Important notification about information and brand names used in this article! The principal mechanism for perinatal morbidity and mortality due to preeclampsia is poor placental and fetal perfusion. The hemoglobin cutoff value commonly used to define anemia is based on the normality definition often applied to other clinical laboratory tests and in anthropometry (10). To ensure the intended benefit of preventing significant iron deficiency anemia, efforts must be devoted toward improving the operation of supplementation programs and toward improving iron nutriture before pregnancy (54). Hemoglobin is the iron-rich, oxygen carrying protein found in red blood cells. Etiology of anemia in pregnancy in south Malawi. The only condition of elevated hemoglobin that is due to the production of defective red blood cells, but not subject to the control of tissue oxygen drive, is polycythemia vera (31). Additionally, the absorption of nonheme iron can be affected by inhibitors or enhancers. Above this hemoglobin concentration, the relation becomes exponential—a small increase in hemoglobin or hematocrit results in a large increase in viscosity (18). ), dry fruits (raisin, almonds, etc. One issue is that the association between mild-to-moderate anemia and other adverse reproductive outcomes is weak (evidence of risk only). This lack of evidence does not negate the evidence for controlling maternal anemia. Moreover, to date, most studies of the relationship of Hb concentrations to pregnancy outcomes have been done in high … Medical evidence shows that very severe anemia is a direct cause of maternal and child mortality. However, a few newborns inherit a gene for HPFH from one parent and a sickle cell gene from the other. The level of hemoglobin usually goes below 10.5b/dl in pregnancy. Treatment options for elevated hemoglobin levels. In addition to poor intakes of bioavailable iron, which is a common problem in developing countries and is related to low intakes of heme iron from animal sources, hookworm infection is prevalent in many tropical areas (24). These issues are discussed below. Better efforts to ensure program functioning appear to be a prudent alternative to abandoning programs. Such a reduction in oxygen transport can be regarded as an adverse health outcome; thus, iron deficiency has a definite effect on health because of anemia (evidence of deficiency). Furthermore, operational aspects of iron supplementation programs must be improved to ensure effectiveness. Likewise, the relation of adverse pregnancy outcomes with high hemoglobin and increased iron stores has been documented. Iron and folate supplementation during pregnancy is commonly practiced to prevent maternal anemia, which is often caused by iron deficiency. Iron is vital for making hemoglobin, the protein in red blood cells that transports oxygen to other cells. Until recently, it was assumed that anemia during pregnancy had few untoward sequelae. Several epidemiologic studies showed that both low and high hemoglobin concentrations are associated with increased adverse birth outcomes, including fetal death, intrauterine growth retardation, preterm delivery, and low birth weight (6–9). (29). However, there is a rise in total circulating hemoglobin directly related to the increase in red cell mass. Because of substantial normal variations in hemoglobin distribution across age, between sexes and races, and at different stages of pregnancy, the cutoff for low or high hemoglobin concentrations should be specific to sex and life cycle (11, 12). A clearly defined pathophysiologic mechanism is required for classification of a nutritional disease or disorder, and an estimated nutrient requirement has been widely used for clinical and public health purposes. Moreover, if multiple deficiencies contribute to the severity of anemia, supplementation with iron alone may not achieve adequate hemoglobin response. They usually occur in the sixth or seventh month of pregnancy, although they can occur in early pregnancy or even, in the mother, after giving birth. Objective: To examine the association of maternal hemoglobin during pregnancy with preterm birth and small for gestational age (SGA). Often, the feasibility of a public health program is based on its cost-effectiveness compared with other programs. It makes me wonder whether iron deficiency anemia is likely to be a major factor in developing countries. Dr Yip: I do not think anybody is discussing parenteral iron as an option right now. Six months after delivery, HbF was measured in all women with high HbF during pregnancy, revealing normal values. About 5 percent of women get preeclampsia during pregnancy. The most plausible explanation for the observed association between a high hemoglobin