Study of Haemoglobin, Iron, Ferritinn and Iron/Ferritin ratio levels in preterm delivery.

Ankita Kondhalkar1, Kavita More2, Sushil Kumar3

PG student1, Associate Professor2 Department of Biochemistry, MGM Medical College, Kamothe Navi Mumbai, Prof and Head3 Department of OBGY, MGM Medical College, Kamothe Navi Mumbai

Email: ac9v9w@r.postjobfree.com

ABSTRACT

Introduction: Preterm birth (PTB) is a major determinant of neonatal mortality and morbidity. Preterm babies are prone to serious illness or death during the neonatal period .PTB is one of the unresolved problems in clinical obstetrics and one of the greatest threats to the developing fetus, there is need to determine predictive biomarker for preterm delivery. Therefore present study aimed to assess serum levels of haemoglobin, iron and Ferittin in preterm and full-term delivery

Materials & Methods: The present study includes total 80 subjects that comprise forty women presenting with preterm onset of labor followed by delivery and forty women who delivered at term served as controls. Blood Samples from the patients were obtained for haemoglobin, iron and ferritin estimation, when patient was in labor. Serum Iron was estimated by coral clinical kit method. Serum ferritin was performed by Electrochemiluminescence method. Haemoglobin levels were measured by automated haematology analyser.

Results: Serum ferritin levels were significantly increased (P<0.001) in preterm delivery as compared to full term delivery. Haemoglobin levels are significantly decreased in preterm delivery (p<0.001) as compared to full term delivery. Serum iron levels were non significantly increased in preterm delivery as compared to the full term delivery.(P 0.05).

Conclusion: Our study showed that low levels of Haemoglobin and elevated ferritin levels may be associated with preterm delivery in asymptomatic pregnant women.Though ferritin is an acute phase reactant is elevated in women predisposed to preterm delivery. Moreover these parameters are cost effective, simple to perform and less time consuming and indicative of subclinical infections of pregnancy which could be one of the reasons for preterm delivery. On the other hand, our study has certain limitations which include smaller sample size of preterm cases and controls. Since preterm labour is multifactorial, various factors may have been unaccounted. A larger sample size research is recommended to address the limitations

INTRODUCTION

The World Health Organization (WHO) defines preterm birth as any birth before 37 completed weeks of gestation, or fewer than 259 days since the first day of the last menstrual period. Preterm birth (PTB) is one of the unresolved problems in clinical obstetrics and one of the greatest threats to the developing fetus. (1) PTB impacts 15 million deliveries annually and results in over one million infant deaths.(2)

In spite of the widespread prevalence of preterm birth, we have limited ability to recognize which patients will be at greatest risk and our ability to offer preventative or even therapeutic measures to those at greatest risk is also limited. (3)

Decades of prematurity research have suggested that intrauterine infection and inflammation plays a critical role in at least 25%–40% of spontaneous preterm births.(4) There are certain potential biomarkers of inflammation-/infection-mediated spontaneous preterm birth have been studied. In addition to this the direct study of gestational tissues (e.g., vaginal epithelium, cervix, endometrium, myometrium, placenta, choriodecidua, and fetal membranes) may provide more accurate localised information on the state of a pregnancy and impending labour, however biological fluids are more easily accessible including whole blood/serum/plasma, urine, saliva, amniotic fluid, and cervicovaginal fluid (CVF) that are more likely to be amenable to the creation of a rapid bedside biomarker test for predicting preterm labour or preterm PROM. These body fluids provide rich sources of proteins and metabolites that vary in concentration in response to pregnancy and adverse pregnancy states. (5)

Identification of a single biomarker to predict spontaneous preterm labour poses a significant challenge due to the heterogeneity of clinical presentations and of the biochemical mechanisms involved in preterm birth. Presently, none of the common late-pregnancy complications including preterm labour can be predicted with sufficient accuracy (sensitivity and specificity) using a single biochemical marker. Therefore the simultaneous estimation of multiple biomarkers may provide a promising approach to improving diagnostic efficiency.(5)

Ferritin- an intracellular iron storage protein, has been studied as a marker for prediction of preterm labor. Ferritin is an acute phase reactant and it increases during inflammation.(6)

Iron - and iron-containing compounds play vital roles in cellular function in all organ systems.(7) Low iron status had been associated with increased risk of preterm and low birth weight. Iron deficiency is suggested to lead changes in stress hormones such as norepinephrine, cortisol and corticotrophin-releasing hormone concentrations, and indexes of oxidative stress that may adversely affect gestation, fetal growth or both. (8)

in view of this the aim of this study was to determine levels of Haemoglobin, Iron and ferritin levels in preterm and full term delivery and to evaluate whether these can be useful to predict preterm delivery.

