Tugas Inggris 3 Session 2

8/19/2019 Tugas Inggris 3 Session 2

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The Journal of the Pakistan Medical AssociationRawalpindi - IslamabadISSN-00-!"#"

$olume "% Number "% Jul - &ec "00'(ri)inal article

Relationship between maternal hemo)lobin and Perinatal outcome*mber Jalil +akhtiar% ,asmeen han% Ra.ia Nasar

/orrespondence1rom &epartment of (bstetrics and 23necolo)3 Islamic International Medical /olle)e Trust% Railwa3 4ospital% Rawalpindi5Recei6ed 1ebruar3 7% "00' Accepted June #7% "00'A+STRA/T

(b8ecti6e To Stud3 the Relationship between Maternal 4emo)lobin and Perinatal

outcome in a cohort of 790 pre)nant women and to hi)hli)ht the importance of antenatalcare re)ardin) maternal health and fetal outcome5

Methods All Sin)leton pre)nancies deli6erin) at Pakistan Railwa3 4ospital Rawalpindifrom Januar3 "00: to &ecember "00! that fulfilled the re;uired criteria were included5Results (ut of the 790 patients% :0" were anemic dl? and :!7 were non anemic5Perinatal outcome included preterm deli6er3% low birth wei)ht% intrauterine )rowthretardation% perinatal death% low ap)r scores and intrauterine fetal deaths5 Risk of pretermand @ow birth wei)ht amon) anemic women was 5: and #57 times more than nonanaemic women5 The neonates of anemic woman also had #5' times increased risk ofha6in) low Ap)ar scores at # min5 Amon) anemic women there was "5" times )reater risk

of intrauterine fetal death than the non-anemic women5/onclusions Re)ular antenatal care from first trimester has a 6ital role in assessin) andmana)in) maternal anemia timel3 and it directl3 affects the perinatal outcome5 The patients with anemia ha6e also hi)her risk of ha6in) low birth wei)ht% preterm births andintra uterine fetal death5


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between low hemo)lobin before deli6er3 and ad6erse out come: while other studies ha6enot found a si)nificant association5! Thus the aim of this stud3 was to e6aluate theantenatal maternal hemo)lobin and find its impact on perinatal outcome5MATDRIA@S AN& MDT4(&S

The stud3 was carried out on pre)nant women attendin) (bstetric outpatient &epartmentof Pakistan Railwa3 4ospital Rawalpindi from Januar3 "00: to &ecember "00!5 Totalnumber of women deli6erin) durin) this period was #!'75 Bomen attendin) the outclinic before ": were of )estation% with sin)leton pre)nanc3 and a)es #7 and abo6e wereincluded in the stud35 Bomen with multiple pre)nancies% past preterm labor and otherassociated medical complications were eCcluded5 Anemia was defined accordin) to B4(criteria i5e5 4aemo)lobin =## )m>dl 5In this stud3% anemia was labeled if 4b was=##)m>dl on " occasions durin) pre)nanc3 and labour54emo)lobin le6els were measured at first 6isit% then at the end of second trimester andtwice in the third trimester5 If the 4emo)lobin le6els were =E )m>dl after : weeks than parenteral iron therap3 either intramuscularl3 or intra6enousl3 were )i6en5 At 4b

=')m>dl blood transfusions were )i6en5 All the information re)ardin) )estational a)e atdeli6er3% complications at deli6er3% fetal outcome in term of wei)ht and Ap)ar score wasrecorded5RDS*@TS

A total of 790 women fulfilled the inclusion criteria% :"0 in non anemic )roup and !:0 inanemic )roup5 Twent3-one women were lost to follow-up after first inter6iew5Mean a)e of the women in anemic )roup was "!57! and ":5"0 in non-anemic )roup5There was no statisticall3 si)nificant difference between the two )roups in terms ofeducation le6el up to primar3


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from !0G to 'G and perinatal mortalit3 from 7G to :G in a stud3 in Ni)eria5E

(ur data showed association of maternal anemia in pre)nanc3 with increased risk ofdeli6er3 of premature and @+B babies% intrauterine death and low Ap)ar score at oneminute5 These deaths were commonl3 found to be due to prematurit3 and sepsis5 Since

our stud3 was done at a tertiar3 care unit and ma8orit3 of women in Pakistan deli6er athome% it is eCpected that the burden of anemia and its effect on pre)nanc3 outcome ismuch )reater outside the hospital settin)s5 Maternal hemo)lobin 6alues durin) pre)nanc3are associated with @+B and preterm birth in a *-shaped relationship with a hi)h rate oflow birth wei)ht at low and hi)h concentration of maternal hemo)lobin5#0It is estimated that '5 million perinatal deaths occur annuall3 in the world ## and% b3correctin) anemia man3 of these deaths can be pre6ented5 This stud3 also showed hi)hratio of perinatal deaths due to prematurit35 Anemia with =4b 7)m>dl has seem to beassociated with birth wei)ht 6alues that are "00-00) lower than in women with H#0)>lhemo)lobin5#" The relationship between anemia and infection has also been proposed#as /orticotrophin Releasin) 4ormones pla3s a role in causin) preterm labor or premature

rupture of membranes5#: Presentation for antenatal care in third trimester is common inour countr35#! Since demand for micronutrients is maCimum in third trimester% this could be one factor underl3in) the hi)h pre6alence of anemia5#9 In conclusion% this stud3showed an association of maternal anemia with increased prematurit3% @+B% intra uterinedeaths and low Ap)ar scores5 (ther nutritional deficiencies can also be the causati6efactors5 1urther studies are needed in this area5RD1DRDN/DS$iteri 1D5 The conse;uences of iron deficienc3 and anemia in pre)nanc35 In NutrientRe)ulation durin) Pre)nanc3% @actation and infant 2rowth5 @5 Alien% J% in) and+5@onnerdal5 Dds5 #EE: Plenom Press% New ,ork% PP5 #"#-#5B4(5 National5 Strate)ies for o6ercomin) Micronutrient Malnutrition5 &ocument D+#EE# 7E>"'5 DCecuti6e +oard% 7Eth Session52re)or3 P% Taslim A5 4ealth Status of the Pakistani population a health profile andcomparison with the *nited States5 Am J Public 4ealth "00# E#E-7Iron deficienc3 anemia Re-eCaminin) the nature and ma)nitude of the public health problem5 Proceedin)s of a conference5 Ma3 "#-":% "0005 +elmont% Mar3land% *SA5 J Nutrition "00###!9!-'075arim SA et al5 Anemia in pre)nanc3-its cause in the underpri6ile)ed class of arachi5 JPak Med Assoc #EE:::E0-"55A//>S/N S/N workshop5S52illespie% J5 e6an3 and J5 Mason% eds5 A//>S/N State of the Art series5 Nutrition polic3 discussion paper No5 E A//>S/N />( B4(% /iene6a% Swit.erland52arn SM5% Ridella SA% Pet.old AS% 1alkner 15 Maternal 4ematolo)ical le6el and pre)nanc3 (utcomes5 Sem5 In Perinatop #E7#!##!-#9"5Murph3 J1% New combe R2% /oles D2% Pearson J15 Relation of 4emo)lobin le6els in1irst and Second Trimesters to (utcome of Pre)nanc35 @ancet #E79 IEE"-EE!51lemin) A15 A stud3 of Anemia of Pre)nanc3 in Ibadan% Bestern Ni)eria with specialReference to 1olic acid &eficienc35 M& Thesis% *ni6ersit3 of /ambrid)e5 #EE# uoted b3 A5 4u)hes in Anema of Pre)nanc3K Maternal 4ealth and Safe Motherhood% B4(%#EE#5


