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- [00:00]
Narrator
No one goes to Hank's for spreadsheets. They go for a darn good pizza. Lately though, the shop's been quiet, so Hank decides to bring back the $1 slice. He asks Copilot in Microsoft Excel to look at his sales and costs and help him see if he can afford it. Copilot shows Hank where the money's going and which little extras make the dollar slice work. Now Hanks has a line out the door. Hank makes the pizza. Copilot handles the spreadsheets. Learn more at m365copilot.com Work Spring Black
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Narrator
Foreign.
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Dr. Chapa
You know that we've covered iron deficiency and anemia, and we've combined the two as iron deficiency anemia. We've covered all of those topics on this podcast in the past, but there's a new publication as of April 2026 in the green Journal that puts a new spin on this issue of iron deficiency anemia in pregnancy. Now now we've and we've covered this that iron deficiency anemia in pregnancy is just not good. It's not good at the cellular level, it's not good for fetal development, and it's actually linked to some adverse maternal and neonatal issues. It's at higher risk of preeclampsia, higher risk of placenta previa and abnormal placentation. Believe it or not, when it's existing in the early part of pregnancy, it's been associated, of course, with fetal growth issues and even placental abruption. So it makes sense that diagnosis, diagnosing and treating anemia during pregnancy could potentially reduce some of those adverse issues. However, however, up Until April of 2026, we really didn't have that evidence. We didn't have that data. It made sense that if we find iron deficiency anemia early on and we tackle it before delivery, that hopefully some of those things may may improve. But we didn't have this data, but now we do. So in this episode, we're going to cover this brand new April 2026 Green Journal publication, which is not a prospective study. It actually is. You know, I've got, I've got some pet peeves with data mining and looking at national databases, but some things you got to do that, then it gives you an overall good gestalt, an overall overview of what's going on. And so I'm okay with that because that's what this is. This is a retrospective study using population based data from a nationwide wide insurance claims data bank. Okay, so I'll be very clear. This is insured patients using data mining and then they looked at the data retrospectively. So it's not an rct. That's one of the big issues. It's not prospective, but nonetheless, some things you have to do kind of at a population level and you got to do it like this to get some info. So here's a question. Is finding iron deficiency anemia early in pregnancy and fixing it, does that improve some maternal and neonatal issues at delivery? It's a great question. And now this helps us answer that. Okay. And I'm just going to tell you I'm a spoil it just a little bit. Even though we're going to get out of the intro here in just a minute, there's some good news about this and some not so good news about this. So we're going to explain that when we come back. This is Dr. Chapma's ob gyn no spin podcast.
- [04:19]
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- [05:12]
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- [05:19]
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Eczema Medication Advertiser
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Dr. Chapa
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- [05:45]
Dr. Chapa
Ba da ba ba ba and participate in McDonald's while supplies last. Yeah. Anemia super, super prevalent in the US in reproductive age women, of course, the majority of that in, you know, excluding hemoglobinopathies and some other weird stuff, which these authors took into account because they wanted to focus on iron deficiency, which is 80% of the type of anemia that reproductive age women have at a population level that's the most common. And that's what we're going to find in pregnancy. Right. So if you have a low H and H, which defies anemia, then we are obligated, of course, to look for hemoglobinopathies as part of maternal carrier screening to begin with, but also to look for ferritin levels to see if it's iron deficient. Remember, in pregnancy, that's a serum ferritin under 30. Okay, that's pretty darn low because it should be significantly higher than that, but the floor is 30. Okay, so if you have a low H and H and you've excluded active bleeding and a hemoglobinopathy, then of course, look at ferritin, because iron deficiency will be very common. Now, there is, of course, you know, vitamin B12 and folate deficiencies. There's other things, but no doubt, in the US at least, iron deficiency is the main issue. And we've got guidance for this. This is nothing new. That goes back to ACOG's Practice Bulletin 233. Remember, that's a hemoglobin less than 11 grams per deciliter in the first and the third trimester, and in the second trimester because you get the hemodilution and, you know, the natural drop in physiologic hemoglobin and hematocrit in the second trimester. That's defined as less than 10.5 for anemia. All right, but you can have low ferritin and not be anemic. Those are two separate things because anemia is a late manifestation, of course, of low ferritin. We've covered all of this in the past. So this new study wanted to find out this question. If we find iron deficiency anemia in the first trimester and we do something about it so