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Iron Deficiency Anemia in Pregnancy

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Iron Deficiency Anemia in Pregnancy Review Iron deficiency anemia in pregnancy Expert Rev. Obstet. Gynecol. 8(6), 587–596 (2013) Christian Breymann Anemia is a common problem in obstetrics and perinatal care. Any hemoglobin (Hb) below Department of Obstetrics and 10.5 g/dl can be regarded as true anemia regardless of gestational age. Main cause of Gynaecology, University Hospital Zurich, anemia in obstetrics is iron deficiency, which has a worldwide prevalence between estimated Obstetric Research, Feto-Maternal 20 and 80% of especially female population. Stages of iron deficiency are depletion of iron Haematology Research Group, stores, iron-deficient erythropoiesis without anemia and iron-deficiency anemia, the most Schmelzbergstr 12 /PF 125, Zurich, Switzerland pronounced form of iron deficiency. Pregnancy anemia can be aggravated by various [email protected] conditions such as uterine or placental bleedings, gastrointestinal bleedings and peripartum blood loss. Beside the general consequences of anemia, there are specific risks during pregnancy for the mother and the fetus such as intrauterine growth retardation, prematurity, feto-placental miss-ratio and higher risk for peripartum blood transfusion. Beside the importance of prophylaxis of iron deficiency, main therapy options for the treatment of pregnancy anemia are oral iron and intravenous iron preparations. KEYWORDS: anemia • intravenous iron • iron deficiency • iron therapy • pregnancy The review focuses on the clinical, diagnostic requirement during that period [3,4].Ifweextrap- and therapeutic aspects of gestational disorder olate from the high prevalence rates of anemia of in mothers, with its far-reaching consequences pregnancy in developing countries and from the for the intrauterine development of the fetus observed relationship between iron deficiency and neonate. Because of its high prevalence, alone and iron-deficiency anemia in the devel- maternal iron-deficiency anemia will be at the oped world, we can assume that the percentage center of the discussion. of cases of iron deficiency per se (i.e., before erythropoiesis is affected) is also higher in devel- Definition of anemia oping countries than actual anemia [5].As The WHO (WHO 1972) defines anemia – expected, there are few studies in developing regardless of its cause – as the presence of a Hb countries that have been able to document iron leveloflessthan11.0g/dlduringpregnancy deficiency without anemia. It should be noted and less than 10.0 g/dl during the postpartum that there are several different stages of iron defi- period. The US Centers of Disease Control rec- ciency, which occur in the following sequence: ommendations (CDC 1989) take into account a. Depletion of the iron stores the observation that there is a trough in the b. Iron-deficiency erythropoiesis in which physiological course of Hb during pregnancy [1]. the indices have not fallen below the defined According to this definition, anemia is present limit values for anemia if the Hb level is less than 11 g/dl during weeks c. Iron-deficiency anemia, the most pro- 1–12 (first trimester) and 29–40 (third trimes- nounced form of iron deficiency ter) of gestation, and less than 10.5 g/dl during Figures for the prevalence of iron deficiency weeks 13–28 (second trimester). These Hb alone, as a precursor of anemia, are available for levels correspond to hematocrit values of 33.0, Europe [4,6]. According to a recent CHERG iron 32.0 and 33.0%, respectively [1,2]. report, the range of prevalence of anemia due to iron deficiency was 20–78% with a global aver- Iron deficiency age of 42.8%. In the authors’ hospital, 50% of Iron deficiency is the most common deficiency pregnant women showed a serum ferritin in women of childbearing age throughout the <15 mg/l at term, that is, they have depleted iron world,andisevenmorecommoninpregnancy, stores [7]. Risk factors to develop iron deficiency as might be expected from the increasing iron and anemia are listed in TABLE 1. www.expert-reviews.com 10.1586/17474108.2013.842683 Ó 2013 Informa UK Ltd ISSN 1747-4108 587 Review Breymann Table 1. Risk factors to develop ID/ IDA in adults. Iron needs in pregnancy During pregnancy, the average total iron requirement has been High menstrual blood loss estimated to be approximately 1200 mg for an average weight of Vegetarians or adults with special diets 55 kg in a pregnant woman. The iron is used mainly for the Athletes increase in maternal erythrocyte mass (450 mg), placenta (90– 100 mg), fetus (250–300 mg) general losses (200–250 mg) and a Chronic blood loss, e.g., intestinal disease blood loss at delivery corresponding to 150 mg iron (300–500 ml Acute blood loss, e.g., surgery bloodloss).Around40%ofwomenbegintheirpregnancywith m Chronic diseases low or absent iron stores (serum ferritin <30 g/l)andupto90% have iron stores of <500 mg (serum ferritin <70 mg/l), which is Parasitic diseases insufficient to meet the increased iron needs during pregnancy ID: Iron deficiency; IDA: Iron-deficiency anemia. and postpartum. Iron absorption