Megaloblastic anaemia of pregnancy: a clinical and laboratory study with particular reference to the total and labile serum folate levels

Abstract

SYNOPSIS It has been shown that the incidence of megaloblastic anaemia in a group of 463 randomly selected pregnant women receiving iron was 12 times as high as in a control group of 235 pregnant women receiving iron and folic acid. The incidence of all types of anaemia in the women receiving iron alone was more than three times the incidence in those having iron and folic acid. Some women who were not anaemic or who had normoblastic anaemia had serum folate levels in the same range as the women with megaloblastic anaemia, but none of the women with megaloblastic anaemia had high serum folate levels. The labile fraction of the serum folate was no more reliable than the total serum folate as a diagnostic criterion of megaloblastic crythropoiesis in the individual case. The blood group distribution in the women with megaloblastic anaemia was the same as in the general population. Babies born to mothers with megaloblastic anaemia tended to be smaller than the rest, although there was no difference in the placental weights.The significance of these findings is discussed.Megaloblastic erythropoiesis, with a varying degree of anaemia, is now known to be common in pregnancy. Although erythropoiesis is restored to normal by folic acid, estimation of the total serum folate is not a reliable guide to diagnosis, as it is in other folate-deficiency states such as steatorrhoea. It has been claimed that the level of the labile fraction of the serum folate (probably 5-methyl-tetrahydrofolic acid) is a reliable diagnostic criterion (Ball and Giles, 1964;Giles, 1966). If this is so, then an important factor in the pathogenesis of megaloblastic anaemia of pregnancy would seem to be an inability to metabolize folate compounds to their most useful form.There have been conflicting reports about the incidence of serious complications such as toxaemia, abortion, antepartum haemorrhage, and premature labour in pregnant women with megaloblastic anaemia (Gatenby and Lillie, iPresent address: Mill Road Maternity Hospital, Liverpool

Daily oral iron supplementation during pregnancy

“…This reason applied to a total of 87 trials. In 44 trials women received different types of iron (for example ferrous iron versus iron fumarate), or women received iron with or without other vitamins or supplements (Afifi 1978; Babior 1985; Balmelli 1974; Burslem 1968; Buss 1981; Carrasco 1962; Castren 1968; Chanarin 1968; Coelho 2000; Dawson 1987; Dijkhuizen 2004; Ekstrom 1996; Fletcher 1971; Giles 1971; Gringras 1982; Hartman-Craven 2009; Hosokawa 1989; Kaestel 2005; Kann 1988; Lira 1989; Ma 2008; Mbaye 2006; Metz 1965; Morrison 1977; Nogueira 2002; Ogunbode 1984; Ogunbode 1992; Osrin 2005; Payne 1968; Rae 1970; Ramakrishnan 2003; Rayado 1997; Rolschau 1979; Roth 1980; Rybo 1971; Saha 2007; Shatrugna 1999; Sjostedt 1977; Srisupandit 1983; Stone 1975; Trigg 1976; Weil 1977; Willoughby 1966; Willoughby 1968). In 34 trials both groups received iron and either different doses of iron were compared (Aaseth 2001; Ahn 2006; Brown 1972; Guldholt 1991; Horgan 1966; Madan 1999; Milman 2005; Nguyen 2008; Reddaiah 1989; Thane-Toe 1982; Thomsen 1993; Vogel 1963; Zhou 2009), or different types of regimen (for example daily versus weekly iron) (Bhatla 2009; Casanueva 2003a; Chew 1996a; Chew 1996b; Ekstrom 2002; Gomber 2002; Goonewardene 2001; Grover 1998; Liu 1996; Mukhopadhyay 2004; Mumtaz 2000; Pena-Rosas 2003; Pita Martin 1999; Quintero 2004; …”

“…In 44 trials women received different types of iron (for example ferrous iron versus iron fumarate), or women received iron with or without other vitamins or supplements (Afifi 1978; Babior 1985; Balmelli 1974; Burslem 1968; Buss 1981; Carrasco 1962; Castren 1968; Chanarin 1968; Coelho 2000; Dawson 1987; Dijkhuizen 2004; Ekstrom 1996; Fletcher 1971; Giles 1971; Gringras 1982; Hartman-Craven 2009; Hosokawa 1989; Kaestel 2005; Kann 1988; Lira 1989; Ma 2008; Mbaye 2006; Metz 1965; Morrison 1977; Nogueira 2002; Ogunbode 1984; Ogunbode 1992; Osrin 2005; Payne 1968; Rae 1970; Ramakrishnan 2003; Rayado 1997; Rolschau 1979; Roth 1980; Rybo 1971; Saha 2007; Shatrugna 1999; Sjostedt 1977; Srisupandit 1983; Stone 1975; Trigg 1976; Weil 1977; Willoughby 1966; Willoughby 1968).…”

“…Hb concentration, prevalence of anaemia and nutrient consumption at baseline and after 10 weeks of supplementation were measuredBoth groups received iron in different regimens (daily versus weekly). Gestational ages were variable among the participants Rae 1970 In this quasi-randomised trial, pregnant women attending antenatal clinic at the Department of Obstetrics and Department of Haematology, Walton Hospital, Liverpool, United Kingdom were assigned to one of two groups: group 1 received 200 mg ferrous gluconate three times a day throughout pregnancy; group 2 received 200 mg ferrous gluconate + 5000 μ g (5 mg) three times a day. Both groups received iron daily.…”

A High Prevalence of Biochemical Evidence of Vitamin B12 or Folate Deficiency does not Translate into a Comparable Prevalence of Anemia

“…In 463 women in Liverpool, the incidence of anemia and megaloblastosis was 31% and 9% respectively in those given iron only, compared with 10% and 1% in those given folic acid [87]. In Manchester, in 1,603 women before 28 weeks, in those given an average of 120 mg folic acid in the pregnancy, the mean postpartum hemoglobin concentration was 111 g/L and the incidence of megaloblastic anemia was 0.3%, compared with 108 g/L and 4%, respectively, in those given iron only [88].…”

Myelodysplastic Syndrome and Pregnancy: The Mayo Clinic Experience

“…Induction chemotherapy with idarubicin and 3 4 to be most common in the third trimester of pregnancy [29,30]. The blood and bone marrow changes of folate deficiency can be mistaken for myelodysplasia or even acute leukemia [31], and there are case reports of pregnant patients with folate deficiency who were treated with cytotoxic agents such as 6-mercaptopurine because they were thought to have leukemia [32].…”