that there's resolution by late pregnancy, does that improve maternal neonatal outcomes? And they picked certain things that they're going to look at for each one of those two boxes. Maternal and neonatal outcomes. Okay. So once again, though, this was a database query from 2018, 2018 to 2023, using commercial insurance. So that's the first thing that that's a very small percentage of my population because majority of ours are state funded or federally funded. But it's still, again, still valuable in what they found. Now, the outcomes that they chose to look at, and they called it, of course, smm, which is severe maternal morbidity. They have to define that because ACOG has their list of SMM that goes back to 2016. And there's a new publication from the college coming out in June of 2026 about how to report SMM and better ways to track that. But there really is not one set. National and international guidance of here's what is severe maternal morbidity. Now, the common sense stuff are on there. A pe. Yes. You go to the unit. Yes. You have massive transfusion protocol. Yes. You have septic shock. Yes. So there's some things that are no brainers. All right. But not everybody agrees on all the other ones. But nonetheless, ACOG does have an SMM table, goes all the way to 2030, 16. That was. That keeps getting reaffirmed. It was last affirmed in 2025. So it's good that they defined what these authors considered smm. That's one of the things that they tracked. And it would be the typical things. Preeclampsia, placental abruption, severe postpartum hemorrhage, blood product, transfusion. They included a spontaneous preterm birth, medically indicated preterm birth, small for gestational age, birth weight, which, remember in the OB side antepartum, that's FGR, because FGR, when the child is born and it's under 10% for gestational age. That's SGA. And they also looked even at placenta previa. So that was their definition of smm. Okay. Now, once again, ACOG has its own list. It's important for you to know what that is. Again, June of 2026, new data from the college coming out on tracking and reporting of that very issue. Fine. And of course, neonatal outcomes, they also included, like, NICU admissions, which is fine as a marker of neonatal depression or need for observation. So they then wanted to find out if you find anemia in the first trimester and you treat it, what happens. So to that end, they had four different types of groups here. Okay. Number one was no anemia found at any point in pregnancy. Okay. So that's kind of like your control. So no anemia. The second is first trimester anemia is found, but then you do something and it resolves. So that's the treatment intervention type. Number three is the group where first trimester anemia was found and it didn't get better, persisted all the way until late pregnancy. That's the third group. And then the fourth one is, hey, there was nothing in the first trimester. But lo and behold, there's new onset late pregnancy anemia. So this one kind of escaped the entire pregnancy. And then boom, at the end. Now they're anemic. So that's how they grouped each one of these four different patient subclasses to figure out what happens. So no anemia at all. Anemia in the first trimester, but then it gets better. Anemia in the first trimester that continued, or no anemia early on, and then boom, at the end there is anemia. All right, so we're going to do this very quickly because it's a very long article. I'm just going to tell you the gist of it and something we can all think about when we have a patient at intake as a new enrollment to prenatal care, who's in the first trimester. You've got to check that H and H, of course, which we always do. And consider hemoglobinopathy screen, which of course is part of maternal carrier screening, and serum ferritin. We do that pretty routinely, almost as part of universal labs, because our patient population is known for their iron deficiency. Okay, so serum ferritin can also be included in that. So does this matter if we change their iron level, if we give them either IV infusion or oral iron, which is still gold standard, right? Oral. Because we don't want to do a lot of interventions, we don't have to. Does it actually change anything at the end of pregnancy? So that was the question. So the short answer is first pregnancy. First pregnancy, sorry. First trimester anemia that persisted into late pregnancy was the worst outcomes. Now that makes sense, right? Because they never got a break. So they come into prenatal care and they're iron deficient. And it continues all throughout pregnancy. They had significantly worse outcomes compared to anemia that got better. Okay. Now obviously the best were those who didn't have any anemia at all. Duh. I mean, that makes sense, right? Let's just get the easy one out. If you're not anemic, you avoid some of the, you dodge some of the bullets. All right? But next best is that if you find it and you do something about it, they're going to get better in some issues. And I'm going to discuss that in a minute. But the worst outcomes were first trimester anemia that persisted into late pregnancy. They had the worst clinical outcomes. Okay, And I'm going to show you what those are in a minute. But once again, in contrast to that, first trimester anemia that resolved by late pregnancy had minimal associations with adverse outcomes. And that suggests that early detection. Here it is, guys. Here's a clinical. Find it early, do something about it so you can mitigate risks.
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Narrator
Duh.
