Background: This study was done to evaluate the effect of maternal anaemia and its severity on gestational age and neonatal outcome.Methods: This was a retrospective study, conducted in Vardhman Mahavir medical college and Safdarjang hospital, New Delhi between April 2012 to March 2013. Cases were divided in three groups i.e. non anaemic, mild to moderately anaemic and severely anaemic (according to WHO classification). A total of 1050 woman (350 in each group) were recruited for study. The following outcome measures were used: preterm delivery (<37 weeks), birth weight, APGAR score, admission of baby in neonatal intensive care unit and early neonatal death. Data was analyzed by Chi-square test. A P value of or less than 0.05 was considered as significant.Results: The risk of preterm delivery, low birth weight, poor APGAR score and admission of baby in neonatal intensive care unit was more in anaemic group and it increased with severity of anaemia which was statistically significant. The increase in risk of early neonatal death was not significant in mild/moderate anaemic group (P value 0.326) while it was statistically significant in severely anaemic group (P value 0.004).Conclusions: Anaemia in pregnancy has a recognizable association with prematurity, low birth weight and poor neonatal outcome.

Aggarwal, Kailash Chander

Gupta, Jyoti

Gupta, Ratan

Rani, Kumari Usha

English

Background: This study was done to evaluate the effect of maternal anaemia and its severity on gestational age and neonatal outcome.Methods: This was a retrospective study, conducted in Vardhman Mahavir medical college and Safdarjang hospital, New Delhi between April 2012 to March 2013. Cases were divided in three groups i.e. non anaemic, mild to moderately anaemic and severely anaemic (according to WHO classification). A total of 1050 woman (350 in each group) were recruited for study. The following outcome measures were used: preterm delivery (&lt;37 weeks), birth weight, APGAR score, admission of baby in neonatal intensive care unit and early neonatal death. Data was analyzed by Chi-square test. A P value of or less than 0.05 was considered as significant.Results: The risk of preterm delivery, low birth weight, poor APGAR score and admission of baby in neonatal intensive care unit was more in anaemic group and it increased with severity of anaemia which was statistically significant. The increase in risk of early neonatal death was not significant in mild/moderate anaemic group (P value 0.326) while it was statistically significant in severely anaemic group (P value 0.004).Conclusions: Anaemia in pregnancy has a recognizable association with prematurity, low birth weight and poor neonatal outcome.

