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Podcast Family we pride ourselves on this show on being somewhat avant garde and forward thinking on the topics that we choose. For example, on February 20, 2026, y', all, five months ago we released an episode called New Data Screen Maternal Ferritin with Prenatal Care. Now in that episode we made the case for checking or including serum ferritin with your initial OB labs and we reviewed a publication from the previous month that was January of 2026, that was released in Lancet Hematology. That study, just as we proposed, made that case for screening for early iron deficiency even without iron deficiency anemia. Because waiting for iron deficiency anemia pop up is too late. We should be preventative rather than reactionary. And I'll get into the reasons for that right after this intro. That study from the Lancet was a multicenter 2 arm randomized control trial and duh, it found that earlier identification of low serum ferritin prevented iron deficiency anemia in the third trimester. Wow. I mean, not mind blowing, right? We get that and that's a win. And back then we also mentioned how Australia was being very forward thinking in this as well with the Australian How Consensus Committee. That's H O W. That stands for Hematology in Obstetrics and Women's Health. That Australian consensus committee now recommends screening for iron deficiency, not just iron deficiency anemia at the start of prenatal care and at 24 to 28 weeks and then again in the third trimester or when necessary. So let's leave that episode and that topic from February 2026 and now let's jump forward to August 2026. Yep. Remember, we pride ourselves on being avant garde because now coming out in August 2026 is a brand new prospective cohort study that was published as a research letter in the Gray Journal. Again, this is coming out August 2026, and guess what its topic is Choosing serum ferritin as part of your initial OB labs so you can identify iron deficiency before the patient gets iron deficiency anemia. Yep. So here we are, six months later, after our episode, a new publication with several sites in the US Participating saying the exact same thing. Y', all. That's what I call avant garde. I think I've set it up enough. We'll be right back in just a moment. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast.
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Avant garde is French for vanguard, a military term used to describe the front line of an army moving into battle.
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Well, I will say that sometimes on this show we venture into unknown territories. Hence the advanced guard, the avant garde, because we actually brought this up months ago. And lo and behold, here it is again in August 2026 in the gray Journal. Because this just makes sense. Guys, there's some things in medicine that there's gaps in data. There's gaps, for example, in what do you do with a patient who first presents after 28 weeks and misses her 24 to 28 week GTT? I mean, the original time to do that is 24 to 28. Do you still screen it? We don't know what the results should be. Do you do another test? Again, that's a gap in the data. So there are things that happen in our guidelines that sometimes you just look at and you're like, well, that's a gap that doesn't make sense. Like looking for iron deficiency anemia. That's great. We should do that. Iron deficiency anemia is linked to both maternal and neonatal adverse issues, so we should get ahead of that. But while the current recommendation is to look for iron deficiency anemia, why do we have to wait for the patient to become anemic? In other words, if a patient is iron deficient, which is defined as a low serum ferritin, and not just in the U.S. but pretty much globally, that's defined as under 30. Right. So under 30 is iron deficiency. Why not get ahead of it? Why do we have to wait for her to be in harm's way, so to speak, in terms of adverse maternal and neonatal outcomes, to do something? So here's a reality, and we can't Minimize this. I think we get so used to seeing iron deficiency anemia in pregnancy because we see it so commonly that it's just like, meh, it becomes kind of bland. Now she's iron deficient, but we should never have that stance. Iron deficiency and iron deficiency anemia, which are two different things, but both are not good for maternal and neonatal outcomes. We know that iron deficiency is linked to poor fetal growth. It's linked to poor placental function, and there's even growing data that it's linked to