Pregnancy
More than 80% of women iron deficient by third trimester of pregnancy
A new study and accompanying editorial has argued for routine iron screening for all pregnant women after research results revealed that more than 80 per cent of women are iron deficient by the third trimester of pregnancy.
When a woman becomes pregnant, her iron requirements increase almost tenfold to support foetal development as well as her own increased iron needs. Her ability to meet these increased iron needs depends on her iron stores at the beginning of the pregnancy as well as the physiological adaptations that enhance iron absorption as pregnancy progresses.
These physiological adaptations, however, are not always enough to support a pregnant woman’s iron needs, especially among the estimated 50 per cent of women who begin pregnancy with depleted iron stores. While often thought of as a problem in low-resource settings, recent studies have documented iron deficiency rates of 33 to 42 per cent among pregnant women in high-resource settings.
Iron deficiency can lead to anaemia, a condition in which the body can’t produce sufficient haemoglobin, which, in turn, limits the red blood cells’ ability to carry oxygenated blood throughout the body.
Anaemia during pregnancy is associated with a higher risk of both adverse maternal outcomes and adverse infant outcomes, including postpartum depression, postpartum haemorrhage, preterm birth, low birth weight, and small-for-gestational age birth. Even without the presence of anaemia, maternal iron deficiency can result in long-term neurodevelopmental challenges for the child.
At the moment, screening for iron deficiency during pregnancy is not universally routine. Moreover, there is no generally agreed upon diagnostic criteria for iron deficiency during pregnancy.
The most recent draft recommendation from the US Preventive Services Task Force, for example, states that “the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anaemia in pregnant women.”
In contrast, the International Federation of Gynecology and Obstetrics and European Hematology Society recommend all pregnant women in their first trimester irrespective of the presence or absence of anaemia be screened for iron deficiency.
Moreover, they also recommend that all women of reproductive age irrespective of the presence or absence of anaemia be screened for iron deficiency.
Even when screening is conducted, it may be insufficient to detect iron deficiency. In clinical practice, for example, haemoglobin is frequently the only benchmark used to evaluate iron status among pregnant women. Haemoglobin, however only provides an indication of anaemia. As a result, poor maternal and infant health outcomes that may develop before iron deficiency advances to anaemia may arise undetected.
Unfortunately, well-designed studies of the changes in iron status during the course of pregnancy are limited.
In response, the authors of a new study evaluated the changes in iron biomarkers throughout pregnancy, established the prevalence of iron deficiency, and proposed iron status benchmarks in early pregnancy that predict iron deficiency in the third trimester.
The authors, Elaine K. McCarthy et al., also sought to determine how common risk factors for iron deficiency such as obesity and smoking affected iron status throughout pregnancy. The study is one of the largest studies ever to document the changes in iron status during pregnancy.
To conduct their research, the authors worked with data collected from 641 women in Ireland who were pregnant and had a successful delivery for the first time and who participated in the IMproved PRegnancy Outcomes via Early Detection (IMPROvED) consortium project.
Samples were taken from the women at 15 weeks, 20 weeks and 33 weeks of pregnancy to determine iron status. Within 72 hours following delivery, information about the pregnancy, delivery, and the baby were obtained from the mother via an interview with a research midwife.
Information pertaining to clinical outcomes and complications during pregnancy and delivery were confirmed by reviewing medical records.
“In this high-resource setting,” the authors found that “iron deficiency defined by a variety of biomarkers and thresholds, was very common during pregnancy, despite the cohort profile as generally healthy.”
Interestingly, none of the study participants were anaemic in the first trimester, yet more than 80 per cent of the women were iron deficient by the third trimester.
In particular, the authors noted that “our cohort had higher rates of deficiency in the third trimester than even some low-resource settings.”
In this study, almost three-quarters of the participants took an iron-containing supplement that contained the Irish/European recommended daily iron allowance of 15 to 17mg. The authors did note that “iron-containing supplements (mainly multivitamins) taken pre/early pregnancy were associated with a reduced risk of deficiency throughout pregnancy, including the third trimester.”
According to the authors, these findings draw attention to “the benefit of screening for iron deficiency with haemoglobin and ferritin in defined low-risk populations.”
Moreover, based on their findings, the authors proposed a threshold for ferritin, a protein that stores iron, of 60µg per litre or less at 15 weeks of pregnancy that predicted the presence of iron deficiency at 33 weeks of pregnancy, defined as 15µg of ferritin per litre or less.
The authors noted that: “This has previously been identified as the inflection point at which foetal iron accretion is compromised, leading to poorer neurocognitive function and earlier onset of postnatal iron deficiency in the offspring.”
In an accompanying editorial to this study, authors Michael Auerbach and Helain Landy bluntly labelled the medical community’s approach to women, including the lack of screening and treating iron deficiency and anaemia among pregnant women, as “misogyny.”
Given the study’s findings, the editorial calls upon the American College of Obstetricians and Gynecologists and the United States Preventive Services Taskforce to “change their approach to diagnosis to screen all pregnant women for iron deficiency, irrespective of the presence or absence of anaemia, and recommend supplementation when present for the most frequent nutrient deficiency disorder that we encounter.”