requirements in the first trimes- ter are around 0.8 mg/day, rising to 7.5 mg/day at third trimester. Risk groups associated with iron deficiency and iron-deficiency Anemia in general & iron-deficiency anemia in anemia in pregnancy and postpartum are listed in TABLE 2. particular Published rates of the prevalence of anemia during pregnancy General consequences of anemia in developing countries range from 53 to 61% for Africa, Any disorder that leads to anemia represents an increased risk from 44 to 53% for South-East Asia and from 17 to 31% of an abnormal course of pregnancy and greater maternal and for Europe and North America [8].Itisassumed that iron infant morbidity and mortality. According to WHO data, ane- and folate deficiency are the most common etiological factors mia is associated with 40% of maternal deaths worldwide [2]. responsible for this situation [5,9].Anemiaofpregnancyisnot The clinical consequences of anemia of pregnancy are closely merely common in these countries, it is also frequently associated with the cause of the anemia. In this respect, it is severe. It is estimated that 20% of pregnant women have Hb difficult to determine whether the maternal and infant risks of less than 8 g/dl, and that between 2 and 7% have a value result from the anemia alone, or whether they are attributable of less than 7 g/dl. The situation is aggravated during the to the cause of the anemia. Thus, the complications that occur postpartum period because of blood loss during labor and in in association with anemia secondary to iron deficiency differ the puerperium. Even in modern obstetrics, peripartum from those associated with anemia secondary to hemoglobinop- blood losses of more than 500 ml are not uncommon. athy in the mother. A variety of the interventions used in obstetrics today, the The following maternal consequences of anemia in preg- technique by which labor is induced, the use of regional anal- nancy are observed regardless of the cause of the anemia. gesia and factors such as assuming an upright position while ‘ ’ giving birth, can all lead to heavier bleeding during labor • Fatigue, exhaustion, weakness, less energy and delivery. • Cardiovascular symptoms (e.g., palpitations) The American College of Obstetricians and Gynecologists • Pallor, pale mucous membranes and conjunctivae has estimated that 5% of women who give birth lose 1000 ml • Tachycardia, hypotension of blood or more during delivery. Bearing in mind that the • Cardiac hypertrophy in chronic cases limit value defining puerperal anemia is 1 g/dl lower, the prev- alence of anemia during this period remains comparable with Iron-deficiency anemia that observed during pregnancy. Maternal risks It is known that iron deficiency influences a whole series of Table 2. Risk groups to develop ID and IDA in body functions, such as physical and mental performance, pregnancy. enzymatic functions (e.g., those of the respiratory chain), ther- moregulation, muscular functions, the immune response and Pregnant women Postpartum neurological functions (TABLE 3) [10,11]. Only a few of these poten- After first trimester ID and IDA during pregnancy tial effects have been specifically investigated in iron-deficiency anemia. In general, iron-deficiency anemia leads to numerous ID prior pregnancy symptoms such as fatigue, a reduction in physical performance Multiple pregnancies Poor socio-economic status and fitness for work, increased cardiovascular stress (tachycar- Short recovery between Poor nutritional status dia, fall in blood pressure), reduced thermoregulation and an pregnancies increased predisposition to infections [11]. Maternal thyroid Multipara function and synthesis of thyroxin is closely linked to maternal iron status [12]. Poor socio-economic status In the gravida, the tolerance for peripartum blood loss is ID: Iron deficiency; IDA: Iron-deficiency anemia. greatly reduced. Maternal mortality increases depending on the 588 Expert Rev. Obstet. Gynecol. 8(6), (2013) Iron-deficiency anemia in pregnancy Review severity of the iron-deficiency anemia. Causes include an Table 3. Maternal consequences of anemia. increased rate of cardiovascular failure, a high risk of hemor- Maternal mortality with high blood loss rhagic shock and higher rates of infection during the puerpe- rium and impaired wound healing [2]. Maternal morbidity may Maternal cardiovascular strain also be associated with additional factors such as socio- Reduced physical and mental performance economic status, the level of medical care, nutritional status, Reduced peripartal blood reserves etc. A general problem in interpreting the available studies is that maternal and fetal outcome have been investigated in rela- Increased risk for peripartal blood transfusion tion to the severity of the anemia, but not in relation to the duration or initial onset of the anemia, or indeed the severity, which goes in parallel with elevated C-reactive protein (CRP) duration or onset of the iron deficiency. levels which finally result in iron restricted erythropoiesis and Taking these limitations into account, several authors have decreased erythropoietin levels.
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