concentration and perinatal morbidity and mortality is that both conditions are often the result of hypertensive disorders of pregnancy or preeclampsia. Two of these cases also had been observed during a successful pregnancy in which the Hb levels were within normal limits. A more recent study, however, did not show that the risk of malaria justifies the withholding of iron (50). Dr Rush: I believe that this is a hypothesis and only ask that we test it. In poor areas, the usual diet often consists mainly of unprocessed grain products that are relatively high in phytate, which is a known inhibitor of iron absorption. Increased hemoglobin-what does that mean? Another risk in many populations is that a small subset of women have conditions known as iron-loading diseases and can be harmed by the extra iron over the long term (1, 46). Increase in the thickness of blood can directly affect the flow of blood in the body of the mother. Dr. Gurmukh Singh answered 49 … A good example is a supplementation study done by Suharno et al (27) in Indonesia, in which combined iron and vitamin A supplementation had a greater effect in correcting maternal anemia than did iron or vitamin A alone. This may also increase the effectiveness of anemia control because other nutrient deficiencies can contribute to the burden of anemia. High blood pressure during pregnancy is dangerous because it interferes with the ability of the fetus to obtain oxygen and nutrients. The process to prove such evidence often involves controlled trials with proper randomization. Randomized placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants. Methods . High Hemoglobin Levels: Seventeen Reasons Your Hemoglobin Production Is Increased, High Blood Pressure During Pregnancy Linked to Risk of Stroke Within Several Years, Ten Ways to Increase Your Hemoglobin Levels Naturally, High Hemoglobin Levels in Newborn Babies and Later in Life, Three Natural Ways to Improve High Hemoglobin Levels and High Iron (Hemochromatosis), Three Things Diabetics Can Do About High Iron and High Hemoglobin Levels. In essence, the hemoglobin-based definition does not provide sufficient information on the meaning of, or reason for, either anemia or high hemoglobin concentrations. "High" is what your doctor's lab says is high. And when her routine blood work came back normal except for high hemoglobin, she took that as a sign she wasn't anemic. Iron supplementation during pregnancy: is it effective? This works at both ends of the distribution. To examine the association of maternal hemoglobin during pregnancy with preterm birth and small for gestational age (SGA). (2). Adamson JW, Fialkow PJ, Murphy S, Prchael JF, Steinmann L. Pritchard JA, Cunningham FG, Pritchard SA. Objective . In South Asia and Africa, where severe maternal anemia is common, classifying very severe anemia as a major cause of maternal mortality along with eclampsia, obstructed birth, hemorrhage, and sepsis is appropriate. Hookworm infection and anemia: an approach to prevention and control. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Primiparas have very little immunity to malaria. This is almost completely replaced by adult hemoglobin (hemoglobin A, HbA) by 6 to 12 months of age. A baby growing in the womb has high levels of HbF. The flow of blood is already restricted by the growth of the fetus. Among these 15 was the only case with intrauterine death of unknown cause. During the past few years, the relation between anemia early in pregnancy and an increased risk of preterm delivery has been suggested. The association between adverse birth outcomes and high hemoglobin concentrations observed in epidemiologic studies does not establish that high hemoglobin concentrations are the direct cause of such adverse outcomes (evidence of risk only). A greater supply of the components for hemoglobin or red blood cells, including iron, will not result in a higher hemoglobin concentration without a tissue hypoxia drive. Sufficient evidence exists to indicate that from a general health viewpoint, an iron-deficient state of nutriture can result in moderate and severe anemia, which is undesirable. In three cases with serial Hb estimations, the levels were 2 SD above the mean one week or more before intrauterine fetal death. Suharno D, West CE, Karyadi D, Hautvast GAJ. An elevated hemoglobin concentration is usually the result of 2 mechanisms: increased red blood cell production as a compensatory mechanism when blood oxygen carrying capacity is compromised to meet the demand of tissue (with a net increase in red cell mass), or contracted plasma volume resulting in an appearance of greater red cell volume (without a net increase in red cell mass) (28). Therefore, proper care should be taken to maintain