Looking to the future, the authors believe that “further good-quality, large-scale longitudinal studies of iron status, with concurrent inflammatory status, are needed to provide the evidence base to help establish much-needed consensus. Moreover, the use of early pregnancy iron biomarkers and thresholds should be instituted in better alignment with clinically meaningful health outcomes.”
The study and editorial have been published in The American Journal of Clinical Nutrition.
Light exercise and less sitting may reduce pregnant women’s risk of serious blood pressure complications, according to a new study.
Researchers have proposed a daily activity and sleep guide that they say was linked to a nearly 30 per cent lower risk of hypertensive disorders of pregnancy.
The suggested pattern includes fewer than eight hours of sedentary time, at least seven hours of light physical activity, around 22 minutes of more intense activity and nearly nine hours of sleep.
The University of Iowa-led study examined the daily behaviours of 470 pregnant women across all stages of pregnancy.
Participants wore monitors that measured physical activity over 24-hour periods and recorded how long they spent asleep.
Hypertensive disorders of pregnancy include chronic high blood pressure, gestational hypertension and pre-eclampsia.
Gestational hypertension is high blood pressure that develops during pregnancy, while pre-eclampsia is a potentially serious condition involving high blood pressure and signs that organs may be affected.
Sedentary behaviour means being mostly inactive, such as sitting or lying down.
Light physical activity can include casual walking, moving around the home or standing.
Moderate to vigorous activity includes movement such as brisk walking, where breathing and heart rate increase.
Kara Whitaker, associate professor in the department of health, sport, and human physiology at Iowa and corresponding author of the study, said: “We are identifying the optimal composition of movement behaviours across the day associated with the lowest risk of developing HDP and the most improved health outcomes.
“This blueprint holds for each and every trimester of pregnancy.”
Study participants were enrolled at sites in Iowa City, Pittsburgh and Morgantown, West Virginia.
The women wore activity and sleep monitors for at least one week during each trimester of pregnancy.
Four in five participants were non-Hispanic white and nearly a quarter lived in rural areas.
The data showed a steep rise in risk among pregnant women who were sedentary for more than 10 hours a day.
Women who increased light physical activity to at least four hours a day reduced their risk of hypertensive disorders of pregnancy to 15 per cent from 30 per cent.
Whitaker said: “Just moving around more seems to have significant health benefits.
“And I think it also may be a more feasible target for women who are pregnant who are not exercising regularly.”
The researchers said they were surprised that longer durations of moderate to vigorous physical activity did not appear to provide additional benefit.
Sleep beyond a certain duration also did not appear to bring major further benefits.
Whitaker said: “Through this study, we are providing evidence that reducing sedentary behaviour and engaging in light physical activity are important, and maybe more important, when it comes to pregnancy and health.”
The findings may be relevant beyond pregnancy because clinical research has shown that women who develop hypertensive disorders of pregnancy are more than twice as likely to develop heart disease later in life.
Cardiovascular disease includes conditions affecting the heart and blood vessels, such as heart disease and stroke.
Whitaker said: “We know that cardiovascular disease is the number one killer of women, and if we can intervene in pregnancy and prevent women from developing a hypertensive disorder of pregnancy, we are putting them on a better trajectory, away from cardiovascular disease and toward more optimal cardiovascular health.”
The study was published online on June 10.
A second study, published online on May 27, looked more closely at the ratio and type of sedentary behaviour and light physical activity linked to a lower risk of hypertensive disorders of pregnancy.
Whitaker is a lead co-author on that study.
Co-authors in the June 10 study include Alex Crisp, Jaemyung Kim, Karina Smith, Donna Santillan, Mark Santillan and Bridget Zimmerman, from Iowa; Jacob Gallagher, from Iowa State University; Melissa Jones, from Oakland University in Michigan; Bethany Barone Gibbs, Katrina Wilhite, Alexis Thrower and Iqra Sheikh, from West Virginia University; and Sabera Rahman, Janet Catov, Christopher Kline and Maisa Feghali, from the University of Pittsburgh.
The National Institutes of Health, the University of Iowa Institute for Clinical and Translational Science, the University of Pittsburgh Clinical and Translational Science Institute and the West Virginia Clinical and Translational Science Institute funded the research.
A £50m maternity consortium will bring together UK clinicians, researchers and communities to tackle the most critical gaps in maternal care.
Funding from the National Institute for Health and Care Research has established the NIHR Inequalities Challenge: Maternity Disparities Consortium under the leadership of the University of Birmingham and Newcastle University.
Higher education bodies, NHS organisations, community groups and voluntary organisations from across the UK will work together through the programme.
The NIHR has committed £50m over five years to support research led by clinicians, researchers and communities across the consortium.
Professor Joht Singh Chandan, consortium co-lead for research at the University of Birmingham, said: “National attention on maternity safety and equity has never been greater, but ambition must now be matched by evidence and implementation.
