Anemia and iron deficiency: effects on pregnancy outcome

Background
Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

Objectives
To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

Selection criteria
Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

Data collection and analysis
Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.

Main results
We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.

Authors' conclusions
Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

Epidural versus non-epidural or no analgesia in labour

Epidemiology and natural history of pelvic floor dysfunction

Obesity and pregnancy: complications and cost

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16-weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data-extracted and quality-assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta-analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post-partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required.

/pdf/the-impact-of-maternal-bmi-status-on-pregnancy-outcomes-with-2rcqmzzcy8.pdf

The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis.

Background The aim was to define reference values for hemoglobin, hematocrit and erythrocyte indices, ie erythrocyte count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), in normal pregnancy and after a normal delivery in non-iron-supplemented and iron supplemented women



Methods Two hundred and six healthy Danish women included at 9–18 weeks of gestation were allocated to treatment with placebo tablets (n=107) or tablets containing 66 mg iron (n=99) Blood samples were obtained at inclusion, every fourth week during gestation, and 8 weeks postpartum



Results All hematologic indices were significantly lower in placebo-treated than in iron-treated women In placebo-treated women, the 5th percentile for hemoglobin was 110 g/L in the 1st trimester; in the 2nd trimester it was 105 g/L in the first and the second, and 103 g/L in the last third; in the 3rd trimester, it was 102 g/L in the first, 100 g/L in the second, and 101 g/L in the last third; postpartum it was 113 g/L In iron-treated women, the 5th percentile for hemoglobin was 111 g/L in the 1st trimester; in the 2nd trimester it was 109 g/L in the first, 106 g/L in the second, and 103 g/L in the last third; in the 3rd trimester, it was 105 g/L in the first and second, and 110 g/L in the last third; postpartum it was 123 g/L



Conclusions Hematologic reference values should be derived from iron replete womenWe suggest that the lowest critical hemoglobin value in iron-treated pregnant women should be 110 g/l (68 mmol/L) in the 1st trimester, and 105 g/L (65 mmol/L) in the 2nd and 3rd trimester

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1034/j.1600-0412.2000.079002089.x

Hemoglobin and erythrocyte indices during normal pregnancy and postpartum in 206 women with and without iron supplementation

In a randomized, double-blind, placebo controlled study of the effect of iron supplementation during pregnancy, iron status (hemoglobin (Hb), serum (S-)transferrin saturation, S-ferritin) and S-erythropoietin (EPO) were assessed in 120 healthy pregnant women at 14-16 weeks of gestation, and just before delivery; 63 women were treated with 66 mg iron daily, and 57 with placebo. There were no differences in baseline values in the two groups. At term, the iron treated group had significantly higher Hb, transferrin saturation, S-ferritin (median 22 micrograms/l vs. 14 micrograms/l, (p < 0.0001) and lower S-EPO compared to the placebo treated group. In the iron group, 30.2% had exhausted iron stores (i.e. S-ferritin < 20 micrograms/l), 6.3% latent iron deficiency (S-ferritin < 20 micrograms/l and transferrin saturation < 15%), and no patients had iron deficiency anemia (S-ferritin < 20 micrograms/l and transferrin saturation < 15% and HB < 110 g/l). In the placebo group, 93.0% had exhausted iron stores, 54.4% latent iron deficiency, and 17.5% iron deficiency anemia; S-EPO was inversely correlated to iron status markers: Hb, rs = -0.51, p < 0.001; transferrin saturation, rs = -0.65, p < 0.0001; S-ferritin, rs = -0.31, p < 0.01, suggesting that the elevation in S-EPO was secondary to iron deficient erythropoiesis. Newborns to iron treated mothers had higher cord S-ferritin, median 155 micrograms/l, than newborns to placebo treated mothers, median 118 micrograms/l (p < 0.02); there were no differences in birth weight, transferrin saturation, or S-EPO.(ABSTRACT TRUNCATED AT 250 WORDS)

Iron status markers and serum erythropoietin in 120 mothers and newborn infants: Effect of iron supplementation in normal pregnancy

Background. To investigate the influence of Body Mass Index on the incidence of labor complications in a population of women with a normal pregnancy. Material and methods. From a local database, information on maternal weight and height was extracted concerning 4258 women who had an uncomplicated pregnancy. After calculation and stratification with respect to Body Mass Index, this was retrospectively related to labor interventions and complications. Results. High Body Mass Index was related to more oxytocin infusion and early amniotomy, but not to vacuum extraction or cesarean section. Primary inertia and, to a minor degree, cephalopelvic disproportion and secondary inertia were seen more often in women with high Body Mass Index. Conclusions. Overweight (25.0 =30.0) are only weak predictors of labor complications, given a normal pregnancy. However, the heavy use of labor augmentation indicates that obese women should not be recommended to give birth in an ABC-clinic or at home.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1034/j.1600-0412.1999.780911.x

The influence of prepregnancy body mass index on labor complications.

Study objective. To study variations in serum relaxin concentrations during normal and abnormal human pregnancy and parturition and in umbilical cord blood.Design and patients. Diurnal variations were determined in samples collected every 2 hours for 24 hours (n=4). Variations during pregnancy were studied in samples taken every 4th week from normal pregnant women (n=26). Additionally samples were collected once a week from the 37th week of pregnancy and until spontaneous delivery (n= 5). Changes in relaxin during early pregnancy (gestational age: 30 to 97 days) were studied in serum from 12 normal pregnant women, 13 with spontaneous abortion and 38 with an ectopic pregnancy. Fetal serum was obtained at delivery from the umbilical vein (n=20). All samples were analysed for relaxin by an ELISA based on human relaxin antibodies.Main results. No diurnal variation in relaxin concentrations were found. In normal pregnant women relaxin concentrations increased during the first 14 weeks of pregnancy. From week 1...

Variations in serum relaxin (hRLX-2) concentrations during human pregnancy

Background. To investigate the relationship between pre-pregnancy obesity, and urinary symptoms, especially urinary incontinence, before, during, and 6–18 months after delivery.



Methods. Body Mass Index extracted from obstetric records. Postal questionnaire.



Material and setting. One hundred and eight women with Body Mass Index of at least 30 kg/m2 delivered at the Obstetric Department, Herning Central Hospital, October 1994 to September 1995. As control served 108 matched, normal weight women delivering during the same period.



Result. Response rate was 83%. Stress incontinence, urgency and the feeling of having a hygienic problem was significantly more common after delivery in both groups, but at any time significantly more common among obese women. Urge incontinence was a numerically small problem after delivery.



Conclusion. Obesity is a potent risk factor for several urinary symptoms after pregnancy and delivery, and a substantial number of women still have problems 6–18 months postpartum.

Anders Ole Agger

Papers

Hemoglobin and erythrocyte indices during normal pregnancy and postpartum in 206 women with and without iron supplementation

Iron status markers and serum erythropoietin in 120 mothers and newborn infants: Effect of iron supplementation in normal pregnancy

The influence of prepregnancy body mass index on labor complications.

Variations in serum relaxin (hRLX-2) concentrations during human pregnancy

Obesity as a predictor of postpartum urinary symptoms