Anemia during pregnancy has significant implications, including altered materno-fetal circulation, deviations from standard uterine artery pulsatility index13, umbilical artery14, and fetal growth15, with potential long-term consequences for newborns in the presence of significant maternal anemia during pregnancy16.
Our study shows that the overall prevalence of anemia among pregnant women in our center is 28.6%. The prevalence is high later in pregnancy, reaching 36.3% in the third trimester. This result is consistent with the findings in RAHMA and consistent with the high prevalence of anemia among women in Saudi Arabia4. Most patients in our study had mild or moderate anemia, but the 2 patients with severe anemia received blood transfusions which were likely avoidable with earlier anemia identification, iron replacement, and follow-up.
The Saudi MOH recommendations in the Mother Health Passport suggest that a CBC and ferritin level must be tested in every trimester17. Following this practice would allow improved identification and follow-up of anemia in this high-risk patient population. According to our data, there is a gap of 50% in orders of CBC (complete blood count) in pregnant women compared to ordering a CBC in every trimester. If the inconvenience of a laboratory visit may be a deterrent for some patients, obstetrics clinics may be equipped with point-of-care testing devices that could provide a hemoglobin and/or hematocrit value within minutes18. Point-of-care testing technologies are widely available as handheld devices or compact benchtop devices. Operating these devices requires staff training and competency evaluation.
In a high-resource setting in Canada, Teichman and colleagues demonstrated that more than 50% of pregnancies were complicated by ID, but only 40% of women were screened for it19. In our study, less than 5% of pregnant women underwent ferritin evaluation. Among those tested, the majority had ferritin levels below 15 ng/ml. These results should urge physicians to screen more women for ID, with or without anemia. Although not in wide use yet, point of care testing devices have been developed for ferritin measurement20,21. Despite limitations of sensitivity and specificity for point-of-care testing in general, their use may be helpful for screening for ID and IDA, reducing the number of patients being sent for central laboratory testing. The study results are consistent with those reported by Drukker, Staines-Urias, Villar, Barros, Carvalho, Munim, McGready, Nosten, Berkley and Norris1 who found there were no neonatal deaths and satisfactory growth, health and motor 115 development of the infants at 1 and 2 years of age were documented. The only a very small 116 proportion (2.8–6.5%) of the variance of Doppler indices was due to between site differences; 117 in addition standardized site difference estimates were marginally outside this threshold in 118 only one of xx comparisons, and this supported the decision to pool data from the three study 119 sites.
We were reassured to find that almost all patients with anemia received oral iron supplementation, with up to 15% receiving intravenous iron. Although oral iron is usually the first line of management in patients with ID or IDA, more pregnant women achieve target hemoglobin with intravenous iron, and more patients have a hemoglobin increase in 4 weeks22. Among anemic patients in the third trimester, the use of intravenous iron is preferred to rapidly treat anemia before delivery. Intravenous iron is also indicated in patients with intolerance of oral iron or inadequate response to it.
Available research does not clearly identify the hemoglobin level that must trigger a blood transfusion during pregnancy. The Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) consensus statement about PBM in obstetrics recommends that obstetric units have guidelines for transfusion in non-bleeding patients who are anemic during pregnancy or postpartum23. A single unit transfusion is recommended followed by reevaluation for the need of additional units. In general, transfusion in patients with IDA may be avoided with access to early screening and effective management in all patient populations at risk of IDA. Transfusion is associated with a myriad of adverse effects and complications, including alloimmunization which may put future pregnancies at risk of hemolytic disease of the fetus and newborn. Additionally, these results are supported by Kassebaum, Arora, Barber, Bhutta, Brown, Carter, Casey, Charlson, Coates and Coggeshall2 Who documented that anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries.
We believe that pregnant women and health care professionals in Saudi Arabia would benefit from development of detailed national guidelines to guide screening and management of ID and IDA in pregnancy. Although the Mother Health Passport developed by the MOH suggests measurement of hemoglobin and ferritin in each trimester, it neither recommends a specific ferritin level, nor does it provide guidance of indications of different treatment options. The Anemia Clinical Pathway endorsed by the Saudi Commission for Health Specialties is a helpful document to educate about approaches to anemia investigation and management in general, pregnancy-specific information are limited24. Once guidelines are developed, lessons learned through implementation science should be used to improve compliance25.
The main limitation of the study is that it was performed in a single tertiary care academic center. Results may be reflective of practices in other academic centers but practice in primary health care centers may be different. The factors that affected ordering practices of intravenous iron could not be identified in this study.
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