STUDY DESIGN:

The present study is the prospective study, carried out in the Department of Biochemistry and Department of Obstetrics & Gynaecology MGM Medical College Navi-Mumbai. Ethical clearance was obtained from Institutional Ethics Review Committee (IERC) M.G.M Medical College, Navi Mumbai, Kamothe.

STUDY POPULATION:

The subjects for the present study were enrolled from Department of OBGY MGM Medical College Navi-Mumbai. The present study includes total 80 subjects ranging age 18-40 years, which were divided into following groups

Control Group- 40 women with full term delivery s

Study Group - 40 women with preterm delivery

Written consent has been taken from women with preterm and post-term delivery

SAMPLE COLLECTION:

5 ml of venous blood sample in plain vial was collected from the patients when patient was in labor, before the administration of any medications. Serum was separated by centrifugation at 3000 rpm for 5 minutes and stored at -20 C till assessment.

Inclusion criteria:

Inclusion Criteria for preterm delivery:-

Pregnant women with less than 37 weeks of gestation

Inclusion Criteria for full-term delivery:

Pregnant women with 38-42 weeks of gestation

Exclusion criteria:

Following patients were excluded from the study:

Maternal uterine anomalies.

Multi-fetal gestation.

Cervical Cerclage.

Lethal fetal anomalies.

METHODS:

Following parameters are performed

Serum Iron was estimated by coral clinical kit method

Serum ferritin was performed by Electrochemiluminescence method

Haemoglobin levels were measured by automated haematology analyser.

OBSERVATIONS AND RESULTS

Table 1: Comparison of mean value of BMI in control and study groups

Parameter

Control group

(Full term delivery)

Mean SD

Study group

(Preterm delivery)

Mean SD

BMI(Kg/m )

24.27 3.54

24.16 4.62#

**p<0.001 (highly significant), # p>0.05 (Not significant)

Table 1: shows that mean levels of BMI non significantly decreased (p>0.05) in study group as compared to control group

Graph 1: Mean levels of BMI in control group (Full term) and study (Preterm) group.

Table 2. Comparison of mean levels of Haemoglobin, Iron & ferritin in control (Full term delivery) and study group. (preterm delivery)

Parameter

Control Group(full term)

Mean SD

Study Group(preterm)

Mean SD

Haemoglobin mg/dl

11.23 1.36

10.32 1.54**

Iron μg/dl

49.55 7.64

51.77 9.29#

Ferritin ng/ml

16.01 14.14

63.74 96.14**

Iron/Ferritin ratio

5.63 4.073

2.18 1.99**

*P 0.05 (significant), # p>0.05 (Not significant)

The result showed that Mean levels of Haemoglobin were significantly decreased in preterm delivery (p<0.001) as compared to full term delivery. The result indicates that mean levels of ferritin were significantly increased (P<0.001) in study group as compared to control group. The result also indicates that iron levels were increased but not statistically significant in study group as compared to the control group. (P>0.05). The iron/Ferritin ratio were statistically significant (P<0.001) in study group as compared to control group.

Graph 2: Mean levels of haemoglobin in control group and study (preterm) group

Graph 3: Mean levels of Iron in control group (Full term Delivery) and study (Preterm Delivery) group.

Graph 4: Mean levels of Ferritin in control group (Full term Delivery) and study (Preterm Delivery) group.

Graph 5: Mean levels of Iron/Ferritin ratio in control group (Full term Delivery) and study (Preterm Delivery) group

DISCUSSION

Preterm labour is the single most important complication of pregnancy in the absence of congenital abnormality, as it is recognized as a worldwide problem responsible for more than 80% of neonatal deaths and more than 50% of long term morbidity in the surviving infants.

In this study there was no significant difference between the two groups as regards BMI and iron level. There was statistically significant difference between two groups as regarding serum ferritin level and haemoglobin level.

Our findings are concurrent with Sukrat B et al(8), Klebanoff MA et al(9), Umber JB et al(10) and Kumar A et al(11).

