case study pregnancy with iron deficiency anemia

SYSTEMATIC REVIEW article

Nutritional factors for anemia in pregnancy: a systematic review with meta-analysis.

• 1 Department of Obstetrics, Kunming City Maternal and Child Health Hospital, Kunming, China
• 2 Kunming Municipal Service Center for Maternal and Child Health, Kunming, China
• 3 Kunming Children's Hospital, Kunming, China
• 4 Department of Pharmacy, Children's Hospital of Kunming Medical University, Kunming, China

Background: Anemia in pregnancy is a serious threat to maternal and child health and is a major public health problem. However, the risk factors associated with its incidence are unclear and controversial.

Methods: PubMed, Ovid Embase, Web of Science, and Cochrane databases were systematically searched (inception to June 27, 2022). The screening of search results, extraction of relevant data, and evaluation of study quality were performed independently by two reviewers.

Results: A total of 51 studies of high quality (NOS score ≥ 7) were included, including 42 cross-sectional studies, six case-control studies, and three cohort studies. Meta-analysis showed that infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year were all risk factors for anemia in pregnancy.

Conclusions: Prevention of anemia in pregnancy is essential to promote maternal and child health. Sufficient attention should be paid to the above risk factors from the social level and pregnant women's own aspects to reduce the occurrence of anemia in pregnancy.

Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier: CRD42022344937.

As a global public health problem, anemia in pregnancy has been shown to be an independent risk factor for adverse maternal and infant outcomes such as blood transfusion, postpartum hemorrhage, cesarean section, hysterectomy, preterm birth, and infectious diseases ( 1 ). It directly threatens the health of about 32 million pregnant women around the world. Especially in developing countries, 56% of pregnant women are affected by it ( 2 , 3 ). Anemia in pregnancy is a global concern as it impairs physical health, cognitive development, productivity, and reflects lagging economic status ( 2 , 4 ). Improving anemia in pregnancy is essential to reduce maternal and infant mortality and serious complications. Unfortunately, even though extensive studies have been conducted over the past 20 years and various national nutrition programs have been implemented to reduce anemia in pregnancy, there has not been much success in eliminating anemia in pregnancy, and it remains a major public health problem ( 4 , 5 ).

It is critical to explore the risk factors that may cause anemia in pregnancy and take preventive strategies as soon as possible. However, the risk factors for anemia in pregnancy are controversial. For example, the findings of Kedir et al. suggest that parasite infection is not a risk factor for anemia in pregnancy ( 6 ). However, other studies in the same area identified parasitic infection as a risk factor for anemia in pregnancy ( 7 , 8 ). It has also been shown that tea/coffee after meals is not a risk factor for anemia in pregnancy (AOR = 1.03, 95% CI: 0.88–2.06) ( 9 ), but the results of Teshome et al. showed a very significant association between tea/coffee after meals and anemia in pregnancy (AOR = 18.49, 95% CI: 6.89–40) ( 10 ). In addition, iron deficiency is considered to be the most common cause of anemia in pregnancy, therefore, most studies recommend that pregnant women should take adequate iron supplements to prevent anemia in pregnancy ( 11 , 12 ). On the contrary, some studies have shown that iron supplementation did not reduce the incidence of anemia in pregnancy ( 13 , 14 ). Some studies have even concluded that even without iron supplementation during pregnancy, the incidence of anemia in pregnant women is not significantly higher ( 15 ). In conclusion, disparate findings on the same exposure factors pose an obstacle to the prevention of anemia in pregnancy and further public health decisions.

The current field lacks definitive evidence on the risk factors for anemia in pregnancy. Therefore, as the first study to systematically summarize the risk factors of anemia in pregnancy, the results of this study can provide a reference for the prevention and treatment of anemia in pregnancy in the future.

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 16 ). The review protocol has been registered with PROSPERO, number CRD42022344937 ( https://www.crd.york.ac.uk/prospero/ ).

Inclusion and exclusion criteria

Patients and diseases (p).

Pregnant women.

Interventions (I)

Report at least one exposure factor associated with anemia in pregnancy.

Control (C)

Studies where adjusted odds ratio (AOR) for exposure factors were available or calculated.

Outcome (O)

Anemia in pregnancy occurs. The diagnostic criteria are hemoglobin ≤ 11 g/dL.

Type of study (S)

Cross-sectional studies, case-control studies, and cohort studies.

Exclusion criteria

Animal studies and cell experiments were excluded. Reviews, case reports, opinion articles, conference abstracts, and non-published data were also excluded.

Data sources and searches

Candidate studies were identified through searches of the PubMed, Web of Science, Cochrane, and Ovid Embase databases from inception until June 27, 2022. Also, the reference lists of the included studies were searched. The retrieval approach of the combination of free words and subject words was adopted. The following terms were combined to generate search keywords: [gestational anemia OR anemia in pregnancy OR (pregnancy OR pregnant OR gestation) AND anemia] AND (hazard OR risk factors OR risk factor OR related factors OR factors OR influence factors OR influencing factors). Further details of the search strategy are shown in Supplementary Table 1 .

Data extraction and risk of bias assessment

Literature screening and data extraction were performed by 2 trained researchers according to the inclusion and exclusion criteria as indicated previously. Extracted content includes: (1) Basic information of included studies: authors, year, country, type of study, sample size, age, method of obtaining information, diagnostic criteria for anemia, and data analysis methods. (2) Exposure factors: Risk factors related to dietary habits, self-condition, and disease history of pregnant women. (3) Key elements of risk of bias assessment.

Based on the Newcastle-Ottawa Scale (NOS), two qualified researchers independently evaluated the inherent risk of bias of included studies from three aspects, including the selection of participants, confounding variables, and measurement of exposure ( 17 ). The evaluation results were scored as low, medium, and high quality, respectively, with scores of 0–3, 4–6, and 7–9.

Statistical analysis

Statistical analysis was performed using STATA 16 software. Results were calculated using adjusted odds ratio (AOR) and 95% confidence interval (95% CI). The χ 2 test was used to evaluate the heterogeneity of the included studies (the test level was α = 0.05), and the size of the heterogeneity was judged according to the I 2 value. When P > 0.05 and I 2 ≤ 50%, it indicated that the heterogeneity of the results of each study was not statistically significant, and a fixed-effects model was used for meta-analysis; otherwise, after further analysis of the source of heterogeneity, a random-effects model was used.

Literature screening results

A total of 4,638 relevant records were obtained from the initial inspection, which were excluded from repeated studies, non-risk factor studies (prevalence, diagnosis, and treatment of anemia in pregnancy), pregnant women without anemia (postpartum anemia, women of childbearing age) and study types that are not consistent (review, conference summary, case report, etc.), 51 studies were finally included. The article screening process is shown in Figure 1 .

Figure 1 . Flow diagram for study inclusion.

Basic information and risk of bias assessment of included studies

A total of 51 studies were included ( 6 – 10 , 13 – 15 , 18 – 60 ), including 42 cross-sectional studies ( 6 – 9 , 13 – 15 , 18 – 29 , 31 – 37 , 39 – 43 , 45 , 47 – 49 , 51 , 53 , 54 , 56 – 58 , 60 ), six case-control studies ( 10 , 30 , 38 , 50 , 52 , 55 ), and three cohort studies ( 44 , 46 , 59 ). The entire population was from developing countries, and 36 study sites were in Ethiopia ( 6 – 10 , 13 – 15 , 18 – 20 , 23 , 26 – 31 , 34 – 43 , 50 , 52 , 55 – 60 ). The total number of patients was 73,919 and in individual study ranged from 163 ( 49 )−12,403 ( 53 ). The patients were aged between 15 and 49 years ( 40 ). Information was obtained through structured questionnaires ( 6 – 10 , 13 – 15 , 18 – 39 , 41 – 45 , 47 – 50 , 52 – 56 , 59 , 60 ), outpatient medical record data ( 40 , 46 , 51 , 58 ), and databases ( 57 ). The diagnostic criteria for anemia were hemoglobin < 11 g/dL, and the statistical analysis methods were multivariable logistic regression. See Table 1 for details.

Table 1 . Basic information of included studies.

The NOS scores of the 51 included studies were all ≥ 7 points, of which 38 studies had a NOS score of 8 points, and 13 studies had 7 points, indicating that the included studies had high research quality. See Supplementary Table 2 for details.

Meta-analysis results

Exposure factors associated with maternal medical history.

A total of four exposure factors associated with medical history may contribute to anemia in pregnancy. Since I 2 = 0, P > 0.05, indicating that there is little possibility of heterogeneity among the studies, a fixed-effect model was used for combined analysis. Meta-analysis showed that parasitic infection (AOR = 2.20, 95% CI: 1.63–2.76) and history of malarial attack (AOR = 2.86, 95% CI: 1.98–3.73) were risk factors for anemia in pregnancy, while HIV status (AOR = 1.36, 95% CI: 0.97–1.75) and abortion history (AOR = 1.05, 95% CI: 0.47–1.63) were not associated with anemia in pregnancy ( Figure 2 ).

Figure 2 . Exposure factors associated with maternal medical history.

Exposure factors associated with dietary habits of pregnant women

A total of eight exposure factors related to dietary habits may contribute to anemia in pregnancy. The fixed effect model was used to analyze the exposure factors of I 2 < 50%. The results showed that tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, diet diversity score ≤ 3 were risk factors for anemia in pregnancy. Iron supplementation was a protective factor for anemia in pregnancy ( Table 2 ). Meta-analysis of the potential risk factors for I 2 > 50 % using a random effect model showed that frequency of eating vegetables ≤ 3 times per week was a risk factor for anemia in pregnancy, while no iron supplementation and drinking were not associated with anemia in pregnancy ( Table 2 ).

Table 2 . Exposure factors associated with dietary habits of pregnant women.