International Journal of Reproduction, Contraception, Obstetrics and Gynecology

   http://dx.doi.org/10.5455/2320-1770.ijrcog20140607                                                                                     Volume 3 · Issue 2    Page 325 International Journal of Reproduction, Contraception, Obstetrics and Gynecology Rani KU et al. Int J Reprod Contracept Obstet Gynecol. 2014 Jun;3(2):325-329 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 Research Article Maternal anaemia and its severity: an independent risk factor for preterm delivery and adverse neonatal outcome Kumari Usha Rani1, Jyoti Gupta1, Ratan Gupta2*, Kailash Chander Aggarwal2                  INTRODUCTION Anaemia has been very important and widespread nutritional disorder in the world affecting a big chunk of global population and is even more prevalent in pregnant woman. India has reported very high prevalence of anaemia in pregnancy. Anaemia in pregnancy is considered as a major risk factor for adverse maternal and fetal outcome. WHO has defined Hb of <11 gm/dl as anaemia in pregnancy. It is divided into three category viz mild degree (9.0-10.9 gm%), moderate degree (7.0-8.9 gm%), and severe degree (<7.0 gm%). Although the association between anaemia in pregnancy and perinatal outcome has been studied extensively, the literature is still conflicting Most of the studies have demonstrated a strong association between maternal anaemia and adverse outcome such as low birth weight, preterm delivery and intrauterine growth retardation,1-5 while study by Xiong X et al.6 found no such association. Study done by B Mahamuda et al.7 had shown poor Apgar score in anaemic group when compared to non-anaemic group, while study done by Reshetnikova OS et al.8 had found no such association. 1Department of Obstetrics & Gynaecology, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India 2Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India  Received: 26 February 2014 Accepted: 25 March 2014  *Correspondence: Dr. Ratan Gupta, E-mail: ratangupta100@yahoo.com © 2014 Rani KU et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: This study was done to evaluate the effect of maternal anaemia and its severity on gestational age and neonatal outcome.  Methods: This was a retrospective study, conducted in Vardhman Mahavir medical college and Safdarjang hospital, New Delhi between April 2012 to March 2013. Cases were divided in three groups i.e. non anaemic, mild to moderately anaemic and severely anaemic (according to WHO classification). A total of 1050 woman (350 in each group) were recruited for study. The following outcome measures were used: preterm delivery (<37 weeks), birth weight, APGAR score, admission of baby in neonatal intensive care unit and early neonatal death. Data was analyzed by Chi-square test. A P value of or less than 0.05 was considered as significant.  Results: The risk of preterm delivery, low birth weight, poor APGAR score and admission of baby in neonatal intensive care unit was more in anaemic group and it increased with severity of anaemia which was statistically significant. The increase in risk of early neonatal death was not significant in mild/moderate anaemic group (P value 0.326) while it was statistically significant in severely anaemic group (P value 0.004). Conclusions: Anaemia in pregnancy has a recognizable association with prematurity, low birth weight and poor neonatal outcome.   Keywords: Maternal anaemia, Preterm, Birth weight, Neonatal outcome, APGAR score DOI: 10.5455/2320-1770.ijrcog20140607 Rani KU et al. Int J Reprod Contracept Obstet Gynecol. 2014 Jun;3(2):325-329 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 3 · Issue 2    Page 326 Keeping all this in view, this study was done to investigate effect of maternal anaemia on gestational age and neonatal outcomes. The following outcome measures were used: preterm delivery (<37 weeks), birth weight, APGAR score, admission of baby in neonatal intensive care unit (NICU) and early neonatal death (death within one week of birth). METHODS This was a retrospective study conducted in Vardhman Mahavir medical college and Safdarjang hospital, New Delhi from April 2012 to March 2013. No intervention for the sake of study was done. Study was done after delivery. Required information was obtained from antenatal card, case history at admission, delivery notes and baby case sheet. The cases were divided in three groups according to haemoglobin level at admission for delivery and third trimester i.e. non-anaemic, mild to moderately anaemic and severely anaemic (as per WHO classification). A total of 1050 woman (350 in each group) were recruited for study. Statistical analysis was done by Chi square test. A P value of or less than 0.05 was considered as significant. Our hospital is a tertiary care hospital. The average number of deliveries per year ranges from 20000 to 25,000. We commonly met patients with anaemia in late pregnancy without prior antenatal care. A large number of unbooked cases (approximately 40-45%) are coming for delivery to our hospital. Inclusion criteria Pregnant woman who delivered in our institute were included in this study. Exclusion criteria  Multiparty (5 and above)  Hypertensive disorders in pregnancy  Pregnancy with diabetes mellitus  Ante partum haemorrhage  Pregnancy with chronic medical illness  Multiple gestations   HIV/HBsAg/VDRL positive cases RESULTS Birth weight- In the present study birth weight < 2 kg was 7.14 % in non-anaemic group, 22 % in mild/moderately anaemic and 50.86% in severely anaemic group; this is respectively about 3.4 times and 7 times more than non-anaemic group. In severely anaemic group only 20 % had birth weight more than 2.5 kg while in non-anaemic group it was 66.86 %. These differences are statistically significant with p value <0.0001.   