Biochemical and Hematological Profile of Anemic And
Non-Anemic Pregnant Women
Zahida Anwar1, Zubaida Abid1,
Tahira Ghazenfer1, Mehreen Lashari1, Jahanzaib Lashari,
Department of Biochemistry, Bolan
University of Medical and Health Sciences Quetta, Pakistan
Department of Physiology, Bolan
University of Medical and Health Sciences Quetta, Pakistan
Correspondence to:
Dr. Zahida Anwar, Email: zahidadr223@gmail.com,
ORCiD: 0000-0002-3884-890X
ABSTRACT
Objective: To determine the biochemical and
hematological profile of pregnant women with and without anemia attending
Sanderman Provincial Hospital, Quetta.
Methods: This
descriptive cross-sectional study was conducted among pregnant women aged
ranged from 18 to 48 years attending the antenatal clinic for the first-time
during February 2019 to August 2019. Hematological parameters like white blood
cells (WBC), hemoglobin (Hb), hematocrit (HCT), Red blood cell distribution
width (RDW), mean corpuscular hemoglobin concentration (MCHC), and mean
corpuscular volume (MCV) were collected. Furthermore, biochemical parameters
like serum ferritin and iron level, total iron-binding capacity (TIBC),
Transferrin saturation (TfS), total bilirubin, direct bilirubin, and indirect
bilirubin were also noted.
Results: Of
357 patients, the mean Hb level was 10.27 + - 1.53 g/dl. Majority of the
pregnant were anemia, i.e. 248 (69.5%). Of these 248 anemic patients, mild
anemia was found in 135 (54.4%), moderate anemia in 100 (40.3%) and severe
anemia was observed in 13 (5.2%) patients. A significantly lower level of Hb (p-value
<0.001), WBC (p-value), HCT (p-value <0.001), MCHC (p-value <0.001),
MCV (p-value <0.001), and RDW (p-value <0.001) was observed in patients
with anemia as compared to non-anemic patients. Moreover, serum ferritin level
(p-value 0.002), serum iron (p-value <0.001), and total bilirubin level
(p-value <0.001) were found to be significantly lower in anemic patients as
compared to non-anemic patients.
Conclusion: The anemia in pregnant women is associated with considerably
low level of hematological and biochemical levels. It is recommended that
health providers should give attention to pregnant women with lower
hematological and biochemical levels to prevent maternal and fetal
complications.
Keywords: Biochemical, Hematology, Anemia,
Pregnant Women
INTRODUCTION
Anemia is the most common nutritional
deficiency in pregnant women. In developing nations such as Pakistan the most
common cause is iron deficiency. It is estimated that 38% of pregnant women
worldwide are affected by anemia.1 In particular, the reported
prevalence of anemia among pregnant women in low- and middle-income countries
is 56%.2 Iron deficiency anemia and the term anemia are often used
interchangeably in pregnancy.
In normal physiology, pregnancy
manifests several changes. The ones that require observation and intervention
are those that change hematological serum levels. Most of these modifications
lead to plasma expansion and hemodilution during pregnancy.3,4
Several hematological and other markers
used to discern iron levels were used in the diagnosis of anemia during
pregnancy.5 These include serum ferritin level, serum iron level,
serum transferrin, transferrin receptor (TfR), total iron-binding capacity
(TIBC), transferrin saturation, MCV, MCHC, and RDW. Moreover, several
biochemical changes are also reported in the literature with respect to anemia
in pregnant women.6,7 Anemia during pregnancy has several well-known
complications regarding fetal and maternal health including increased risk of
preterm birth, perinatal mortality, and intrauterine growth retardation.6 Maternal
stores of iron are depleted during pregnancy to supply the fetus for the
formation of fetal hemoglobin
We were unable to reach consensus
cutoff values due to the varying results found across the literature as well as
a lack of a specific population. Across the length of pregnancy, there are
multiple assays repeated at intervals to monitor all the parameters according
to assure both maternal and fetal wellbeing. Despite anemia being a preventable
condition in pregnancy, there is very limited local research work available on
the hematological and biochemical difference in pregnant women with anemia.
