Annals of Hematology

, 90:1247 | Cite as

Postpartum anemia I: definition, prevalence, causes, and consequences

Review Article

Abstract

This review provides a status on the definition, prevalence, causes, and consequences of anemia in women who have given childbirth, i.e., postpartum anemia. The diagnosis of iron deficiency anemia relies on a full blood count including hemoglobin, serum ferritin, and serum soluble transferrin receptor, which appear to be reliable indicators of anemia and iron status 1 week postpartum while serum transferrin saturation is an unreliable indicator several weeks after delivery. It is recommended that postpartum anemia should be defined by hemoglobin <110 g/L at 1 week postpartum and <120 g/L at 8 weeks postpartum. The major causes of postpartum anemia are prepartum anemia combined with acute bleeding anemia due blood losses at delivery. Normal peripartum blood losses are approximately 300 ml, but hemorrhage >500 ml occur in 5–6% of the women. In healthy women after normal delivery, the prevalence of anemia (hemoglobin <110 g/L) 1 week postpartum is 14% in iron-supplemented women and 24% in non-supplemented women. In consecutive series of European women, the prevalence of anemia 48 h after delivery is approximately 50%. In developing countries, the prevalence of postpartum anemia is in the range of 50–80%. Postpartum anemia is associated with an impaired quality of life, reduced cognitive abilities, emotional instability, and depression and constitutes a significant health problem in women of reproductive age.

Keywords

Anemia Iron deficiency Ferritin Hemoglobin Iron Postpartum hemorrhage Postpartum period Pregnancy Transferrin receptor 