Exposure factors associated with maternal conditions

A total of 20 exposure factors associated with maternal conditions may contribute to anemia in pregnancy. Multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, and birth interval ≤ 2 year were all risk factors for anemia in pregnancy. Overweight was a protective factor, and the remaining exposure factors were not associated with anemia in pregnancy ( Table 3 ).

Table 3 . Exposure factors associated with maternal conditions.

Publication bias

Funnel plots were drawn for exposure factors with more than 10 studies to detect publication bias. The results showed that the funnel plots were basically symmetrical, suggesting a small possibility of publication bias ( Figure 3 ).

Figure 3 . Results of publication bias. (A–I) Funnel plots of exposure factors with more than 10 studies.

Summary of evidence related to maternal medical history

Due to poverty, lack of safe drinking water, poor hygiene, and malnutrition, combined with the immunomodulatory and physiological changes that occur during pregnancy, pregnant women are often more vulnerable than non-pregnant women to intestinal parasite invasion, especially in developing countries ( 61 ). More than 7 million pregnant women worldwide are infected with hookworm, and 10 million pregnant women in Africa are infected with schistosomiasis ( 62 , 63 ). Parasites entering the gut can attach to the mucosa and submucosa of the small intestine, destroy capillaries and arterioles and feed on the exuding blood ( 64 ). Our findings suggest that parasitic infection is one of the risk factors for anemia in pregnancy. This finding is consistent with the study conducted by Alem et al. ( 65 ). In developing countries, infection of young women, pregnant women, and their infants with intestinal parasites, especially hookworms, can lead to deficiencies in iron, total energy, protein, and folic acid and zinc, leading to low birth weight, intrauterine growth retardation, and higher morbidity and mortality of anemia in pregnancy ( 58 ). Moreover, as another common risk factor, infection with malaria is also susceptible to anemia in pregnancy. Notably, studies on malaria have come from both Ethiopia and Ghana. Their geographical location in the tropics has an important impact on the distribution of malaria. Sequestration of plasmodium in the placenta avoids spleen clearance, thereby predisposing pregnant women to malaria. Malaria causes anemia in a variety of ways, including excessive depletion of non-parasitic red blood cells, immune destruction of parasitic red blood cells, and impaired erythropoiesis due to bone marrow dysfunction ( 66 , 67 ). Other studies have shown that pregnant women infected with HIV are more likely to develop anemia than those who are not infected with HIV ( 41 ). This may be due to the properties of the virus that lead to increased metabolic and nutritional requirements and directly inhibit the production of red blood cells in the body ( 68 ). Although our meta-analysis showed no significant association between HIV infection and anemia in pregnancy. However, the lower limit of confidence interval of our results is close to 1, suggesting to some extent the correlation between HIV infection and anemia in pregnancy.

Summary of evidence related to maternal status

Previous study has shown that the risk of anemia in pregnancy increases with the number of births. The risk of developing anemia in pregnancy was nearly 3 times higher for women with 2–3 children and 4 times higher for women with 4 or more children compared to only one child ( 69 , 70 ). This is because pregnant women do not have enough time to recover from the nutritional burden of their previous pregnancy, especially folic acid, and iron deficiency. Maternal serum and erythrocyte folate concentrations also decline from the fifth month of pregnancy and remain low for a considerable time after delivery ( 6 ). The same is true for our combined analysis of 12 studies, finding that women with more than 3 children were more likely to develop anemia in pregnancy. In addition, multiple pregnancies, multiparous, and birth interval ≤ 2 years are also risk factors for anemia in pregnancy. Like the reasons for having more children, these factors lead to impaired iron stores in pregnant women, and to a certain extent, they impair the normal physiological functions and anatomical structures of pregnant women. Studies have shown that during pregnancy, the incidence of anemia increases more than 4 times from the first trimester to the third trimester, and the prevalence in the third trimester is as high as 30–45% ( 71 ). This is consistent with our findings that early pregnancy is less prone to anemia, whereas second and third trimesters are significantly associated with anemia. It may be related to the rapid growth of the fetus in the second and third trimesters and the significant increase in the demand for nutrients such as iron ( 72 ).

According to the World Health Organization, anemia in pregnancy is more prevalent in developing countries, such as Africa and Southeast Asia, where dietary diversity, living standards, and education levels are all poorer ( 73 ). In addition, lack of knowledge about anemia, infrequent antenatal check-ups, and unplanned pregnancies naturally lead to more threats of anemia in local pregnant women ( 74 ). As our study shows, 51 studies are from developing countries, especially Ethiopia, Ghana, and other countries. Also, low household income, no antenatal care, rural residence, underweight, middle upper arm circumference < 23, and illiteracy are all risk factors for anemia in pregnancy. Although unplanned pregnancy and lack of understanding of anemia were not statistically associated with anemia in pregnancy. However, according to the OR value of more than 1, and the lower limit of the 95% confidence interval close to 1, it is suggested that these two exposure factors are related to anemia in pregnancy to a certain extent.

Summary of evidence related to dietary habits in pregnant women

In fact, the most common cause of anemia in pregnancy is iron deficiency, while other causes are rare ( 2 ). Although our study shows that lack of iron supplementation during pregnancy is not associated with anemia, the likely reason is that pregnant women obtain adequate iron intake through other means such as diet. However, our study also shows that iron supplementation is a protective factor in reducing the occurrence of anemia. This fully illustrates the importance of ingesting or supplementing adequate iron during pregnancy. Adequate intake of macro- and micronutrients, quantity and variety of diets is a challenge in many countries, especially developing ones ( 75 , 76 ). After combined analysis of exposure factors related to dietary habits of pregnant women, we found that meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, tea/coffee after meals, diet diversity score ≤ 3, frequency of eating vegetables ≤ 3 times per week were all risk factor for anemia in pregnancy. This is consistent with the findings of Roess et al. Tea and coffee contain compounds that affect iron absorption such as tannins and polyphenol, meat is a good source of heme iron and protein of high biological value, and fruits rich in ascorbic acid can enhance iron absorption ( 77 ). Therefore, eating less or not eating meat and fruits will also lead to insufficient iron intake, which will eventually lead to the occurrence of anemia ( 78 , 79 ). In addition, vegetables are a food source of folic acid, and folic acid deficiency is associated with anemia in pregnancy ( 80 ).

Although anemia in pregnancy is a global public health problem, we must acknowledge that anemia in pregnancy often differs between developed and developing countries and is one of the distinct health disparities between developed and developing countries ( 81 ). The prevalence of anemia in pregnancy in developing countries ranged between 53.8 and 90.2%, compared with 8.3% in developed countries ( 82 ). There are many factors that contribute to this difference. Compared with developed countries, medical resources are scarce in developing countries, pregnant women are less likely to receive adequate or quality health care, and they are at higher risk of exposure to diseases such as malaria and parasitic infections that cause anemia in pregnancy ( 83 ). Although we conducted a comprehensive search of current mainstream databases, the studies we included were all from developing countries, and evidence from developed countries was lacking. Therefore, our findings are only applicable to developing countries. More findings from developed countries are needed in the future to provide a global picture of risk factors for anemia in pregnancy.

Strengths and limitations

Strengths: (1) As the first study in the current field to systematically summarize the risk factors of anemia in pregnancy, this study may serve as the best evidence for the prevention of anemia in pregnancy in the future. (2) This study was based on AOR rather than OR analysis, avoiding the interaction between multiple exposure factors, and the results were more in line with the actual situation. (3) According to the NOS scoring results, we found that the quality of evidence of the 51 included studies was high, which ensured the reliability of the meta-analysis results.

Limitations: (1) The included studies were all from developing countries, especially Ethiopia, therefore, our findings are only applicable to some countries, not all countries. (2) Include only English literature, which may lead to language bias. (3) The gray literature and conference abstracts were not searched, which may lead to publication bias.

Conclusions

The high incidence and serious harm of anemia in pregnancy make it urgent to systematically summarize its risk factors. Evidence from 51 high-quality studies showing infected parasite, history of malarial attack, tea/coffee after meals, meal frequency ≤ 2 times per day, frequency of eating meat ≤ 1 time per week, frequency of eating vegetables ≤ 3 times per week, multiple pregnancies, multiparous, low household income, no antenatal care, rural residence, diet diversity score ≤ 3, have more than 3 children, history of menorrhagia, underweight, family size ≥ 5, middle upper arm circumference < 23, second trimester, third trimester, birth interval ≤ 2 year, these 20 exposure factors were all risk factors for Anemia in Pregnancy. Therefore, health institutions and pregnant women themselves should focus on the above risk factors for better prevention and early detection of anemia in pregnancy.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author/s.

Author contributions

YSu proposed ideas and designed protocol. JZ and QL were responsible for data analysis and writing of the paper. YSo, LF, and LH were responsible for literature screening, data extraction, and quality evaluation. All authors contributed to the article and approved the submitted version.

We acknowledge the financial support from Kunming Health Science and Technology Personnel Training Project (No. 2022-SW-93).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1041136/full#supplementary-material

Abbreviations

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; AOR, adjusted odds ratio; NOS, Newcastle-Ottawa Scale.

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Keywords: anemia, pregnancy, systematic review, nutritional factors, evidence

Citation: Zhang J, Li Q, Song Y, Fang L, Huang L and Sun Y (2022) Nutritional factors for anemia in pregnancy: A systematic review with meta-analysis. Front. Public Health 10:1041136. doi: 10.3389/fpubh.2022.1041136

Received: 10 September 2022; Accepted: 26 September 2022; Published: 14 October 2022.

