Iron Deficiency Anemia in Pregnancy after Bariatric Surgery: Etiology, Risk Factors, and How to Manage It / Anemia ferropriva na gestação após cirurgia bariátrica: Etiologia, fatores de risco e como tratar

Abstract Objective Pregnancy after bariatric surgery is a reality of the 21st century and therefore is essential that all obstetricians know how to manage it. The most prevalent nutritional deficiency is iron deficiency and, consequently, anemia. Although bariatric surgery and pregnancy are already risk factors for anemia, we evaluated in our study if there were any other risk factors and actions to improve hemoglobin levels in this population. Methods We performed a retrospective cohort study, and performed frequency measurements and analyzes of odds ratio, X2 and Fisher exact test to evaluate the risk factors. Results We evaluated 44 pregnancies after bariatric surgery, with an incidence of anemia of 62%, and the only identifiable risk factor for anemia was being black. As for the treatment, the iron salt used for oral supplementation did not associate with anemia risk, and in 27% of the patients, the adjustment of the oral dosage was enough for improvement in hemoglobin levels, but in 36% supplementation with intravenous iron was necessary. Conclusion Being black is a risk factor for anemia. The type of iron salt does not correlate with the incidence of anemia, and for the treatment and improvement of iron dosages, it seems an effective increase in iron intake.

Resumo Objetivo A gestação após cirurgia bariátrica é uma realidade do século XXI e, portanto, é de suma importância que os obstetras saibam conduzir o pré-natal dessas gestantes. A deficiência nutricional mais prevalente nessa população é a deficiência de ferro, que tem como consequência a anemia. Apesar da própria gestação e da cirurgia serem fatores de risco para anemia ferropriva, realizamos um estudo para avaliar se existem outros fatores que são de risco e quais condutas podem melhorar os níveis de hemoglobina nessa população. Métodos Trata-se de um estudo de coorte retrospectiva, e foram realizadas medidas de frequência e análise odds ratio, X2, e teste de exato de Fisher para a avaliação dos fatores de risco. Resultados Foram avaliadas 44 gestações após cirurgia bariátrica com incidência de anemia de 62%, sendo que o único fator de risco identificado foi a etnia preta. O sal de ferro utilizado na reposição não se associou com o risco de anemia. Em somente 27% das gestantes o ajuste da dose oral de ferro foi suficiente para corrigir a anemia, enquanto em 36% foi necessária a suplementação com ferro endovenoso. Conclusão Ser de etnia preta foi fator de risco para anemia após cirurgia bariátrica e o tipo de sal de ferro para suplementação não se correlacionou com a incidência de anemia. Para o tratamento da anemia, somente o ajuste da dose da medicação parece ser suficiente para a resolução desta.

Prevalencia y evolución de la anemia en embarazadas del Hospital Central de las Fuerzas Armadas / Prevalence and evolution of anemia in pregnant women at the Central Hospital of the Armed Forces / Prevalência e evolução da anemia em mulheres grávidas no Hospital Central das Forças Armadas

Introducción: de acuerdo a los datos de la Organización Mundial de la Salud la prevalencia de anemia ferropénica en el embarazo oscila entre el 20 y el 39% de los mismos en Latinoamérica, siendo asociada con resultados adversos para la salud. Materiales y métodos: se realizó un estudio observacional, descriptivo, de corte transversal, donde fue estudiada la frecuencia de la anemia en las embarazadas usuarias del Hospital Central de las Fuerzas Armadas, y su evolución posterior luego del embarazo. Resultados: se observó que el 15,7% de las pacientes presentaba anemia en el embarazo, con un buen porcentaje de pacientes que cumplían el tratamiento con hierro indicado, y que sólo un bajo porcentaje realizaba un control de la anemia luego del embarazo. Discusión: el porcentaje de pacientes con anemia en el embarazo en este centro asistencial se encuentra por debajo de los porcentajes establecidos en la literatura internacional, se analizan las causas y se verifica que existe una dificultad en el seguimiento de estas pacientes luego del embarazo.

Introduction: according to World Health Organization data, the prevalence of iron deficiency anemia in pregnancy ranges between 20 and 39% of pregnancies in Latin America, being associated with adverse health outcomes. Materials and Methods: an observational, descriptive, cross-sectional, descriptive study was carried out to study the frequency of anemia in pregnant women users of the Central Hospital of the Armed Forces of Montevideo, and its subsequent evolution after pregnancy. Results: it was observed that 15.7% of the patients had anemia during pregnancy, with a good percentage of patients who complied with the indicated iron treatment, and only a small number of patients underwent anemia control after pregnancy. Discussion: the percentage of patients with anemia in pregnancy in this health care center is below the percentages established in the international literature, the causes are analyzed and it is verified that there is a difficulty in the follow-up of these patients after pregnancy.

