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Peter Kranke, MD, MBA, MME, and colleagues call for clarifications to the August 2024 recommendations with more real-world considerations.
Clinicians have called on the United States Preventive Services Task Force (USPSTF) to clarify its recommendations for and to advocate for universal screening of iron deficiency screening in pregnant women in a letter published today in JAMA.1
“In view of the simple treatment option, we recommend early detection and treatment of iron deficiency in pregnancy, including the use of intravenously administered iron when necessary, to prevent adverse maternal and fetal outcomes,” Peter Kranke, MD, MBA, MME, University Hospital Würzburg, Germany, and colleagues wrote in the letter.1
The letter comes after the USPSTF published its final recommendation statement for iron deficiency screening in pregnancy in August 2024.2 Its recommendation stated that the current evidence is insufficient to evaluate the benefits and harms of screening and routine iron supplementation for iron deficiency and iron deficiency anemia during pregnancy to prevent adverse maternal and infant health outcomes.
The Grade I statement recommendations apply to asymptomatic pregnant adolescents and adults but do not apply to those who are severely malnourished, have symptoms of iron deficiency or anemia, or have specific hematologic conditions or nutritional deficiencies that may increase the need for iron intake.
“This recommendation is consistent with the 2015 recommendation statement on screening and supplementation for iron deficiency anemia in pregnancy,” wrote Wanda K. Nicholson, MD, MPH, MBA, Milken Institute of Public Health, George Washington University.2 “In 2015, the USPSTF concluded that the current evidence was insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes (I statement).”
To search for evidence supporting iron deficiency screening in pregnant women, the USPSTF performed a search in the Ovid MEDLINE and Cochrane databases through May 2023 and surveillance through May 2024, which yielded 17 trials (n = 24,023) on maternal iron supplementation.3
While data showed that iron supplementation was linked to a lower risk of maternal iron deficiency anemia and iron deficiency at term, compared with placebo or no iron supplementation, no statistically significant differences in maternal quality of life, gestational diabetes, maternal hemorrhage, hypertensive disorders of pregnancy, cesarean delivery, preterm birth, infant low birth weight, or infants small for gestational age were observed. Thus, the USPSTF could not make a conclusive recommendation but urged clinicians to use their clinical judgment when screening for iron deficiency and anemia or providing routine iron supplementation during pregnancy.2
In the new letter Kranke and colleagues stressed that while no randomized trials gave conclusive evidence of routine screening’s benefit, the real-world impact of not screening could be significant.1 They point out that clinician judgment may leave pregnant women with iron deficiency undetected, as the symptoms of iron deficiency and iron deficiency anemia, including fatigue, muscle weakness, and cognitive disturbances, often overlap with over pregnancy symptoms. Notably, they point out that the JAMA Patient Page defines anemia as having symptoms including fatigue, weakness, and shortness of breath, and this definition includes almost all pregnant patients.
In view of the adverse effects of iron deficiency anemia and the natural history of untreated iron deficiency to progressing anemia, we are convinced that virtually all pregnant individuals would benefit from screening,” Kranke and colleagues wrote.1