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Copyright © 2022 Zhang, Li, Song, Fang, Huang and Sun. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yu Sun, sunyu527826568@126.com

† These authors have contributed equally to this work and share first authorship

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• Case report
• Open access
• Published: 13 September 2021

Critical iron deficiency anemia with record low hemoglobin: a case report

• Audrey L. Chai   ORCID: orcid.org/0000-0002-5009-0468 1 ,
• Owen Y. Huang 1 ,
• Rastko Rakočević 2 &
• Peter Chung 2  

Journal of Medical Case Reports volume  15 , Article number:  472 ( 2021 ) Cite this article

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Anemia is a serious global health problem that affects individuals of all ages but particularly women of reproductive age. Iron deficiency anemia is one of the most common causes of anemia seen in women, with menstruation being one of the leading causes. Excessive, prolonged, and irregular uterine bleeding, also known as menometrorrhagia, can lead to severe anemia. In this case report, we present a case of a premenopausal woman with menometrorrhagia leading to severe iron deficiency anemia with record low hemoglobin.

Case presentation

A 42-year-old Hispanic woman with no known past medical history presented with a chief complaint of increasing fatigue and dizziness for 2 weeks. Initial vitals revealed temperature of 36.1 °C, blood pressure 107/47 mmHg, heart rate 87 beats/minute, respiratory rate 17 breaths/minute, and oxygen saturation 100% on room air. She was fully alert and oriented without any neurological deficits. Physical examination was otherwise notable for findings typical of anemia, including: marked pallor with pale mucous membranes and conjunctiva, a systolic flow murmur, and koilonychia of her fingernails. Her initial laboratory results showed a critically low hemoglobin of 1.4 g/dL and severe iron deficiency. After further diagnostic workup, her profound anemia was likely attributed to a long history of menometrorrhagia, and her remarkably stable presentation was due to impressive, years-long compensation. Over the course of her hospital stay, she received blood transfusions and intravenous iron repletion. Her symptoms of fatigue and dizziness resolved by the end of her hospital course, and she returned to her baseline ambulatory and activity level upon discharge.

Conclusions

Critically low hemoglobin levels are typically associated with significant symptoms, physical examination findings, and hemodynamic instability. To our knowledge, this is the lowest recorded hemoglobin in a hemodynamically stable patient not requiring cardiac or supplemental oxygen support.

Peer Review reports

Anemia and menometrorrhagia are common and co-occurring conditions in women of premenopausal age [ 1 , 2 ]. Analysis of the global anemia burden from 1990 to 2010 revealed that the prevalence of iron deficiency anemia, although declining every year, remained significantly high, affecting almost one in every five women [ 1 ]. Menstruation is considered largely responsible for the depletion of body iron stores in premenopausal women, and it has been estimated that the proportion of menstruating women in the USA who have minimal-to-absent iron reserves ranges from 20% to 65% [ 3 ]. Studies have quantified that a premenopausal woman’s iron storage levels could be approximately two to three times lower than those in a woman 10 years post-menopause [ 4 ]. Excessive and prolonged uterine bleeding that occurs at irregular and frequent intervals (menometrorrhagia) can be seen in almost a quarter of women who are 40–50 years old [ 2 ]. Women with menometrorrhagia usually bleed more than 80 mL, or 3 ounces, during a menstrual cycle and are therefore at greater risk for developing iron deficiency and iron deficiency anemia. Here, we report an unusual case of a 42-year-old woman with a long history of menometrorrhagia who presented with severe anemia and was found to have a record low hemoglobin level.

A 42-year-old Hispanic woman with no known past medical history presented to our emergency department with the chief complaint of increasing fatigue and dizziness for 2 weeks and mechanical fall at home on day of presentation.

On physical examination, she was afebrile (36.1 °C), blood pressure was 107/47 mmHg with a mean arterial pressure of 69 mmHg, heart rate was 87 beats per minute (bpm), respiratory rate was 17 breaths per minute, and oxygen saturation was 100% on room air. Her height was 143 cm and weight was 45 kg (body mass index 22). She was fully alert and oriented to person, place, time, and situation without any neurological deficits and was speaking in clear, full sentences. She had marked pallor with pale mucous membranes and conjunctiva. She had no palpable lymphadenopathy. She was breathing comfortably on room air and displayed no signs of shortness of breath. Her cardiac examination was notable for a grade 2 systolic flow murmur. Her abdominal examination was unremarkable without palpable masses. On musculoskeletal examination, her extremities were thin, and her fingernails demonstrated koilonychia (Fig. 1 ). She had full strength in lower and upper extremities bilaterally, even though she required assistance with ambulation secondary to weakness and used a wheelchair for mobility for 2 weeks prior to admission. She declined a pelvic examination. No bleeding was noted in any part of her physical examination.

Koilonychia, as seen in our patient above, is a nail disease commonly seen in hypochromic anemia, especially iron deficiency anemia, and refers to abnormally thin nails that have lost their convexity, becoming flat and sometimes concave in shape

She was admitted directly to the intensive care unit after her hemoglobin was found to be critically low at 1.4 g/dL on two consecutive measurements with an unclear etiology of blood loss at the time of presentation. Note that no intravenous fluids were administered prior to obtaining the hemoglobin levels. Upon collecting further history from the patient, she revealed that she has had a lifetime history of extremely heavy menstrual periods: Since menarche at the age of 10 years when her periods started, she has been having irregular menstruation, with periods occurring every 2–3 weeks, sometimes more often. She bled heavily for the entire 5–7 day duration of her periods; she quantified soaking at least seven heavy flow pads each day with bright red blood as well as large-sized blood clots. Since the age of 30 years, her periods had also become increasingly heavier, with intermittent bleeding in between cycles, stating that lately she bled for “half of the month.” She denied any other sources of bleeding.

Initial laboratory data are summarized in Table 1 . Her hemoglobin (Hgb) level was critically low at 1.4 g/dL on arrival, with a low mean corpuscular volume (MCV) of < 50.0 fL. Hematocrit was also critically low at 5.8%. Red blood cell distribution width (RDW) was elevated to 34.5%, and absolute reticulocyte count was elevated to 31 × 10 9 /L. Iron panel results were consistent with iron deficiency anemia, showing a low serum iron level of 9 μg/dL, elevated total iron-binding capacity (TIBC) of 441 μg/dL, low Fe Sat of 2%, and low ferritin of 4 ng/mL. Vitamin B12, folate, hemolysis labs [lactate dehydrogenase (LDH), haptoglobin, bilirubin], and disseminated intravascular coagulation (DIC) labs [prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, d -dimer] were all unremarkable. Platelet count was 232,000/mm 3 . Peripheral smear showed erythrocytes with marked microcytosis, anisocytosis, and hypochromia (Fig. 2 ). Of note, the patient did have a positive indirect antiglobulin test (IAT); however, she denied any history of pregnancy, prior transfusions, intravenous drug use, or intravenous immunoglobulin (IVIG). Her direct antiglobulin test (DAT) was negative.

A peripheral smear from the patient after receiving one packed red blood cell transfusion is shown. Small microcytic red blood cells are seen, many of which are hypochromic and have a large zone of pallor with a thin pink peripheral rim. A few characteristic poikilocytes (small elongated red cells also known as pencil cells) are also seen in addition to normal red blood cells (RBCs) likely from transfusion

A transvaginal ultrasound and endometrial biopsy were offered, but the patient declined. Instead, a computed tomography (CT) abdomen and pelvis with contrast was performed, which showed a 3.5-cm mass protruding into the endometrium, favored to represent an intracavitary submucosal leiomyoma (Fig. 3 ). Aside from her abnormal uterine bleeding (AUB), the patient was without any other significant personal history, family history, or lab abnormalities to explain her severe anemia.

Computed tomography (CT) of the abdomen and pelvis with contrast was obtained revealing an approximately 3.5 × 3.0 cm heterogeneously enhancing mass protruding into the endometrial canal favored to represent an intracavitary submucosal leiomyoma

The patient’s presenting symptoms of fatigue and dizziness are common and nonspecific symptoms with a wide range of etiologies. Based on her physical presentation—overall well-appearing nature with normal vital signs—as well as the duration of her symptoms, we focused our investigation on chronic subacute causes of fatigue and dizziness rather than acute medical causes. We initially considered a range of chronic medical conditions from cardiopulmonary to endocrinologic, metabolic, malignancy, rheumatologic, and neurological conditions, especially given her reported history of fall. However, once the patient’s lab work revealed a significantly abnormal complete blood count and iron panel, the direction of our workup shifted towards evaluating hematologic causes.

With such a critically low Hgb on presentation (1.4 g/dL), we evaluated for potential sources of blood loss and wanted to first rule out emergent, dangerous causes: the patient’s physical examination and reported history did not elicit any concern for traumatic hemorrhage or common gastrointestinal bleeding. She denied recent or current pregnancy. Her CT scan of abdomen and pelvis was unremarkable for any pathology other than a uterine fibroid. The microcytic nature of her anemia pointed away from nutritional deficiencies, and she lacked any other medical comorbidities such as alcohol use disorder, liver disease, or history of substance use. There was also no personal or family history of autoimmune disorders, and the patient denied any history of gastrointestinal or extraintestinal signs and/or symptoms concerning for absorptive disorders such as celiac disease. We also eliminated hemolytic causes of anemia as hemolysis labs were all normal. We considered the possibility of inherited or acquired bleeding disorders, but the patient denied any prior signs or symptoms of bleeding diatheses in her or her family. The patient’s reported history of menometrorrhagia led to the likely cause of her significant microcytic anemia as chronic blood loss from menstruation leading to iron deficiency.

Over the course of her 4-day hospital stay, she was transfused 5 units of packed red blood cells and received 2 g of intravenous iron dextran. Hematology and Gynecology were consulted, and the patient was administered a medroxyprogesterone (150 mg) intramuscular injection on hospital day 2. On hospital day 4, she was discharged home with follow-up plans. Her hemoglobin and hematocrit on discharge were 8.1 g/dL and 24.3%, respectively. Her symptoms of fatigue and dizziness had resolved, and she was back to her normal baseline ambulatory and activity level.

