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.
A preeclampsia study has found unusual cell activity in mothers and babies that could reveal new targets for treatment.
The condition affects 2 to 4 per cent of pregnancies worldwide and is a leading cause of maternal and foetal mortality.
There is currently no cure, and severe cases can put both the mother and baby at risk.
Scientists from UCL and University College London Hospitals found that stressed placental cells, poorly functioning blood vessels and an overactive immune response all contribute to the condition.
Preeclampsia causes high blood pressure during pregnancy. It can affect blood flow to the baby and cause symptoms such as swelling, headaches, blurred vision and pain under the ribs.
Without treatment, it can damage the mother’s health, slow the baby’s growth and, in severe cases, become life-threatening.
Previous research has focused only on the placenta, the organ that develops during pregnancy to support the baby’s growth, rather than the tissues around it.
The researchers said the findings could reveal new therapeutic targets, which are biological processes that future treatments could be designed to alter.
Senior author professor Sara Hillman, of the UCL EGA Institute for Women’s Health, said: “We studied individual cells from both the mother and the baby to see how their activity changes in healthy pregnancies compared with preeclampsia.
“This helped us to confirm some changes already suspected in the condition and also discover new ones.”
The team studied 20 pregnant women recruited at UCLH, including 10 with severe preeclampsia and 10 without the condition.
They used genomic testing to examine individual cells in the placenta and other tissues where cells from the developing baby and mother come into contact.
Genomic testing examines genetic information to help researchers understand how cells behave and the roles they may play.
The other tissues studied were the myometrium, the muscular layer of the womb, and the chorioamniotic membranes, which surround the baby during pregnancy.
The team compared cells from healthy pregnancies and those affected by preeclampsia at different gestational ages, meaning different stages of pregnancy.
They used technology that can read the genetic information of thousands of individual cells at the same time, allowing them to see what each cell was doing and where it was located in the tissue.
In preeclamptic pregnancies where babies were born prematurely, before 37 weeks, during the third trimester, placental cells showed signs of stress and low oxygen levels.
The cells also did not use energy in the normal way.
Some cells responsible for reshaping the mother’s blood vessels were not working properly, the researchers found, which may affect blood flow to the baby.
There were also signs of an overactive immune response in the placenta, nearby tissues and the mother’s blood.
The researchers said this response, together with other stress molecules released by the placenta, helps explain why preeclampsia affects the whole body and can become serious.
They hope the findings will help researchers find treatments for the condition and potentially save lives.
Co-lead author Dr Yara Sanchez Corrales, of the UCL Great Ormond Street Institute of Child Health, said: “These findings point to specific biological processes that could be targeted with treatments. Acting early in pregnancy, especially in more severe early-onset cases, could help improve outcomes and reduce the high risks associated with severe preeclampsia.
“We hope that our findings may set us on the path to reducing premature births and fatalities associated with preeclampsia.”
Co-lead author Mr Theodoros Xenakis, of the UCL Great Ormond Street Institute of Child Health, said: “Future studies may provide an even clearer picture of the biological changes linked to the disease by including more participants and using even more precise methods.”
Pregnancy complications may increase women’s risk of peripheral artery disease later in life, new research suggests.
The study analysed data from more than two million women in Sweden who gave birth to single babies between 1973 and 2015.
Led by Casey Crump, the research examined the long-term risk of peripheral artery disease among women who experienced preterm delivery, pre-eclampsia, gestational diabetes or other adverse pregnancy outcomes.
Crump, professor in the department of family and community medicine at McGovern Medical School at UTHealth Houston, said: “Our prior work has already shown that adverse pregnancy outcomes are associated with long-term risks of heart disease, stroke, and heart failure.
“This study builds on that work by showing that these women have an increased risk of peripheral artery disease, an important but understudied cardiovascular condition.”
Peripheral artery disease is often a precursor to long-term cardiovascular complications, including stroke, ischaemic heart disease and premature death.
The condition affects millions of people worldwide and occurs when narrowed arteries reduce blood flow, most commonly to the legs and feet.
Ischaemic heart disease occurs when the heart does not receive enough blood and oxygen, usually because the arteries have narrowed.