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Dr. Chapa
I mean, it's one of those things like it makes sense, but we actually didn't have the data to prove that until April of 2026. I'm gonna tell you what got better, so. Well, I'm do it right now. The main thing that got better, if you found first trimester immune and you fixed it by late pregnancy, you significantly reduced non transfusion related severe maternal morbidity. Smm. Phenomenal. Phenomenal. Now, and I mentioned this in the intro, unfortunately. And the weird thing, the weird thing is that unfortunately, even if your anemia gets better by the end of pregnancy, two things that were still there as a risk, that were smaller, but it still hung out still higher than those without anemia was that those patients, again, who had anemia early on, but then it resolved by late pregnancy, they were still at risk of having abnormal bleeding and needing a blood transfusion, and they were still at risk of having an SGA child. So now intuitively you're like, well, wait a minute, they fixed the iron. Why is that kid still at risk of sga? Easy. Because implantation early on is what sets the stage for pupper fetal growth. So if you're anemic in the first trimester, that potentially is the theory. You're going to get poor vessels and angiogenesis at implantation. So the risk of having a neonate that was SGA at birth was elevated for both persistent anemia all throughout pregnancy and even those with resolved anemia. So one thing that doesn't get better is the SGA risk if they have first trimester anemia. All right, is that fascinating or what? And it does make sense. So yes, there was still even with anemia that resolved, there was definitely a reduction in non transfusion severe maternal morbidity. And that's good. However, the risk of blood transfusion and the risk of having a small for gestational age newborn remain elevated. Now why the blood transfusion now? If you think like, wait a minute, they're not anemic anymore, I fixed it. So why are there risk of blood transfusion? It has to do with that same issue of initial bad implantation early on. Remember, these are patients who are anemic in the first trimester. So the thought is it's the dominoes already started the cascade, man. You can mitigate some of the risks, but because it was there early on, early on in pregnancy, some of the issues you cannot undo. Mainly the risk for blood transfusion and the risk for small for gestational age. Guys, this is why super important that when you do your well woman care and the reproductive age to say you've got to fix your anemia. So include a ferritin for your well woman exams. Definitely. We do a CBC already. But just because they have normal H and H does not mean that they are not iron deficient. You gotta look at the ferritin for that. Even though other things may give you some markers. Like you can see a little microcytosis starting even with a normal H and H, but ferritin gets you the diagnosis of iron deficiency. Okay, so this is good to know because this stresses the point that you've got to fix this before they get pregnant. Because the best outcomes were those patients who started pregnancy without iron deficiency and who never developed it. That just makes sense. I want to read something here from the their discussion section because it clears this up very nicely. All right, now the good news is before I read this little extra and I'm going to be done here in a minute, the good news is, is that pretty much close to half of those who were diagnosed with anemia responded to some kind of treatment. So in this publication, 47% had resolved anemia by late pregnancy. And again, resolution of anemia definitely good. Definitely Associated with less risk for certain issues, however. And the biggest drop was in non transfusion, severe maternal morbidity. That's all good. And the risk of blood transfusion was lower. However, the risk of blood transfusion was still there. Right. So it didn't eliminate it, it just reduced it. It mitigated the risk, as the authors describe. All right, all right, so let me read you this excerpt explaining these things, and I'm gonna wrap it up here quickly. So the big take home is, number one, look for this before they get pregnant. Number two, if they don't, because none of my patients come in until they're already pregnant. Maybe that's your population, too. Diagnose it. Look for it and diagnose it as soon as possible, which includes a CBC so you can look at indices, of course, do a hemoglobinopathy check, which is part of maternal carrier screening, and consider serum ferritin to get on top of this quickly so that we can fix it. So number one is not having an anemia when you start pregnancy. That's the best. Number two, if you find it, fix it so that it's not there at late pregnancy to reduce severe maternal morbidity. And while they still were at risk for SGA and blood transfusion, that risk is smaller. All right, so let me read you this excerpt, and then we're going to start to wrap this thing up. Okay? Oh, did I give you the title of this? I'm not sure if I did or not. Anyway, this is April of 2026, and the title of this from the Green Journal. Michael just sent me a note. You never even talked about the title. Thank you. I'm doing it now. You could have told me that at the beginning, but I didn't see that. Sorry. All right, so anyway, here it is. Pregnancy outcomes Associated with Anemia in the First Trimester and Anemia Resolution by late pregnancy. Again, pregnancy outcomes associated with Anemia in the First Trimester and Anemia Resolution by late pregnancy. Green journal, April of 2026. Thanks, Michael. Sorry about that. All right.
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Dr. Chapa
So what? Yeah, so that's the title. All right. So now let's go back to the discussion real quick. Quote we additionally report remember these are the authors. This is inter discussion that we're going to wrap it up. Quote we additionally report that resolution of anemia did not eliminate increased risk of blood product transfusion and was in fact associated with a higher risk of some outcomes like postpartum hemorrhage. End quote. So let's stop there. So as I said, reduce the risk, reduce the anemia. So you're gonna fix some things but not everything. The risk of blood transfusion was in fact still there because the risk of postpartum hemorrhage is still there. And that has to do with likely poor implantation because of the jacked up anemia affects angiogenesis neo angiogenesis at implantation early in the first trimester. Okay, so they go on to explain this. Here we go. Quote Additionally remember these are the authors. Additionally because key processes including placentation told you and vascular remodeling largely occur in the first trimester, anemia during this window may have disproportionate long term effects even if later corrected. This pattern underscores the potential importance of identifying and managing anemia before conception in addition to early pregnancy. End quote. There it is. So it does make sense. Some things, some big bad things do get better by correction of anemia. But some things you can't undo because it was there to start with. So podcast family, a good reminder for all of us again to look for this in our preconception reproductive age. Patients look for this in early pregnancy. And the good news is yes, we can definitely drop non transfusion related of your maternal morbidity. But some things the risks don't go away. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Michael. Thank you for your little messages. I do read them. I read them a little late, but I do read them. All right Michael, now that we've done all that, let's take it home. This is Dr. Chapa's OBGYN no Spin podcast.