References

  1. 1.
    Milman N (2008) Prepartum anaemia: prevention and treatment. Ann Hematol 87:949–959PubMedCrossRefGoogle Scholar
  2. 2.
    Protonotariou E, Chrelias C, Kassanos D, Kapsambeli H, Trakakis E, Sarandakou A (2010) Immune response parameters during labor and early neonatal life. In Vivo 24:117–123PubMedGoogle Scholar
  3. 3.
    Bodnar LM, Siega-Riz AM, Miller WC, Cogswell ME, McDonald T (2002) Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J Epidemiol 156:903–912PubMedCrossRefGoogle Scholar
  4. 4.
    Bergmann RL, Richter R, Bergmann KE, Dudenhausen JW (2010) Prevalence and risk factors for early postpartum anemia. Eur J Obstet Gynecol Reprod Biol 150:126–131PubMedCrossRefGoogle Scholar
  5. 5.
    Åkesson A, Bjellerup P, Berglund M, Bremme K, Vahter M (1998) Serum transferrin receptor: a specific marker of iron deficiency in pregnancy. Am J Clin Nutr 68:1241–1246PubMedGoogle Scholar
  6. 6.
    Åkesson A, Bjellerup P, Berglund M, Bremme K, Vahter M (2002) Soluble transferrin receptor: longitudinal assessment from pregnancy to postlactation. Obstet Gynecol 99:260–266PubMedCrossRefGoogle Scholar
  7. 7.
    Milman N, Byg K-E, Bergholt T, Eriksen L, Hvas A-M (2006) Body iron and individual iron prophylaxis in pregnancy—should the iron dose be adjusted according to serum ferritin? Ann Hematol 85:567–573PubMedCrossRefGoogle Scholar
  8. 8.
    Goetzl L, Manevich Y, Roedner C, Praktish A, Hebbar L, Townsend DM (2010) Maternal and fetal oxidative stress and intrapartum term fever. Am J Obstet Gynecol 202(363):e1–e5PubMedGoogle Scholar
  9. 9.
    Larsson A, Palm M, Hansson L-O, Basu S, Axelsson O (2008) Reference values for α1-acid glycoprotein, α1-antitrypsin, albumin, haptoglobin, C-reactive protein, IgA, IgG and IgM during pregnancy. Acta Obstet Gynecol Scand 87:1084–1088PubMedCrossRefGoogle Scholar
  10. 10.
    Breymann C, Richter C, Hüttner C, Huch R, Huch A (2000) Effectiveness of recombinant erythropoietin and iron sucrose vs. iron therapy only, in patients with postpartum anemia and blunted erythropoiesis. Eur J Clin Invest 30:154–161PubMedCrossRefGoogle Scholar
  11. 11.
    Wågström E, Åkesson A, Van Rooijen M, Larson B, Bremme K (2007) Erythropietin and intravenous iron therapy in postpartum anemia. Acta Obstet Gynecol Scand 86:957–962PubMedCrossRefGoogle Scholar
  12. 12.
    Hendrick V, Altshuler LL, Suri R (1998) Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics 39:93–101PubMedGoogle Scholar
  13. 13.
    Lee W, Pivarnik J (1992) Hemodynamic studies during pregnancy. J Matern Fetal Med 1:75–77CrossRefGoogle Scholar
  14. 14.
    Varga I, Rigó J Jr, Somos P, Joó JG, Nagy B (2000) Analysis of maternal circulation and renal function in physiologic pregnancies; parallel examinations of the changes in the cardiac output and the glomerular filtration rate. J Matern Fetal Med 9:97–104PubMedCrossRefGoogle Scholar
  15. 15.
    Milman N, Agger OA, Nielsen OJ (1991) Iron supplementation during pregnancy. Effect on iron status markers, serum erythropoietin and human placental lactogen. A placebo controlled study in 207 Danish women. Dan Med Bull 38:471–476PubMedGoogle Scholar
  16. 16.
    Koller O (1982) The clinical significance of hemodilution during pregnancy. Obstet Gynecol Surv 37:649–652PubMedCrossRefGoogle Scholar
  17. 17.
    World Health Organization (2001) Iron deficiency anemia. Assessment, prevention, and control. WHO/NHD/01.3Google Scholar
  18. 18.
    Bodnar LM, Cogswell ME, Scanlon KS (2002) Low income postpartum women are at risk of iron deficiency. J Nutr 132:2298–2302PubMedGoogle Scholar
  19. 19.
    Milman N, Byg K-E, Graudal N, Agger AO (2000) Reference values for hemoglobin and erythrocyte indices during normal pregnancy in 206 women with and without iron supplementation. Acta Obstet Gynecol Scand 78:89–98CrossRefGoogle Scholar
  20. 20.
    Milman N, Bergholdt T, Byg K-E, Eriksen L, Hvas A-M (2007) Reference intervals for haematological variables during normal pregnancy and postpartum in 433 healthy Danish women. Eur J Haematol 79:39–46PubMedCrossRefGoogle Scholar
  21. 21.