“Through this consortium, we will work across the UK to understand what works, for whom and in what contexts, and to ensure that research leads to practical changes in care for the women, babies and families who need them most.”
The launch comes at a pivotal moment for UK maternity care, with growing national attention on improving safety, equity and women’s experiences of care.
The government’s renewed Women’s Health Strategy highlights the need to improve care before and between pregnancies for underserved communities.
Against that backdrop, the consortium will generate the evidence, interventions and research capacity needed to help turn national ambition into practical improvements for women, babies and families.
University of Birmingham is leading work to improve maternity care pathways across the antenatal, intrapartum and postnatal periods.
Antenatal care covers pregnancy before labour, while intrapartum care refers to care during labour and birth.
The consortium will examine how women and families can be better supported before pregnancy and between pregnancies.
This includes improving access to advice and care that can help people prepare for pregnancy, manage existing health conditions and reduce risks before they build up.
Other research will focus on improving care during pregnancy, birth and the early weeks after birth.
This will include work on major causes of poor maternal health, such as high blood pressure, diabetes in pregnancy, obesity, perinatal mental health and complications during recovery after birth.
Professor Judith Rankin OBE, consortium co-lead for research and capacity development at Newcastle University, said: “This funding represents a critical opportunity to make the step change we need to improve outcomes for women and their babies.
“Alongside the research, the Consortium will be investing in tomorrow’s research leaders today to ensure we have the capacity to deliver on improving pregnancy outcomes, access to, and experience of, care.”
The University of Liverpool has secured £1.8m to test a device for postpartum bleeding and launch a new women’s health studio.
The PPH Butterfly is designed to help control postpartum haemorrhage, which is severe bleeding after childbirth and a leading cause of maternal death worldwide.
The funding will support research into how the device can be used in clinical practice and generate evidence to inform its wider adoption.
The university has launched the Women’s Health Innovation Studio, known as the WIN Studio, alongside the project.
The £1.8m initiative is predominantly funded by the National Institute for Health and Care Research, which is providing £1.5m, with additional support from the university.
The PPH Butterfly project will involve a multi-centre clinical trial across the UK and a global feasibility study looking at how practical it would be to use the device in different healthcare settings.
The WIN Studio is led by Andrew Weeks, professor of international maternal health care at the University of Liverpool and a senior investigator at the National Institute for Health and Care Research, and Dr Teesta Dey, a tenure track fellow in the department of women’s and children’s health.
Dr Dey will also lead the PPH Butterfly project.
Its work will cover conditions linked to female biology, including endometriosis, menopause and pregnancy-related complications.
It will also support technologies for diseases that affect women differently or disproportionately, even when they are not usually classed as gender-specific conditions.
Dr Dey said: “Women’s health has often been marginalised within healthcare systems and innovation markets, resulting in treatments, devices and care models that fail to adequately account for women’s specific needs. WIN Studio seeks to change this status quo and reconfigure how health technologies are conceived and delivered.
“The funding from NIHR for this £1.8m project is precisely the kind of innovation the WIN Studio exists to foster: clinically urgent, women-centred, and with the potential to save lives at scale.”
The studio recently hosted an event at Liverpool Women’s University Hospital as part of the Liverpool City Region Combined Authority’s Innovation Investment Fortnight.
Seven innovations are currently undergoing clinical testing through the studio, with three developed internally.
The studio will work closely with NHS University Hospitals Liverpool Group and provide clinical, regulatory and commercial support to people developing women’s health technologies.
It will also involve patients and members of the public in shaping research priorities and product development.
Its wider programme includes collaborations involving clinicians, engineers, economists, academics and policymakers.
The project team says the PPH Butterfly is a simple, low-cost device designed to control severe bleeding quickly and with minimal training.
According to the team, postpartum haemorrhage causes around 70,000 deaths globally each year, equal to about one death every seven minutes.
The device previously received £1.1m in funding from the National Institute for Health and Care Research.
The latest £1.5m grant will support a randomised UK trial, in which participants are allocated to different treatment groups by chance, and a global feasibility assessment.
Weeks said: “In an area where women face deep health inequalities, WIN Studio has a vital role to play. By working in partnership with the NHS, local government and communities, we can ensure that research leads to real-world impact.
“Liverpool has a highly integrated ecosystem of academic, clinical and commercial expertise. By bringing these together under a single platform, the WIN Studio aims to act as a national exemplar for equitable health innovation. Transforming the way medical technologies are developed is essential to addressing gender disparities in healthcare outcomes.”
Another product supported by the university, the LifeStart Trolley, has already reached commercialisation.
The small mobile resuscitation trolley allows newborn care to be carried out at the bedside while the baby’s umbilical cord remains intact, enabling delayed cord clamping.
Delayed cord clamping means waiting before cutting the cord so blood can continue flowing from the placenta to the baby after birth.
Clinical trials conducted around 10 years ago found that life-saving care could be provided successfully at the bedside using the trolley.
It was later commercialised by Inspiration Healthcare and is now used in more than 70 UK maternity units and in 36 countries, including Norway, Italy and the US.
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