Discussion and conclusions

This patient presented with all the classic signs and symptoms of iron deficiency: anemia, fatigue, pallor, koilonychia, and labs revealing marked iron deficiency, microcytosis, elevated RDW, and low hemoglobin. To the best of our knowledge, this is the lowest recorded hemoglobin in an awake and alert patient breathing ambient air. There have been previous reports describing patients with critically low Hgb levels of < 2 g/dL: A case of a 21-year old woman with a history of long-lasting menorrhagia who presented with a Hgb of 1.7 g/dL was reported in 2013 [ 5 ]. This woman, although younger than our patient, was more hemodynamically unstable with a heart rate (HR) of 125 beats per minute. Her menorrhagia was also shorter lasting and presumably of larger volume, leading to this hemoglobin level. It is likely that her physiological regulatory mechanisms did not have a chance to fully compensate. A 29-year-old woman with celiac disease and bulimia nervosa was found to have a Hgb of 1.7 g/dL: she presented more dramatically with severe fatigue, abdominal pain and inability to stand or ambulate. She had a body mass index (BMI) of 15 along with other vitamin and micronutrient deficiencies, leading to a mixed picture of iron deficiency and non-iron deficiency anemia [ 6 ]. Both of these cases were of reproductive-age females; however, our patient was notably older (age difference of > 20 years) and had a longer period for physiologic adjustment and compensation.

Lower hemoglobin, though in the intraoperative setting, has also been reported in two cases—a patient undergoing cadaveric liver transplantation who suffered massive bleeding with associated hemodilution leading to a Hgb of 0.6 g/dL [ 7 ] and a patient with hemorrhagic shock and extreme hemodilution secondary to multiple stab wounds leading to a Hgb of 0.7 g/dL [ 8 ]. Both patients were hemodynamically unstable requiring inotropic and vasopressor support, had higher preoperative hemoglobin, and were resuscitated with large volumes of colloids and crystalloids leading to significant hemodilution. Both were intubated and received 100% supplemental oxygen, increasing both hemoglobin-bound and dissolved oxygen. Furthermore, it should be emphasized that the deep anesthesia and decreased body temperature in both these patients minimized oxygen consumption and increased the available oxygen in arterial blood [ 9 ].

Our case is remarkably unique with the lowest recorded hemoglobin not requiring cardiac or supplemental oxygen support. The patient was hemodynamically stable with a critically low hemoglobin likely due to chronic, decades-long iron deficiency anemia of blood loss. Confirmatory workup in the outpatient setting is ongoing. The degree of compensation our patient had undergone is impressive as she reported living a very active lifestyle prior to the onset of her symptoms (2 weeks prior to presentation), she routinely biked to work every day, and maintained a high level of daily physical activity without issue.

In addition, while the first priority during our patient’s hospital stay was treating her severe anemia, her education became an equally important component of her treatment plan. Our institution is the county hospital for the most populous county in the USA and serves as a safety-net hospital for many vulnerable populations, most of whom have low health literacy and a lack of awareness of when to seek care. This patient had been experiencing irregular menstrual periods for more than three decades and never sought care for her heavy bleeding. She, in fact, had not seen a primary care doctor for many years nor visited a gynecologist before. We emphasized the importance of close follow-up, self-monitoring of her symptoms, and risks with continued heavy bleeding. It is important to note that, despite the compensatory mechanisms, complications of chronic anemia left untreated are not minor and can negatively impact cardiovascular function, cause worsening of chronic conditions, and eventually lead to the development of multiorgan failure and even death [ 10 , 11 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

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AC, OH, RR, and PC managed the presented case. AC performed the literature search. AC, OH, and RR collected all data and images. AC and OH drafted the article. RR and PC provided critical revision of the article. All authors read and approved the final manuscript.

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Chai, A.L., Huang, O.Y., Rakočević, R. et al. Critical iron deficiency anemia with record low hemoglobin: a case report. J Med Case Reports 15 , 472 (2021). https://doi.org/10.1186/s13256-021-03024-9

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DOI : https://doi.org/10.1186/s13256-021-03024-9

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• Menometrorrhagia
• Iron deficiency
• Critical care
• Transfusion

Journal of Medical Case Reports

ISSN: 1752-1947

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• Research article
• Open access
• Published: 06 April 2020

The contribution of iron deficiency to the risk of peripartum transfusion: a retrospective case control study

• H. VanderMeulen 1 ,
• R. Strauss 2 ,
• Y. Lin 2 , 3 ,
• A. McLeod 4 ,
• J. Barrett 5 ,
• M. Sholzberg 3 , 6 , 7 &
• J. Callum 2 , 3  

BMC Pregnancy and Childbirth volume  20 , Article number:  196 ( 2020 ) Cite this article

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A Correction to this article was published on 17 April 2020

This article has been updated

Iron deficiency in pregnancy is associated with inferior maternal and fetal outcomes. Postpartum depression, prematurity, intrauterine growth restriction, impaired childhood cognition and transfusion are all sequelae of maternal iron deficiency anemia. Transfusion to women of childbearing age has important consequences including increasing the risk of hemolytic disease of the fetus and newborn with future pregnancies. The relative contribution of iron deficiency to transfusion rates in the peripartum period is unknown. This study aimed to identify the prevalence of iron deficiency and anemia in pregnant women that received peripartum transfusions relative to age-matched non-transfused controls.

We performed a retrospective case-control study of all women that were transfused in the peripartum period from January, 2014 to July, 2018. Cases were compared to the next age matched control to deliver at our institution. The primary objective was to determine the proportion of patients with iron deficiency in pregnancy or anemia in pregnancy in cases and controls. Charts were reviewed for predisposing risk factors for iron deficiency, laboratory measures of iron deficiency and anemia, iron supplementation history and maternal and fetal outcomes. Factors associated with peripartum transfusion were analyzed using a multivariate logistic regression.

169 of 18, 294 (0.9%) women were transfused in the peripartum period and 64 (44%) of those transfused received 1 unit. Iron deficiency or anemia were present in 103 (71%) transfused women and 74 (51%) control women in pregnancy (OR 2.34, 95% CI: 3.7–18.0). Multivariate analysis identified social work involvement (adjusted OR 4.1, 95% CI: 1.8–10.1), intravenous iron supplementation in pregnancy (adjusted OR 3.8, 95% CI: 1.2–17.4) and delivery by unscheduled cesarean section (adjusted OR 2.8, 95% CI: 1.3–6.2) as significant predictors of peripartum transfusion.

Conclusions

Pregnant women being followed by a social worker, receiving intravenous iron supplementation in pregnancy or who deliver by unscheduled cesarean section are more likely to receive a red blood cell transfusion. Women with iron deficiency or anemia in pregnancy are at increased risk of peripartum blood transfusions and warrant early and rigorous iron supplementation.

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A drop in hemoglobin (Hb) level is a physiologic consequence of pregnancy due to an expanded plasma volume. The maternal serum hemoglobin typically reaches the physiological nadir at 24–32 weeks gestation [ 1 ]. Iron requirements steadily rise in each trimester, reaching a peak of 7.5 mg/d in the 3rd trimester [ 1 ]. Overall, pregnancy has a net iron loss of approximately 740 mg [ 2 ]. In Canada, 23% of pregnant women are anemic (Hb < 110 g/L in 1st and 3rd trimesters, < 105 g/L in 2nd trimester) [ 3 , 4 ] and an estimated 85% of these cases are attributable to iron deficiency [ 5 ]. In its early stages, iron deficiency can occur without anemia. Ferritin is the best marker of iron deficiency in pregnancy and a serum ferritin less than 30 μg/L has a sensitivity of 92% for iron deficiency with a positive predictive value of 83% [ 6 ]. Recent Canadian data showed that over 73% of pregnant women had ferritin levels < 30 μg/L at first obstetrical evaluation [ 7 ].

Maternal health is impacted by anemia during pregnancy. A recent analysis describes a 2.36 fold higher risk of maternal death in women with severe anemia (hemoglobin < 70 g/L) [ 8 ]. The risk of postpartum depression is also higher in women with iron deficiency anemia (IDA) [ 9 ]. Given iron’s critical role in DNA synthesis and cellular metabolism [ 10 ], it is not surprising that it also plays a crucial role in fetal development. In fact, maternal IDA increases the risk of prematurity [ 11 , 12 ], fetal intrauterine growth restriction [ 11 , 13 ], developmental delay [ 14 ] and perinatal mortality [ 12 , 13 ]. The risks associated with anemia in pregnancy correlate best with hemoglobin levels tested in the first trimester, prior to significant plasma expansion [ 15 ].

In addition to these adverse outcomes, treating iron deficiency can also prevent red blood cell (RBC) transfusions for severe, symptomatic anemia. Avoiding RBC transfusions in pregnant women and women of childbearing age is key to preventing the development of red blood cell alloantibodies and hemolytic disease of the fetus and newborn in subsequent pregnancies [ 16 ], as one in fifteen recipients of RBC transfusions will develop an alloantibody [ 17 ]. Further, any transfusion carries the risk of identification errors, viral or bacterial infection, transfusion associated circulatory overload or other transfusion reactions [ 18 ].

Given the high prevalence of iron deficiency in pregnant women, our goal was to elucidate the relative contribution of untreated iron deficiency to peripartum RBC transfusions. We present a case control study aimed at identifying the prevalence of iron deficiency or anemia in pregnant women that were transfused in the peripartum period compared to controls.