Introdução: de acordo com dados da Organização Mundial da Saúde, a prevalência de anemia por deficiência de ferro na gravidez varia entre 20 e 39% das gestações na América Latina, e está associada a resultados de saúde adversos. Materiais e Métodos: foi realizado um estudo observacional, descritivo, transversal e descritivo para estudar a freqüência da anemia em gestantes usuárias do Hospital Central das Forças Armadas, e sua posterior evolução após a gravidez. Resultados: observou-se que 15,7% das pacientes tiveram anemia durante a gravidez, com uma boa porcentagem de pacientes que cumpriram o tratamento com ferro indicado, e apenas uma baixa porcentagem teve controle da anemia após a gravidez. Discussão: a porcentagem de pacientes com anemia na gravidez em nosso centro de atendimento está abaixo das porcentagens estabelecidas na literatura internacional, analisamos as causas e verificamos que existe uma dificuldade em monitorar essas pacientes após a gravidez.

Clinicopathological study of anemia during pregnancy

Background: In developing countries the prevalence of anemia among pregnant women averages 60% resulting in varying levels of adverse pregnancy outcomes. Iron, Vitamin B12 and folic acid deficiencies, malaria, intestinal parasitic infections and hemoglobinopathies are the principal causes of anemia in pregnancy. Above nutritional requirements increase during pregnancy and if it is not maintained, may result in adverse maternal and fetal outcomes. The aim of this study was to study the prevalence of anemia in pregnant mothers, study the clinical patterns of anemia in pregnancy and to study the histopathological patterns of anemia during pregnancy.Methods: This is a prospective study done on 60 pregnant women whose hemoglobin level is less than 10.9 gm/dL. Blood samples were taken, and peripheral blood smears were examined along with their complete clinical and obstetric history.Results: Out of 60 cases of anemia, 40% were found to have dimorphic anemia, 30% with microscopic hypochromic anemia, 20% of patients have normocytic hypochromic anemia, 1.7% had sickle-cell anemia and 8.3% of patients were thalassemia cases. The risk factors for anemia in this study is noted to be low social economic status, occurrence of complications during previous pregnancy and multiparty. In this study anemia was more commonly found in the multigravida women and in the third trimester of pregnancy.Conclusions: With improved social economic conditions, early detection, good antenatal care, awareness regarding available treatment, a healthy diet, routine antenatal counselling and adequate iron supplementation, anemia in pregnancy can be avoided.

Complicaciones obstétricas y perinatales en pacientes con anemia / Obstetric and perinatal complications in anemic patients

Resumen OBJETIVO: Determinar la relación entre complicaciones obstétricas y perinatales con la anemia durante el embarazo. MATERIALES Y MÉTODOS: Estudio ambispectivo, observacional y transversal. Se incluyeron pacientes en trabajo de parto, con embarazo único, atendidas entre marzo y octubre de 2017 en el Hospital General Dr. Salvador Zubirán Anchondo, Chihuahua, Chih. Se excluyeron las pacientes con embarazo complicado por defectos congénitos, que hubieran recibido anticoagulantes, con diagnóstico médico de hemoglobinopatías, hemofilias, preeclampsia, síndrome de HELLP, partos instrumentados y distocias, diabetes gestacional, nefropatías, hepatopatías, tabaquismo y toxicomanías. Complicaciones valoradas: amenaza de aborto, amenaza de parto pretérmino, parto pretérmino, ruptura prematura de membranas, infección de vías urinarias, peso al nacer, valoración de Apgar al minuto y a los 5 minutos, hemorragia obstétrica. Se entrevistó a todas las pacientes para evaluar los antecedentes ginecoobstétricos y se tomó una muestra de sangre venosa para determinar: hemoglobina, hematocrito, cantidad de glóbulos rojos, volumen corpuscular medio, concentración de hemoglobina corpuscular media. Se registraron las mediciones antropométricas, valores de Apgar y complicaciones perinatales del expediente clínico. RESULTADOS: Se estudiaron 1051 pacientes divididas en dos grupos: con anemia (n = 172) y sin anemia (n = 879). Se consideró anemia a la hemoglobina menor de 11 g/dL o hematocrito menor de 33%. Se clasificaron de acuerdo con la OMS como: anemia leve 10-10.9 g/dL, moderada 7-9.9 g/dL y severa menos de 7.0 g/dL. La prevalencia de anemia fue de 16%. La anemia leve se identificó con mayor frecuencia 10% (n = 111), anemia moderada y severa 6% (n = 61). Las complicaciones maternas y neonatales no mostraron asociación con la anemia materna durante el embarazo. La hemotransfusión fue mayor en pacientes con anemia (9 vs 1%). CONCLUSIÓN: Se identificó anemia materna en 16% de los casos y se asoció con necesidad de transfusión de hemoderivados en el posparto o posquirúrgico de cesárea.

