Iron Deficiency/Iron Deficiency Anemia: - PowerPoint Presentation

Slide1

Iron Deficiency/Iron Deficiency Anemia:

Peri

-partum period in Iran

Dr

Sedigheh

Hantoushzadeh

, Prof of

Perinatalogy

(Tehran University of Medical sciences)

Globally, there is a high prevalence of

anemia

3

1.

Kassebaum

NJ

et al

. Blood 2014;123:615–24; 2. WHO. The global prevalence of anaemia in 2011 http://apps.who.int/iris/bitstream/10665/177094/1/9789241564960_eng.pdf?ua=1&ua=1; 3. WHO. Worldwide prevalence of anaemia, 1993–2005. 2008 http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

0

25

50

Prevalence

of anaemia

2,3,

*

(%

±

95% CI)

42.6

Children

<5 years

2

25.4

Children

≥5 years3

29.0

Non-pregnant women2

38.2

Pregnant women2

12.7

23.9

Men

3

Elderly3

Estimated global prevalence of anemia in 2010: 32.9%

1

Iron deficiency

anemia

is highly prevalent across all ages and all regions, and particularly in pregnant women

1

4

1

. WHO. The Global Prevalence of

Anaemia in 2011 http://apps.who.int/iris/bitstream/10665/177094/1/9789241564960_eng.pdf?ua=1&ua=1; 2. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Lancet 2017;390:1211–59WHO region

Children (6–59 months)

Non-pregnant

women (15–49 years)

Pregnant women

(15–49 years)

African region

32 (30 to 34)

41 (36 to 46)

44 (42 to 47)

Region of the Americas

56 (48 to 63)

55 (44

to 62)

60 (52 to 68)

South-East

Asia region

41 (34 to 54)

45 (35 to 53)

47 (42 to 54)

European region

54 (44 to 65)

55 (46 to 61)

62 (54 to 71)

Eastern Mediterranean region

38 (33 to 43)

45 (39 to 50)

49 (46 to 54)

Western Pacific

region

64 (46 to 73)

59 (44 to 70)

61 (49 to 72)

Global

42 (38 to 46)

49 (43 to 53)

50 (47 to 53)

In 2016, the prevalence of IDA was estimated at 1.24 billion cases (95% UI 1.21 billion to 1.28 billion)

2

Estimated percentage (95% CI) of anaemia caused by , iron deficiency

1

CI, confidence interval; ID, iron deficiency; IDA,; UI, uncertainty interval

Globally

prevalence of anemia among pregnant women (%): 1990-2016

5

World Health Organization, Global Health Observatory Data Repository/World Health Statistics (apps.who.int/

gho

/data/node.main.1?lang=en)

The World Bank 2017

Defining Iron

deficiency anaemia

:

Hb

thresholds for antenatal ID/IDA classification

1–36

WHO. Worldwide prevalence of anaemia, 1993–2005. 2008. http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf; CDC. MMWR 1998;47(RR-3):1–29; 3. Breymann C, Huch R. Uni-Med Verlag AG, Bremen 2008; 4. Milman N. Ann Hematol 2008;87:949‒59

The WHO defines antenatal anemia as Hb <11.0 g/dL1

However, the CDC also accounts for variations in the physiological concentration of Hb during the gestational stages of pregnancy2,3

Hb

threshold for ID/IDA (g/dL)

Pregnancy

Overall

1

<11.0

By gestation stage

2,3

First trimester

<11.0

Second trimester

<10.5

Third trimester

<11.0

Hb levels begin to fall towards the end of the first trimester, reaching the lowest point at ~25 weeks (second trimester)

4

Hb levels then progressively increase to reach peak concentrations just before delivery

4

Hb level <12.0 mg/dL is the Hb threshold for anaemia in non-pregnant and postpartum women

1,2

Red dotted lines: 10% standardized difference between covariates. *

Propensity score regression analyses for cases with severe anaemia matched (1:2) with cases without severe anaemia, adjusting for

PPH

, general anaesthesia, admission to intensive care, sepsis, pre-

eclampsia

or

eclampsia, thrombocytopenia, shock, massive transfusion, severe oliguria

, failure to form clots, and severe acidosis as confounding variables; †Hb concentration <7.0 g/dL in a blood sample obtained before death; ‡Death any time after admission until 7th day postpartum or dischargeThe WHO multi-country survey showed that severe antenatal anemia is associated with maternal mortality17e1. Daru J et al. Lancet Glob Health 2018;6:e548–54Odds of maternal death were higher in women with severe anaemia vs those without:

OR 43.35; 95% CI: 35.03–53.65; P<0.0001; aOR

2.36; 95% CI: 1.60–3.48; P<0.0001

Pregnancies: n=312,281

Cases of severe anaemia:

†

n=4687

Maternal deaths:

‡

n=341

Adjusted multilevel logistic analysis: n=312,281

Propensity score regression analysis: n=12,470

Propensity score*

aOR 1.86 (95% CI: 1.39–2.49; P

<0.0001)

PPH

Shock

Admission to intensive care unit

Pre-eclampsia or eclampsia

Sepsis

Massive transfusion

General anaesthesia

Failure to form clots

Thrombocytopenia

Oliguria

Severe acidosis

Unmatched

Matched

–20

0

20

40

60

80

100

aOR

, adjusted odds ratio; CI, confidence interval;

Hb

, haemoglobin; OR, odds ratio; PPH, postpartum haemorrhage

Antenatal anaemia is an independent risk factor for severe PPH:

Findings

from Norway

1

8

1.

Nyfløt LT et al. BMC Pregnancy & Childbirth

2017;17:17Independent risk factor for severe PPHaOR95% CIP valuePrevious severe PPH8.975.25–15.33<0.001Anticoagulant medication4.792.72–8.41<0.001

Antenatal anaemia (Hb ≤9.0 g/dL)4.27

2.79–6.54<0.001

Severe pre-eclampsia or HELLP

syndrome3.031.74–5.27

<0.001

Uterine fibromas2.711.69–4.35

<0.001

Multiple pregnancy2.111.39–3.22

<0.001Mode of delivery

Spontaneous vaginalInstrumental vaginalIn-labour caesareanElective caesarean

Ref1.501.951.661.17–1.93

1.53–2.471.22–2.240.001<0.0010.006

IVF/ICSI1.881.33–2.65<0.001

Fever (>38 °C)1.881.28–2.750.001

Labour induction1.691.39–2.05<0.001

Labour augmentation1.591.32–1.91

<0.001

Case-control study in a cohort of women who gave birth at one of three hospitals in Norway between Jan 2008 and Dec 2011

1064 cases of severe

PPH

*2059 random controls selected

Antenatal anaemia (Hb ≤9.0 g/dL)

Women with severe PPH: n=74 (7.0%) Control women (no PPH): n=38 (1.9%)

OR: 4.11, 95% CI: 2.76–6.13; P<0.001

43,105 deliveries

*Blood loss ≥1500 mL or transfusion for severe blood loss

aOR

, adjusted odds ratio; CI, confidence interval;

Hb

, haemoglobin; ICSI, intracytoplasmic sperm injection; IVF, in vitro fertilization; OR, odds ratio; PPH, postpartum haemorrhage

Only one publication reported that RBCT was required because of the anaemic status of the mother prior to caesarean section

1

9

1.

Eyelade

OR

et al

. Ann Ib Postgrad Med 2015;13:29–35706 women scheduled for emergency or elective caesarean section between March and August 2011 at a teaching hospital in NigeriaAssociation between independent variables and risk of blood transfusion

Variable

All participants, N=706

No blood, n=642

Received blood, n=64

P

value

HIV Status

Negative

641 (90.8%)

581 (90.5%)

60 (93.8%)

0.391

Positive

65 (9.2%)

61 (9.5%)

4 (6.2%)

Preoperative

PCV

(N=

695)

<26

33 (4.7%)

12 (36.4%)

21 (63.6%)

<0.001

>

26

662 (95.3%)

620 (93.7%)

42 (6.3%)

CS type

Primary

475

434 (91.4%)

41 (8.6%)

0.248

Repeat (twice)

162

149 (92.0%)

13 (8.0%)

More than twice

69

59 (85.5%)

10 (14.5%)

Years of experience of lead surgeon

<4 years

563 (79.7%)

529 (94.0%)

34 (6.0%)

0.013

4 years

143 (20.3%)

123 (86.0%)

20 (14.0%)

Indication for CS

Antepartum haemorrhage

638 (90.3%)

600 (94.0%)

38 (6.0%)

<0.001

No

antepartum

haemorrhage

68 (9.6%)

42 (61.8%)

26 (38.2%)

Estimated blood loss

<

500

mL

381 (54%)

365 (95.8%)

16 (4.2%)

<0.001

501–999 mL

266 (37.7%)

253 (95.1%)

13 (4.9%)

>

1

000 mL

59 (8.4%)

24 (40.7%)

35 (59.3%)

Conclusion

:

Pre-operative anaemia, increasing parity and severe blood loss at surgery significantly contribute to the requirement for blood transfusion in patients undergoing caesarean section

CS, caesarean section; PCV, packed cell volume;

RBCT, red blood cell transfusion

National Integrated Micronutrient Survey 2012;

Pura

Bahar

study

National Integrated Micronutrient Survey in 2012

:

Anemia

status based on the region and gender by Zone

11

1.