A retrospective case-control study was carried out with cases defined as all obstetric patients receiving a peripartum RBC transfusion between January, 2014 and July, 2018 during admission to the obstetrical unit at Sunnybrook Health Sciences Centre, Toronto, Canada. High risk referrals comprise 20% of the approximately 4000 deliveries per year at our institution. Cases were identified through the blood bank information system (HCLL, Wellsky, USA). Patients were excluded if they had a clear alternative explanation for their anemia (e.g., chronic kidney disease, malignancy, bone marrow failure syndrome), had a pre-existing transfusion dependence, had differential hemoglobin targets for transfusion (e.g., sickle cell disease), or did not receive the majority of their prenatal care at our institution (defined as women whose care was transferred to our institution for delivery only). Controls were defined as obstetrical patients delivering at our institution that did not receive a transfusion at the time of delivery. A single control was selected as the next age-matched delivery following the transfused case.

Demographic and laboratory data were collected from patient charts retrospectively. Transfusion data were collected from the blood bank information system. Based on the literature and biologic plausibility, risk factors for and laboratory measures associated with iron deficiency, anemia and transfusion were established [ 19 , 20 ]. Demographic variables collected included age, ethnicity, multiple gestation, social work involvement, history of heavy menstrual bleeding, history of chronic malabsorption (e.g. celiac disease, inflammatory bowel disease, bypass surgery), vegetarianism/veganism, hyperemesis gravidarum, and consumption of prenatal vitamins and iron supplements during pregnancy. Patients’ past medical history, including obstetrical and gynecologic history, and dietary restrictions were collected from their prenatal record. This record is standard and mandated for all pregnancies in the province of Ontario, Canada. Median household income was assigned based on geographic location of residence by postal code using publicly available records from Statistics Canada (Ottawa, Canada). Delivery outcomes and perinatal outcomes were also collected including incidence of primary postpartum hemorrhage (defined by > 1000 mL of blood loss within 24 h of delivery as estimated on their delivery record, or documentation of postpartum hemorrhage in the chart), maternal infection, fetal demise, prematurity (< 37 weeks gestational age), low birth weight (< 2500 g), maternal ICU admissions, hysterectomies and cesarean sections (planned and unplanned). We collected components of the complete blood count (hemoglobin, mean corpuscular volume (MCV), red blood cell distribution width (RDW)) and iron studies (ferritin, transferrin saturation (TSAT) and total iron binding capacity (TIBC)) in the year prior to pregnancy, during pregnancy and up to 6 months postpartum.

The primary objective was to determine the proportion of patients with iron deficiency in pregnancy (ferritin < 30 μg/L, TSAT < 20% or last documented MCV < 80 fL when previously normal) or anemia in pregnancy (Hb < 110 g/L in 1st or 3rd trimester or < 105 g/L in 2nd trimester) in cases and controls.

The secondary objectives were to determine the rate of suboptimal care as defined by any of the following quality indicators: 1) Unaddressed anemia in pregnancy (defined by anemia (as above) without either the measurement of a ferritin or transferrin saturation and total iron binding capacity, or without iron treatment documented in the antepartum record; and absence of a known red cell disorder as documented in laboratory information system or antenatal record. The standard of care in Canada is to offer hemoglobin electrophoresis or high performance liquid chromatography to at-risk women [ 21 ]); 2) Identified but uncorrected iron deficiency in pregnancy: clear iron deficiency (ferritin < 30 μg/L) without documentation of commencing oral iron replacement at a dose of at least 30 mg of elemental iron or administration of intravenous iron; 3) Identified but uncorrected iron deficiency anemia in pregnancy: clear iron deficiency anemia (ferritin < 30 μg/L and anemia (defined above)) without documentation of commencing oral iron replacement at a dose of at least 30 mg of elemental iron or administration of intravenous iron; 4) Mild anemia (Hb 100–109 g/L in 1st and 3rd trimester, Hb 100–104 g/L in 2nd trimester) and moderate anemia (Hb 90–99 g/L) in pregnancy; and 5) Hb < 90 g/L postpartum with uncorrected iron deficiency (defined above) at last measurement in the current pregnancy.

Descriptive statistics were summarized using medians and interquartile ranges for continuous variables and proportions for categorical variables. To identify statistically significant predictive factors associated with peripartum transfusion, univariate logistic regression was performed with case/control status as the dependent variable. We included predefined risk factors for iron deficiency, anemia and transfusion which were selected based on biologic plausibility and sufficient data. Statistically significant variables at a threshold of alpha 0.05 were included in a multivariate logistic regression model to quantify predictive factors associated with transfusion at delivery. Maternal and fetal outcomes were excluded from our multivariate analysis in order to focus on preexisting risk factors for transfusion. Odds ratio (OR) and the 95% confidence interval (CI) were calculated for each predictive factor. All statistical analyses were performed using Statistical Analysis Software (SAS version 9.4; Cary, NC).

This study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board, #221–2018; this approval allowed access to the data used for this research.

Demographics

Between January, 2014 and July, 2018, 18, 294 women delivered at our institution. Of those, 169 (0.9%) women received an RBC transfusion in pregnancy or up to 6 weeks postpartum. Twenty four cases did not meet the inclusion criteria: received the majority of their care at other institutions (missing baseline laboratory data) [ 7 ], chronic kidney disease [ 7 ], sickle cell disease [ 4 ], aplastic anemia [ 2 ], rectal cancer [ 1 ], B cell acute lymphoblastic leukemia [ 1 ], pre-existing transfusion dependence due to unknown hematologic disorder [ 1 ] and a planned open hysterectomy at the time of delivery for uterine fibroids [ 1 ]. After excluding these 24 women, 145 cases remained and were matched to controls, resulting in an overall cohort size of 290 patients.

The mean patient age was similar in both groups (34.5 ± 5.0) (mean age of 33.1 for all deliveries at this centre during time period). Baseline characteristics of the population are presented in Table  1 . Transfused cases as compared to controls were more likely to be primiparous (20% vs 15%), to have non-singleton pregnancies (8% vs 4%) and to be delivered by cesarean section (60% vs 38%).

Transfusion metrics

A total of 431 units of RBCs were transfused to 169 women (72 units were transfused to the 24 excluded patients and 359 to the 145 cases). For the 145 cases, 64 (44%) women received 1 unit of red blood cells, 48 (33%) received 2 units, and 33 (23%) women required 3 or more units (Fig.  1 ). Four women were transfused antepartum and 141 were transfused at delivery or postpartum (Fig.  2 ). The median pre-transfusion hemoglobin was 65 g/L (IQR 11.25). Ninety-four of the 145 cases had a document of postpartum hemorrhage on their record and 15 were transfused as part of a massive transfusion protocol. In contrast, only 4 controls had documented postpartum hemorrhage.

Number of units of red blood cells transfused per patient ( N  = 145 patients)

Timing of peripartum red blood cell transfusions ( N  = 145 patients)

Primary outcome

Iron deficiency or anemia were present in 103 (71%) transfused women and 74 (51%) control women in pregnancy (OR 2.34, 95% CI: 1.4–3.8). Secondary outcomes are reported in Table  2 . The odds of moderate postpartum anemia (Hb < 90 g/L) with uncorrected iron deficiency in pregnancy (OR 7.7, 95% CI: 3.7–18.0), moderate anemia in pregnancy (OR 5.2, 95% CI: 1.1–49.9) and mild anemia in pregnancy (OR 3.2, 95% CI: 1.8–6.2) were significantly higher in transfused women relative to controls.

Iron status

Iron deficiency was identified in 27 of 85 cases (32%) and 9 of 41 controls (22%) in the year prior to pregnancy. In pregnancy, 72 cases (50%) and 62 controls (43%) had iron deficiency, and 32 cases (22%) and 11 controls (8%) had iron deficiency anemia. Iron deficiency was identified in 14 of 144 cases (10%) and 5 of 75 controls (7%) who had a CBC, TSAT, and/or ferritin in the period from 24 h postpartum to 6 months postpartum (Table  3 ). Fifty-one (35%) transfused women received oral iron replacement in pregnancy compared to 37 (26%) women in the control group. Of these 88 women treated with oral iron, 7 transfused cases and 1 control case were started on oral iron within 4 weeks of delivery. Twenty-two (15%) transfused women and 3 (2%) control women received intravenous iron therapy in pregnancy. Iron sucrose was the formulation used in all cases at a dose of 200–300 mg IV per infusion. Sixteen of the 22 (73%) transfused women who received intravenous iron were given their first dose within 3 weeks of delivery (Fig.  3 ). Of the transfused women, 7 received 1 dose of intravenous iron in pregnancy, 13 received 2 doses and 2 received 3 doses. In the control group, 1 woman received 2 doses of intravenous iron in pregnancy and 2 women received 3 doses of intravenous iron in pregnancy.

Use of and timing of oral and intravenous iron supplementation in pregnancy

( N  = 145 cases, N  = 145 controls)

Univariate analysis

Results of the univariate regression analysis are detailed in Table  4 . Socioethnic factors including Caucasian ethnicity (OR 0.4, 95% CI: 0.2–0.7), social work involvement during pregnancy (OR 5.0, 95% CI: 2.4–11.7) and residency in a low-income neighborhood (OR 2.0, 95% CI: 1.2–3.5) had significant associations with the odds of transfusion. Women with anemia of any etiology in pregnancy had 4 times higher odds of receiving a transfusion (OR 4.0, 95% CI: 2.3–7.1). Transfused women had higher rates of IDA in pregnancy (OR 3.3, 95% CI: 1.7–7.1). Vaginal delivery was associated with lower odds of transfusion (OR 0.4, 95% CI: 0.3–0.7), while delivery by unplanned cesarean section was associated with higher odds (OR 3.7, 95% CI: 2.2–6.4).

Multivariate analysis

The multivariate analysis included all statistically significant baseline predictors of transfusion from the univariate analysis (Table  5 ). Social work involvement in pregnancy (OR 4.1, 95% CI: 1.8–10.1), IV iron supplementation in pregnancy (OR 3.8, 95% CI: 1.2–17.4) and delivery by unplanned cesarean section (OR 2.8, 95% CI: 1.3–6.2) were independently associated with higher odds of peripartum transfusion.