Symptoms of peripheral artery disease can include leg pain, cramps while walking, numbness, cold feet and sores on the feet or legs that are slow to heal.
Crump said women who experience pregnancy complications have an important opportunity after giving birth to make plans with their primary care doctor to monitor long-term risks.
Women who have experienced complicated pregnancies should speak with their doctor about possible future cardiovascular health risks.
Checks for blood pressure, diabetes and cholesterol are important.
While the period after childbirth is an important time for women to monitor their health, Crump said it is never too late to lower the risk of peripheral artery disease.
He said: “Women with a history of adverse pregnancy outcomes who seem to be doing well may still have a higher risk that can emerge later in life.”
Crump also suggested preventive steps such as avoiding smoking, maintaining a healthy weight and following a healthy lifestyle.
He stressed the importance of long-term follow-up care and conversations with healthcare providers to help protect cardiovascular health later in life.
A high-powered ultrasound treatment could help identical twins affected by a rare and serious condition during early pregnancy, an initial study suggests.
Twin-to-twin transfusion syndrome, or TTTS, causes uneven blood flow between identical twins who share a placenta.
The imbalance can leave one baby dangerously small and the other too large, putting both babies’ survival at risk.
Brioney Garrett’s daughters were in danger before doctors used the world-first treatment to seal the blood vessels causing the problem without an operation.
Nancy and Margo were born healthy and, now aged four, are due to start school.
Researchers from Queen Charlotte’s and Chelsea Hospital tested the non-invasive procedure in 10 women from the UK and elsewhere in Europe after scans detected TTTS during early pregnancy.
Five women needed further treatment, while 12 of the 20 babies survived following the procedure.
The researchers described having a treatment that did not require a needle or telescope to be inserted into the mother’s abdomen as “extremely exciting”.
However, they said larger studies involving more pregnant women were needed before the procedure could be offered more widely.
Garrett described her daughters as “my miracle twins”.
She said: “We were in a very dire situation and I don’t forget that.
“It stays with me always how things could have been. Every day I still count my blessings.”
TTTS affects between 10 and 15 per cent of identical twins who share a placenta, representing around 300 to 400 pregnancies in the UK each year.
The uneven blood flow causes excess fluid to build up around the larger recipient baby, while leaving dangerously little fluid around the smaller donor baby.
Treatment usually involves inserting a needle into the womb to drain some of the fluid or using a laser to seal the connecting blood vessels.
Garrett’s procedure took about 20 minutes. She lay flat while a specially designed machine directed high-powered ultrasound waves at small blood vessels in her placenta.
She said: “It was very quick and pretty painless.”
Christoph Lees, head of fetal medicine at Imperial College Healthcare NHS Trust and professor of obstetrics at Imperial College London, described the research as “very promising”.
He said: “If this could work in a fully-fledged study, it could give hope to a lot of women who otherwise might have to have quite invasive treatment.”
Ultrasound is commonly used during medical scans to produce images of the body, but this procedure uses much more focused waves.
Heat generated by the waves can seal blood vessels about 2mm in diameter and located around 5cm to 6cm beneath the skin.
The procedure blocked blood flow in 90 per cent of the vessels treated during the study, with no unwanted side-effects reported.
Twins Trust, which supported the study, said the approach could make a significant difference for families affected by TTTS.
Helen Peck, head of healthcare engagement and research, said: “Any procedure that is non-invasive and can potentially identify TTTS earlier and improve outcomes for our families with this life-threatening condition could be a turning point.”
Scans carried out weeks after Garrett’s procedure showed that blood flow between the babies had been rebalanced, although other problems developed during the pregnancy.
Garrett said Margo, who had too little fluid around her, “was in a much better position” and that “the strain on Nancy’s heart had eased”.
Nancy and Margo were born at nearly 34 weeks, weighing 3lb 7oz and 3lb 3oz respectively.
Garrett said: “They were both healthy, and Margo wasn’t as small as we worried she was going to be.”
The twins are due to start primary school in September.
Garrett said: “They’re funny, smart, energetic little girls that just fit right in with their age group.”
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