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$erma /% &har 25 Relationship of maternal anemia% birth wei)ht and perinatalmortalit3 a hospital stud35 Indian Pediatr #E'9#:9E-:#5Sha.ia T% 1aheem S% Saad R5 Perinatal mortalit3 A sur6e35 Pak J (bstet 23naecol#EE:'#-75Steer P% Alam MA% Badsworh J% Belch A5 Relationship between maternal haemo)lobin is

concentration and birth wei)ht in different ethnic )roups5 +rit Med J #EE!#0:7E-E#54ooton TM% Scholes &% 4u)hes JP% Binter /% Roberts P@% Stapleton AD% et al5 A prospecti6e stud3 of risk factors for s3mptomatic urinar3 tract infection in 3oun) women5 N Dn)l J Med #EE9 !:97-':5han MM5 Dffect of maternal anemia on fetal parameters5 J A3ub Med /oll Abbottabad"00##7-:#5Islam ML% @amber) A/% +hu3an MA% Salamatulla 5 Iron status of premenopausalwomen in two re)ions of +an)ladesh Pre6alence of deficienc3 in hi)h and low socio-economic )roup5 Dur J /lin Nutr "00#!! !E7-90:5+lot &&% Tehernin 25 Iron deficienc3 in pre)nanc3 effects on the newborn5 /urr (pin4ematol #EEE99!-'05

D11D/T (1 MATDRNA@ ANDMIA AT 4I24 A@TIT*&D (N IN1ANT4DMAT(/RIT AN& (,2DNATI(NMARIA D5 RAMIRDL-/AR&I/4% MA,*( SAIT(% R(+DRT 45 2I@MAN% @*IS D5DS/ATD% J(4N J5 STR(*SD% /4RIST(P4DR A+R4D@% /(@@DDN J(4NS(N%RI$A 2A@/4DN% AN& /4RISTIAN T5 +A*TISTAAsociacin +enOfica Pro3ectos en Informtica% Salud% Medicina 3 A)ricultura


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ﾵﾧA+STRA/T4ematocrit le6els were determined in 9 mothers li6in) at hi)h altitudes

http://www.ajtmh.org/cgi/content/full/70/4/420#R1%23R1http://www.ajtmh.org/cgi/content/full/70/4/420#R1%23R1http://www.ajtmh.org/cgi/content/full/70/4/420#R4%23R4http://www.ajtmh.org/cgi/content/full/70/4/420#R4%23R4http://www.ajtmh.org/cgi/content/full/70/4/420#R5%23R5http://www.ajtmh.org/cgi/content/full/70/4/420#R5%23R5http://www.ajtmh.org/cgi/content/full/70/4/420#R8%23R8http://www.ajtmh.org/cgi/content/full/70/4/420#R8%23R8http://www.ajtmh.org/cgi/content/full/70/4/420#R9%23R9http://www.ajtmh.org/cgi/content/full/70/4/420#R9%23R9http://www.ajtmh.org/cgi/content/full/70/4/420#R10%23R10http://www.ajtmh.org/cgi/content/full/70/4/420#R10%23R10http://www.ajtmh.org/cgi/content/full/70/4/420#R4%23R4http://www.ajtmh.org/cgi/content/full/70/4/420#R5%23R5http://www.ajtmh.org/cgi/content/full/70/4/420#R8%23R8http://www.ajtmh.org/cgi/content/full/70/4/420#R9%23R9http://www.ajtmh.org/cgi/content/full/70/4/420#R10%23R10http://www.ajtmh.org/cgi/content/full/70/4/420#R1%23R1


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6a)inal deli6er35 Patients were eCcluded for an3 of the followin) pre-deli6er3complications pre-eclampsia% eclampsia


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and no )ross mo6ements eCcept occasional startles5 The infants were obser6ed for threeminutes in a definable state before collectin) data5 The Sa(" le6els were recorded at one-minute inter6als for a total of #0 minutes durin) each of the three acti6ities5ﾵ9%ﾧﾵ# ﾧ/are was taken to ensure that the pulse rate displa3ed on the oCimeter reflected the heartrate heard b3 stethoscope5 Respirator3 rate was counted b3 auscultation for a one-minute

period durin) ;uiet sleep and the awake state onl35 &ata was re8ected when the infantsacti6it3 was not clearl3 classifiable or when the pulse oCimetr3 was less than 9!G

The newborns had a mean umbilical cord 6enous blood hematocrit of !'5EG


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ﾵﾵﾧﾧ$iew lar)er 6ersion


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ﾵﾧ&IS/*SSI(NThis stud3 demonstrated a hi)h pre6alence of anemia in women )i6in) birth to children

of normal birth wei)ht at hi)h altitudes at a Peru6ian Andean hospital5 In these Peru6ianwomen li6in) at hi)h altitudes% maternal anemia was not a risk factor for newborn anemiaor h3poCemia5Maternal anemia is common in both de6eloped and de6elopin) countries% 3et its effect onneonatal hematocrit le6els has not been well eCplored5 An article from Ni)eriaﾵ#7 ﾧ andone from Turke3ﾵ#E ﾧ demonstrated that low-altitude mothers that are anemic ha6eneonates that are not anemic5 1urthermore% the Turkish stud3 demonstrated that maternalanemia present in women li6in) at low altitudes was attended b3 increased fetaler3thropoietin le6els and increased er3thropoesis5ﾵ#E ﾧ (ur stud3 in Peru is the first todemonstrate that at hi)h altitude maternal anemia does not ad6ersel3 affect either theinfants hematocrit or oC3)en content5 Moreo6er% no infant born to an anemic woman was