Maternofetal outcomes

Transfused women had more primary postpartum hemorrhage (defined as > 1000 mL blood loss within 24 h of delivery) (OR 65.0, 95% CI: 22.7–185.8) and bacterial infections (OR 25.8, 95% CI: 3.4–193.8). Maternal infections in the transfused women included chorioamnionitis [ 9 ], endometritis [ 6 ] and surgical site infections [ 1 ], among others [ 4 ]. In the control group, 1 woman was diagnosed with chorioamnionitis. Babies born to transfused mothers had higher rates of fetal demise (OR 9.5, 95% CI: 2.2–41.9), prematurity (OR 8.3, 95% CI 4.4–15.7), low birth weight (OR 6.8, 95% CI: 3.6–12.8), and NICU admission (OR 5.5, 95% CI: 2.8–10.7) (Table 4 ).

To our knowledge this is the first study to assess the burden of iron deficiency in women transfused in the peripartum period. We find that transfused women were more than 2-times more likely to have iron deficiency or anemia in pregnancy. Women treated with intravenous iron in pregnancy (OR 3.8), women who delivered by unplanned cesarean section (OR 2.8), and women being followed by a social worker (OR 4.1) were also found to have increased odds of peripartum transfusion. In addition, 77% of women received only 1–2 units of red blood cells. These findings suggest that there is an opportunity to identify and treat iron deficiency before and during pregnancy to mitigate the risk of transfusion and that coordination between physicians and social workers may be a useful strategy to identify and reach women at higher risk.

At our institution, 70% of pregnant women had a ferritin checked and only 65% with documented iron deficiency were prescribed oral iron supplementation. The American College of Obstetricians and Gynecologists (ACOG) [ 22 ], Centers for Disease Control (CDC) [ 23 ], and World Health Organization (WHO) [ 4 ] all recommend screening asymptomatic pregnant women for IDA using serum hemoglobin and ferritin levels, and universal iron supplementation during pregnancy with a dose of 30–60 mg/day of elemental iron [ 23 , 24 ]. In anemic women, they suggest increasing the dose to 60–120 mg/day of elemental iron [ 23 ]. A consensus statement from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) suggests daily oral iron (30-60 mg) supplementation in areas with a high prevalence of anemia in pregnancy and screening for iron deficiency in all non-anemic women at risk of ID [ 25 ]. The U.S. Preventative Task Force cites a lack of evidence to support routine screening or routine iron supplementation in pregnancy [ 26 ]. Perhaps as a result of this ambiguity, less than one third of American obstetrician-gynecologists have been shown to provide routine iron supplementation to their pregnant patients [ 27 ]. The NATA consensus statement also supports intravenous iron consideration in women with ID and Hb < 80 g/L or in newly diagnosed IDA after 34 weeks gestation [ 25 ]. In our study patients, however, we noted a delay in the initiation of intravenous iron in pregnancy: three-quarters of intravenous iron was given within 3 weeks of delivery, leaving little time for erythropoiesis to correct the red cell mass. The reasons for this delay are likely multifactorial, including a lack of physician comfort with prescribing intravenous iron in pregnancy, difficulty accessing the drug, and challenges in facilitating drug infusion. When possible, we recommend earlier consideration of intravenous iron in women not responding to oral iron, not tolerating oral iron or with moderate to severe anemia to ensure sufficient time to correct the anemia before delivery.

Despite a publicly funded healthcare system in Ontario, oral and intravenous iron are not universally funded as general list products and as such coverage is provided out-of-pocket, through third-party private insurance plans or via exceptional access public funding. However, this does not address the “working poor” who cannot pay out-of-pocket, do not have private insurance and also do not meet criteria for exceptional access public funding. This results in health inequity between high and low income families and likely contributes to the higher incidence of untreated iron deficiency in those of lower socioeconomic status [ 28 ]. Moreover, these women are less likely to eat a diet rich in iron as many of these foods are particularly expensive (e.g. red meat). Since children born to iron deficient mothers have higher rates of developmental delay [ 14 ] and impaired self-regulation [ 29 ], there is a compounding disadvantage of being born into a low-income household. Further, these babies may represent a more medically complex population since in our study, babies born to transfused mothers had higher rates of prematurity and lower birth weights. We also found that Caucasian women had lower peripartum transfusion rates which is in keeping with prior literature [ 30 ]. Multiple factors including diet, socioeconomic status and genetics may be at play since Black women have lower hemoglobin levels [ 31 ] and non-Caucasians have higher rates of hemoglobinopathies [ 32 , 33 ]. Further research is required to fully understand this phenomenon and the maternal and fetal benefits of removing barriers to IV iron in pregnancy.

The peripartum transfusion rate at our institution (0.9%) was comparable to that in other high resource settings [ 19 , 20 ]. Interestingly, 44% of transfused women received just one unit of red blood cells, suggesting that many of the transfusions given were potentially avoidable with diligent prevention of iron deficiency anemia prior to delivery. Avoiding blood transfusions in women of childbearing age is essential to preventing complications such as alloantibody formation and hemolytic disease of the fetus and newborn in future pregnancies. Postpartum transfusion also has other important implications for women: those transfused 1 to 2 units of blood after obstetrical hemorrhage have longer hospital stays, higher ICU admission rates and hospital readmission rates and lower breastfeeding rates [ 34 ]. Further, when postpartum women are transfused in the absence of hemorrhage, their risk of severe morbidity with subsequent pregnancies is over four fold [ 35 ].

Next steps include clarifying the factors that contribute to higher peripartum transfusion rates in non-Caucasian women and women with complex social situations and quality improvement initiatives to target earlier and more intensive iron replacement in pregnant women. Additional studies need to be performed to understand the proportion of transfusions in these subgroups of patients that can be prevented with oral and intravenous iron. Prospective studies are needed to determine if aggressive iron management in pregnancy will reduce the proportion of women transfused and impact important maternal and fetal outcomes.

Limitations

First trimester ferritin testing is not part of Canadian obstetrical guidelines and 30% of the patients in this study did not have a ferritin level checked in pregnancy. As such, this study may underestimate the incidence of peripartum iron deficiency. Further, some women received part of their antenatal care at an outside institution and we did not have access to these records or laboratory results for the analysis. As this was a retrospective study, the prescription of oral iron may not be routinely documented in patients’ medication records or clinic notes and therefore may not have been captured.

In summary, iron deficiency in pregnancy is common, under-recognized and undertreated. It has implications for mothers and babies and predisposes women to blood transfusions which may have severe consequences for future pregnancies. Women being followed by a social worker appear particularly vulnerable and warrant more attention paid to iron replacement and we hypothesize that social and financial barriers may be impairing access to treatment. We advocate for early recognition of iron deficiency by screening all pregnant women with a first trimester ferritin, diligent use of early oral iron replacement, and improved access to intravenous iron replacement in pregnancy for all women irrespective of their financial resources.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Change history

17 april 2020.

Following publication of the original article [1], we have been notified that there is a missing conflict of interest.

Abbreviations

Iron deficiency anemia

Mean corpuscular volume

Red blood cell distribution width

Transferrin saturation

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Acknowledgements

The authors would like to thank Chantal Armali for her help in organizing this study and Liying Zhang for her assistance with statistical analysis.

This research received funding support from Canadian Blood Services (Transfusion Medicine Research Program Support Award), funded by the federal government (Health Canada) and the provincial and territorial ministries of health. The views herein do not necessarily reflect the views of Canadian Blood Services or the federal, provincial, or territorial governments of Canada.

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Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada

H. VanderMeulen

Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada

R. Strauss, Y. Lin & J. Callum

Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada

Y. Lin, M. Sholzberg & J. Callum

Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada

Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Canada

Li Ka Shing Knowledge Institute, Toronto, Canada

M. Sholzberg

Department of Medicine, St. Michael’s Hospital, Toronto, Canada

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Contributions

HV contributed to study design, data collection, data analysis, interpretation of the data and authorship of the manuscript. RS contributed to data collection and data analysis. YL contributed to study design, interpretation of the data and manuscript revision. AM contributed to interpretation of the data and manuscript revision. JB contributed to interpretation of the data and manuscript revision. MS contributed to interpretation of the data and manuscript revision. JC contributed to study design, interpretation of the data and manuscript revision. All authors read and approved the final manuscript.

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Correspondence to H. VanderMeulen or J. Callum .

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This study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board, #221–2018.

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Dr. Michelle Sholzberg has received honoraria for advisory boards from Pfizer. The remaining authors declare that they have no competing interests.

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VanderMeulen, H., Strauss, R., Lin, Y. et al. The contribution of iron deficiency to the risk of peripartum transfusion: a retrospective case control study. BMC Pregnancy Childbirth 20 , 196 (2020). https://doi.org/10.1186/s12884-020-02886-z

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Iron Deficiency Anemia in Pregnancy

Affiliation.

• 1 Department of Obstetrics and Gynaecology, University Hospital Zurich, Obstetric Research, Feto- Maternal Haematology Research Group, Zurich, Switzerland. Electronic address: [email protected].
• PMID: 26404445
• DOI: 10.1053/j.seminhematol.2015.07.003

Anemia is a common problem in obstetrics and perinatal care. Any hemoglobin below 10.5 g/dL can be regarded as true anemia regardless of gestational age. Reasons for anemia in pregnancy are mainly nutritional deficiencies, parasitic and bacterial diseases, and inborn red blood cell disorders such as thalassemias. The main cause of anemia in obstetrics is iron deficiency, which has a worldwide prevalence between estimated 20%-80% and consists of a primarily female population. Stages of iron deficiency are depletion of iron stores, iron-deficient erythropoiesis without anemia, and iron deficiency anemia, the most pronounced form of iron deficiency. Pregnancy anemia can be aggravated by various conditions such as uterine or placental bleedings, gastrointestinal bleedings, and peripartum blood loss. In addition to the general consequences of anemia, there are specific risks during pregnancy for the mother and the fetus such as intrauterine growth retardation, prematurity, feto-placental miss ratio, and higher risk for peripartum blood transfusion. Besides the importance of prophylaxis of iron deficiency, the main therapy options for the treatment of pregnancy anemia are oral iron and intravenous iron preparations.