METHODS
A descriptive cross-sectional study was
conducted at Sanderman Provincial Hospital, Quetta from February 2019 to August
2019. The study was conducted after getting approval from the institutional
committee. Moreover, informed consent was also obtained from all study
participants.
Open Epi sample size calculator was
used for the estimation of sample size taking confidence interval 95%, margin
of error 5%, reported prevalence of anemia in pregnant women 63.2%6.
The estimated sample size came out to be 357.
Hemoglobin (Hb) cut off value adjusted
to sea level altitude was used to define anemia on the basis of gestational age
and to classify severity using criteria as devised by WHO. The presence of Hb
value <11.0 g/dl at 1st and 3rd trimesters and
<10.5 g/dl at 2nd trimester was classified as anemia. As far as
the severity is concerned, 10-11g/dl Hb level at 1st and 3rd
trimesters and 10-10.5 g/dl Hb level at 2nd trimester were
classified as mild anemia. Pregnant women having a Hb value of 7-10g/dl was
classified as moderate anemia, and Hb level of <7g/dl were classified as
severe anemia.
A venous blood sample of 5 milliliters
was drawn for hematological and biochemical analysis in between 8 am and 9 am. Hematological parameters like white blood cells (WBC),
Hb, hematocrit (HCT), Red blood cell distribution width (RDW), mean corpuscular
hemoglobin concentration (MCHC), and mean corpuscular volume (MCV) were
collected. Furthermore, biochemical parameters like serum ferritin level, serum
iron level, total iron-binding capacity (TIBC), Transferrin saturation (TfS),
total bilirubin, direct bilirubin, and indirect bilirubin was also noted.
Statistical analysis was performed
using SPSS version 24. Quantitative variables like age, hemoglobin level, WBC,
Hb, HCT, MCHC, MCV, RDW, serum ferritin level, serum iron level, TIBC, TfS,
total bilirubin, direct bilirubin, and indirect bilirubin were calculated using
mean and standard deviation. Frequency and percentages were calculated for
variables like types of anemia and severity of anemia. The mean difference of
hematological and biochemical parameters was compared with respect to the
status of anemia. An independent t-test was applied. A comparison was also done
to see the association of anemia status with serum ferritin level and severity
of anemia. Chi-square test was applied. p-value <0.05 taken as significant.
RESULTS
Of 357 patients, the mean age of the
patients was 27.29 + -2.68 years. The mean
Hb level was 10.27 + -1.53 g/dl. There were 248 (69.5%) anemic and 109 (30.5%)
non-anemic patients. Of these 248 anemic patients, mild anemia was found in 135
(54.4%), moderate anemia in 100 (40.3%) and severe anemia was observed in 13
(5.2%) patients.
The hematological analysis showed a mean serum Hb level was
found to be 9.89 + -1.42 g/dl, WBC 7.84 +
-1.85 x 103/ uL, HCT 31.46 + -2.57 %, MCHC 32.03 + -1.29g/dl, MCV
80.32 + - 3.71 fl, and RDW 15.83 + -1.37 %. A significantly lower level of Hb (p-value <0.001),
WBC (p-value), HCT (p-value <0.001), MCHC (p-value <0.001), MCV (p-value
<0.001), and RDW (p-value <0.001) was observed in patients with anemia as
compared to non-anemic patients. (Table
1)
The biochemical analysis revealed that mean Serum Ferritin
level was 35.99 + -25.53 ng/l, Serum Iron
level 116.51 + -37.65 ug/dl, TIBC 307.54 + -74.47 ug/dl, TfS 20.88 + -6.70 %, Total
Bilirubin 18.05 + -1.76 μmol/l, Direct Bilirubin 5.57 + -0.71 μmol/l,
and Indirect Bilirubin 12.32 + -0.92 μmol/l. Except TfS (p-value 0.419),
direct bilirubin level (p-value 0.645), and indirect bilirubin (p-value 0.778),
all other biochemical parameters like serum ferritin level (p-value 0.002), serum
iron (p-value <0.001), and total bilirubin level (p-value <0.001) were found
to be significantly lower in anemic patients as compared to non-anemic
patients. (Table
2)
Serum ferritin level of ≤30ng/l was significantly
higher (n=159, 64.1%) among anemic patients as compared to non-anemia (n=44,
40.4%) (p-value <0.001). (Figure 1) Similarly, serum ferritin level of ≤30ng/l
was significantly higher (n=13, 100%) in patients with severe anemia as
compared to mild (n=86, 63.7%) and moderate anemia (n=60, 60%) (p-value 0.018).
