Gabriela Bencaiova

Iron prophylaxis in pregnancy: intravenous route versus oral route.

OBJECTIVE To assess and compare the efficacy and safety of two and three doses of intravenous iron sucrose with daily oral ferrous sulphate in the prophylaxis of iron deficiency anaemia in pregnant women. STUDY DESIGN 260 women with singleton pregnancy who met inclusion criteria and who gave informed consent were randomised between the 21st and 24th week into either the intravenous iron group or the oral iron group. Of 130 women in the intravenous iron group, 75 women received two doses of 200mg iron sucrose and 55 three doses of 200mg iron sucrose. The first dose was administered between the 21st and 24th gestational weeks, the second between the 28th and 32nd and the third between the 35th and 37th. The women of the oral group were given oral tablets of 80 mg ferrous sulphate daily, beginning on the day of study enrolment and stopping on the day of delivery. RESULTS There was a non-significant trend to a higher frequency of responders (haemoglobin> or =11 g/dl) in the intravenous iron group (75 vs. 80%). There was a significant difference of repleted iron stores before delivery (ferritin>50 microg/l) in the group with three intravenous iron doses in comparison to the oral iron group (49 vs. 14%; p<0.001). No differences were observed in regard to maternal and perinatal outcomes. CONCLUSIONS There was no clinically significant difference in the haematological, maternal and foetal outcomes in the parenteral route of iron prophylaxis in pregnant women.

Anemia—prevalence and risk factors in pregnancy

BACKGROUND To assess the prevalence of decreased iron stores and anemia in pregnant women. To determine whether the risk factors: socio-demographic background, age, BMI, and parity are associated with abnormal hemoglobin concentrations and/or abnormal iron status. METHODS A longitudinal study was carried out at the Department of Obstetrics, University Hospital of Zurich to establish the risk factors and prevalence of the decreased iron stores and anemia in early pregnancy. In order to determine the hematological parameters and ferritin levels, venous blood samples of 470 singleton pregnancies between 16 and 20 pregnancy weeks were collected. According to hemoglobin and iron status, the patients were divided into four groups: patients with iron deficiency anemia, patients with decreased iron stores, patients with anemia for other reasons and normal patients. The determinants socio-demographic background, age, BMI and parity were explored using multiple logistic regression analysis. RESULTS The prevalence of decreased iron stores (ferritin<20 μg/l) was observed in 31.8% of subjects (149/470) and anemia (Hb<110 g/l) in 18.5% (87/470). The prevalence of iron deficiency anemia was higher among women coming from former Yugoslavia and developing countries (p=0.004 and p=0.012). In patients coming from developing countries, a significant increase of anemia for other reasons was observed (p=0.027) and in patients older than 30 years, a significant increase of decreased iron stores (p=0.018). CONCLUSIONS In our study population with low parity, the prevalence of abnormal hemoglobin and abnormal iron status was 50.2% (236/470), and socio-demographic background was the most important risk factor of anemia.

Selective Use of Recombinant Human Erythropoietin in Pregnant Patients with Severe Anemia or Nonresponsive to Iron Sucrose Alone

Objective: To evaluate the effectiveness of a stepwise use of recombinant human erythropoietin (rhEPO) in pregnant patients with severe anemia or nonresponsive to intravenously administered iron only. Methods: All subjects had iron deficiency anemia, i.e., a hemoglobin (Hb) level <10.0 g/dl and ferritin ≤15 μg/l. Patients with an Hb level ≥9.0 g/dl and <10.0 g/dl received 200 mg iron sucrose intravenously twice weekly. If response to therapy was poor, patients additionally received 10,000 U rhEPO twice weekly. Patients with an Hb level <9.0 g/dl primarily received iron sucrose and rhEPO likewise. Results: Of the 84 patients, 59 had a baseline Hb level between 9.0 and 9.9 g/dl, of whom 32 responded poorly, thus receiving additional rhEPO. Twenty-five patients had a baseline Hb level <9.0 g/dl. The overall Hb level after therapy was 11.0 g/dl (±0.5, range 10.0–12.6 g/dl). Mean duration of therapy was 3.5 weeks (7 infusions). Conclusion: This study shows an effective treatment regimen for patients with various degrees of anemia in pregnancy. Iron sucrose is a safe and effective treatment option. In cases of severe iron deficiency anemia or poor response to parenteral iron therapy additional administration of rhEPO might be considered. However, the mechanism for not responding to intravenous iron therapy despite iron deficiency anemia still remains unclear to a large extent.

Screening for β-Thalassaemia Trait in Anaemic Pregnant Women

Aims: To find a clinically practicable parameter for the identification of β-thalassaemia trait (β-TT) in anaemic pregnant women on the basis of routine use of haematological examination. Methods: During 1998–2002, 304 anaemic pregnant women were observed in anaemia consultation hours. A retrospective study was carried out with the aim of finding a screening method for β-TT in anaemic pregnant women. We compared a sensitivity and a specificity of six different parameters for identification of β-TT. On the basis of a sensitivity and a specificity for each parameter, we calculated Youden’s index, the likelihood ratio and determined the receiver-operating curves. The logistic regression of the variables MCV, MCH and microcytosis was accomplished. Results: The analysis using receiver-operating curves as well as a calculation of Youden’s index showed that the best parameter for screening of β-TT in anaemic pregnant women is MCV ≤75 fl. For differentiation between patients with iron deficiency anaemia (IDA) alone and patients with β-TT and concomitant IDA, microcytosis ≥15% was the most sensitive. By using MCH we identified 100% of patients in the group with β-TT but only 67% of patients in the group with IDA. Conclusion: Our results suggest identification of β-thalassaemia on the basis of quantification of HbA2 in all patients with MCV ≤75 fl and normal iron status.