anemic% demonstratin) the abilit3 of the fetus to adapt to maternal anemia e6en underconditions of hi)h altitude5The Sa(" le6els of infants born to anemic and non-anemic mothers were similar5 +oththe mother and fetus ha6e se6eral mechanisms for adaptin) to the oC3)en demands of afetus5 (C3)en deli6ered to the fetus depends on utero-placental blood flow% maternal 4b%6entilation% and maternal oC3)en saturation5The in6erse relationship between maternal and newborn hematocrit su))ests that fetalhematopoiesis can successfull3 compensate for maternal anemia5 The fetus ma3 be protected from h3poCemia b3 increased blood flow and impro6ed fetal oC3)en eCtractionoccurrin) as a response to maternal anemia at hi)h altitudes5 &ata demonstratin) thesemechanisms are onl3 a6ailable from studies in sheep5ﾵE%ﾧﾵ#0 ﾧ (ne of the factors thatma3 influence this adaptation ma3 be a )reater hemodilution durin) pre)nanc3 at hi)heraltitudes than that found durin) pre)nanc3 at sea le6el% resultin) in an enhanced placental perfusion5ﾵ#" ﾧ(n the fetal side% at hi)h altitudes newborns ha6e enhanced er3thropoiesis and hi)h le6elsof blood 4b 1% and as a result ha6e much less se6ere intrauterine h3poCia than do children born to women nati6e to low altitudes5ﾵ:%ﾧﾵ"0 ﾧ After birth% althou)h the neonate has ahi)h le6el of 4b 1% its hi)h affinit3 for oC3)en ma3 actuall3 limit the release of oC3)enfrom red blood cells5 In contrast% a postnatal increase in the le6el of "%-diphospho)l3cerate promotes the release of oC3)en from 4b and thus lowers Sa(" for a)i6en partial pressure of arterial oC3)en in the first week of life at sea le6el5 ﾵ"# ﾧInfants in our stud3 had Sa(" cur6es 6er3 similar to infants born to both Tibetan womenand to American women li6in) at a hi)h altitude in @ead6ille% /olorado5 ﾵ9%ﾧﾵ# ﾧ Thedecrease in Sa(" durin) the first week of life and the increase thereafter was consistentwith pre6ious obser6ations with similar eCperimental desi)ns at %9!7 meters and %#00meters5ﾵ9%ﾧﾵ# ﾧ (ur stud3 also demonstrated that throu)hout the four-months of thestud3 period% infants born to anemic mothers did not show an3 difference in their Sa("le6els compared with those born to non-anemic mothers5 This would be eCpected due totheir hi)her 4b le6els5

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Infants had hi)her oC3)enation le6els while awake compared with when feedin) orsleepin)5 This was also reported in pre6ious studies in /olorado% Tibet% +oli6ia% and Peru5ﾵ9%ﾧﾵ#%ﾧﾵ""%ﾧﾵ" ﾧ As such% studies on infants at hi)h altitudes need to standardi.e6alues based on the acti6it3 of the bab35ﾵ#: ﾧMaternal anemia at hi)h altitudes does not ad6ersel3 affect hematocrit or newborn

oC3)en content amon) normal wei)ht infants5 There is a need for studies in neonates thateCamine the mechanism for this successful adaptation at hi)h altitudes5

Recei6ed Jul3 #% "005 Accepted for publication &ecember #0% "005Acknowled)ments Be thank &rs5 Jaime Le)arra% Manuel 2utierre.% /arlton D6ans%@arr3 Moulton% (scar $ille)as% and /ar3n +ern for their ad6ice% J5 +5 Phu and &5 Sara for their technical assistance% and the staff of DsSalud 4ospital of @a (ro3a% especiall3 &r52odofredo Pebe Sala.ar% for their cooperation51inancial support This stud3 was supported b3 the 1o)art3-National Institutes of 4ealthtrainin) pro)ram International Trainin) and Research in Dmer)in) Infectious &iseases)rant &: TB00E#0-0!S#% National Institute of Aller)3 and Infectious &iseases T2-!

)rant AI-0'9:9-0% and the anon3mous R2-DR fund for tropical medicine research5Authors addresses Maria D5 Ramire.-/ardich% @uis D5 Dscate% /hristopher abrhel%/olleen Johnson% Ri6ka 2alchen% and /hristian T5 +autista% A5 +5 PRISMA% /arlos2on.ales "!#% *rb5 Maran)a% San Mi)uel% @ima "% Peru5 Ma3uko Saito% St5 @ukes @ifeScience Institute% E-# Akashicho% /huoku% Tok3o% #0:-7!90% Japan5 Robert 45 2ilman%&epartment of International 4ealth% The Johns 4opkins School of Pubic 4ealth% 9#! North Bolfe Street% Room B!0% +altimore% M& "#"0!% Telephone :#0-9#:-E!E%1aC :#0-9#:-9090% D-mails ﾵr)ilmanV8hsph5edu ﾧ and ﾵr)ilmanVprisma5or)5pe ﾧ 5John J5 Strouse% &epartment of Pediatrics% &i6ision of 4ematolo)3% The Johns 4opkins*ni6ersit3 School of Medicine% ! Rutland Road% +altimore% M& "#"0!5

ﾵﾧRD1DRDN/DS2amboa R% Marticorena D% #E'#5 Presin arterial pulmonar en el reciOn nacido en las)randes alturas5 Arch Inst +iol Andina : !!Q!95ﾵMedline ﾧhalid MD% Ali MD% Ali L% #EE'5 1ull-term birth wei)ht and placental morpholo)3 athi)h and low altitude5 Int J 23naecol (bstet !' "!EQ"9!5ﾵMedline ﾧJensen 2M% Moore @2% #EE'5 The effect of hi)h altitude and other risk factors on birthwei)ht independent or interacti6e effectW Am J Public 4ealth 7' #00Q#00'5ﾵAbstract>1ree 1ull TeCt ﾧ+allew /% 4aas J&% #E795 4ematolo)ic e6idence of fetal h3poCia amon) newborn infantsat hi)h altitude in +oli6ia5 Am J (bstet 23necol #!! 99Q9E5ﾵMedline ﾧLamudio S% &roma T% Nork3el ,% #EE5 Protection from intra-uterine )rowth retardationin Tibetans at hi)h altitude5 Am J Ph3s Anthropol E# "#!Q"":5ﾵISIﾧﾵMedline ﾧ Nierme3er S% ,an) P% Shanmina% &rolkar% Lhuan) J% Moore @2% #EE!5 Arterial oC3)ensaturation in Tibetan and 4an infants born in @hasa% Tibet5 N Dn)l J Med #":7Q #"!"5ﾵAbstract>1ree 1ull TeCt ﾧMoore @2% Lamudio S% Lhuan) J% Sun S% &roma T% "00#5 (C3)en transport in Tibetanwoman durin) pre)nanc3 at %9!7 M5 Am J Ph3s Anthropol #:: :"Q!5