Table 1: Comparison of birth weight between nonanaemic and anaemic groups.  Birth weight Gestational      age Normal Hb (n=350) Mild/moderate anaemia (n=350) Severe anaemia (n=350) P value <2 kg Term 14 32 73 <0.0001 Preterm 11 45 105 Total 25 (7.14%) 77 (22%)  178 (50.86%) 2-2.5 kg Term 52 88 28 Preterm 39 101 74 Total 91 (26 %) 189 (54%) 102 (29.14%) >2.5 kg Term 214 60 39 Preterm 20 24 31 Total 234 (66.86 %) 84 (24%) 70 (20%)  Table 2: Comparison of gestational age at delivery and neonatal outcome between nonanaemic and anaemic groups.   Variables Normal Hb (n=350) Mild/moderate anaemia (n=350) Severe anaemia (n=350) P value Preterm delivery 70 (20% ) 170 (48.57%) 210 (60%) <0.0001 Poor APGAR score (at 5 min <7 ) 33 (9.43%) 87 (24.86%) 146 (41.71%) <0.0001 NICU admission 29 (8.29%) 56 (16%) 118 (33.71%) <0.0001 Early neonatal death 11 (3.14%) 16 (4.57%) 36 (10.29%) <0.0001 Rani KU et al. Int J Reprod Contracept Obstet Gynecol. 2014 Jun;3(2):325-329 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 3 · Issue 2    Page 327 Pre term delivery in non-anaemic group was 20% while it was 2.4 times and 3 times more in mild/moderately anaemic group and severely anaemic group respectively. Poor Apgar score (taken at 5 minutes <7) was 9.43% in non-anaemic group and it was increased to 2.6 times in mild/moderately anaemic group and 4.4 times in severely anaemic group.  Admission to neonatal intensive care unit (NICU) was almost double in mild/moderately anaemic group and about 4 times more in severely anaemic group when compared to non-anaemic group. Early neonatal death was 3.08 % in non-anaemic group and while it was 1.4 times and 3.2 times more in mild/moderately anaemic group and severely anaemic group respectively. All these differences are statistically significant having P value <0.0001.  Group analysis Table 3 to 6 shows analysis between non-anaemic versus mild/moderately anaemic group, non-anaemic versus severely anaemic group and mild/moderately anaemic versus severely anaemic group.    Table 3: Pre-term.  Anaemia P value Variable Normal Hb  Mild/moderate anaemia  Pre-term  70 (20%) 170 (48.57%) <0.0001 Normal Hb Severe anaemia  70 (20%) 210 (60%) <0.0001 Mild/moderate anaemia Severe anaemia  170 210 (60%) 0.002  Table 4: APGAR score.   Anaemia P value Variable Normal Hb  Mild/moderate anaemia  Poor APGAR 33 (9.43%) 87 (24.86%) <0.0001 Normal Hb Severe anaemia  33 (9.43%) 146 (33.71%) <0.0001 Mild/moderate anaemia Severe anaemia  87(24.86%) 146 (33.71%) <0.0001 When analysis done in relation to severity of anaemia (table 3 to 6) it was found that all parameters studied except early neonatal death had statistically significant increased risk with both groups of anaemia and it increases with severity of anaemia. Increased risk of early neonatal death was not significant in mild/ moderate group (P value 0.326) while it was significant in severely anaemic group (P value 0.004). Table 5: NICU admission.   Anaemia P value Variable Normal Hb  Mild/moderate anaemia  NICU admission 29 (8.29%) 56 (16%) 0.002 Normal Hb Severe anaemia  29 (8.29%) 118 (33.71%) <0.0001 Mild/moderate anaemia Severe anaemia  56 (16%) 118 (33.71%) <0.0001  Table 6: Early neonatal death.  Anaemia P value Variable Normal Hb  Mild/moderate anaemia  Early neonatal death 11(3.14%) 16 (4.57%) 0.326 Normal Hb Severe anaemia  11 (3.14%) 36 (10.29%) <0.0001 Mild/moderate anaemia Severe anaemia  16 (4.57%) 36 (10.29%) 0.004  Limitations In the present study outcome evaluated were affected by few co-factors such as socioeconomic condition and poor nutrition which could not be eliminated. Anaemia and poor nutrition frequently co-exist and it contributes to several maternal diseases which may affects pregnancy outcome & fetal development. We also could not eliminate possibility of co-existing maternal infection with anaemia which may have influence the result. Anaemia diminishes resistance to infection and these factors generally co-exist. DISCUSSION Anaemia is a common problem during pregnancy. Pregnancy outcomes vary depending on its type and severity. In our study the risk of low birth weight and preterm delivery is more in anaemic group and it increases with severity of anaemia. Study done by Jain Preeti et al. and Levy et al.1,2 also showed higher rates of preterm deliveries and low birth weight among mother with anaemia. Study by Umber et al.5 showed that risk of preterm and low birth weight among anaemic woman was 3.4 and 1.8 times more than non-anaemic group. They have taken two group for study, anaemic <11 gmHb and non-anaemic >11 gmHb. This is in agreement with our Rani KU et al. Int J Reprod Contracept Obstet Gynecol. 