Sukrat B et al. reported that pregnant women with haemoglobin concentration below 9, 10, and 11 g/dL had higher risk of PTBs compared with pregnant women with haemoglobin concentration 11– 13.9 g/dL. Haemoglobin above 14 g/dL did not increase the risk, they also showed that low haemoglobin concentration in early pregnancy (<20 weeks gestation) was associated with PTB.(9)

These findings may be explained by reduced oxygen transportation from the mother to fetus and may reflect inadequate iron reserves during early pregnancy. (8)

Klebanoff MA et al. showed that anemia during the second trimester was associated with preterm birth. (9)

Umber J.B et al. demonstrated that risk of preterm and low birth weight among anaemic woman was 3.4 and 1.8 times more than non-anaemic group. (10)

Kumar KJ et al. showed that there was the incidence of low birth weight babies was significantly more in mothers who were anaemic in their third trimester. Preterm deliveries occurred more frequently in mothers who were anaemic in their second and third trimesters. (11)

We found decreased level of haemoglobin in preterm women’s as compare to term women’s it indicated that is anaemia. 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.

In present study, we found mean levels of iron was non-significantly increased in preterm (study group) as compared to the full term (control). (P>0.05) (Table: 2 Graph: 3)

Our study is concurrent with study of Valappil SA et.al(12), Allen LH(13), Tripathi R et al(14) and Kaneshige E et.al(15)

Valappil SA et.al(12) demonstrated that there was no statistical significant difference in mean iron value of women with PROM and spontaneous preterm labour when compared to the control group (P> 0.05), there was mild increase in the serum iron values in the PPROM cases. This could be due to covert process of infection in PPROM cases which is known to raise serum iron as a result of tissue damage. Allen LH et al(13) reported that there was no evidence to support a relationship between iron deficiency as cause of premature birth and low birth weight.

Tripathi R et al(14) showed that serum iron levels were less in women who delivered preterm as compared to the women who delivered at term but the difference was not statistically significant ( 0.053). Further they reported that in developing countries like India the etiology of preterm birth might be more related to nutrition and specifically deficiency of micronutrients like iron.

Kaneshige E et al(15) demonstrated that, the serum iron levels were higher in the study group (PROM) as compared to the control group (third trimester) although the difference was not statistically significant. The lack of statistical significance may be due to the wide range in serum iron levels. However, this mild increase in study groups could be due to a covert process of infection, which is known to raise serum iron as a result of tissue damage.

We found no statistical difference of iron in preterm delivery as compared to full term delivery may be due to the wide range in serum iron levels and day to day variations in serum iron. Serum iron values in an individual can vary within a single day or from day to day .However, this non significant rise in study groups might be due to idiopathic infection, which leads to tissue damage and that could lead to slight increase in iron level.

In present study, we found mean levels of ferritin were significantly increased in preterm delivery (study group) as compared to the full term delivery (control). (P<0.001) (Table: 2 Graph: 4)

Our study is concurrent with study of Singh B et al, (16) Movahedi M et al, (17) Tamura T et al (18), Nandini MD et al(19) and Saha CK et al(20)

Singh B et al. (16) showed that the ferritin is a potential biomarker in the prediction of preterm delivery.

Movahedi M et al. (17) showed that, on 222 singleton pregnancies, 69 (31.1%) had preterm delivery and 153 (68.9%) had term delivery). Women who delivered before 37 weeks had a higher mean serum ferritin concentration than those who delivered after 37 weeks of gestation (26.7 5.5 ng/ml vs. 19.8 3.6ng/ml, (P <0.001).

Tamura T et al.(18) reported that women with higher serum ferritin concentrations, compared with those women with lower concentrations experienced an almost threefold increased risk of delivering preterm.

Nandini MD et al.(19) showed that high serum ferritin level is a risk factor for preterm labor, therefore Serum ferritin may be considered as a biochemical marker for detecting preterm labor, as it is cost effective and easily done in laboratories.

Saha CK et al.(20) showed that the serum ferritin level was significantly higher in preterm delivery.

In pregnancy there is change in vaginal pH which may result in vain cervical infection. This follows bacterial colonization and macrophage infiltration at the chorionic deciduas interface and ferritin is produced as part of acute phase response. Brails ford proposed that the increased extracellular ferritin has an important role in host defence against bacteremia by stimulating oxidative metabolism. Thus the high serum ferritin level in the study group is most likely a part of acute phase reaction to a subclinical infection and not due to iron overload. (13)

We found significantly high levels of ferritin in preterm delivery as compared to full term delivery might be due to sub clinical infections. Ferritin is formed as a part of an acute phase response and involved in host defence mechanism.

CONCLUSION

Our study conclude that significant rise in serum ferritin and decreased level of haemoglobin in preterm delivery as compared to full term delivery indicate that these biomarkers can be used as predictive biomarker for preterm delivery.

Moreover these parameters are cost effective, simple to perform and less time consuming and indicative of subclinical infections of pregnancy which could be one of the reasons for preterm delivery. On the other hand, our study has certain limitations which include smaller sample size of preterm cases and controls. Since preterm labour is multifactorial, various factors may have been unaccounted. A larger sample size research is recommended to address the limitations.