    Milman N, Ibsen KK, Christensen JM (1987) Serum ferritin and iron status in mothers and newborn infants. Acta Obstet Gynecol Scand 66:205–211PubMedCrossRefGoogle Scholar
  22. 22.
    Somdatta P, Reddaiah VP, Singh B (2009) Prevalence of anemia in the postpartum period: a study of a North Indian village. Trop Doct 39:211–215PubMedCrossRefGoogle Scholar
  23. 23.
    Richter C, Huch A, Huch R (1995) Erythropoiesis in the postpartum period. J Perinat Med 23:51–59PubMedCrossRefGoogle Scholar
  24. 24.
    Milman N, Bergholt T, Eriksen L, Byg K-E, Graudal N, Pedersen P, Hertz J (2005) Iron prophylaxis during pregnancy—how much iron is needed? A randomised, controlled study of 20 to 80 mg ferrous iron daily to pregnant women. Acta Obstet Gynecol Scand 84:238–247PubMedGoogle Scholar
  25. 25.
    Milman N (2011) Anemia—still a major health problem in many parts of the world! Ann Hematol 90:369–377PubMedCrossRefGoogle Scholar
  26. 26.
    Milman N, Byg K-E, Hvas A-M, Bergholt T, Eriksen L (2006) Erythrocyte folate, plasma folate and plasma homocysteine during normal pregnancy and postpartum: a longitudinal study comprising 404 Danish women. Eur J Haematol 76:200–205PubMedCrossRefGoogle Scholar
  27. 27.
    Milman N, Byg K-E, Bergholt T, Eriksen L, Hvas A-M (2006) Cobalamin status during normal pregnancy and postpartum. A longitudinal study comprising 406 Danish women. Eur J Haematol 76:521–525PubMedCrossRefGoogle Scholar
  28. 28.
    Mørkbak AL, Hvas A-M, Milman N, Nexø E (2007) Holotranscobalamin remains unchanged during pregnancy. Longitudinal changes of cobalamins and their binding proteins during pregnancy and postpartum. Haematologica 92:1711–1712PubMedCrossRefGoogle Scholar
  29. 29.
    Milman N, Byg K-E, Ovesen L (2000) Iron status in Danes updated 1994. II. Prevalence of iron deficiency and iron overload on 1319 women aged 40–70 years. Influence of blood donation, alcohol intake, and iron supplementation. Ann Hematol 79:612–621PubMedCrossRefGoogle Scholar
  30. 30.
    Milman N, Clausen J, Byg K-E (1998) Iron status in 268 Danish women aged 18–30 years. Influence of menstruation, method of contraception, and iron supplementation. Ann Hematol 76:13–19CrossRefGoogle Scholar
  31. 31.
    Nybo M, Friis-Hansen L, Felding P, Milman N (2007) Higher prevalence of anemia among pregnant immigrant women compared to pregnant ethnic Danish women. Ann Hematol 86:647–651PubMedCrossRefGoogle Scholar
  32. 32.
    Waldmann A, Koschizke JW, Leitzmann C, Hahn A (2004) Dietary iron intake and iron status of German female vegans: results of the German vegan study. Ann Nutr Metab 48:103–108PubMedCrossRefGoogle Scholar
  33. 33.
    Harvey LJ, Armah CN, Dainty JR, Foxall RJ, John Lewis D, Fairweather-Tait SJ (2005) Impact of menstrual blood loss and diet iron on iron deficiency among women in the UK. Br J Nutr 94:557–564PubMedCrossRefGoogle Scholar
  34. 34.
    Milman N, Søndergaard M, Sørensen CM (1985) Iron stores in female blood donors evaluated by serum ferritin. Blut 51:337–345PubMedCrossRefGoogle Scholar
  35. 35.
    Milman N, Kirchhoff M (1991) Influence of blood donation on iron stores assessed by serum ferritin and haemoglobin in a population survey of 1359 Danish women. Ann Hematol 62:27–32CrossRefGoogle Scholar
  36. 36.
    Milman N, Kirchhoff M, Jørgensen T (1992) Iron status markers, ferritin and hemoglobin in 1359 Danish women in relation to menstruation, hormonal contraception, parity and postmenopausal hormone treatment. Ann Hematol 65:96–102PubMedCrossRefGoogle Scholar
  37. 37.
    Milman N (2006) Iron prophylaxis in pregnancy—general or individual and in which dose? Ann Hematol 85:821–828PubMedCrossRefGoogle Scholar
  38. 38.
    Makrides M, Crowther CA, Gibson RA, Gibson RS, Skeaff CM (2003) Efficacy and tolerability of low-dose iron supplements during pregnancy: a randomised controlled trial. Am J Clin Nutr 78:145–153PubMedGoogle Scholar
  39. 39.
    Royal College of Obstetricians and Gynaecologist, Green top guidelines, November 2009 http://www.rcog.org.uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf
  40. 40.