Mild Anemia and Pregnancy Outcome in a Swiss Collective

Background. Over half of all women in the world experience anemia during their pregnancy. Our aim was to investigate the relation between hemoglobin and iron status examined in second trimester and pregnancy outcome. Methods. In a prospective longitudinal study, 382 pregnant women were included. Blood samples were examined for hematological status and serum ferritin between 16 and 20 weeks and for hemoglobin before delivery. The adverse maternal and perinatal outcomes were determined. Regression analysis was performed to establish if anemia and low serum ferritin are risk factors for pregnancy complications. Results. There was no increase of complications in women with mild anemia and in women with depleted iron stores. The finding showed that mild iron deficiency anemia and depleted iron stores are not risk factors for adverse outcomes in iron supplemented women. Conclusions. Mild anemia and depleted iron stores detected early in pregnancy were not associated with adverse maternal and perinatal outcomes in iron supplemented women.

Variable Efficacy of Recombinant Human Erythropoietin in Anemic Pregnant Women with Different Forms of Heterozygous Hemoglobinopathy

Objective: The aim of this study was to determine the response to recombinant human erythropoietin (rhEPO) in anemic pregnant women with heterozygous hemoglobinopathies. Methods: A prospective study including 19 consecutive pregnant women with anemia and heterozygous hemoglobinopathy was performed. Treatment wasdivided into two phases: the initial low-dose phase and the subsequent high-rhEPO phase. In the initial phase, 3 × 10,000 U of rhEPO was administered with intravenous iron sucrose. In patients showing a poor response (Hb increase <1 g/dl) to low-dose rhEPO, the rhEPO dose was increased to 20,000 U per treatment in the subsequent phase. Results: All patients showed stimulation of erythropoiesis as evidenced by an increase in hemoglobin. In 13 patients, a good response to therapy was observed (mean Hb increase 1.6 ± 0.5 g/dl). In 6 patients, resistance to rhEPO was noted (mean Hb increase 0.5 ± 0.5 g/dl). The mean gestational age at the start of therapy was 28 weeks of gestation and at the end 32 weeks. The mean duration of a complete therapy was 3.5 weeks (range 2–4.5 weeks). If calculated for body weight, the initial low- rhEPO dose of 160.4 ± 30.6 U/kg body weight/treatment was increased to 320.9 ± 61.2 U/kg body weight/treatment in the subsequent phase. Conclusion: Response to rhEPO treatment differs widely in anemic pregnant patients with heterozygous hemoglobinopathy. Resistance was observed in anemic pregnant patients with the β-thalassemia trait originally from the Mediterranean region.

Acquired sideroblastic anaemia following progesterone treatment in pregnancy

© 2009 The Authors 235 Journal compilation

Treatment of Anemia of Chronic Disease with True Iron Deficiency in Pregnancy

Objective We assess and compare the efficacy of anemia treatment in pregnant women with anemia of chronic disease with true iron deficiency and in women with iron deficiency anemia. Study Design Fifty patients with moderate anemia (hemoglobin 8.0–9.9 g/dl) and iron deficiency (ferritin < 15 μg/l) were treated in the Anemia Clinic at the Department of Obstetrics. Results All patients showed stimulation of erythropoiesis as evidenced by an increase in reticulocyte count at day eight of therapy and showed an increase in hemoglobin and hematocrit at the end of therapy (p < 0.001). The target hemoglobin (≥10.5 g/dl) was achieved in 45/50 women (90%). 12 patients showed anemia of chronic disease with true iron deficiency (12/50; 24%). Seven women (7/12; 59%) with anemia of chronic disease and iron deficiency responded well to anemia treatment. 50% of women with anemia of chronic disease and iron deficiency (3/6) responded well to intravenous iron, and 67% (4/6) responded well to the combination of intravenous iron and recombinant human erythropoietin. Conclusion Because of frequent true iron deficiency in pregnant women with anemia of chronic disease, anemia of chronic disease in pregnancy is often falsely diagnosed as iron deficiency anemia.

Red blood cell parameters in antenatal nonsickling hemoglobinopathy screening.

Objective To find a hematological parameter and the cut-off level for identification of nonsickling hemoglobinopathies in pregnant women. Materials and methods Venous blood samples of 849 women with singleton pregnancies were collected at the first visit. All women who met inclusion criteria were examined for nonsickling hemoglobinopathy. On the basis of the sensitivity and the specificity of different cut-off levels for hematological parameters, we calculated the optimal clinically practicable parameter for screening of nonsickling hemoglobinopathies in pregnant women. Results On the basis of the sensitivity and the specificity, the best screening parameters for the identification of nonsickling hemoglobinopathies among nonanemic pregnant women are mean corpuscular volume (MCV) with cut-off ≤80 fL (Youden’s index 91.2%), mean corpuscular hemoglobin (MCH) <27.5 pg (Youden’s index 90.7%), and microcytosis (MRC) ≥3% (Youden’s index 90.2%). An analysis using receiver operating characteristic curves and the calculated Youden’s index showed that MCV ≤76 fL, MCH ≤24 pg, or MRC ≥10% are the best red blood cell indices for the screening of nonsickling hemoglobinopathy among anemic women with iron deficiency. Conclusion Our results suggest targeted screening for nonsickling hemoglobinopathies in nonanemic pregnant women with MCV ≤80 fL, MCH ≤27.5 pg, or MRC ≥3% and in anemic women with MCV ≤76 fL, MCH ≤24 pg, or MRC ≥10%.