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Weird Signs Of Iron Deficiency In Women: How To Spot This Often Undiagnosed Condition, According To Doctors

Have you been craving ice lately?

What do ice cravings, hair loss, and mood changes have in common? They're all potentially weird signs of iron deficiency, which is actually relatively prevalent in women.

An estimated 14 percent of U.S. adults are lacking this mineral responsible for making red blood cells, according to a September 2024 JAMA Open Network report . However, when you hone in, 34 percent of women between the ages of 18 and 50 are iron deficient, the study says.

There’s one slight problem: While iron deficiency was found to be “very common” in the “apparently healthy” general population and associated with all-cause mortality in a 2020 article published in Clinical Research in Cardiology , it’s also not routinely screened for. “There are a lot of people who are iron deficient for so long and don't even know,” says Imo J. Akpan, MD, a hematologist at NewYork-Presbyterian/Columbia University Irving Medical Center. “Picking it up early can lead to it being treated early and potentially prevent anemia and other symptoms,” including restless leg syndrome, impaired neurocognitive function, and decreased physical capacity, the 2024 study found.

Women in particular are at risk mainly because of their reproductive systems; if you’re getting a period each month, you’re losing iron through menstrual blood . Plus, pregnant people have an increased need for iron to support their fetus.

Here’s what you need to know about recognizing the signs of an iron deficiency—and the fixes you can make to help get your levels back on track.

Meet the experts: Imo J. Akpan , MD, is a hematologist at NewYork-Presbyterian/Columbia University Irving Medical Center. Keri Peterson , MD, is an internal medicine specialist and WH Advisory Board member.

What is iron and how does it function in the body?

Iron is a naturally-occurring mineral that plays a big role in transporting oxygen around your body. Its number one job is making hemoglobin, which carries oxygen to your red blood cells, and myoglobin, which carries oxygen to your muscles, per the National Institute of Health .

“Iron is a metal that is very abundant on the earth and unfortunately it's also one of the most common deficiencies that we have,” says Dr. Apkan. In order to test for an iron deficiency, providers tend to look at your ferritin, a protein found in your blood that contains iron. You can think of this number as a savings account, she says. The reserves are used when needed and replenished through your diet.

It’s common to hear about iron in the context of anemia, which is a condition that can be caused when iron stores are too low. Anemia is when you don’t have enough red blood cells, which iron plays a role in making, but the test for it wouldn’t catch an iron deficiency.

Signs Of Iron Deficiency

Though iron deficiencies aren’t routinely checked for, they can have a big impact on your quality of life. If you’re iron deficient, you might experience any of the following, according to the experts. Although, experiencing one or more of these symptoms alone does not mean you have an iron deficiency.

• Feeling dizzy, lightheaded, or fainting
• Pica, or cravings for non-food, like ice
• Chest pains, including discomfort or pinching
• Impaired brain function
• Exercise intolerance
• Shortness of breath
• Irritability or mood changes
• Restless leg syndrome

How is an iron deficiency diagnosed?

First, if you’re ever experiencing severe and/or worrying symptoms of any kind, you should always call your doctor or 9-11. After more serious conditions are ruled out (like in the case of chest pains, a heart problem), providers may do a blood test to look at ferritin levels, which is a protein in your blood that contains iron and will tell you just how much you have stored up in your savings account. Normal levels of ferritin are between 30 and 150 nanograms per milliliter for women, and anything below 30 would be deficient, says Dr. Akpan.

When iron is low, it’s because you’re either not getting enough of it or you’re losing too much, says Keri Peterson, MD, an internal medicine provider and WH Advisory Board member. You get iron through your diet, so getting enough could be a challenge for vegetarians or vegans because we absorb iron best from meat sources, she says. If you have a gastrointestinal condition like irritable bowel syndrome , Crohn’s Disease , or Celiac Disease, or have had bariatric surgery, you also might have a tougher time absorbing iron and therefore not be getting enough, adds Dr. Akpan. Some medicines might also affect iron absorption.

When it comes to losing iron, this could be from getting your period or more serious conditions like ulcers, fibroids , or colorectal cancer . For menopausal people, it’s especially important to get to the bottom of an iron deficiency because it can’t be explained by a period, says Dr. Peterson. Otherwise, periods are the most common reason why a woman might be iron deficient, says Dr. Akpan. While you shouldn’t need to do anything special with your diet that time of month to make up for the iron lost, if your period is so heavy that it’s causing a deficiency, you should see your doctor.

Iron levels are also particularly important for pregnant people, who need more of it to support their growing fetus. In the first trimester, you’ll only need an additional .5 milligrams of iron per day, but by the third trimester, you’ll need an extra six milligrams, says Dr. Akpan. (But always talk to your doctor for personalized recommendations before starting any new supplement.) Because so many people are unknowingly deficient, this could pose a problem going into pregnancy, she says. Pregnant people who don’t know they are iron deficient are at risk for developing anemia. Additionally, severe iron deficiency could lead to abnormal placentas, premature delivery, or low birthweight, according to a 2020 study published in Nutrients . If you’re newly pregnant and have a question about your iron levels, ask your doctor for a test.

How To Boost Your Iron Levels

Boosting iron levels can be pretty simple—and you should be back on track in as quickly as 48 hours or a few months depending on your starting point and the treatment you select with your doctor, says Dr. Akpan.

Make sure you’re getting enough iron through your diet.

You absorb iron best through meat sources, says Dr. Peterson. Iron-rich foods include beef, chicken, eggs, lamb, ham, and turkey and plant-based options include dried beans, lentils, chickpeas, peas, almonds, sunflower seeds, spinach, broccoli, and prune juice. You can also find cereals that are fortified with iron, Dr. Peterson adds. And, BTW, some foods inhibit iron absorption, so you might want to space them out when you’re trying to get more iron-rich foods into your day. Coffee, tea, and calcium can all make it harder to absorb iron. Meanwhile, vitamin C can increase iron absorption.

A well-balanced diet should be giving you a sufficient amount of iron, Dr. Akpan says, but if you’re looking to track your intake, the NIH recommends 18 milligrams a day for women between the ages of 19 and 50.

Consider iron supplements.

Iron supplements can also help you get your levels back up, but you should talk to your doctor before taking them. “You want to make sure you’re being monitored closely,” says Dr. Akpan. Your doc will best be able to recommend which supplement to take, how much, and how often. They’ll also check back in with you to make sure they’re going well. Dr. Peterson says she usually checks in with a patient after one or two months to see if their iron levels have improved.

Some downsides to iron supplements could be a metallic taste in your mouth, constipation, or diarrhea.

Ask your doc about an iron infusion.

Iron infusions are for people who don’t tolerate supplements well, have a tough time absorbing iron, or for people who need to boost their levels quickly.

“Intravenous iron is very efficient,” says Dr. Peterson. “You can replenish your stores with one intravenous treatment.” One downside? It isn’t always covered by insurance and can be costly.

Olivia Luppino is an editorial assistant at Women’s Health where she covers health and fitness. She previously wrote for The Cut, POPSUGAR, and Salon and has written about everything from New York Fashion Week to dating app trends to the United States Women’s National Soccer team (a.k.a. her heroes). When she isn’t writing, Olivia is likely catching up on Bravo shows or running late to barre class.

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A study on anemia and its risk factors among pregnant women attending antenatal clinic of a rural medical college of West Bengal

Anuradha sinha.

1 Department of Pathology, Purulia Government Medical College, Purulia, West Bengal, India

Moumita Adhikary

2 Department of Microbiology and Pathology, Rampurhat Government Medical College, Rampurhat, West Bengal, India

Jyoti P. Phukan

Sonal kedia.

3 Department of Anesthesiology and Gynecology and Obstetrics, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India

Tirthankar Sinha

Background:.

Anemia is the commonest nutritional deficiency disorder in the world, particularly in developing countries. Though anemia is easily treatable and largely preventable disease if timely detected, it still continues to be significantly prevalent among pregnant women.

The aim of this study was to measure the extent of anemia in pregnancy and to assess the association of risk factors with anemia.

Study Design:

Hospital-based cross-sectional descriptive study.

Materials and Methods:

A total of 200 women were selected among pregnant women attending antenatal clinic. Sampling was done by selecting every fifth woman visiting antenatal clinic within the duration of two months on alternate days. Data were collected using a predesigned, pretested semi-structured schedule. Hemoglobin concentrations were also recorded for each patient. Data were analyzed using Chi-square test and 'T' test of significance. A value of P < 0.05 was considered significant.

We found overall prevalence of anemia to be 90% among pregnant women. Most of the anemic patients (60.5%) belong to moderate severity according to the World Health Organization classification. Three factors namely socioeconomic status, gravida and time of 1 st antenatal visit were significantly associated with prevalence of anemia in pregnancy ( P < 0.05).

Conclusion:

In this study, a high prevalence of anemia was found in pregnant women. Low socioeconomic status, multigravida and delayed visit to antenatal clinic were significantly associated with anemia in pregnancy. So, awareness and education programs should be generated to make people come to know about anemia, its complications during pregnancy and ways to prevent it.

