The World Congress of the Royal College of Obstetricians and Gynaecologists (RCOG) was held on the 28–30 March 2014 in Hyderabad, India1. This global event was represented by over 50 countries and more than 3,500 delegates, speakers and exhibitors.
Researchers presented data on the importance of iron therapy, in particular for averting blood transfusion in women with abnormal uterine bleeding and anaemia. The ability of intravenous iron to correct prepartum anaemia, despite previous failure of oral iron, was also highlighted. In addition, analyses in an Indian population demonstrated that iron therapy may improve maternal and perinatal mortality and morbidity, and researchers emphasised the importance of improving awareness of iron therapy, which may lead to a decreased risk of anaemia among pregnant women.
Iron deficiency featured as a key variable in patient outcomes for pregnant women and neonates, with data indicating that iron deficiency may be a potential cause of disparity in infertility rates between ethnic groups. Furthermore, researchers highlighted that haemoglobin alone is not an adequate measurement for a diagnosis of iron deficiency in pregnancy, and that red cell indices may be used for iron status assessment. Highlights from some of these key studies related to iron therapy and deficiency are presented below2,3.
Preoperative iron therapy and erythropoietin may avert blood transfusion in women with abnormal uterine bleeding and severe anaemia2
Mohan S1, Marwaha A1, Gami N2, Sandhu N1, Singh S2
1Army College of Medical Sciences, New Delhi, India; 2University College of Medical Sciences, New Delhi, India
The objective of this study was to assess the effectiveness of erythropoietin in reducing risk of exposure to allogenic blood transfusion in women with severe anaemia and abnormal uterine bleeding (AUB). The authors explain that the use of blood conservation techniques is important in patients with AUB as preoperative blood loss is common and allogenic blood transfusion carries risk of transfusion reactions, as well as infection transmission.
Women (n=15) with abnormal uterine bleeding and severe anaemia were administered iron sucrose 200 mg and erythropoietin 200 IU on alternate days. An average rise in haemoglobin of 1.2 g from the first week of therapy was observed. Although the authors do not state length of the dosing period or parameters for diagnosis of severe anaemia in the abstract, they suggest that the rapid rise in haemoglobin reduced the need for blood transfusion both intraoperatively and postoperatively. They conclude that, in haemodynamically stable patients with severe anaemia, blood transfusion can be averted by preoperative iron therapy.
Iron deficiency may be a cause of ethnic group disparities in infertility2
Lavu D1, Uppal H2, Katragadda A3, Ahmed A4, Potluri R4
1Department of Obstetrics and Gynaecology, University Hospital Of North Staffordshire, Stoke-on-Trent, UK; 2Department of Psychiatry of Learning Disability, Brooklands Hospital, Birmingham, UK; 3Infertility Specialist, Anu Test Tube Baby Center, Hyderabad, India; 4School of Medical Sciences, Aston University, Birmingham, UK
Lower success rates of in vitro fertilisation (IVF) in South East Asian countries compared to Western countries is considered a result of variations in methodology and expertise. However, recent research into the effects of ethnicity on success rates of infertility procedures in western countries has suggested that other factors may contribute to this ethnic disparity.
Hospital admissions data for infertile female patients (n=522,223) of various ethnic groups were analysed to identify comorbidities that might cause ethnic disparity in infertility and related procedures.
Mean age of patients with infertility was significantly lower in the South East Asian population compared with the Caucasian population (30.6 ± 4.7 vs 32.8 ± 4.9 years, respectively; p<0.001). Mean age for IVF was also significantly lower in the South East Asian population (30.4 ± 4.3 vs 32.7 ± 4.4 years, respectively; p<0.001). Analyses also showed that South East Asian patients have a significantly higher prevalence of hypothyroidism, obesity and iron deficiency anaemia compared with Caucasians but a lower prevalence of endometriosis.
There were several limiting factors to the study, such as differences in disease burden between ethnic groups, which may indicate under diagnosis of certain disorders in a population. The authors suggest that hypothyroidism, obesity and/or iron deficiency anaemia are related to disparity in infertility between ethnic groups but highlight that further data are required.
Intravenous iron therapy may correct prepartum anaemia, following failure of oral iron3
Mathews A, Verghese K
Pondicherry Institute of Medical Sciences, India
Anaemia contributes to approximately 20% of maternal mortality in India. Approximately 65–70% of antenatal patients are anaemic, and the majority also have iron deficiency. The authors of this study aimed to investigate the efficacy of intravenous iron therapy in treating moderate iron deficiency anaemia in pregnancy, and to analyse anaemia prevalence and need for prepartum blood transfusion during labour.
