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A (0:01)
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You know, it's one of those things. The more that we study, the more that we know, the more questions are generated. Isn't that great? I mean, that is by definition, the process of science. I mean, you make a hypothesis, you test a hypothesis, you generate more questions. You're like, oh, great, now I'm going in five different directions. You test those hypotheses. Onward and onward. That's the way it is. We've known for a long time that iron deficiency anemia during pregnancy is associated with some bad things. I mean, iron deficiency anemia has been linked to low birth weight, preterm delivery, perinatal mortality. It's been linked in some studies to postpartum depression and poor mental and psychomotor performance in the offspring. Now notice what I said and notice what I stressed there. Iron deficiency anemia. Now here's the catch, okay? Iron deficiency anemia in pregnancy is bad. Of course, it also increases the risk of blood transfusion at time of birth. However, if iron deficiency anemia is bad. So let's think one step back. Shouldn't we take care of iron deficiency first before the patient becomes anemic? Remember that there's two different tests here, guys. There's serum ferritin, which has high sensitivity and specificity for iron deficiency. And in pregnancy in general, that has been marked as a ferritin serum level of under 30 as evidence of iron deficiency in pregnancy. So you have ferritin level which is iron deficient. And then you have anemia, which is a low hematocrit or hemoglobin. Now, with time, iron deficiency, what sets up first that comes first will eventually show up as iron deficiency anemia. Mind blowing, right? I Mean, how's that for high quality data right here? I mean, that just makes sense, right? That's a normal pathophysiology of iron deficiency anemia. Nobody wakes up one morning and goes, well, I wasn't iron deficient anemic yesterday, but somehow I am today. It's a process where iron first gets depleted in body stores as ferritin, then manifests as iron deficiency anemia. Now, of course, the CDC says and ACOG say, look, we should really screen for iron deficiency anemia because of those complications that we've already discussed that are associated with iron anemia in pregnancy. However, here's the catch, and it's controversial. Okay, well, rather than waiting for the patient to have iron deficiency anemia, why don't we check first to make sure the patient is not iron deficient? In other words, should we be including serum ferritin in the prenatal labs? Okay, now let me. Let me just be very clear here. Some of you already do that. I do. We do. We include serum ferritin in there because it's part of fine tuning micronutrients to correct any micronutrient depletion. And we're going to get into this in this episode because there is evidence, guys, that outside of low H and Hs, okay, outside of anemia, iron deficiency is super prevalent. At least it is in the US and it depends on who you read. But in general, look at these numbers. In general, based on population studies, anywhere from 19 up to 42% of non anemic pregnant women. Did y' all get that, guys? All right, so this is the. The H and H is still okay. It hasn't even dipped yet. But according to some evidence, anywhere from 19 up to 42% of non anemic patients that enter into prenatal care have iron deficiency. So here's where I'm getting at. If iron deficiency is bad and eventually will manifest as iron deficiency anemia, should we be including this? Now, I know what your first question is. Well, what does ACOG say? Well, ACOG says we should screen for iron deficiency anemia with a CBC and of course, use indices. And then those who fall below the level of anemia diagnosis in pregnancy, then you can consider serum ferritin as well as things like troll iron binding capacity. All of this is in ACOG's guidance, which is practice bulletin number 23 3. But this is very similar, guys, to TXA. Remember, the original endorsement of translate acid at time of delivery by ACOG was for established postpartum hemorrhage meaning 1000mls of blood loss or more, or signs or symptoms of hypovolemia based on the woman trial. Then came all of the other data that said, you know, rather than waiting for the patient to have postpartum hemorrhage, why not give that prophylactically? Especially when the patient has additional risk factors at an EBL or QBL of 500 or. And again, the data is a little controversial. We've covered all of the data on TXA before. But the whole point is rather than waiting for the patient to actually have a condition which is now morbid, like postpartum hemorrhage, where you then give txa. The same can be said here for interventions early to identify iron deficiency before the patient has iron deficiency anemia. Okay, so I'm going to be very clear. Yes, both cdc, SMFM, and acog. I guess not both. That's three of them. So all three of the major organizations say we should screen for iron deficiency anemia. No question. However, since iron deficiency anemia is one thing and iron deficiency is another, and there's data that women enter prenatal care already iron deficient, anywhere from 19 to 42%. Doesn't it make sense to include maternal serum ferritin, an initiation of prenatal care? I'm going to go through the data, and then again, you do what you do. Maybe have a journal club about it. I'll put the references, of course, in our show notes. But this is something that actually came up in our own faculty group discussion where somebody said, hey, a resident checked out to me and said, this patient has LO ferritin iron deficient and was asking about IV iron transfusion, maybe because a patient couldn't tolerate PO iron, but the patient's H and H was normal. So the faculty said, but she's not anemic. So who was right here? And so I very quickly defended the resident because in this case it needed to be defended, which is, hey, guys, even without iron deficiency anemia, iron deficiency by itself is bad. And there is data. Here it is, guys. Is there any evidence that fixing iron deficiency even without anemia, is there any evidence that that is beneficial? Because if there is no evidence that is beneficial, then it's just opinion. But there is evidence that fixing iron deficiency even before the patient gets anemic actually has some benefit in pregnancy. I'm gonna give you that data when we come back right now after this intro.