http://www.ajtmh.org/cgi/content/full/70/4/420#R6%23R6http://www.ajtmh.org/cgi/content/full/70/4/420#R6%23R6http://www.ajtmh.org/cgi/content/full/70/4/420#R13%23R13http://www.ajtmh.org/cgi/content/full/70/4/420#R13%23R13http://www.ajtmh.org/cgi/content/full/70/4/420#R22%23R22http://www.ajtmh.org/cgi/content/full/70/4/420#R22%23R22http://www.ajtmh.org/cgi/content/full/70/4/420#R23%23R23http://www.ajtmh.org/cgi/content/full/70/4/420#R23%23R23http://www.ajtmh.org/cgi/content/full/70/4/420#R14%23R14http://www.ajtmh.org/cgi/content/full/70/4/420#R14%23R14mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ajtmh.org/cgi/external_ref?access_num=5162449&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=5162449&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=9215488&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=9215488&link_type=MEDhttp://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=ajph&resid=87/6/1003http://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=ajph&resid=87/6/1003http://www.ajtmh.org/cgi/external_ref?access_num=3089016&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=3089016&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=A1993LC84700006&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=A1993LC84700006&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=8317562&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=8317562&link_type=MEDhttp://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=nejm&resid=333/19/1248http://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=nejm&resid=333/19/1248http://www.ajtmh.org/cgi/content/full/70/4/420#R6%23R6http://www.ajtmh.org/cgi/content/full/70/4/420#R13%23R13http://www.ajtmh.org/cgi/content/full/70/4/420#R22%23R22http://www.ajtmh.org/cgi/content/full/70/4/420#R23%23R23http://www.ajtmh.org/cgi/content/full/70/4/420#R14%23R14mailto:[email protected]:[email protected]://www.ajtmh.org/cgi/external_ref?access_num=5162449&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=9215488&link_type=MEDhttp://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=ajph&resid=87/6/1003http://www.ajtmh.org/cgi/external_ref?access_num=3089016&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=A1993LC84700006&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=8317562&link_type=MEDhttp://www.ajtmh.org/cgi/ijlink?linkType=ABST&journalCode=nejm&resid=333/19/1248


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Moore @2% "00#5 4uman )enetic adaptation to hi)h altitude5 4i)h Alt Med +iol " "!'Q "'E5ﾵMedline ﾧ&elpapa D4% Ddelstone &I% Mille3 JR% +alsan M% #EE"5 Dffects of chronic maternalanemia on s3stemic and uteroplacental oC3)enation in near-term pre)nant sheep5 Am J(bstet 23necol #99 #00'Q#0#"5ﾵMedline ﾧ

Paulone MD% Ddelstone &I% Shedd A% #E7'5 Dffects of maternal anemia on uteroplacentaland fetal oCidati6e metabolism in sheep5 Am J (bstet 23necol #!9 "0Q"95ﾵMedline ﾧ

/apurro 4% orich.k3 S% 1onseca (% /aldeiro-+arcia R% #E'75 A simplified method fordia)nosis of )estational a)e in the newborn infant5 J Pediatr E #"0Q#""5 ﾵISIﾧﾵMedline ﾧ/ohen J4% 4aas J&% #EEE5 4emo)lobin correction factors for estimatin) the pre6alenceof iron deficienc3 anemia in pre)nant women residin) at hi)h altitude in +oli6ia5 Pan AmJ Public 4ealth 9 E"QEE5 Nierme3er S% Shaffer DM% Thilo D% /orbin /% Moore @2% #EE5 Arterial oC3)enation and pulmonar3 arterial pressure

http://www.ajtmh.org/cgi/external_ref?access_num=11443005&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=11443005&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=1550135&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=1550135&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=3799755&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=3799755&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=A1978FE44700032&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=A1978FE44700032&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=650322&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=650322&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=11443005&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=1550135&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=3799755&link_type=MEDhttp://www.ajtmh.org/cgi/external_ref?access_num=A1978FE44700032&link_type=ISIhttp://www.ajtmh.org/cgi/external_ref?access_num=650322&link_type=MED


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SupplementAnemia% Iron and Pre)nanc3 (utcomeﾵ# ﾧ %ﾵ" ﾧTheresa (5 Scholl and Thomas Reill3X

&epartment of (bstetrics and 23necolo)3% *ni6ersit3 of Medicine and &entistr3 of NewJerse3-S(M and X &epartment of Primar3 /are% *ni6ersit3 of Medicine and &entistr3 of New Jerse3-S4RP% Stratford% NJ 0707:To whom correspondence should be addressed5

ﾵﾧ A+STRA/TBhen maternal anemia is dia)nosed before midpre)nanc3% it has been associated with anincreased risk of preterm deli6er35 Maternal anemia detected durin) the later sta)es of pre)nanc3% especiall3 the third trimester% often reflects the eCpected


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ﾵﾧ Maternal anemia durin) earl3 )estation and poor pre)nanc3 outcomeThe relationship between anemia or iron deficienc3 anemia and increased risk of pretermdeli6er3


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than a twofold risk for preterm deli6er3


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deli6ered at later )estational periods5 This report did demonstrate a weak association between anemia earl3 in the third trimester and preterm deli6er35 After 0 wk% anemiawas not associated with an increased risk of preterm deli6er35

ﾵﾧ

4i)h hemo)lobin% ferritin and poor pre)nanc3 outcome2arn et al5 @ for hemo)lobin5Steer et al5 @ was associated with up to a se6enfold increase in risk of low birthwei)ht and fi6efold increase in risk of preterm deli6er35(ther findin)s with hi)h maternal hemo)lobin ha6e been obser6ed earl3 in pre)nanc3% aswell as durin) the third trimester5 Murph3 et al5


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ﾵﾧ Ad6erse effects of iron supplementation(ne concern 6oiced about iron supplementation durin) pre)nanc3 is that because ironalla3s the fall in hemo)lobin durin) pre)nanc3% iron-induced macroc3tosis could increase

blood 6iscosit3 to a de)ree that would impair uteroplacental blood flow% decrease placental perfusion and increase risk of placental infarction


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de6elopment with the potential to cause oCidati6e dama)e to &NA% lipids and protein


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#5 A)arwal 5 N5% A)arwal &5 5% Mishra 5 P5 Impact of anaemia proph3laCis in pre)nanc3 on maternal haemo)lobin% serum ferritin and birth wei)ht5 Indian J5 Med5 Res5#EE#E:"''-"70ﾵMedline ﾧ"5 /enters for &isease /ontrol and Pre6ention /&/ criteria for anemia in children andchildbearin)-a)ed women5 Morb5 Mortal5 Bkl35 Rep5 #E7E7:00-:0:ﾵMedline ﾧ

5 2arn S5 M5% Ridella S5 A5% Pet.oid A5 S5% 1alkner 15 Maternal hematolo)ic le6els and pre)nanc3 outcomes5 Semin5 Perinatol5 #E7#!#!!-#9"ﾵMedline ﾧ:5 2oldenber) R5 @5% Mercer +5 M5% Miodo6nik M5% Thurnau 25 R5% Meis P5 J5% MoawadA5% Paul R5 45% +ottoms S5 15% &as A5% Roberts J5 M5% McNellis &5% Tamura T5 Plasmaferritin% premature rupture of membranes% and pre)nanc3 outcome5 Am5 J5 (bstet523necol5 #EE7#'E#!EE-#90:ﾵMedline ﾧ!5 2oldenber) R5 @5% Tamura T5% &u+ard M5% Johnston 5 D5% /opper R5 @5% Ne))ers ,5Plasma ferritin and pre)nanc3 outcome5 Am5 J5 (bstet5 23necol5 #EE9#'!#!9-#!EﾵMedline ﾧ95 2utterid)e J5M5/5% 4alliwell +5 AntioCidants in Nutrition% 4ealth and &isease #EE:(Cford *ni6ersit3 Press New ,ork% N,5