A hospital-based, observational study was conducted on pregnant women of any parity, between 16 and 34 weeks gestation, with moderate anaemia (haemoglobin 7–9.9 g/dL), despite oral iron treatment. After the cause of anaemia was confirmed to be iron deficiency, intravenous iron therapy was administered (200 mg iron sucrose in 100 ml saline infusion over 30 minutes, 3–5 days apart). Total dose was calculated according to body weight (kg) x (target haemoglobin – initial haemoglobin [g/L]) x 0.24 plus 500 mg. Haematological parameters and ferritin were measured 4 weeks before and 4 weeks after treatment.
Rise in haemoglobin was achieved in 70% of patients (mean increase of 3.72 g/dL). All these patients entered term gestation with haemoglobin >11g/dL. Mean serum ferritin increased from 16.73 to 80.02 g/dL). There was a reduction in anaemia prevalence during labour for the period before iron therapy compared with during (48 to 15%) and in the need for blood transfusion in early labour (27 to 3%). The authors concluded that, where oral iron has failed to prevent anaemia, intravenous iron therapy should be given early during the third trimester to reduce the risk of anaemia at term.
Low awareness and education about iron therapy may lead to increased risk of anaemia among pregnant women2
Dorairajan G1, Palanivel C1, Sakthi D2
1Jawaharlal Nehru Institute of Postgraduate Medical Education and Research (JIPMER), India; 2Indira Gandhi Medical College, Puducherry, India
Iron deficiency anaemia during pregnancy continues to be prevalent despite increased accessibility and free cost and availability of iron therapy for pregnant women in India. This study investigated factors hindering uptake of iron therapy among pregnant women and the influence on anaemia prevalence.
The cross-sectional study was conducted on women in their third trimester, through a structured self-administered questionnaire and open-ended interview. Of 599 women, 34.6% were found to be mildly anaemic, 27.2% moderately anaemic and 0.5% severely anaemic. Only 48% took oral iron therapy regularly and one quarter of those who took treatment irregularly discontinued due to side effects. Only 20% were aware that iron is available in intravenous form and 35% had negative beliefs about iron intake.
Multivariate logistic regression analysis revealed that lack of education regarding iron therapy and lack of counselling by health workers emerged as significant modifiable factors predicting anaemia during pregnancy. The authors provide further information in their presented poster.
Red cell indices may be used for iron status screening in pregnancy2
Muteshi C, Obura T
Aga Khan University, Nairobi Kenya
Iron deficiency is the most common cause of anaemia in pregnancy. Reliance on haemoglobin estimation alone for diagnosis of iron deficiency may lead to detection at a late stage of deficiency, increasing risk of anaemia. This study aimed to determine the diagnostic utility of mean corpuscular volume (MCV) and mean corpuscular haemoglobin concentration (MCHC) in iron status assessment of pregnant women with normal haemoglobin.
The cross-sectional study assessed iron status in 155 pregnant women by measuring ferritin levels. MCV and MCH were measured to determine the sensitivity and specificity for these indices in predicting iron status. Mean haemoglobin was 12.4 g/dL and 32% of women had low ferritin despite normal haemoglobin. The MCV had a specificity of 84.7 (95% CI: 79.7–89.2) for determining normal iron status whereas the MCHC had a sensitivity of 77.8% (95% CI: 66.3–86.6) in detecting low iron status whilst haemoglobin was normal.
Although full sensitivity and specificity for both MCV and MCHC is not given in the abstract, the authors conclude that red blood cell indices can reliably identify pregnant women at low risk of iron deficiency when haemoglobin is normal. Further data is required to confirm this finding.
Iron therapy may improve maternal and perinatal mortality and morbidity2
Iyerpadi Garden Hospital, India
This retrospective study evaluated hospital record data from approximately 10,000 patients to identify factors that impact maternal and perinatal outcomes in a population of tea estate workers in India.
Factors evaluated included medical interventions such as deworming and administration of folic acid, calcium and iron therapy, and implementation of medical tests (such as absolute neutrophil count and urine chorionic gonadotropin testing), obstetric examination and maternal screening for diabetes, hypertension, pre-eclampsia and thyroid diseases. Other factors investigated were discouragement of pregnancies at <20 years of age and implementation of maternal health education.
Over the course of the study period, reductions were observed in perinatal, neonatal, infant and maternal mortality rate, percentage of low birth weight, and still birth rate. The authors describe how each factor contributed to these reductions in the full poster. They conclude that simple interventions can substantially impact on perinatal and maternal morbidity and mortality in selected patient populations.