the ideal hemoglobin level during pregnancy. Among them, some health issues are found to occur often, like issues with the hemoglobin level of the blood. The iron necessities go up considerably when a woman is pregnant. It is to be expected that pregnant women as a group, in most populations, including those in developed countries, have some degree of iron deficiency; iron supplementation can cause a significant rise in hemoglobin concentrations in those who are iron deficient. Higher Hemoglobin Levels to Control High Blood Pressure: Is It As Simple as Taking Iron Supplements? Once hemoglobin concentrations reach ≥ 180 g/L, the blood viscosity reaches a level that impairs microcirculation and an inadequate amount of oxygen is transported to tissues, similar to the situation with severe anemia. During pregnancy, elevated iron stores are needed to form hemoglobin not only of the maternal blood cells, but also of the fetal erythrocytes. The reason is simple: in pregnancy, the blood volume of a woman increases by half to provide essential nutrition to the developing baby. Its production usually falls to a low level within a year after after birth and reaches adult level within 1-2 years. Analogous with mild anemia being within 10 g/L of the cutoff, a mild-high hemoglobin concentration would be 160–170 g/L. Iron deficiency anemia and maternal mortality. The level of HbF usually drops to tiny amounts about 6 months after birth. Nevertheless, this did not ring true. Iron deficiency can be a major contributory factor to very severe anemia, but no evidence exists to show that a very high hemoglobin concentration is due to too much iron or to iron supplementation. Hemoquant determination of hookworm-related blood loss and its role in iron deficiency in African children, Iron status and inflammatory processes in anaemic children, Not only supplementation with iron but also with vitamin A is necessary to combat nutritional anemia in pregnant women in West Java, Indonesia, Some clinical aspects of life at high altitudes, The effect of cigarette smoking on hemoglobin levels and the diagnosis of anemia, Polycythemia vera: stem cell and probable clonal origin of the disease, Changes in the blood volume during pregnancy and delivery, The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases, High hemoglobin levels during pregnancy and fetal risk, Increased 2nd trimester hemoglobin concentration in pregnancies later complicated by hypertension and growth retardation: early evidence of reduced plasma volume, The significance, diagnosis, and treatment of maternal hypovolemia as associated with fetal maternal illness, Gender differences and low birth weight with maternal smokeless tobacco use in pregnancy, Assessment of the prevalence and the nature of iron deficiency for populations: the utility of comparing hemoglobin distributions, Hemoglobin as a predictor of response to iron therapy and its use in screening and prevalence estimates, The role of malaria in nutritional anemia, The effect of iron supplementation during pregnancy, given by traditional birth attendants, on prevalence of anemia and malaria. If the cause of significant anemia is iron deficiency (evidence of deficiency), prevention and correction of iron deficiency anemia are indicated. In this supplement, Rush (2) questions the benefit of routine iron supplementation in relation to the evidence of the harm or burden of anemia on reproductive outcomes. Lu ZM, Goldenburg RL, Cliver SP, Cutter G, Blankson ML. Dr Rush: A comment on the ethics committee problem. From an operational viewpoint, implementing iron supplementation programs is not an easy task because of the cost and multiple steps involved, including adequate communication with health workers and expectant mothers (3, 4, 23). These issues are separate and, given sufficient resources, we could pursue both programs. But there are relatively few early warning signals that preeclampsia is about to occur. Dr Yip: Assume that you have a normal hemoglobin distribution for women in the second trimester of pregnancy under normal healthy conditions. In an exercise state, however, any loss of hemoglobin or red blood cell mass can be detected as loss in work capacity, even within a hemoglobin range of 120–130 g/L (20). Very high hemoglobin concentrations cause high blood viscosity, which results in both compromised oxygen delivery to tissues and cerebrovascular complications. During the past few years, the relation between anemia early in pregnancy and an increased risk of preterm delivery has been suggested. high hemoglobin is one of those things which variate and could one day be sky high and other day, just normal. This study aimed to investigate whether changes in Hb levels from early to mid- or