2014 Jun;3(2):325-329 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 3 · Issue 2    Page 328 study which shows preterm and low birth weight 3.4 and 2.4 times more in mild/moderately anaemic cases. They have also shown poor APGAR score in anaemic group which supports our study. Studies done by Kumar et al., Malhotra et al. and K Jagdish et al.10-12 had shown such an association only when mothers are severely anaemic. However study done by Xiong X et al.6 shows no significant difference in gestational age and birth weight between anaemic and control group. According to them, maternal anaemia during early pregnancy was associated with slightly increase preterm birth and non-statistically significant increase low birth weight, however there was a non-statistically significant inverse relationship between anaemia during late pregnancy and preterm & low birth weight. Some studies have also shown that increase in Hb beyond a certain level could in fact have a negative outcome.12-13 According to study done by Lu ZM et al.13 both early and later in pregnancy Haematocrit above 40% were associated with preterm deliveries and fetal growth retardation. In our study poor APGAR score (taken as score less than 7 at 5 minutes), early neonatal death and NICU admission were higher in anaemic group than non-anaemic group and it was statistically significant. This is in agreement with many studies.5,7,14,15  Study done by Ram Hari et al.14 showed perinatal death 5% in nonanaemic group 11% in severely anaemic group. Present study also shows early neonatal death 3.08% in non-anaemic group and 10.08% in severely anaemic group.  Hussein L et al.3 found that risk of preterm delivery and low birth weight were significantly increased with severity of anaemia but in contrast to our study, they found no association between severity of anaemia and APGAR score and early neonatal deaths. CONCLUSION The current study shows that prematurity, low birth weight and poor neonatal outcome is directly related to anaemia and it increases with severity of anaemia.  India has high prevalence of anaemia and it is a measure cause maternal and neonatal morbidity and mortality. As per report published in “The Times of India’ on 8th & 11th June 201216 India recorded highest number of preterm birth in 2010, nearly 24% or one in four children born prematurely across the globe in 2010 were from India”. Prematurity is a leading cause of neonatal mortality and morbidity in India. Anaemia being an important cause of preterm birth and poor neonatal outcome, proper antenatal care, good nutrition and iron supplementation throughout the pregnancy can prevent all these adverse outcomes. Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required REFERENCES 1. Jain Preeti, Kural M, Joshi Tulika. Maternal and fetal outcome in cases of severe anaemia with pregnancy in rural setup. Int J Med Appl Sci. 2013;2(3):318-33.  2. Levy a, Fraser D, Katz M, Mazor M, Sheiner E. Maternal anaemia during pregnancy is an independent risk factor for low birth weight and preterm delivery. Eur J Obstet Gynecol Reprod Biol. 2005;122(2):182-6. 3. Hussein L. Kidanto, Ingrid Mogren, Gunilla Lindmark, Siriel Massawe, Lennarth Nystrom. Risks for preterm delivery and low birth weight are independently increased by severity of maternal anaemia. South African Med J. 2009;99(2):98-102. 4. Rusia U, Madan N, Agarwal N, Sikka M, Sood SK. Effect of maternal iron deficiency anaemia on foetal outcome. Indian J Pathol Microbiol. 1995;38:273-9. 5. Umber Jalil Bakhtiar, Yasmeen Khan, Razia Nasar. Relationship between maternal haemoglobin and perinatal outcome. Rawal Med J. 2007;32(2):102-4. 6. Xiong X, Buekens P, Alexander S, Demianczuk N, Wollast E. Anemia during pregnancy and birth outcome: A meta-analysis. Am J Perinatol. 2000;17(3):137-46. 7. B. Mahamuda, Tanira S, W. Feroza, Perven HA, A. Shamim. Effects of maternal anaemia on neonatal outcome. Bangladesh J Med Sci. 2011;10(3):177-80. 8. Reshetnikova OS, Burton GJ, Teleshova OV. Placental histomorphometry and morphometric diffusing capacity of the villous membrane in pregnancies complicated by maternal iron-deficiency anaemia. Am J Obstet Gynecol. 1995;173(3):724-7. 9. K. Jagdish Kumar Asha, D. Srinivasa Murthy, M. S. Sujatha, V. Z. Manjunath. Maternal anaemia in various trimesters and its effect on newborn weight and maturity. Int J Prev Med. 2013;42(2):193-9. 10. Kumar A, Chaudhary K, Prasad S. Maternal Indicators and obstetric outcome in the north Indian population: a hospital based study. J Postgrad Med. 2010;56:192-5.  11. Malhotra M, Sharma JB, Batra S, Sharma S, Murthy NS, Arora R. Maternal and perinatal outcome in varying degrees of anemia. Int J Gynaecol Obstet. 2002;79:93-100.  12. Steer PJ. Maternal haemoglobin concentration and birth weight. Am J Clin Nutr. 2000;71(5):1285-7. 13. Lu ZM, Goldenbeeg RL, Cliver SP, Cutter G, Blankson M. The relationship between maternal hematocrit and pregnancy outcome. Obstet Gynaecol. 1991;77:190-4. Rani KU et al. Int J Reprod Contracept Obstet Gynecol. 2014 Jun;3(2):325-329 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 3 · Issue 2    Page 329 14. Ram Hari Ghimire, Sita Ghimire. Maternal and fetal outcome following severe anaemia in pregnancy. J Nobel Med College. 2013;2(1):22-6. 15. Lone FW, Qureshi RN, Emanuel F. Maternal anaemia and its impact on perinatal outcome. Trop Med Int Health. 2004;9(4):486-90. 16. Kounteya Sinha. India shares highest preterm birth burden. The Times of India, 8th June 2012. Available at http:// www.google.co.in./http://timesofindia.indiatimes.com.      DOI: 10.5455/2320-1770.ijrcog20140607 Cite this article as: Rani KU, Gupta J, Ratan Gupta R, Aggarwal KC. Maternal anaemia and its severity: an independent risk factor for preterm delivery and adverse neonatal outcome. Int J Reprod Contracept Obstet Gynecol 2014;3:325-9. 

Maternal anaemia and its severity: an independent risk factor for preterm delivery and adverse neonatal outcome

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Maternal anaemia and its severity: an independent risk factor for preterm delivery and adverse neonatal outcome

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International Journal of Reproduction, Contraception, Obstetrics and Gynecology