2. Twin Pregnancy and Iron Deficiency Anemia: What You Need to Know?
Dr. Mohammed Khairy Ali
Lecturer of Obstetrics and Gynecology
Woman’s Health Hospital-Assiut university- Egypt

3. INTRODUCTION

4. Introduction
Anemia is the most worldwide health problem affecting pregnant women in both developed and developing countries.
During pregnancy, there is an inconsistent increase in plasma volume, RBC volume and hemoglobin mass. The increased rate in plasma volume is more than the RBC mass resulting in physiological anemia of pregnancy.
Iron deficiency anemia (IDA) is the commonest type of anemia during pregnancy.
The pregnant woman needs about 1000mg of iron during pregnancy, 500–600mg for RBCs formation, 300mg for fetus and placenta and the remaining for the uterine growth.
Bah et al 2016
Sharma et al 2016
Khaskheli et al 2016

5. Introduction
Diet alone cannot give pregnant woman the daily required amount of the iron (27 mg/day), so the Centers for Disease Control and Prevention recommend that pregnant women should take a daily supplement of 30mg of elemental iron as a preventive measure.
Oral iron is a cheap, effective and relatively safe line to prevent IDA during pregnancy.
Iron amino acid chelates have been emerged to be used as agents for prevention and treatment of IDA. These agents provide maximum bioavailability and maximum efficacy with minimal unpleasant side effects.
Esen et al 2016
Tangeda et al 2016
Breymannet al 2015

6. Introduction
A twin pregnancy has a significant role in perinatal morbidity and mortality due to increased risks of low birth weight and preterm birth.
The iron requirement for twin pregnancy is probably double fold that of a singleton pregnancy resulting in higher rate of IDA.
Twin pregnancies have been associated with significant maternal physiological changes compared to the usual singleton pregnancy changes including plasma volume expansion and decreased hemoglobin concentration.
The rate of IDA in twin pregnancy is 2.4–4 times higher than in singleton pregnancies.
McAndrew et al 2016
Goodnight et al 209
ACOG 2008

7. Introduction
ACOG states that supplementation of non-anemic twin gestations of 30 mg daily of elemental iron would be appropriate to meet the increased maternal and fetal needs of the pregnancy.
Overall, the data are still conflicting about the optimum dose of prophylactic iron supplementation during twin pregnancies.
So; we assumed that the non-anemic women with twin gestations may need a double daily dose (60mg) of elemental iron to meet the increased maternal and fetal needs of the twin's pregnancy.
ACOG 2008

8. Introduction
To our knowledge, no clinical trial has been registered or conducted to test the effect of 30 mg and 60 mg elemental iron in prevention of IDA in twin pregnancy in non-anemic mothers.

9. OBJECTIVE

10. Objective
The aim of our study was to compare the effectiveness of 27mg elemental iron versus 54mg elemental iron in prevention of IDA in non-anemic women with twin gestations.

11. MATERIAL AND METHODS

12. Study Setting: WHH, Assiut University, Egypt.
Materials and Methods
Type of the study: Open, parallel, randomized controlled trial (NCT ).
Study Setting: WHH, Assiut University, Egypt.
Study period: From August 2015 and June 2016.

13. Inclusion criteria Pregnant women in twins (±12 weeks).
Materials and Methods
Inclusion criteria
Pregnant women in twins (±12 weeks).
Normal BMI (18.5–22.5 kg/m2).
Normal hemoglobin level (>11 g/dL).
Normal hematocrit (Hct 31–41%).
Normal ferritin level (6–130 ng/mL).

14. Women with low ferritin level (6 ng/mL).
Materials and Methods
Exclusion criteria
Women had micronutrient supplements containing iron prior to enrollment in study in the last 6 months.
Anemic women (11 g/dL).
Women with low ferritin level (6 ng/mL).
Had a recent blood transfusion.
Threatened miscarriage.
Pathological blood loss.
Vegetarian diet.
Intolerant to oral iron form.
History of hematologic disorder or chronic diseases.

15. Further evaluation 2- General and physical examination.
Materials and Methods
Further evaluation
1- Full history taking: Age, parity and gestational age. All risks factors for IDA were revised with the recruited women
2- General and physical examination.
3- Complete blood picture and ferritin level were also obtained.
4- Ultrasound evaluation.

16. Randomization Intervention
Materials and Methods
Randomization
Randomization was done by computer-generated random table.
Intervention
The eligible women were allocated to either:
Group I (27mg elemental iron); received amino acid chelated ferrous bis-glycinate (PHARA FERRO 27, Devart Lab Company, Egypt) once daily starting at 12 weeks until 36 weeks.
Group II (54mg elemental iron); received the same drug; twice daily for the same duration.

17. Materials and Methods
Study outcomes
Primary outcome was the difference of mean level of maternal Hb and Hct at 36 weeks.
Secondary outcomes
The number of women who developed anemia during pregnancy.
The difference in serum ferritin level at 36 weeks.
The incidence of patients' reported side effects.
Failure of intervention was defined as either development of anemia (Hb 10.5 g/dL in second trimesteror 11 g/dL in third trimester) and need for starting therapeutic iron thereby or opting to stop treatment due to patient's incompliance.

18. Materials and Methods
The participants were followed up at Our Antenatal
Clinic according to our institutional management
protocol till 36 weeks of gestation. At each visit,
women were evaluated in detail regarding symptomatology
and physical examination. Women were asked
to report any side effects during the course of drug
2 M. K. ALI ET AL.
intake as nausea/vomiting, loss of appetite, abdominal
pain, diarrhea, metallic taste in the mouth and black
staining of the stool. Complete blood count and ferritin
were performed at monthly interval.
All women were advised to continue iron thereby
and follow up visits after 36 weeks, if wish, at our
Antenatal Clinic. Finally, the women were classified
into completed the study or lost from the study.
Women who were delivered before 36 weeks were
excluded from the final analysis.

19. RESULTS

21. Aspirin plus omega 3 (n= 34)
Table (1): Baseline characteristics of the participants
Group I
Aspirin (n= 34)
Group II
Aspirin plus omega 3 (n= 34)
P-value
Mean ± SD
Age (years)
27.50 ± 4.84
27.12 ± 4.33
0.721
Parity
2.97 ± 1.71
2.88 ± 1.61
0.745
Number of previous abortions 16 15
0.808
Number of previous C.S 17
Number of living children
2.79 ± 1.65
2.59 ± 1.42
0.482
Gestational age
30.24 ± 0.55
30.03 ± 0.39
0.069
BMI
21.53 ± 2.69
21.23 ± 1.49
0.985

22. Table (2): The main study outcomes (estimated fetal weight)

23. Table (3): Doppler blood flow changes in both uterine and umbilical arteries from before to 6 weeks after treatment

24. Table (4): Delivery and neonatal outcomes data

25. CONCLUIONS

26. Conclusions
1. Both aspirin and omega-3 fatty acids are effective in increasing fetal and birth in IUGR after 6 weeks of use with favorable neonatal outcome. 2. However, the combing between aspirin with omega-3 is superior to aspirin only for achieving this effect. 3. The increase in uterine and umbilical blood flow may be behind this treatment effect.

28. Thanks
for your
attention by
MOHAMMED KHAIRY