(Figure 2)
|
Table
1: Mean difference of hematological characteristics with respect to anemic
status of the patients (n=357) |
|||||
|
Variables |
Overall |
Anemic |
Non-Anemic |
p-value |
95% CI |
|
Mean + - SD |
Mean + - SD |
||||
|
Hemoglobin, g/dl |
9.89 + - 1.42 |
9.04 + - 0.63 |
11.84 + - 0.59 |
<0.001 |
-2.94 to -2.65 |
|
WBC, x 103/uL |
7.84 + - 1.85 |
6.65 + - 0.41 |
10.57 + - 0.33 |
<0.001 |
-4.01 to -3.84 |
|
HCT, % |
29.93 + - 0.81 |
34.98 + - 1.59 |
<0.001 |
-5.30 to -4.79 |
|
|
31.25 + - 0.56 |
33.81 + - 0.51 |
<0.001 |
-2.67 to -2.43 |
||
|
78.13 + - 0.83 |
85.35 + - 2.71 |
<0.001 |
-7.59 to -6.85 |
||
|
16.35 + - 1.26 |
14.62 + - 0.63 |
<0.001 |
1.48 to 1.98 |
||
|
WBC: White blood cells, HCT:
Hematocrit, MCHC: Mean corpuscular hemoglobin concentration, MCV: Mean
corpuscular volume, RDW: Red cell distribution width. All data presented as mean + -SD. Independent t-test applied, p-value
<0.05 taken as significant. |
|||||
|
Table
2: Mean difference of biochemical characteristics with respect to anemic
status of the patients (n=357) |
|||||
|
Variables |
Overall |
Anemic (n=248) |
Non-Anemic (n=108) |
p-value |
95%
CI |
|
33.24 + - 24.82 |
42.43 + - 26.20 |
0.002 |
-14.90
to - 3.45 |
||
|
99.01 + - 29.27 |
156.06 + -20.24 |
<0.001 |
-63.14 to - 50.95 |
||
|
309.19 + - 71.58 |
304.33 + -80.07 |
0.573 |
-12.04 to 21.77 |
||
|
20.69 + - 6.84 |
21.32 + -6.44 |
0.419 |
-2.14 to 0.89 |
||
|
18.25 + - 1.81 |
17.59 + -1.55 |
<0.001 |
0.25 to 1.04 |
||
|
5.56 + - 1.81 |
5.60 + -0.69 |
0.645 |
-0.20 to 1.24 |
||
|
12.30 + - 0.89 |
12.33 + -0.95 |
0.778 |
-0.23 to 0.18 |
||
|
TIBC: Total Iron Binding Capacity, TfS: Transferrin
saturation. All data presented as mean + - SD. Independent t-test applied, p-value <0.05 taken as
significant. |
|||||
Figure 1: Frequency of anemia status by categories
of serum ferritin (n=248)
Figure 2: Comparison of
types of anemia with serum ferritin level (n=248)
DISCUSSION
This study has reported a significantly
lower threshold of both hematological and biochemical parameters in pregnant
women with anemia as compared to non-anemia. A more detailed analysis of our
results showed that though mild and moderate anemia was noted in majority of
the pregnant women, the overall anemia prevalence was predominantly higher in
pregnant women, i.e. 69.5%. Comparing to current literature, a study conducted
by Baig-Ansari et al in an urban city of Pakistan, the anemia prevalence in
pregnant women is reported as 90%.8 Similar to our study, in their
study the prevalence of mild anemia was found to be highest followed by
moderate anemia, and then severe anemia. Similarly, a recent study from Lahore,
Pakistan has also reported more than half, i.e. 57.7% pregnant women with
anemia.9 Similar to the study of Baig-Ansari et al8, a
relatively higher proportion of anemia, i.e. 64% and 68% was reported in a
recent studies conducted in India.10,11 These findings are
surprisingly higher compared to the findings reported in a low-income country like
Ethiopia in which the anemia in pregnant women ranges from 16.88% to 52%.12-19
In a recent study conducted in Ghana, amongst 400 pregnant women, 50.8%
of pregnant women had anemia.20 The variability in the prevalence of
the disease can be attributed to the variability of socioeconomic standards
across Pakistan. Lower-income households often have fewer means to correct
nutritional deficiencies even if they are aware of them. The same subset is
also more likely to have consecutive pregnancies, leading to a further
detriment in the problem.