late pregnancy is associated with birth outcomes. The mother developed eclampsia or preeclampsia in a prior pregnancy. By 24 months of age, Hb F levels decrease to adult levels of 0 - 2% of the total hemoglobin; however, a few individuals may have slightly higher levels (5%) for 2?3 years. Well, an increased level of fetal haemoglobin is not a problem in itself. This leads to the question, Why provide iron supplementation if there is no evidence of beneficial reproductive outcomes? However, studies focusing on Hb levels and pregnancy … Three elementary and clinical factors—ergometrine, blood transfusion, and the rule for flying squads—suggest that iron deficiency anemia does not seem to come into the historical picture for hemorrhage-related maternal mortality on a crude basis. Regarding the high-end hemoglobin issue, let us assume the population mean hemoglobin concentration is ≈140 g/L. In three cases with serial Hb estimations, the levels were 2 SD above the mean one week or more before intrauterine fetal death. Clinicians were free to treat in whatever way they chose. Heilman L, Siekmann U, Schmid-Schonbein H, Ludwig H. Hallberg L, Hulthen L, Bengston C, Lapidus L, Lindstedt G. Presented at the meeting Iron and Maternal Mortality in the Developing World, held in Washington, DC, July 6–7, 1998. Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. During pregnancy, the upper level for defining high hemoglobin would be lower than that in nonpregnant women because of the physiologic changes in the hemoglobin concentration during pregnancy (12). It can result in low birth weight or premature delivery. When blood transfusion became widely available to the public, which was during World War II, hemorrhage-related deaths also fell. For example, greater saturated fat intake increases the risk of coronary heart disease. This is much lower than the high hemoglobin concentration known to cause circulation complications and reduced oxygen transport to tissue (hemoglobin >170 g/L) (6, 7) and is well within the normal hemoglobin range for pregnant women. The other is cigarette smoking, which causes part of the hemoglobin to become nonfunctional as a result of binding with carbon monoxide (30). Klebanoff MA, Shiono PH, Berendes HW, Rhodes GG. [. Epidemiologic studies that showed an association between maternal anemia and increased risk of poor birth outcomes did not establish a causal relation (evidence of risk only) (6–9). Mild anemia is routinely defined as a hemoglobin value within 10 g/L of the anemia cutoff value. The purpose of this review is to look at normal and abnormal hemoglobin values in terms of their causes and consequences. Hemoglobin isn't the same thing as hematocrit, the ratio of the total volume of red blood cells to the total volume of the blood. When multiple factors contribute to the severity of anemia, iron deficiency is always a major factor (evidence of deficiency) (23). Evidence of risk is based on finding associations between nutritional factors and adverse health outcomes, often by observational studies. In most children, hemoglobin F decreases and is replaced with hemoglobin A during the first few months of life. The most common example is acute dehydration, which can raise the hemoglobin concentration by 10–15%. There was a further significant fall when the chief medical officer of health at the Ministry of Health in the beginning of the postwar period introduced a rule to the flying squads sent out for cases of hemorrhages. Ray Yip, Significance of an abnormally low or high hemoglobin concentration during pregnancy: special consideration of iron nutrition, The American Journal of Clinical Nutrition, Volume 72, Issue 1, July 2000, Pages 272S–279S, https://doi.org/10.1093/ajcn/72.1.272S. This genetic disorder enables affected individuals to absorb excessive amounts of iron. Routine, universal, unmonitored supplementation with oral iron is unlikely to be of much benefit to the severely anemic woman. In fact, hemoglobin response to iron supplementation is by far the most reliable method for diagnosing iron deficiency anemia in an individual or a population (44). PMID: 7543865 Are you at risk of developing preeclampsia? Every complete blood count routinely measures hemoglobin. Preventing and controlling iron deficiency anemia through primary health care. If you know you are prone to preeclampsia, then there are simple changes in prenatal nutrition, adding magnesium supplements [10], for example, that can help reduce the risk of your disease. Such evidence justifies efforts to prevent and treat significant iron deficiency, including iron supplementation during pregnancy when iron requirements are particularly difficult to meet.
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