'5 4emminki D5% Rimpela *5 Iron supplementation% maternal packed cell 6olume% andfetal )rowth5 Arch5 &is5 /hild5 #EE#a99:""-:"!ﾵAbstract>1ree 1ull TeCt ﾧ75 4emminki D5% Rimpela *5 A randomi.ed comparison of routine 6ersus selecti6e ironsupplementation durin) pre)nanc35 J5 Am5 /oll5 Nutr5 #EE#b#0-#0ﾵAbstract ﾧE5 4emminiki D5% Starfield +5 Routine administration of iron and 6itamins durin) pre)nanc3 re6iew of controlled clinical trials5 +r5 J5 (bstet5 23naecol5 #E'77!:0:-:#0ﾵMedline ﾧ#05 Institute of Medicine% /ommittee on Nutritional Status durin) Pre)nanc3 and@actation Nutrition durin) Pre)nanc3 #EE0"'"-"E7 National Academ3 PressBashin)ton% &/5##5 lebanoff M5 A5% Shiono P5 45% +erendes 45 B5% Rhoads 25 25 1acts and artifactsabout anemia and preterm deli6er35 J5 Am5 Med5 Assoc5 #E7E"9"!##-!#!ﾵAbstract ﾧ#"5 lebanoff M5 A5% Shiono P5 45% Selb3 J5 $5% Trachtenber) A5 I5% 2raubard +5 I5 Anemiaand spontaneous preterm birth5 Am5 J5 (bstet5 23necol5 #EE##9:!E-9ﾵMedlineﾧ

Maternal Anemia A Pre6entable iller

http://jn.nutrition.org/cgi/external_ref?access_num=1959958&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=1959958&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=2542755&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=2542755&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=7198826&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=7198826&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=9855604&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=9855604&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=8942514&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=8942514&link_type=MEDhttp://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=archdischild&resid=66/4_Spec_No/422http://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=archdischild&resid=66/4_Spec_No/422http://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jamcnutr&resid=10/1/3http://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jamcnutr&resid=10/1/3http://jn.nutrition.org/cgi/external_ref?access_num=350260&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=350260&link_type=MEDhttp://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jama&resid=262/4/511http://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jama&resid=262/4/511http://jn.nutrition.org/cgi/external_ref?access_num=1986627&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=1986627&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=1959958&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=2542755&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=7198826&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=9855604&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=8942514&link_type=MEDhttp://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=archdischild&resid=66/4_Spec_No/422http://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jamcnutr&resid=10/1/3http://jn.nutrition.org/cgi/external_ref?access_num=350260&link_type=MEDhttp://jn.nutrition.org/cgi/external_ref?access_num=350260&link_type=MEDhttp://jn.nutrition.org/cgi/ijlink?linkType=ABST&journalCode=jama&resid=262/4/511http://jn.nutrition.org/cgi/external_ref?access_num=1986627&link_type=MED


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Iron deficienc3 is one of the most pre6alent nutritional deficiencies inthe world and is reported b3 theBorld 4ealth (r)ani.ation


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anemia underscore the ur)ent needto refocus resources and public health priorities to more effecti6el3 tackle the problem5#5 Anemia and iron deficienc3

are hi)hl3 pre6alent conditionswith ma8or conse;uences for health% sur6i6al% and economicde6elopmentAnemia pre6alence is hi)hest amon) pre)nant women% infants% and 3oun)children due to the hi)h iron demandsof )rowth and pre)nanc35 (n a6era)e%:!G of pre)nant women and :EG of # Mason% Ri6ers and 4elwi)5 Recent trends in malnutrition in de6elopin) re)ions$itamin A deficiencies%

anemia% iodine deficienc3% and child underwei)ht%K 1ood and Nutrition +ulletin "9 !'-#9"% "00!5chidren under fi6e 3ears of a)e areanemic in de6elopin) re)ions5# Theconse;uences of anemia includeY Increased maternal and perinatalmortalit3Y Increased numbers of preterm birth and>or low birthwei)htY Impaired co)niti6e de6elopment inchildrenY Reduced adult work producti6it34ence% anemia pre6ention pro)ramscan contribute si)nificantl3 to achie6in)man3 of the Millennium &e6elopment2oals


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AnemiaIron &eficienc3Anemia1i)ure # Iron deficienc3% iron deficienc3 anemia

AI&S and other infectious diseases/(NSD*DN/DSY Increasedmaternal and perinatalmortalit3Y Increasednumbers of preterm birth and>or low birthwei)htY Impairedco)niti6ede6elopmentY Reduced work producti6it3)lobal burden of disease5 RecentB4( anal3sis of causes of maternaldeath showed that hemorrha)e is thema8or contributor to maternal deathsin de6elopin) countries5"In a separate anal3sis% iron deficienc3anemia


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increased mortalit3 risk5 Pre6iousestimates of the number of women atincreased risk of death associated withanemia onl3 considered those womenwith se6ere anemia5 In li)ht of the

meta-anal3sis results% more pre)nantwomen are estimated to be at risk%since the ma8orit3 of anemic womenha6e hemo)lobin concentrations between ' and #" )>d@


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#:G*nsafe Abortion!G*nclassified9G

(bstructed@abor 'G(ther &irect/auses !GSepsis ##G43pertensi6e&isorder #0GAnemia7G&eathsAssociated

with I&A""G1i)ure "5 /auses of Maternal &eath" and /ontribution of Iron&eficienc3 Anemia


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Importance b3 Re)ione3l hi)h6 medium

t low:5 nowin) the 6arious causes of anemia in a tar)et population isthe first step in desi)nin) tailoredinter6ention strate)iesThe main causes of anemia includeY inade;uate intake and poor absorption of ironY malaria% particularl3 in 3oun)children and pre)nant womenY hookworms

Y diarrhea% 4I$>AI&S and other infectionsY )enetic disorders women of reproducti6e a)ewhen the3 are applied effecti6el3 toa population with known causes of anemia5Y *ni6ersal supplementation of pre)nant women with dail3 ironfolic acid tablets9


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Y 1ortification of commonl3consumed food products withmicronutrients'Y /ontrol of malaria b3 intermittent pre6enti6e treatment


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Y Partners for Parasite /ontrolen>?Y 2lobal 1und for AI&S% Tuberculosisand Malaria )ac?This report is the product of a collaboration amon) *SAI&s A"L Micronutrient and/hild +lindnessPro8ect% A//DSS Pro)ram% and 1ood and Nutrition Technical Assistance


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and counselin) work to supportwomen5Y Supplies of iron>folic acidsupplements


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75 Pro)ress of anemia pro)ramsis bein) monitoredTo monitor the pro)ress of anemia pro)rams at the national le6el% the&emo)raphic and 4ealth Sur6e3