    Rajan PV, Wing DA (2010) Postpartum hemorrhage: evidence-based medical interventions for prevention and treatment. Clin Obstet Gynecol 53:165–181PubMedCrossRefGoogle Scholar
  41. 41.
    Groot AN, van Roosmalen J, van Dongen PW, Borm GF (1996) A placebo-controlled trial of oral ergometrine to reduce postpartum hemorrhage. Acta Obstet Gynecol Scand 75:464–468PubMedCrossRefGoogle Scholar
  42. 42.
    Gilbert L, Porter W, Brown VA (1987) Postpartum haemorrhage—a continuing problem. British Journal of Obstetrics and Gynaecology 94:67–671PubMedCrossRefGoogle Scholar
  43. 43.
    Kavle JA, Khalfan SS, Stoltzfus RJ, Witter F, Tielsch JM, Caulfield LE (2006) Measurement of blood loss at childbirth and postpartum. Int J Gynecol Obstet 95:24–28CrossRefGoogle Scholar
  44. 44.
    Roberts CL, Ford JB, Thomson JF, Morris JM (2008) Population rates of hemorrhage and transfusions among obstetric patients in NSW: a short communication. Aust N Z J Obstet Gynaecol 48:481–484PubMedCrossRefGoogle Scholar
  45. 45.
    Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B (2008) Prevalence and risk factors of severe obstetric hemorrhage. BJOG 115:1265–1272PubMedCrossRefGoogle Scholar
  46. 46.
    Oyelese Y, Ananth CV (2010) Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol 53:147–156PubMedCrossRefGoogle Scholar
  47. 47.
    Newton M (1966) Postpartum hemorrhage. Am J Obstet Gynecol 94:711–717PubMedGoogle Scholar
  48. 48.
    Danish Society for Obstetrics and Gynaecology http://www.dsog.dk
  49. 49.
    Rouse DJ, MacPherson C, Landon M, Varner MW, Leveno KJ, Moawad AH et al (2006) Blood transfusion and cesarean delivery. Obstet Gynecol 108:891–897PubMedCrossRefGoogle Scholar
  50. 50.
    Bruner A, Joffe A, Duggan AK, Casella JF, Brandt J (1996) Randomised study of cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls. Lancet 348:992–996PubMedCrossRefGoogle Scholar
  51. 51.
    Rowland TW, Deisroth MB, Green GM, Kelleher JF (1988) The effect of iron therapy on the exercise capacity of non-anemic iron-deficient adolescent runners. Am J Dis Childhood 142:165–169Google Scholar
  52. 52.
    Gibbs R (1980) Clinical risk factors for puerperal infection. Obstet Gynecol 55(Suppl 5):178S–184SPubMedGoogle Scholar
  53. 53.
    Vora M, Gruslin A (1998) Erythropoietin in obstetrics. Obstetrical and Gynecological Survey 53:500–508PubMedCrossRefGoogle Scholar
  54. 54.
    Beard JL, Hendricks MK, Perez EM et al (2005) Maternal iron deficiency anemia affects postpartum emotions and cognition. J Nutr 135:267–272PubMedGoogle Scholar
  55. 55.
    Corwin EJ, Murray-Kolb LE, Beard JL (2003) Low hemoglobin level is a risk factor for postpartum depression. J Nutr 133:4139–4142PubMedGoogle Scholar
  56. 56.
    Beard JL, Hendricks MK, Perez EM, Murray-Kolb LE, Berg A, Vernon-Feagans L, Irlam J, Isaacs W, Sive A, Tomlinson M (2005) Maternal iron deficiency anemia affects postpartum emotions and cognition. J Nutr 135:267–272PubMedGoogle Scholar
  57. 57.
    Meyer JW, Eichhorn KH, Vetter K, Christen S, Schleusner E, Klos A, Huch A, Huch R (1995) Does recombinant human erythropoietin not only treat anemia but reduce postpartum (emotional) distress as well? J Perinat Med 23:99–109PubMedCrossRefGoogle Scholar
  58. 58.
    Murray-Kolb LE, Beard JL (2009) Iron deficiency and child and maternal health. Am J Clin Nutr 89:946S–950SPubMedCrossRefGoogle Scholar
  59. 59.
    World Health Organization. Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement. Geneva: World Health Organization, 1999Google Scholar
  60. 60.
    Potts M, Campbell M (2004) Three meetings and fewer funerals: misoprostol in postpartum hemorrhage. Lancet 364:1110–1111PubMedCrossRefGoogle Scholar
  61. 61.
    Tsu VD, Shane B (2004) New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop. Int J Gynecol Obstet 85(Suppl 1):S83–S93CrossRefGoogle Scholar
  62. 62.
    Recommendation to prevent and control iron deficiency in the United States. MMWR Morb Mortal Wkly Rep 1998; 47(RR-3):13–25Google Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Department of Clinical BiochemistryNæstved HospitalNæstvedDenmark
  2. 2.VirumDenmark

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