Introduction

Anemia has been recognized as the most common form of nutritional deficiency worldwide, particularly in developing countries like India. Though anemia is easily treatable and preventable disease, it continues to be significantly associated with pregnancy. Diminished intake and increased demand, excess demand in case of multigravid woman and altered metabolism along with the background characteristics like low socioeconomic status, illiteracy, early age of marriage associated with increase in susceptibility to infectious diseases like hookworm infestations may serve to be the underlying factors associated with prevalence of anemia during pregnancy. According to the World Health Organization (WHO) prevalence of anemia among pregnant women varies from 14% in developed countries to 65%–75% in India.[ 1 ] In women, anemia may become the underlying cause of maternal mortality and perinatal mortality.[ 2 ]

Hemoglobin value <11 g/dL is defined as anemia in pregnancy by WHO.[ 3 ] Anemia in pregnancy can be further divided as mild, moderate and severe anemia for hemoglobin level 10.0–10.9 g/dL, 7–9.9 g/dL and severe <7 g/dL.[ 4 ]

Various studies showed an association between anemia and maternal mortality.[ 5 , 6 , 7 ] Apart from maternal mortality, anemia in pregnancy may result in intrauterine growth retardation, low birth weight, still-birth, and neonatal death.[ 8 , 9 , 10 , 11 ]

In view of low dietary deficiency of iron and folic acid, and high prevalence of anemia among pregnant women, India started the National Nutritional Anemia Prophylaxis Program (NNAPP) to prevent anemia among pregnant women.[ 12 ] Through this program 100 mg of ferrous iron and 500 mcg folic acid tablets distributed to pregnant woman through Urban Family Welfare Centers in urban areas and Primary Health Centers in rural areas. Despite of these preventive measures, anemia in pregnant women is still very much prevalent in India.[ 12 , 13 ]

The key for safe motherhood is reduction of maternal anemia. The risk factors of anemia particularly during pregnancy are multifactorial and complex.[ 14 ] So, knowledge of these risk factors and compliance of respondents towards implemented government program is very much essential to prevent anemia and its consequences.

Primary health care physicians are the first contact physician in the community who can play a very important role in identification and treatment of anemia.[ 15 ] Many issues associated with anemia can be assessed and modified at the primary care level such as dietary habits, multi parity etc.

Hence, this study was undertaken with the following aims and objectives:

• To determine the magnitude of anemia in pregnant women according to severity among study population, and
• To find out association of anemia with different socio-demographic factors.

Materials and Methods

Study subjects and study area.

This cross-sectional study was conducted in a rural teaching hospital of West Bengal, India for a duration of 2 months. This rural medical college is situated in a backward area of western West Bengal which caters mainly economically poor population. Data collected from 200 pregnant women (Cases). Every fifth patient was taken attending antenatal clinic (ANC) and first patient was selected randomly. A consent form was filled by each participant.

Inclusion and exclusion criteria

Inclusion criteria.

Pregnant women attending ANC who filled the consent form having their Hemoglobin (Hb) report. Confirmation of pregnancy was done by either urinary pregnancy test and/or by pelvic ultrasonography.

Exclusion criteria

Unwilling pregnant women and who did not have hemoglobin report with them were excluded from the study.

Ethical consideration

The study was approved by the institutional ethics committee before commencing the study. The study was done as a part of the Indian Council of Medical research short-term studentship program (ICMR-STS). It was obtained on 21/03/2012.

Data collection

Data were collected from every participant using a predesigned, pretested semi-structured schedule. Sociodemographic particulars and data regarding reproductive behavior were collected. Socioeconomic status was determined based on Tendulkar's committee poverty line where the income of less than rupee 673 per month was considered as low socio-economic status. Hemoglobin level is also recorded from the available investigation report. All hemoglobin levels estimated by the cyanmethemoglobin method.

Statistical analysis

Chi-square test and 'T' test of significance were used to show any association between risk factors and severity of anemia. A 'P' value <0.05 was considered statistically significant to show an association between the particular risk factor and severity of anemia.

Results and Observations

In our study, 200 pregnant women were included. The demographic characteristics of the pregnant women were shown in Table 1 . The most common age group in our study was 20-30 years (54.5%) and majority were of low socioeconomic status (58%) [ Table 1 ]. Maximum numbers of study subjects were Hindu (94.5%).

Distribution of pregnant women according to variable characteristics ( n =200)

Among the pregnant women, 90% suffered from anemia; majority had moderate anemia (60.5%), followed by mild anemia (29%). Only 1 woman was suffering from severe anemia while the rest had no anemia [ Table 2 ].

Distribution of severity of anemia among pregnant women according to WHO criteria

Hb=Hemoglobin

Association of anemia with low socioeconomic status was found to be 63.93%, 51.72% and 35% for severe and moderate, mild and no anemia respectively [ Table 3 ] which was statistically significant [P = 0.03]. However, no significant association of severity of anemia with the educational status of the pregnant women was detected.

Distribution of pregnant women according to socio economic status with respect to severity of anemia ( n =200)

χ 2 =7.002, P =0.030 (S). S=Significant

Also, severity of anemia is associated with time of first antenatal visit which is statistically significant [ Table 4 ]. However, severity of anemia with respect to age and religion were not significant.

Distribution of pregnant women according to time of 1 st antenatal visit with respect to severity of anemia ( n =200)

χ 2 =27.549, P =<0.001 (S). S=Significant

Anemia in pregnancy is a major health issue in India. The reason being low socioeconomic status, less dietary intake of iron and folic acid, short spacing of multiple pregnancies, excessive bleeding during labor, infections like malaria and hookworm infestations.[ 16 ]

In West Bengal, National Family Health Survey-3 found the prevalence of anemia among pregnant women of age group 15–49 years to be 62.6%.[ 17 ] This is less than our study, where we found it to be 90%; which is similar to other Indian studies done by Lokare et al ., Gautam et al ., Toteja et al . and ICMR Taskforce Multicenter Study[ 12 , 18 , 19 , 20 ] On the contrary, few recent studies done in African continent found the prevalence of anemia in pregnant women as low as 25.8% to 37.6%.[ 21 , 22 ] This variation may be due to various socio-demographic and comorbid conditions. Also, as our study participants are mainly poor from tribal population with low socioeconomic status, therefore the prevalence of anemia during pregnancy may be remarkably high.

Majority of cases in our study had moderate anemia (60.5%), mild anemia (29.0%) and one case of severe anemia which was found to be similar to Vindhya et al ., Mahamud et al ., Sarala V et al .[ 15 , 21 , 23 ]

There was no association found between age group and religion with anemia unlike Viveki et al . who found higher maternal anemia for age group above 26 years.[ 24 ] Studies done in Aurangabad city and New Delhi in India showed that severity of anemia decreases with higher per capita income, which is similar to our study.[ 12 , 19 ]

Time of ANC visit also plays an important role in reducing maternal anemia. 1 st Trimester visit with prescription of proper diet, iron and folic acid supplements have reduced severe anemia remarkably in our study which is like study done by Mangla et al .[ 25 ]

Still a remarkably high prevalence of anemia among pregnant women showed that anemia is endemic in this region irrespective of age, religion, education status, occupation etc., Various socio-cultural problems like taking vegetarian diet, having tea after food, open field defecation predisposing women to hook worm infestation and other associated infections may serve as important factor behind high prevalence of anemia in the pregnant women. Age of marriage didn't show any association with respect to severity of anemia in this study suggesting that multiple pregnancies, heavy menstrual blood loss or multiple abortions because of some false cultural belief like the desire to have a boy child may be the reasons behind high prevalence of anemia. Thus, gravida showed a significant association with severity of anemia.

In our study, we found that majority of pregnant women did not consume the minimum number of iron and folic acid tablets. This suggested lack of compliance or low efficacy of government policies to provide regular supplementation. Also lack of motivation and education towards utility of supplementation may be the cause to serve high prevalence of anemia. However mere use of this supplementation during pregnancy cannot solely serve the purpose, as other etiologies like hookworm infestations, malarial infection and other infections may be an issue which needs to be taken under consideration.

Limitations of the study

The study was conducted with a small sample size in a hospital which increases the possibility of error. If it would have been a longitudinal study rather than cross-sectional, then a better association between anemia and its risk factors could have been assessed. Mother's status of anemia could not be traced at different trimesters of pregnancy because of short duration of the study period. No test was done, or report was checked to find out any infectious disease like hookworm infestation or malaria and others to serve as etiology behind anemia. Morphology of red blood cell was also not recorded, which could help us to find its etiology.

Recommendations

Based on our study, we have the following recommendations to prevent and/or decrease the severity of anemia among pregnant women:

• Awareness and Education programs should be generated to make people come to know about anemia, its complications, and ways to prevent it.
• Especially adolescent girls should be educated to make them aware of the upcoming problem if not taken care since the same age.
• Woman of childbearing age should be motivated to take the required supplementation before conceiving and to continue with it till breastfeeding the baby.
• Education of the male partner regarding the complications of the disease and the utility of the supplementary diet during pregnancy may help the pregnant woman a lot to execute these policies in her daily life.
• To add support to supplementation food fortification with essential vitamins and minerals may serve the purpose. Iron fortification may be used in commonly used food like salt and sugar to build up iron stores and such things should be easily accessible and affordable by the common people. Mere cooking of food in cast iron utensil may reduce the severity of anemia.
• Advertisement programs should be generated to draw the attention of policymakers as anemia is one of the major global problems.

In summary, this study revealed a high prevalence of anemia in pregnancy, irrespective of age, religion, education status and occupation. Anemia is found to be endemic in this region, due to various unfavorable socio-demographic factors. As we all know, prevention is better than cure, therefore, these findings may help our policymakers and health care providers to change policies, add new strategies and educates the society to save from maternal anemia.

Financial support and sponsorship

Indian Council of Medical Research – Short Term Studentship (ICMR-STS).

Conflicts of interest

There are no conflicts of interest.