Bushehr

,

Hormozgan

, Khuzestan

2.

Sistan Baluchestan, southern Khorasan, Eastern Kerman3. Golestan, Northern Khorasan4. Gilan,

Mazandaran

5. Fars, Kerman,

Kohkiluyeh and

Boyerahmad

6. Ilam

, Kurdistan, Kermanshah, Lorestan,

Hamedan

7. Tehran, Alborz

8.

Azarbaijan, Ardebil

9. Semnan

, Central Khorasan

10. Yazd, Isfahan, Chaharmahal Bakhtiari

11. Zanjan, Qazvin, Qom, Arak

Zone

Anemia

based on

Hb

Urban areas

Rural areas

Total

Zone

(1)

19.7

14.5

17.3

Zone

(2)

10.9

10.2

10.7

Zone

(3)

29.4

16.2

22.8

Zone

(4)

11.3

8.5

10.5

Zone

(5)

22.0

29.3

26.0

Zone

(6)

9.7

8.6

9.5

Zone

(7)

26.7

23.8

29.1

Zone

(8)

11.6

8.3

11.3

Zone

(9)

11.3

3.4

9.1

Zone

(10)

18.4

9.2

14.6

Zone

(11)

13.5

16.5

14.7

Total

14.4

14.1

14.3

Anemia

status based on the region and zone,

pregnant women in the 5th month of pregnancy and more

National Integrated Micronutrient Survey 2012;

Pura

Bahar

study

12

Status

Urban areas

Rural areas

Total

Iron storage deficiency

(low ferritin)

14.1

13.8

14.0

At risk

of iron deficiency

anemia

(normal

Hb

+ low ferritin+ low MCV)

1.0

0.7

0.9

Iron deficiency

anemia

(low

Hb+ low ferritin+ low MCV)

0.0

1.7

0.6

Prevalence of iron storage deficiency, at risk of iron deficiency

anemia

, and iron deficiency

anemia

based on the region,

pregnant women in the 5th month of pregnancy and more

National Integrated Micronutrient Survey 2012;

Pura

Bahar

study

In this study, iron storage deficiency and risk of iron deficiency anemia in pregnant women

was

higher in Urban areas, but iron deficiency anemia was higher in rural areas

.

The

results showed that iron storage deficiency in pregnant women in 2012 (14%) was significantly reduced compared to 2001 (42.3%) (p<0.0001).

0.9% of pregnant women were at risk of iron deficiency anemia in 2012 compared to 2001 (32.6%) (p<0.0001).

Prevalence of iron-deficiency anemia in these subjects was (0.6%) in 2012 compared to 2001 (10.4%) (p<0.0001).

National Integrated Micronutrient Survey 2012;

Pura

Bahar

study

Hb

based on the region

:

pregnant women in the

5

th month of pregnancy and more

14

National Integrated Micronutrient Survey 2012;

Pura

Bahar study

Systematic Review and Meta-Analysis of the prevalence of anemia among pregnant Iranian women (2005 - 2015)

Scientific Journal of School of Public Health and Institute of Public Health Research /30 Vol. 14, No. 1, Spring 2016

18

articles with a combined sample size of 51,521 were

investigated

average age of 26.17 years

The prevalence of anemia in pregnant Iranian women was estimated at 17.9%

(CI: 95%; 14.7 - 21.1)The highest and lowest percentages were reported in Iran’s central (24.9%) and western (6.3%) partsThe prevalence of anemia among rural (17.6%) and urban (22.1%) pregnant Iranian women was also determined

Systematic Review and Meta-Analysis of the prevalence of anemia among pregnant Iranian women (2005 - 2015)

Scientific Journal of School of Public Health and Institute of Public Health Research /30 Vol. 14, No. 1, Spring 2016

The results of this study show an increase in the prevalence of anemia compared to a previous systematic review study conducted in Iran between

1993 and 2005

which reported the prevalence as

12.4%

The cause of this increase in recent years could be inappropriate nutrition or unethical use of iron and folic acid supplements by pregnant mothers