REFERENCES

1.Howson CP, Kinney MV, Lawn J. Born Too Soon: the global action report on preterm birth. March of Dimes, PMNCH, Save the Children, WHO; 2012

Bhatia K, Mukherjee B, Ambade V. Serum ceruloplasmin in predicting preterm labour. International Journal of Contemporary Medical Research 2016; 3(11):3321-3324

2.Bastek JA and Elovitz MA, The role and challenges of biomarkers in spontaneous preterm birth and preeclampsia, Obstet Gynecol 2013; 99 (4):1117-1123

3.Rathore S, Gupta A, Singh B, Rathore R Comparative study of trace elements and serum ceruloplasmin level in normal and pre-eclamptic pregnancies with their cord blood Biomedical Research 2011; 22 (2): 209-212

4.Georgiou H, Quinzio M, Shaun M, Brennecke P. Predicting Preterm Labour: Current Status and Future Prospects. 2015,;25( 4):223–235

5.Ramsey PS, Tamura T, Goldenberg RL, Mercer BM, Iams JD, Meis PJ, et al.; National Institute of Child Health and Human Development, Maternal-Fetal Medicine Units Network. The preterm prediction study: Elevated cervical ferritin levels at 22 to 24 weeks of gestation are associated with spontaneous preterm delivery in asymptomatic women. Am J Obstet Gynecol 2002;186:458-63

6.Milman N. Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much! 2012; 90(4):369–377.

7.Rosas JP, Regil LM, Dowswell T, Viteri FE. Daily oral iron supplementation during pregnancy. 2012;11(3):1-14

8.Sukrat B, Wilasrusmee C, Siribumrungwong B, McEvoy M, Okascharoen C, Attia J, Thakkinstian A et.al. Hemoglobin Concentration and Pregnancy Outcomes: A Systematic Review and Meta-Analysis. BioMed Research International 2013;38(3):1-9.

9.Klebanoff MA, Shiono PH, Selby JV, Trachtenberg AI, Graubard BI. Anemia and spontaneous preterm birth. Am J Obstet Gynecol 1991; 164:59–63

10.Umber J B, Khan Y, Nasar R. Relationship between maternal haemoglobin and perinatal outcome. Rawal Med J. 2007; 32(2):102-4

11.Kumar KJ, Srinivasa M, Sujatha MS,2 and Manjunath VG. Maternal Anemia in Various Trimesters and its Effect on Newborn Weight and Maturity: An Observational Study. Int J Prev Med. 2013 ; 4(2): 193–199.

12. Valappil .SA, Varkey .M, Areeckal. B, Thankan .K, Siva M.D. Serum Ferritin as A Marker for Preterm Premature Rupture of Membranes –A Study From A Tertiary Centre in Central Kerala Journal of Clinical and Diagnostic Research. 2015; 9(7): 09-12

13.Allen LH. Biological mechanisms that might underlie iron’s effects on fetal growth and preterm birth. Journal of Nutrition 2001; 131:581S–589.

14.Tripathi R, Tyagi S, Singh N,Y Mala, Singh C, Bhalla P, et al. Can Preterm Labour Be Predicted in Low Risk Pregnancies? Role of Clinical, Sonographic, and Biochemical Markers .Journal of Pregnancy2014 ;7(9):1-7-(38)

15.Kaneshige E. Serum ferritin as an assessment of iron stores and other hematologic parameters during pregnancy. Obstet Gynecol 1981;57:238-242

16.Singh B, Goswami B, Gupta N, Bajaj AD, MallikaV. Potential biochemical markers for preterm labor: A pilot study North India. Indian J Clin Biochem 2010;26:41-5

17. Movahedi M, Saiedi M, Gharipour M, Aghadavoudi O Diagnostic Performance of Descriminative Value of the Serum Ferritin Level for Predicting Preterm Labour. J Res Med Sci. 2012;17(2):164- 166

18. Tamura T, Goldenberg RL, Johnston KE, Cliver SP, Hickey CA. Serum ferritin: a predictor of early spontaneous preterm delivery. Obstetrics and Gynecology 1996; 87:360–365

19.Nandini M D et al. Study of serum ferritin levels in preterm labor Science and Technology March 2015; 14(2): 477-48

20.C.K. Saha, V. Jain, Gupta U, N. Varma Serum ferritin level as a marker of preterm labor. International Journal of Gynecology & Obstetrics. 2000; 71:107-111

Contact this candidate