Abstract OBJECTIVE: Determinate the association between adverse perinatal outcomes and anemia in pregnant women. MATERIALS AND METHODS: Observational, prospective-retrospective and cross-sectional study. Including women in birth labor attended at Hospital General Dr. Salvador Zubirán Anchondo in Chihuahua City, during March to October 2017. Inclusion criteria considered women with single pregnancy. Exclusion criteria with present conditions: congenital deformities, use of anticoagulants, blood diseases, preeclampsia, HELLP syndrome, instrumental delivery with forceps, dystocia, maternal diabetes, kidney and liver diseases, use of tobacco and other drugs. Adverse perinatal outcomes included were: miscarriage risk, preterm labor, preterm birth, pre labor rupture of membranes, urinary infection, low birth weight, Apgar score at birth and after five minutes, obstetric hemorrhage. Patients were interviewed to evaluate obstetric background; blood venous sample was taken to determine haemoglobin, hematocrit, red blood cells number, medium corpuscular volume, medium corpuscular hemoglobin concentration. Birth data was registered from medical records. RESULTS: Two groups were integrated: with anemia (n=172) and without anemia (n=879). Patients with anemia were those with haemoglobin less than 11 g/dL or hematocrit less than 33% according World Health Organization anemia classification: mild 10-10.9 g/dL, moderate 7-9.9 g/dL and severe less than 7.0 g/dL. Anemia frequency was calculated in 16%, mild anemia frequency was 10% (111 patients), 6% moderate and severe anemia (n = 61). Both groups developed patients with adverse perinatal outcomes. Transfusion of blood products showed higher frequency in anemic patients (9% versus 1% control group). CONCLUSION: Anemia prevalence calculated in 16% associated with transfusion of blood products, during puerperium or after c-section period.

Effects of Regular Iron Supplementation on Hemoglobin and Perinatal Complication of Pregnant Women and Neonates / 中国药房

OBJECTIVE:To study the effects of regular iron supplementation on hemoglobin and perinatal complication of pregnant women and neonates. METHODS:In retrospective analysis,the information of 606 pregnancy women were collected from Chongqing People’s Hospital during May 2016-May 2017. According to the regularity of iron supplementation,they were divided into regular iron supplementation group (142 cases),irregular iron supplementation group (218 cases) and no iron supplementation group(246 cases). The levels of hemoglobin in pregnant women were determined in 3 groups before childbirth and 3-7 d after childbirth. The incidence of gestational hypertension,premature rupture of membranes and puerperal infection in pregnant women were recorded in 3 groups. Birth weights of neonates delivered by pregnant women were recorded in 3 groups, and the levels of hemoglobin in umbilical cord blood of neonates were also detected. Apgar score was used to evaluate whether neonates were born with hypoxia or asphyxia. The average days of hospitalization were counted for pregnant women of 3 groups. RESULTS:The levels of hemoglobin in regular ion supplementation group before and after childbirth were significantly higher than irregular ion supplementation group and no ion supplementation group;the incidence of gestational hypertension,premature rupture of membranes and puerperal infection were significantly lower than irregular ion supplementation group and no ion supplementation group,average hospitalization days were significantly less than irregular ion supplementation group and no ion supplementation group, the levels of hemoglobin in umbilical cord blood of neonates and birth weight in regular ion supplementation group were significantly higher than irregular ion supplementation group and no ion supplementation group,with statistical significance(P＜0.05). There was no statistical significance in the incidence of constipation in pregnant women and the ratio of Apgar score of the neonates＜7 among 3 groups (P＞0.05). CONCLUSIONS:Regular iron supplementation can remarkably decrease the incidence of anemia,gestational hypertension,premature rupture of membrane and puerperal infection in pregnant women,shorten average hospitalization time,and increase average birth weight of neonates and the level of hemoglobin in umbilical cord blood.