Systematic Review and Meta-Analysis of the prevalence of anemia among pregnant Iranian women (2005 - 2015)

Scientific Journal of School of Public Health and Institute of Public Health Research /30 Vol. 14, No. 1, Spring 2016

Between 2005 and 2015, the prevalence of anemia in pregnant Iranian women has been 17.9% (CI: 95%; 14.7 - 21.1). The lowest prevalence (3.6%) was reported in a study conducted in Kermanshah in 2010 and the highest prevalence (46%) was reported in another study performed in Esfahan in

2012

Systematic Review and Meta-Analysis of the prevalence of anemia among pregnant Iranian women (2005 - 2015)

Scientific Journal of School of Public Health and Institute of Public Health Research /30 Vol. 14, No. 1, Spring 2016

This study has estimated the prevalence of anemia in pregnant Iranian women from 2005 to 2015 to be 17.9%. According

to the WHO

5

% - 19.9% is the range in which the prevalence of anemia can be considered a mild health problem in a country, placing Iran in this group

.The WHO reports the prevalence of anemia in pregnant Iranian women to be estimated at 40% ,which

is inconsistent with the results of this study. The reduction of the prevalence of anemia in pregnant Iranian women could be due to the use of iron and folic acid supplements at health centers and also a national program to enrich flour with iron and folic acid.

T

he efficacy of early iron supplementation on postpartum depression, a randomized double‑blind placebo‑controlled trial,2017

Mahdi Sheikh,

Sedigheh

Hantoushzadeh,

Mamak Shariat, Zahra Farahani

, Ozra EbrahiminasabEur J Nutr (2017) 56:901–908Purpose: Evaluating early iron supplementation in nonanemic mothers with postpartum depression (PPD) Methods: This randomized, double-blind, placebo-controlled trial evaluated 70 mothers with PPD. One week after delivery, the mothers were randomly allocated in the irontreated (50 mg elemental iron/daily) and placebo-treated groups Conclusions: Early iron supplementation in mothers with PPD significantly improves the iron stores and causes a significant improvement in PPD with a 42.8 % improvement rate during 6 weeks. Continued PPD might be related to the lower postpartum ferritin levels in untreated mothers

20

Anemia

status of different age/sex groups

:

Second national integrated micronutrient survey in Iran in 2018

Second national integrated micronutrient survey in Iran: Study design and preliminary findings. Archives of Iranian medicine. 2018

Pouraram

H, et al. study

Status

Age group

Total

%

Urban areas

P value

Rural areas

P value

Male

Female

Male

Female

Anemia

(low ferritin)

15-23 months

17.1

16.2

13.0

0.015

23.4

21.2

0.253

6 years

9.9

9.8

8.0

0.125

12.9

11.0

0.249

Adolescent

9

4.7

11.4

0.000

8.1

13.7

0.000

pregnant

14.3

-

14.4

-

-

14.1

-

Adult

10.3

6.4

12.3

0.000

10.3

14.0

0.002

IDA

(low

Hb

,

ferritin,

MCV)

15-23 months

4.2

2.1

2.4

0.870

8.0

9.8

0.707

6 years

0.5

0.5

0.5

0.985

0.0

1.2

1.000

Adolescent

2.2

0.8

3.2

0.044

1.9

3.0

0.510

pregnant

0.6

-

0.0

-

-

1.7

-

Adult

3.0

0.6

0.6

0.002

0.0

5.3

0.007

The

lowest prevalence of anemia was found in adolescent boys (5.8%), in comparison with girls (12.1%), with a statistically significant

difference.

The

findings

showed that the highest prevalence of IDA was found in 15- to 23-month-old children (8.8%) in rural areas, four times higher than that in urban areas (2.2%).IDA in rural pregnant women was higher than urban pregnant women;

but no statistically significant difference was found between in urban and rural areas. Low ferritin was more common in pregnant women in urban areas, but was higher in rural areas in children, Adolescent

s and adults

Second national integrated micronutrient survey in Iran: Study design and preliminary findings. Archives of Iranian medicine. 2018

Pouraram H, et al. study

Conclusions:

22

PPH, postpartum haemorrhage

Recent evidence supports antenatal anaemia and PPH as independent risk factors for maternal mortality

Grand

multiparity

, decreased inter-pregnancy interval, and being of ethnic minority increase the risk of both antenatal anaemia and PPH

There is a direct correlation between antenatal anaemia and risk of PPH in both developing and developed nationsAntenatal anaemia worsens maternal outcomes in cases of PPH