possibly, you know, some negative neurodevelopmental issues because iron is a vital micronutrient in the fetus. It helps with neurological processes, including myelination. It has to do with monoamine neurotransmitter metabolism. And there's even some data, guys, that it can affect negatively some epigenetic postsynaptic changes in the kid's brain. So this is a big deal, right? We should never become laissez faire with iron deficiency anemia and pregnancy. Plus, maternal iron deficiency, with or without anemia in the last two trimesters, increases the risk of low birth weight, which, again, irrespective of fetal iron stores, is itself a risk to poor neurodevelopment. So there's a lot of things here. One study not long ago actually said that the maternal serum ferritin had to be above 60. 60, guys, 6, 0. Just at the end of the first trimester, around 14 to 15 weeks, to ensure adequate fetal loading throughout the remainder of pregnancy and to protect neurodevelopment. Y', all, I'm telling you, we check for serum ferritin at the start of prenatal care whenever the patient enters. We do. We include that with our IOB labs, initial OB labs, and we have found serum ferritins of 6. Okay, I'm like, lady, holy moly, you have no iron stores. And by the way, that is both with and without iron deficiency anemia, which has to do with. With a certain cutoff, again, of your hemoglobin or hematocrit per trimester. So iron deficiency, if left to brew long enough, without fail, will show up as iron deficiency anemia. And what I'm trying to say is, as these authors that we're about to talk about are saying as well, is why wait for the patient to have an abnormality when there's an easy way to get ahead of this, especially IV iron, which bypasses the GI tract and avoids all the negative GI effects of oral iron supplementation. Not that iron. Oral iron is bad at All I'm not saying that. I'm saying it's definitely the option for those where compliance is an issue. Because it's tough, man. Taking iron every day or preferably every other day so you don't block your hepcidin receptors. You know, it's tough. But that publication really raised a lot of eyebrows with a maternal serum ferritin of greater than 60 as well as proposed as best for fetal neurodevelopment at 14 to 15 weeks when my patient population has ferritin levels of 6 and 7. Okay, so this is a big issue. Now, remember this. It's not just about pregnancy. And when she's born, that's it. This continues into early childhood for the child. Recent studies revealed that as much iron that is present in the kid at nine months has to do with maternal factors in the last part of pregnancy. In other words, we help load that child up for successful first year of life based on iron stores, based on mom's iron status. And here's another plug. Don't forget, guys, don't forget about that delayed cord clamp, which again has moved from 30 seconds to 60 seconds, especially in the preterm infants. Remember, that was ACOG's last update on delayed cord clamping. September 2025. That really. We should be going for 60 seconds in everybody. Okay? Unless the kid needs some kind of immediate resuscitation. 60 seconds of delayed cord clamp helps move that blood to that child to help give that big push of iron that's protective to the child against a variety of things, including poor neurodevelopment. Okay, so in addition to delayed cord clamping, which is not our topic, our topic is checking for serum ferritin. Getting mom primed for delivery by avoiding iron deficiency anemia really should be one of our tasks, right? Not just identify when it happens, but doing something to prevent it. This is what we covered back in February of 2026. That's a lot. Boy. All of that was off script, by the way. None of that was was what I was supposed to cover, but it's still super important. But that does bring us to this new publication from the American Journal of OB GYN, the gray journal that is coming out August 2026. And it's point of reference, we're actually recording this in July of 2026. So this is not officially out yet, though it's out ahead of print. So this is very nice. It's very concise, it's very quick. There's actually a little video that goes along with this in the Gray Journal. And I like this because it's representative. Kind of a good snapshot around the country. I mean, it's got people from the east coast, from Brown University all the way to the west coast with Portland, Oregon. Plus there's contributors from Salt Lake City, from Miami, from Birmingham, from Ann Arbor and Georgetown in D.C. so that's quite the spread.
