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 ID: 931162
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Slide1
Slide2Iron Deficiency/Iron Deficiency Anemia:
Peri
-partum period in Iran
Dr
Sedigheh
Hantoushzadeh
, Prof of
Perinatalogy
(Tehran University of Medical sciences)
Slide3Globally, 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
Slide4Iron 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
Slide5Globally
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
Slide6Defining 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
Slide7Red 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
Slide8Antenatal 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
Slide9Only 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
Slide10National Integrated Micronutrient Survey 2012;
Pura
Bahar
study
National Integrated Micronutrient Survey in 2012
:
Anemia
status based on the region and gender by Zone
Slide1111
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
Slide1212
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
Slide13In 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
Slide14Hb
based on the region
:
pregnant women in the
5
th month of pregnancy and more
14
National Integrated Micronutrient Survey 2012;
Pura
Bahar study
Slide15Systematic 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
Slide16Systematic 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
Slide17Systematic 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
Slide18Systematic 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.
Slide19T
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
Slide2020
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
Slide21The
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
Slide22Conclusions:
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