Our study also found a
significantly lower Hb, and WBC levels were found in pregnant women with anemia
than that of non-anemic pregnant women, along with lower HCT, MCV, MCHC, and
RDW values. These findings are consistent with the current literature. Various
studies including studies done outside of Pakistan such as Ahenkorah
et al, James et al and Anchang-Kimbi et al report similarly decreased levels of hemoglobin and white
blood cells.6,21,22 Since HCT expresses the concentration of Hb in
blood, the reduced Hb in the blood give a lower HCT Value.23
Additionally, a physiologic change in pregnancy is the increase in plasma
volume and hormonal changes, which may give a lower HCT due to hemodilution and
fluid retention.1 A low mean corpuscular volume (MCV) is a marker of
microcytic anemia, most commonly iron deficiency anemia, which is expected and
often prophylactically treated in pregnancy.
In our study, a
significantly lower prevalence of serum ferritin was also reported in anemic
patients. In addition, a significantly higher proportion of low serum ferritin
was also reported in patients with severe anemia. Among anemic pregnant women,
the presence of noticeably low levels of serum iron, ferritin, and transferrin
saturation are supportive of findings in recent studies including the finding
by Ahenkorah B et al6 and Raza et al24. Decreased values
for serum iron, ferritin, and transferrin on blood assays are suggestive of
iron deficiency anemia. As our study found there a was a higher incidence of
pregnant anemic women with low iron, among anemic pregnant women. This supports
our previous stipulation of the presence of iron deficiency anemia.25
This belief is compounded by the fact that our study found a higher mean TIBC
level in pregnant women as compared to those who were not. A higher TIBC is
also an indication of iron deficiency.
The findings of the current
study could be highlighted in the light of various limitations including the
fact that biochemical and hematological profiles for each trimester of the
pregnancy are not reported in the current study. It is expected that serum
levels of iron and hemoglobin may shift during the curse of pregnancy and so,
the stage of pregnancy is a variable that would have provided additional
clarity in our work. Moreover, other effect modifiers like residence,
educational status, occupational status, and socioeconomic status are also not
reported in this study. As we have noted, such qualifiers affect the maternal
health of women in many ways. In addition, the dietary habits of women in our
study with and without anemia is also an important factor which needs to be
explored. An important strength of our work is the combination of measurement
of biochemical and hematological parameters, we have been able to accomplish
despite an operation in a low resource setting. This is unlike many other
studies, where the two types of tests have been reported using separate
samples, which may be a cause for variability. These lab test samples were
drawn from the same patient, synchronously, while in other studies, different
subjects were used. This helps keep the data consistently uniform and removes a
source of uncertainty.
CONCLUSION
Maternal health and the morbidity and
mortality associated with it is an important source of concern in Pakistan. The
anemia in pregnant women is associated with a considerably low level of
hematological and biochemical levels. It is recommended that health providers
should give attention to pregnant women with lower hematological and
biochemical levels to prevent maternal and fetal complications. More resources
need to be targeted toward educating women in how pregnancy affects their
nutritional needs, as well as consideration for prophylactic supplement use
during pregnancy. More studies need to be done on the ways these changes affect
women across various economic classes in Pakistan and how availability and
adherence to education regarding these subjects can improve the quality of healthcare
they receive.
ETHICAL APPROVAL: The study
was approved by the Sanderman
Provincial Hospital, Quetta.
AUTHORS' CONTRIBUTION:
ZA, JL conceived and designed study, ML, JL, ZA did data collection, ZA did
analysis, ZA, TG did manuscript writing. ZA: did manuscript editing. All
authors gave final approval of manuscript.
CONFLICT OF INTEREST: The
authors have no conflict of interest to declare.
FUNDING: The authors did
not receive any financial support for the research and publication.
Received:
Accepted: August 28, 2020
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