Comparison of the efficacy of iron amino acid chelate and ferrous sulfate in the treatment of iron deficiency anemia among pregnant women seen at the out-patient department of a tertiary medical center on 2016-2017 / Philippine Journal of Obstetrics and Gynecology

Background@#Anemia is a major global problem that affects women and prevalent during pregnancy. Effective management is needed to prevent adverse maternal and pregnancy outcomes. Ferrous iron salts are the preparation of choice and recommended for both prevention and treatment of iron deficiency anemia (IDA). However, most commonly available iron supplement are poorly absorbed, with gastrointestinal disturbances as side effect.@*Objective@#To compare the efficacy of iron amino acid chelate and ferrous sulfate in the treatment of IDA among pregnant women seen at the out-patient department of a tertiary medical center.@*Methodology@#This study is a single blind randomized clinical trial which included women 18 to 40 years old, with singleton pregnancies diagnosed with IDA without any co-existing fetal and maternal complications seen at the OutPatient Department. Forty eight eligible participants were randomized, with 24 women allocated on each treatment arm who took their assigned treatment twice a day for 90 days. Hemoglobin, hematocrit, MCHC, MCV, RDW & serum ferritin levels were taken at baseline and monitored on days 30, 60 and 90 from initiation of treatment. Mean blood parameters between two treatment arms were compared on days 30, 60 and 90 post-treatment as well as the mean difference of blood parameters on days post-treatment from the baseline using T-test. Chi-square was used to compare adverse effects between two treatment arms.@*Results@#No statistically significant differences in the mean blood parameters on days 30 and 60 of treatment between Iron amino acid chelate and Ferrous sulfate. It was only on day 90 from initiation of treatment when there were a significantly higher hematocrit and MCHC and lower RDW in Iron amino acid chelate compared to Ferrous sulfate group. All of the CBC parameters on days 30, 60, and 90 post-treatment when compared to baseline level were significantly increased for both treatment arms. However, day 90 level of serum ferritin in the Iron amino acid chelate group significantly increased unlike those in ferrous sulfate group.@*Conclusion@#Iron amino acid chelate is comparable to Ferrous sulfate in the treatment of IDA among pregnant women. Iron amino acid chelate was found to be superior to Ferrous sulfate in achieving optimum treatment response even at a lower dose with lesser adverse effects. Hence, better oral iron treatment tolerability, thereby, compliance to long-term therapy can be expected resulting to successful treatment outcome.

Evaluation of efficacy, safety and cost of oral and parenteral iron preparations in patients with iron deficiency anemia.

Objective: To compare the efficacy and safety of different oral and parenteral iron preparations in patients with anemia. Methods: An observational, prospective study in patients of anemia in pregnancy and chronic kidney disease (CKD) receiving iron sucrose, oral ferrous ascorbate and ferrous sulfate were included. Demographic details, clinical history, baseline hemoglobin, anemia indices data were recorded in a case record form. The patients were followed up monthly for 12 weeks and observed for clinical and haematological improvement and adverse drug reactions (ADRs). The data was analyzed using paired t-test, unpaired t-test and Fisher`s exact test. Results: Out of 232 patients, 84 received iron sucrose, 62 ferrous ascorbate and 86 ferrous sulfate. Oral and parenteral iron preparations significantly (P<0.0001) improved mean hemoglobin, anemia indices and serum ferritin at the end of study. However, mean increase in hemoglobin and anemia indices were significant (P<0.0001) with iron sucrose (4.42 ± 0.17gms/dL) as compared to ferrous ascorbate (3.45 ± 0.1) and sulfate (3.3 ± 0.4). Increase in serum ferritin was more and rapid (at 4 weeks) with iron sucrose as compared to ferrous ascorbate in CKD patients. Surprisingly, ADRs were more in patients treated with oral ferrous sulfate (86%) and ascorbate (71%) compared to iron sucrose (63%). Conclusion: Parenteral iron sucrose improves hemoglobin. anemia indices and replenish iron stores rapidly and is well tolerated than oral iron preparations.

Iron-Folic Acid Intake Among Pregnant Women in Anumanthai PHC of Villupuram, Tamil Nadu.

Background: Prevalence of anemia in India is among the highest in the world. Apart from other causes of anemia, iron or folate deficiency is the most common cause, especially during pregnancy. Although, supplementation of diet with iron and folic acid (IFA) tablets has been a part of the Ministry of Health and Family Welfare Program for over three decades, levels of IFA intake during pregnancy remain low. Material and methods: A descriptive study was conducted among 132 postnatal women registered in Anumanthai primary health center (PHC), Villupuram, Tamil Nadu, catering to a population of 56,142 through eight subcenters to explore factors affecting compliance to IFA. One hundred thirty-two postnatal women were interviewed after taking informed consent in local language using a pretested structured proforma. Statistical analysis was done using SPSS Version 16. Results: Majority of the study subjects (134; 98%) were in the age group of 20-29 years. First-trimester registration was 99.4% and 99.3% received at least three antenatal visits at the PHC. Fifty-four (40%) of the study subjects did not consume any IFA tablet at all. Only 31.1% of the study subjects were aware that IFA tablets should be consumed for 100 days. About 25.9% consumed at least above 90 IFA tablets and only 5.9% consumed more than 100 IFA tablets. Nausea and vomiting 85 (63%) and counseling by village health nurse 115 (89%) were reported to be the most common hindering and facilitating factors, respectively. Conclusion: Despite high rates of antenatal visits, the intake of IFA was low.

