title: [Review by expert group in the diagnosis and treatment of anemia in pregnant women. Federación Mexicana de Colegios de Obstetricia y Ginecología].
abstract: BACKGROUND
  According to data from the World Health Organization and UNICEF from year 2009, iron deficiency is the most widespread nutritional deficiency worldwide. This deficiency causes an imbalance between needs and iron supply, which consequently results in anemia. Around the world, two million people suffer from anemia, half of which is due to iron deficiency. The most impacted groups are children and teenagers, due to their highest requirements derived from the growing process, and women in their reproductive age, due to their loss of iron derived from menstruating or to their highest iron needs during pregnancy. This increase in needs is not satisfied by the regular diet, since it includes an insufficient amount and/or low bioavailability of iron.
  
  
  OBJECTIVE
  To share with the medical community treating pregnant women the experience of an expert group so that they always bear in mind the repercussions caused by anemia during pregnancy, know more about the diagnostic possibilities and have a reference point for prescribing iron supplements.
  
  
  METHODS
  The consensus method was used through the expert panel group technique. Two rounds were taken for structuring the clinical questions. The first one was to facilitate working groups their focusing in the clinical topics and the population of interest; the second one was to aid in posing specific questions observing the Patient, Intervention, Compare and Outcome (PICO) structure. The primary and clinical secondary study variables were defined by the working groups from the previously developed questions and during the face-to-face working period, according to the natural history of the disease: risk factors, diagnostic classification, (either pharmacological or non pharmacological) treatment and prognosis. The level of evidence and clinical recommendation was classified based on the Evidence Classification Level and Clinical Recommendation of the Medicine Group based on Evidence from Oxford University.
  
  
  RESULTS
  In Mexico, 20.6% of pregnant women suffer from anemia, especially those between 15 and 16 years old, who prevail in 42.4% and 34.3% percent, respectively. Almost half the cases are due to iron deficiency. This type of anemia is associated with a higher risk of pre-term delivery, of low birth weight and perinatal death. The first assessment of an anemic pregnant woman shall include the medical history, a physical examination and the quantification of the erythrocyte indices, serum concentrations of iron and ferritin. The measurement of this last one has the highest sensitivity and specificity for diagnosing iron deficiency. Daily oral iron supplementation, at a 60-to-120 mg dosage, may correct most of mild-to-moderate anemias. The most appropriate treatment is with iron salts (iron sulfate, polimaltose iron complex or iron fumarate). In case of intolerance to iron sulfate or fumarate, polimaltose iron is a better tolerated option. Treatment shall be administered until the hemoglobin values are > 10.5 g and ferritin is between 300 and 360 microg/dL, and such levels shall be observed for at least one year. Parenteral administration is an alternative for patients with a severe intolerance to oral administration; even when the possibility of anaphylaxis shall be considered it is lower when using ferrous sacarate. Transfusion is reserved for patients with hemoglobin lower than 7 g/dL or having an imminent cardio-respiratory decompensation.
  
  
  CONCLUSIONS
  Iron deficiency is the highest prevailing nutritional deficiency worldwide and its consequences during pregnancy may be highly risky for both the mother and her child. Anemia diagnosis may easily be achieved through a blood analysis including the serum ferritin determination. Serum iron measurement shall not be used as the only marker to set the diagnosis. It is important to rule out other causes, in addition to the deficiencies, which produce anemia in a patient. It is essential to suggest the administration of iron supplements not only during the antenatal period but also after birth o even after a miscarriage to fulfill the need for depleted iron. In severe anemias (hemoglobin being lower than 9.0 g/L), iron doses higher than 120 mg a day may be required. Treatment shall always begin orally, and if this is not well tolerated, parenteral administration shall be used.
authors.affiliation: Federación Mexicana de Colegios de Obstetricia y Ginecologia, A. C.
authors.forename: Jose de Jesús
authors.initials: Jde J
authors.lastname: Montoya Romero
authors.forename: Ernesto
authors.initials: E
authors.lastname: Castelazo Morales
authors.forename: Emilio
authors.initials: E
authors.lastname: Valerio Castro
authors.forename: Gerardo
authors.initials: G
authors.lastname: Velázquez Cornejo
authors.forename: David Antonio
authors.initials: DA
authors.lastname: Nava Muñoz
authors.forename: Jaime Arturo
authors.initials: JA
authors.lastname: Escárcega Preciado
authors.forename: Javier
authors.initials: J
authors.lastname: Montoya Cossío
authors.forename: Guadalupe Mireya
authors.initials: GM
authors.lastname: Pichardo Villalón
authors.forename: Aristeo
authors.initials: A
authors.lastname: Maldonado Aragón
authors.forename: Héctor Rogelio
authors.initials: HR
authors.lastname: Santana García
authors.forename: Sergio
authors.initials: S
authors.lastname: Fajardo Dueñas
authors.forename: César Germán
authors.initials: CG
authors.lastname: Mondragón Galindo
authors.forename: Teresa
authors.initials: T
authors.lastname: García Lee
authors.forename: Angel
authors.initials: A
authors.lastname: García
authors.forename: Marcela
authors.initials: M
authors.lastname: Hernández de Morán
authors.forename: Luis Eduardo
authors.initials: LE
authors.lastname: Chávez Güitrón
authors.forename: Carlos
authors.initials: C
authors.lastname: Jiménez Gutiérrez
mesh_terms: D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000145:classification / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D018798:Anemia, Iron-Deficiency / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D015415:Biomarkers; D001803:Blood Transfusion; D019317:Evidence-Based Medicine; D005260:Female; D005293:Ferritins / Q000097:blood; D005313:Fetal Death / Q000209:etiology; D005315:Fetal Diseases / Q000209:etiology / Q000517:prevention & control; D005492:Folic Acid / Q000008:administration & dosage / Q000627:therapeutic use; D014943:Global Health; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007231:Infant, Newborn; D007501:Iron / Q000008:administration & dosage / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D019266:Iron, Dietary / Q000493:pharmacokinetics; D008800:Mexico / Q000453:epidemiology; D008875:Middle Aged; D011181:Postnatal Care / Q000379:methods / Q000592:standards; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000145:classification / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D011295:Prenatal Care / Q000379:methods / Q000592:standards; D015995:Prevalence; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D055815:Young Adult
chemical_list: D015415:Biomarkers; D006454:Hemoglobins; D019266:Iron, Dietary; D005293:Ferritins; D005492:Folic Acid; D007501:Iron