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# &widedi and Schultink5 Reducin) anemiaamon) Indian adolescent )irls throu)h once-weekl3supplementation with iron and folic acid%K S/N News##E-"% "0095Au)ust "009

:1I2*RD 5 Nicara)ua Pre6alenceof anemia in mothers>care)i6ers#EE% "000 _ "00Source SI$IN "00:��

33.6

23.716.1

Percentage Hb < 12 g/dL


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Review article

Progestogen-only contraceptive use amongwomen

with sicle cell anemia! a systematic review "enni#er $% Legardy&' $athryn (% )urtis*H+ )ollaborating )enter in Reproductive Health' ,ivision o# Reproductive Health' )enters #or ,isease)ontrol and Prevention' tlanta' . 01' 3Received 24 "uly 20056 accepted 11 ugust 2005bstract &he use o# progestogen-only contraceptives among women with sicle cell anemia hasgenerated concerns about possible hematologicaland other clinical complications% 7ased on the literature' we assessed whether use o#progestogen-only contraceptives is associated withadverse health e8ects among women with sicle cell anemia% *e searched the (9,L:;9database #or articles published in peer-reviewed ournals between 1=>> and 3eptember 200 that were relevant to sicle cell anemia and useo# progestogen-only contraceptives% +# the

40 articles identi?ed through the search' @ met the criteria #or this review% &hese studies didnot identi#y any adverse events or clinically orstatistically signi?cant adverse changes in hematological or biochemical parametersassociated with the use o# progestogen-onlycontraceptive methods% 3iA studies suggested that users eAperienced a decrease in clinicalsymptoms and less #reBuent and severe pain#ulcrises compared with nonusers% lthough data are limited' these studies suggest thatprogestogen-only contraceptives are sa#e #or womenwith sicle cell anemia%, 200> 9lsevier :nc% ll rights reserved%$eywords! 3icle cell anemia6 Progestogen6 )ontraception6 3ystematic review1% :ntroduction3icle cell disease is caused by the pairing o# an inheritedautosomal recessive gene Ch-globinD' which a8ects the redblood cells E1'2F% ,eoAygenation o# the red blood cellscauses these cells to change #rom their normal round shapeto a rodlie sicle shape% &hese sicle-shape cells adhere tothe blood vessels' eventually clogging the vessels andblocing normal Gow o# blood and oAygen to organs andtissue% +# the several #orms o# this disease' the mostcommon and severe is sicle cell anemia% Primarily' peopleo# #rican and (editerranean ancestry are a8ected by thedisease and o#ten are carriers o# the trait% 7ased on statistics#rom the ;ational Heart' Lung' and 7lood :nstitute' in thenited 3tates' approAimately 1 in every 500 #ricanmerican babies and 1000100 Hispanic merican babiesare diagnosed with this disease each year% &he sicle celltrait Cone copy o# the gene that causes sicle cell anemiaD ispresent in an estimated 2 million mericans EF% &hemedical complications that arise #rom this disease includechronic anemia' episodes o# musculoseletal pain orbcrises'I acute chest syndrome and stroe% :n addition'sicle cell disease in women has been associated withsigni?cant maternal morbidity and mortality E'5F%sing contraception and becoming pregnant are maordecisions #or a woman with sicle cell anemia because o# the related medical complications% Historically' it has been


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recommended that women with sicle cell anemia avoidpregnancy' become sterile or have an abortion because o# the increased ris o# maternal and #etal mortality E'5F%(aternal and perinatal mortality rates associated with siclecell disease have declined signi?cantly over time' due toadvancements in medical technology and obstetric and

perinatal care% However' a recent study showed that womenwith sicle cell anemia still have an increased ris o# pregnancy complications' such as premature rupture o# themembranes' preterm labor' antepartum admission andpostpartum in#ections E5F%*omen with sicle cell anemia who want to avoidpregnancy need to have appropriate and reliable counselingregarding contraceptive use% However' there have not beenany clear universal guidelines established #or contraceptive0010-4@2/J see #ront matter , 200> 9lsevier :nc% ll rights reserved%doi!10%101>/%contraception%2005%0@%010

& )orresponding author% &el%! K1 440 @@ >516 #aA! K1 440 @@>=1%9-mail address! legardycdc%gov C"%$% LegardyD%)ontraception 4 C200>D 1=5 20

use among these women% &raditionally' sicle cell diseasehas been considered a contraindication to the use o# combined oral contraceptives C)+)sD' especially in 9uropeE>F% Met' evidence is limited regarding the e8ects o# )+)use in this population E2'>@F% &he *orld Health +rganiNationC*H+D currently classi?es sicle cell anemia as a)ategory 2 #or )+)s' meaning that the bene?ts o# )+) useamong women with this condition generally outweigh thetheoretical or proven riss E=F% &here have also beenconcerns about the sa#ety o# using intrauterine devicesC:,sD #or women with sicle cell disease' but studies haveshown that copper :,s are a sa#e method o# contraception#or these women E>'10F% :n addition' *H+ classi?es sicle

cell anemia as )ategory 1 #or :, use' meaning there is norestriction #or their use E=F% Oor progestogen-only contraceptivesCi%e%' pills' inectables and implantablesD' possiblehematological and other clinical complications are the maorconcerns regarding the use o# these contraceptives amongwomen with sicle cell anemia%*e conducted this systematic review in preparation #oran 9Apert *oring .roup o# international #amily planningeAperts convened by *H+ in +ctober 200 to develop andrevise medical eligibility criteria #or contraceptive use% :nthis report' we evaluate the scienti?c evidence regardingwhether women with sicle cell anemia eAperience adversehealth e8ects while using progestogen-only contraceptives'

as well as provide the *H+ recommendations that werederived in part #rom this evidence% *e considered the#ollowing progestogen-only contraceptive methods! ;orplantand ;orplant-2 or "adelle Clevonorgestrel-releasingcontraceptive implantsD' :mplanon Cetonogestrel-releasingcontraceptive implantsD' niplant Cnomegestrol acetatereleasingcontraceptive implantsD' depot medroAyprogesteroneacetate C,(PD inectables' norethisterone enanthateC;9&-9;D inectables and progestogen-only contraceptive