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Now, let me just get to this quickly because this is a redo, more emphasis, of what I kind of brought up in February of 2026 to plead with you to always check for iron deficiency anemia. That's current guidance. But to also get ahead of it and, and to look for serum ferritin at the start of prenatal care, because that's exactly what these authors in the gray in August of 2026 are saying to do. All right, again, a little avant garde, because we said that six months ago. Anyway, I digress. As the authors state in this publication, quote, we aimed to examine the association between first trimester iron deficiency without anemia and subsequent development of IR of antenatal iron deficiency anemia. This was done in order to support our ongoing multicenter randomized trial on the optimal iron therapy for antenatal iron deficiency anemia. End quote. So let's stop there. Okay, so there's a lot there. Short of it is they said, look, we're doing a separate trial on what's the best way to supplement iron, but in order to find out who's iron deficient, we started looking for serum ferritin universally at the start of prenatal care. That's pretty much the way it is. And they recognize that they're doing that to help their trial, even though it's not part of current recommendations. Let me read that directly. Quote. We initiated universal ferritin screening, although this practice is not currently recommended, end quote, just like I told you. So this is where it comes up that there's some gaps in our guidelines. Why should we be looking for the end result of iron deficiency and not get ahead of it? I don't know. I don't know. But, but we pretty much should. So this is a prospective cohort study with pregnant women that had singleton first trimester pregnancies who were able to have their OB labs taken at that time. And they also included a cbc, of course, to look for existing anemia. This was with patient recruitment from February 2023 to July 2025. Now, those with anemia at the start of prenatal care were excluded because they took. They, you know, they already had that problem identified. That's a separate issue. We were looking, they were looking at this publication as we are, to identify low serum ferritin to get ahead of this as a preventative and or prophylactic measure. All right, so the primary outcome was iron deficiency anemia prior to childbirth. And this was basically what the same thing that was done in January 2026 when we covered that publication out of Lancet Hematology. So let me give you these numbers and then we're done here because this is a no brainer. Now, although 511 pregnant women were taken in, 9% had first trimester iron deficiency anemia and were excluded. I'm actually surprised by that. I think that's pretty low that only 9% had anemia. However, 25%, according to these authors in these cohorts had first trimester iron deficiency without anemia. So this was one in four. Okay, now that's impressive. One in four had iron deficiency. And we'll get into what they found here in a minute. But nonetheless, one in four in our population, guys, it's one in two to one in three. I mean, we have a relatively lower socioeconomic indigent population. A lot of them are just arrived to this country, say what it is, and maybe poor nutrition is an issue. So it is like not unusual, as I mentioned a while ago, to have a patient who comes in for their initial OB and you know, their ferritin is like under 10. I mean, that's really low. So 30 is a cutoff for iron deficient. Less than 15 is what's considered by the CDC and international guidelines as severe deficiency all right. Okay, fine. So short of it is what happened. Well, of course, those with iron deficiency without anemia, the majority, that 67%, went on to develop iron deficiency anemia before childbirth. So even if they don't have anemia when they start just being iron deficiency without anemia, 67% went on to develop iron deficiency anemia before childbirth. That represents a nearly twofold increased risk compared to those who were iron replete and non anemic in the first trimester. So guys, how is this confusing? I mean, this is a no brainer. If you're iron deficient in the first trimester and you have something that's taking a high iron demand stress on the body, maybe it's not enough just to wait for them to get iron deficiency anemia despite the fact that their H and H is normally good in the first trimester. Okay. Because iron deficiency is not measured by your H and H, that's measured by your serum ferritin. So it makes sense, doesn't it, to be preventative rather than reactive. And again, I said this, we said this six to seven months ago in February 2026. So let me just read you this very quickly. Okay? Read you this conclusion that we're done. As these authors say, these findings suggest that identifying and treating iron deficiency without anemia in the first trimester may provide an opportunity to prevent iron deficiency anemia and its associated morbidity. End quote. Ya think? I mean, this is a no brainer. No brainer. So why is it that right now it's not universal standard to screen for serum ferritin and is beyond me. I don't have an answer for that. And so as these authors say, we did this because we were kind of doing a trial to look for iron deficiency anemia. So we wanted to kind of figure this out and help with patient identification and possibly recruitment. So they started adding ferritin even though, quote, it is not currently recommended as a standard. End quote. Podcast family. The whole purpose we're doing this is just bring this up. Ferritin and initial OB labs. It's a good idea. Get it? Why not? And if anything, it's a good patient education tool that we can show them. Look, your serum ferritin is 15. It's not going to get better on itself. And while oral replacement is fine, there is a role for IV use in addition to oral iron repletion because the IV infusion can get away from the GI side effects and ensure better compliance. So just something to think about. So ferritin at initial OB? Yeah, I told you back in February of 2026. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Michael Another We've done all that. Come on now, let's take it home. This is Dr. Chapa's OBGYN no Spin podcast. Sam.