Factores que inlluyen la adherencia a la suplemntación con sulfato ferroso durrante el embarazo / Factors influencing adherence to supplementation with iron sulfate during pregnancy

El uso de sulfato ferroso en la prevención de las anemias durante el embarazo es obligatorio y gratuito a la paciente por el SUMI, sin embargo, se desconoce el nivel de adherencia a la prescripción durante los controles prenatales y los factores que influyen en la falta de adherencia, la identificación de estos factores corresponde al objetivo de este trabajo. Se presenta un estudio tipo caso control llevado a cabo en 182 mujeres que se encontraban en su puerperio inmediato en el Hospital Materno Infantil Germán Urquidi entre agosto y septiembre del 2009, de las cuales 135 pacientes fueron catalogadas con mala adherencia (casos) y 47 con buena adherencia (controles). Se buscaron factores epidemiológicos, factores dependientes de la terapéutica, efectos adversos, relación médico-paciente y percepción/actitudes frente al medicamento. Resultados: La adherencia reportada fue del 26%. La falta de estudios de primaria completos (OR=2,12; p=0,0355), la presencia de náuseas (OR 3,05; p= 0,02) y el tiempo prolongado de tratamiento (OR 2,46; p=0,011) demostraron estadísticamente disminuir la adherencia a sulfato ferroso. Contribuyen con una buena adherencia la toma del medicamento en un horario regular (0R=0,49 p=0,01) y la confianza en el médico que prescribió el sulfato ferroso (OR 0,34 p=0,046). Para lograr una buena adherencia de las mujeres se debe reforzar la relación médico - paciente y la explicación sobre los efectos del medicamento de acuerdo al nivel de instrucción de la paciente.

The use of ferrous sulfate in the prevention of anemia during pregnancy is free and required for patients by the Universal Maternal Child Insurance (SUMI), however, the level of drug adherence at prenatal checkups and the factors influencing non-adherence are unknown. The purpose of this study is the identification of these factors. We present a case-control study of 182 women in the immediate postpartum period in the "German Urquidi Maternal Child Hospital" from August to September 2009, of which 135 patients were categorized with poor adherence (cases) and 47 women with good adherence (controls). We analyzed epidemiological factors, therapy-dependent factors, adverse effects, physician-patient relationships, and patient perception / attitudes towards medication. Results: The drug adherence was 26%. Incomplete primary education (OR = 2.12, p = 0.0355), presence of nausea (OR 3.05, p = 0.02) and the long time of treatment (OR 2.46, p=0.011) demonstrated a negative effect on drug adherence. Factors associated with good drug adherence were a strict regular dosing schedule (OR = 0.49, p = 0.01) and a trusting relationship with the prescribing physician (OR 0.34, p = 0.046). To achieve a good drug adherence should improve the relation doctor - patients and explanations about the drug's effects by level of education of the patient.

Prevalen Anemia Semasa Mengandung dan Factor-Factor Mempengaruhinya di Johor Bahru

Introduction: Anemia in pregnancy is still a public health problem in developing countries including Malaysia. Early screening of pregnant mothers who have risk factors of anemia could help identifying these potential anemic mothers and hence targeted for intervention. Methodology: A cross sectional study IN 2008 was conducted among pregnant women who attended government health clinics in Johor Bahru district to assess the prevalence of anemia in pregnancy and factors associated with it using a structured questionnaire. Result: Prevalence of anemia in pregnancy (Hb<11.0 g/dl) was 36.6% and majority in mild category (Hb 9-<11 g/dl). The associated factors of anemia in pregnancy were birth spacing, dietary intake with high iron content and iron pill consumption. Multivariate analyses revealed that iron pill intake was the most important factor influencing anemia in pregnancy. Discussion and conclusion: Even though Johor Bahru is a big town with good health facilities, the prevalence of anemia in pregnancy was quite high. Results were compared with previous studies. Emphasis on compliance to iron pills is very important in prevention and treating anemia in pregnancy