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pills Cany #ormulationD%2% (aterials and methods*e searched the (9,L:;9 database #or articles Cin alllanguagesD published in peer-reviewed ournals #rom 1=>>to 3eptember 200% 3earch terms included bsicle celldiseaseI or banemiaI along with the #ollowing terms! CaD

depot and medroAyprogesterone 14-acetate or medroAyprogesteroneacetate' CbD ,(P' CcD progestogen-only contraceptionor progestational hormones or progestogen and onlyand contraceptive agents' CdD norethisterone-enanthate' CeD;9& 9;' C#D contraception' CgD contraception or #emalecontraception' ChD implants' CiD ;orplant' CD niplant' CD "adelle' ClD :mplanon' CmD levonorgestrel' CnD etonogestrel'and CoD e8ects and contraceptive agents or contraceptives%*e also searched the re#erence lists o# the articlesidenti?ed by the electronic search and letters to the editorto identi#y additional relevant articles% *e did not considerunpublished manuscripts' dissertations or abstracts #romscienti?c con#erences%2%1% 3tudy selection3eventy articles were identi?ed by searching (9,L:;9and by reviewing re#erence lists% 9ight o# the 40 articlesmatched the goal o# the review' which was to evaluate healthoutcomes related to progestogen-only contraceptive useamong women with sicle cell anemia% &hese articles wereselected a#ter reviewing the titles' abstracts and articles% &heeight articles eAamined the sa#ety o# using di8erentprogestogen-only contraceptive methods among womenwith sicle cell anemia' including clinical and otherhematological e8ects%2%2% 3tudy Buality assessment*e summariNed and systematically assessed the evidenceusing a standard abstract #orm% 9ach article was reviewed#or Buality using a preliminary dra#t o# the grading systemdeveloped by the .rades o# Recommendation ssessment',evelopment and 9valuation C.R,9D *oring .roupCppendiA D E11F%2%% ,ata synthesis &his review includes two randomiNed controlled trialsCR)&sD' two non-randomiNed controlled trials' two prospectivecohort studies and two cross-sectional studies C &able 1D%,ue to the overall low prevalence o# sicle cell anemia in thegeneral population' the sample siNes o# these studies weresmall% &he studies reported means and standard deviations'percentages or Bualitative results' so summary odd ratioswere not calculated%

% Results%1% :mplantables C;orplant' ;orplant-2' "adelle andniplantD prospective cohort study conducted in ;igeriaevaluated the sa#ety o# ;orplant use among 25 womenwith homoNygous sicle cell anemia E12F% &hese womenwere #ollowed #or a mean o# 12 months a#ter insertion%+utcomes were measured pre- and postinsertion #or eachwoman' and the women served as their own controls% t


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baseline' these women had not eAperienced a pain#ul crisisor serious in#ection in the past month6 had no clinicalevidence o# gall bladder disease6 and had no history orevidence o# aplastic crisis' diabetes' bleeding disorders'myocardial in#arction' stroe or severe liver' renal' seletal'pulmonary' sin or ocular disease% :nsertion o# the ;orplant

did not cause any serious or uneApected adverse sidee8ects% 7y using paired t tests' this study showed nostatistically signi?cant changes a#ter ;orplant was insertedin the means o# any o# the ?ve biochemical and siAhematological parameters measured% Oor eAample' the #etalhemoglobin CHbOD percent Chematological parameterD preandpostinsertion mean was %1 and %' respectively% Oorthe serum albumin Cbiochemical parameterD' the preandpostinsertion mean was %@ and %=' respectively% &his study

"%$% Legardy' $%(% )urtis / )ontraception 1=> 4 C200>D 1=520had a high retention rate C2/25 participantsD that allowed#or @0 power to detect an adverse event occurring in 4o# the participants%:n two studies conducted in 7raNil' which eAamined thee8ects o# niplant' no adverse e8ects were reported amongwomen with sicle cell anemia% &en otherwise healthywomen o# reproductive age with sicle cell anemia wereenrolled in a 1-year' prospective cohort study to eAamine thee8ects o# using niplant on carbohydrate metabolism E1F% &hese participants had no contraindications to hormonalcontraceptives and had not used a hormonal contraceptive inthe past > months% &he outcomes o# interest were glucosetolerance and insulin levels' measured pre- and postinsertion'and the women served as their own controls% Participants didnot eAperience any changes in these outcomes during thestudy period% &he womenQs #asting glycosylated hemoglobinlevels be#ore insertion ranged #rom 44 to =0 mg/dl' and by

the end o# the study' their levels were 4> to = mg/dl%3imilarly' the serum insulin levels did not vary signi?cantlypre- and postinsertion% non-randomiNed controlled trialassessed the sa#ety and clinical e8ects o# niplant useamong 0 women with sicle cell anemia C20 niplant usersand 10 nonusersD E1F% *omen who received niplantshowed a signi?cant decline in the number o# clinicalsymptoms Ce%g%' headaches' body weaness and limb painD'had no pain#ul crises in the ?rst > months o# #ollow-upcompared to the control group C50 and 0 at 1 and months' respectivelyD' and a#ter >-months' both groupseAperienced in#reBuent mild crises% #ter analyNing thehematological and biochemical parameters' only one parameter

showed a signi?cant change% :n the niplant group' theO-cell percentage' which is the proportion o# red blood cellswith HbO' increased during 1 year o# #ollow-up C>%> and1%0 at baseline and 12 months' respectivelyD comparedwith the nonuser group C%> and %1' respectivelyD%%2% :nectables C,(P and ;9&-9;D+ne non-randomiNed controlled trial compared the e8ectso# ,(P with a )+) C(icrogynonD on the #reBuency andintensity o# pain#ul crises in homoNygous sicle cell


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patients E15F% &his trial was conducted at the *H+)ollaborative )entre #or Research contraceptive clinic inPanama% &hirteen women received ,(P' 1 received)+)s and 1> were controls% lthough authors state thatthe groups were randomly assigned' the process is unclearbecause the third group consisted entirely o# surgically

steriliNed patients% &here were no signi?cant di8erencesbetween the three groups in their hematological parametersduring #ollow-up% However' 50 o# women in the ,(Pgroup were pain #ree by months and 40 in this group by12 months% &his eAperience was similar in the )+) group'but at lower rates C24% at months and 55%5 at 12monthsD% Oor the control group' @ and 50 were pain #reeby and 12 months' respectively%n R)& that included a crossover period assessed thehematological and clinical e8ects o# ,(P use on homoNygoussicle cell disease patients in "amaica E1>F% &wenty-?vewomen were enrolled at a hospital #or a 2-year period%*omen received three inections o# either ,(P or saline at-month intervals' and then eAperienced a >-month washoutperiod% #ter the washout period' they received threeinections' months apart' o# the alternate preparation6 theorder o# the administration was randomly chosen% *omeneAperienced rises in their average level o# #etal HbO' totalhemoglobin' red cell count' red cell mass and red cell survivalwhile using ,(P% ,uring the ,(P phase' the mean andstandard deviation #or the red cell count at baseline was0%= C0%14D and at 0 wees was 1%0 C0%1@D compared to theplacebo phase during which no signi?cant change occurredbetween the time intervals% Results also showed decreases inreticulocytes' irreversibly sicle cell C:3)D counts and totalbilirubin levels during the ,(P phase o# the study% ,uringthe 0-wee period' 2= and 5= episodes o# bone pain wereeAperienced by >1 o# the women in the ,(P phaseand @4 o# the women in the placebo phase' respectively%*e did not identi#y any studies evaluating use o# ;9&-9; among women with sicle cell disease%%% ll progestogen-only contraceptives &wo cross-sectional studies showed no adverse e8ectsamong women with sicle cell disease and use o# varioustypes o# contraceptives Ci%e%' )+)s' ,epo-Provera and:,sD% study o# 0 women with sicle cell disease attwo London hospitals eAamined the e8ects o# estrogen andprogestogen contraceptives on the red cell de#ormability atatmospheric partial oAygen pressure C p+2D E14F% &his crosssectionalstudy divided women into three categories! women

not using eAogenous hormones' women using monophasic)+) pill C)+)D and women using progestogen-only contraceptives%Participants using progestogen-only contraceptivesCtype not speci?edD eAperienced a lower mean cloggingrate C2%5O0%4D compared with the )+) group C%0O1%>Dand control group C%O0%4D% &he red cell transit time#or the progestogen-only group was 2%>O0%4 comparedwith the control group C2>%>O14%=D6 however' the )+)group red cell transit time was lower than progestogen-only


