Serum ferritin thresholds for the diagnosis of iron deficiency in pregnancy: a systematic review

Abstract

The aim of this review was to understand the landscape of serum ferritin in diagnosing iron deficiency in the aetiology of anaemia in pregnancy. Iron deficiency in pregnancy is a major public health problem leading to the development of anaemia. Reducing the global prevalence of anaemia in women of reproductive age is a 2025 global nutrition target. Bone marrow aspiration is the gold standard test for iron deficiency but requires an invasive procedure; therefore, serum ferritin is the most clinically useful test. We undertook a systematic search of electronic databases and trial registers from inception to January 2016. Studies of iron or micronutrient supplementation in pregnancy with pre-defined serum ferritin thresholds were included. Two independent reviewers selected studies, extracted data and assessed quality. There were 76 relevant studies mainly of observational study design (57%). The most commonly used thresholds of serum ferritin for the diagnosis of iron deficiency were <12 and <15 ng mL^-1 (68%). Most primary studies provided no justification for the choice of serum ferritin threshold used, but 25 studies (33%) used thresholds defined by expert consensus in a guideline development process. There were five studies (7%) using a serum ferritin threshold defining iron deficiency derived from primary studies of bone marrow aspiration. Unified international thresholds of iron deficiency for women throughout pregnancy are required for accurate assessments of the global disease burden and for evaluating effectiveness of interventions addressing this problem.

Keywords: iron deficiency; pregnancy; serum ferritin.

Figure 1

Flow chart of studies included in this systematic review of serum ferritin thresholds defining iron deficiency in pregnancy.

Figure 2

Quality assessment of studies included in the review of serum ferritin thresholds defining iron deficiency in pregnancy. Based on a quality assessment tool comprising of six questions described in the Methods section.

Figure 3

World map demonstrating the geographical distribution of serum ferritin thresholds used in studies of iron or multiple micronutrient supplementation in pregnancy. Shaded areas demonstrate countries contributing data to this systematic review.

Figure 4

Histogram of serum ferritin (ng mL⁻¹) thresholds defining iron deficiency in pregnancy, arranged by study design. *A threshold of <12 ng mL⁻¹ for antenatal women and <15 ng mL⁻¹ for post‐natal women was used in this study.