in adverse maternal-fetal consequences. The purpose of this document is to provide a brief overview of the causes of anemia in pregnancy, review iron requirements, and provide recommendations for screening and clinical management of anemia during pregnancy.
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48
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Kling PJ. Ironing Out the Details of Maternal-Fetal Iron Trafficking: New Tools in the Toolbox. J Nutr 2021; 151:2509-2510. [PMID: 34320201 PMCID: PMC8417915 DOI: 10.1093/jn/nxab247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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49
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Imai K. Parity-based assessment of anemia and iron deficiency in pregnant women. Taiwan J Obstet Gynecol 2021; 59:838-841. [PMID: 33218398 DOI: 10.1016/j.tjog.2020.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE This study aimed to separately evaluate the prevalence of anemia and iron deficiency in nulliparous and multiparous women. MATERIALS AND METHODS We retrospectively examined data of women who delivered in our clinic from January 2016 to December 2018. Inclusion criteria were delivery occurring at ≥36 weeks and singleton pregnancy. Pregnant women with severe medical disorders were excluded. We estimated complete blood count (CBC) and serum ferritin (SF) in the first trimester and only CBC in the late second trimester. Data of nulliparas and multiparas were analyzed separately. Statistically significance was set at p < 0.05. RESULTS Totally, 481 nulliparas and 603 and multiparas were enrolled. Mean hemoglobin values in the first trimester were 12.6 ± 1.0 and 12.4 ± 1.0 g/dl (p < 0.001), while median SF values were 42.7 (12.2, 108.2) and 27.7 (8.0, 72.6) ng/ml (p < 0.001) in nulliparas and multiparas, respectively. Hemoglobin in the late second trimester was 11.2 ± 0.9 and 10.7 ± 1.0 g/dl (p < 0.001) in nulliparas and multiparas, respectively. Low ferritin levels (SF < 12 ng/ml) were more frequently found in multiparas than in nulliparas (111/603 vs. 46/481, p < 0.001, Odds ratio [OR] = 2.13). Anemia in the first trimester (hemoglobin<11.0 g/dl) was found in 3.5% (17/481) and 8.8% (53/603) (p < 0.001; OR, 2.63), while that in late second trimester (hemoglobin<10.5) was observed in 21.0% (101/481) and 36.3% (219/603) (p < 0.001, OR = 2.15) nulliparas and multiparas, respectively. Non-anemic women (hemoglobin level ≥11.0) with low ferritin levels (SF < 12 ng/ml) in the first trimester showed higher rate of anemia development in the second trimester than those with both normal hemoglobin and ferritin levels, irrespective of parity (51.3% [19/37] vs. 16.2% [69/427], p < 0.001 in nulliparas and 76.9% [60/78] vs. 26.5% [125/472], p < 0.001 in multiparas]. CONCLUSION Anemia and low SF levels occurred more commonly in multiparous than in nulliparas. Further, low SF was a risk factor for anemia development in later pregnancy.
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Affiliation(s)
- Kimitoshi Imai
- Imai OB/GYN Clinic, Suehiro-cho 117-1, Aoi-ku, Shizuoka, 420-004, Japan.
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50
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Fisher AL, Sangkhae V, Balušíková K, Palaskas NJ, Ganz T, Nemeth E. Iron-dependent apoptosis causes embryotoxicity in inflamed and obese pregnancy. Nat Commun 2021; 12:4026. [PMID: 34188052 PMCID: PMC8242011 DOI: 10.1038/s41467-021-24333-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 06/11/2021] [Indexed: 11/29/2022] Open
Abstract
Iron is essential for a healthy pregnancy, and iron supplementation is nearly universally recommended, regardless of maternal iron status. A signal of potential harm is the U-shaped association between maternal ferritin, a marker of iron stores, and risk of adverse pregnancy outcomes. However, ferritin is also induced by inflammation and may overestimate iron stores during inflammation or infection. In this study, we use mouse models to determine whether maternal iron loading, inflammation, or their interaction cause poor pregnancy outcomes. Only maternal exposure to both iron excess and inflammation, but not either condition alone, causes embryo malformations and demise. Maternal iron excess potentiates embryo injury during both LPS-induced acute inflammation and obesity-induced chronic mild inflammation. The adverse interaction depends on TNFα signaling, causes apoptosis of placental and embryo endothelium, and is prevented by anti-TNFα or antioxidant treatment. Our findings raise important questions about the safety of indiscriminate iron supplementation during pregnancy.
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Affiliation(s)
- Allison L Fisher
- Molecular, Cellular & Integrative Physiology Graduate Program, University of California, Los Angeles, Los Angeles, CA, USA
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Veena Sangkhae
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kamila Balušíková
- Department of Biochemistry, Cell and Molecular Biology & Center for Research of Diabetes, Metabolism and Nutrition, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nicolaos J Palaskas
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tomas Ganz
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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