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% :), Cn _2@D!?ve in#ected'11 menorrhagia'none discontinued1% Large samplesiNe2% 9Aamineddi8erenttypes o# contraceptives1% )annotassesstemporalassociation2% )riseswere not

measure#or everyc o n t r a c ep t i v etypeLowCcontinued on neAt pageD

"%$% Legardy' $%(% )urtis / )ontraception 4 C200>D 1=520 201 &able 1 CcontinuedDuthor CyearD +bective 3tudy design +utcome Results 3trengths *eaness .radingo# Bualitydadevoh and:saacsC1=4D E1=F(easuring thee8ects o# progestationalagent on sicling

in vitro a#ter oraladministrationR)& with crossover conducted6>-wee period o# each placebogroup CvitaminsD and megestrolacetate6 eight teenage ;igerianpatients6 seven #emales and onemale with sicle cell anemia%;one o# the sicle patients werein crisis and pain #ree in thepreceding month' had notreceived a blood trans#usion inthe preceding year and were notsu8ering #rom other disease6recruited at the niversity)ollege Hospital' :badan' sicle

anemia clinicPercent sicling in vitroand the number o# patientswho improved weremeasured1% +verall'sicling occurredhigher amongmegestrol acetatepatients at 1-hperiod2% :ndividual sicling


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rates were the sameas the group rates#or the megestrolacetate group% &he irreversible sicledcells in the subectsdo not appear to bea8ected by

megestrol acetate1% R)& 1% *ashout periodwas notdescribed2% RandomiNationwas notdescribed% 3mall samplesiNe% ,i8erentdoses wereadministeredthat were notconsistent withtypicalcontraceptive

dosageÊery lowP)Ê' paced cell volume6 ()Ê' mass cell volume6 H,L' high-density lipoprotein6 Hb' hemoglobin 6 Hb'hemoglobin6 ()H)' mean corpuscular hemoglobin concentration6 :3)' irreversibly sicled cells6HbO' #etal hemoglobin%

"%$% Legardy' $%(% )urtis / )ontraception 202 4 C200>D 1=520placebo or vice versa% )apsules o# 500 g megestrol acetatewere administered once a wee #or 1 wee' then twice in thesecond wee and daily in the third wee% multivitamin'which was used as the placebo' was administered on thesame schedule% &he megestrol acetate did not cause anyadverse e8ects among sicle cell anemia patients' and it didnot seem to a8ect the irreversibly sicled cells% ;one o# themegestrol acetate patients eAperienced bone pain during thestudy compared to 50 o# the placebo group whoeAperienced mild bone pain%% ,iscussion+verall' these studies #ound no clinically or statisticallysigni?cant adverse e8ects associated with progestogen-onlycontraceptive use among women with sicle cell disease% :n#act' several studies suggested that progestogen-onlycontraceptive users had signi?cantly better outcomes whencompared to nonusers% &he results #rom a maority o# thestudies reported that clinical symptoms Ce%g%' pain#ul crises'headache' body weanessD improved during the time inwhich the participants were receiving the progestogen-onlycontraceptive E11>'1@'1=F% :mprovements in biochemicaland hematological parameters Ci%e%' red cell de#ormability'HbO'clogging rate and red cell transit timeD were also reported% &his systematic review is limited by the number o# studies that were available% :n addition' the design' methodso# analysis and methods #or measuring the hematologicaland clinical complications associated with taing progestogen-only contraceptives varied #rom study to study% ;evertheless'the overall methodological Buality o# the studieswas considered to be bintermediate%I 3even o# the eightstudies reviewed had small sample siNes' but the retention


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rate #or these studies was relatively high E1214'1=F%lthough the studies had limitations' the overall ?ndingsare consistent in showing no negative e8ects associatedwith using progestogen-only contraceptives among womenwith sicle cell disease% 3ome evidence suggested thatit may be bene?cial Cclinically and biochemicallyD #or

this population to use progestogen-only contraceptives%7ased in part on these ?ndings' the *H+ has recommendedthat sicle cell anemia be classi?ed as a )ategory 1 #orprogestogen-only contraceptives' meaning that there are norestrictions #or use o# these contraceptives among womenwith sicle cell anemia E=F%cnowledgments &his review was supported by resources #rom the *orldHealth +rganiNation' the %3% )enters #or ,isease )ontroland Prevention C),)D' %3% gency #or :nternational,evelopment C3:,D and the %3% ;ational :nstitute o# )hild Health and Human ,evelopment C;:)H,D% &he ?ndings and conclusions in this report are those o# the authorCsD and do not necessarily represent the views o# the #unding agencies%ppendiA % 3tudy Buality assessment:ndividual study! 9ach study was given a rating o# verylow' low' intermediate or high based on the interval validityo# the study% :# the study was indirect' the Buality o# theindividual study was lowered by one level% :# the study wasdirect' the Buality o# evidence was ept the same% 3imilarly'i# there was sparseness o# the data' the Buality o# theindividual study was lowered by one level%7ody o# evidence! &he Buality o# the body o# evidencewas the highest rating given to an individual study% :# theresults were inconsistent' then the Buality o# the body o# theevidence was lowered by one level% :# results wereconsistent' then the Buality o# the body o# the evidencewas le#t at the original level% 3imilarly' i# there was reportingbias Cpublication biasD' then the Buality o# the body o# evidence would be lowered by one level%Re#erencesE1F shley-$och ' Mang I' +lney R3% 3icle hemoglobin CHb 3D alleleand sicle cell disease! a Hu.9 review% m " 9pidemiol 20006151!@=5%E2F Oreie H(% 3icle cell diseases and hormonal contraception% cta+bstet .ynecol 3cand 1=@6>2!211 4%Iuality o# evidence across the studies #or each mainoutcomeR)& Iuality o# the evidence

+bservationalstudies;o serious Gaws instudy BualityHigh 9Atremely strongassociation and nothreats to validity3erious Gaws in designor eAecution


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or Buasi-eAperimentaldesign:ntermediate 3trong and consistentassociation andno plausiblecon#ounders

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Tugas Inggris 3 Session 2