Maternal malnutrition during pregnancy among women with sickle cell disease

Paiva, Leticia Vieira; Igai, Ana Maria Kondo; Nomura, Roseli Mieko Yamamoto

doi:10.1590/1806-9282.20230967

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Revista da Associação Médica Brasileira

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Original Article • Rev. Assoc. Med. Bras. 69 (12) • 2023 • https://doi.org/10.1590/1806-9282.20230967 copy

Maternal malnutrition during pregnancy among women with sickle cell disease

Authorship SCIMAGO INSTITUTIONS RANKINGS

SUMMARY

OBJECTIVE:

The objective of this study was to compare the nutritional status and dietary intake of pregnant women with sickle cell disease (SS hemoglobinopathy and SC hemoglobinopathy) to healthy controls and report the maternal and perinatal outcomes.

METHODS:

This is a prospective, longitudinal cohort study. Pregnant women with a diagnosis of sickle cell disease and control group were recruited in an outpatient clinic of a tertiary care hospital in São Paulo, Brazil. Maternal anthropometric data and dietary intake data were collected at the second and third trimesters.

RESULTS:

A total of 49 pregnancies complicated by sickle cell disease were included. Prepregnancy body mass index was significantly lower in the SS hemoglobinopathy group (n=26, median 20.3 kg/m²) than the SC hemoglobinopathy group (n=23, 22.7 kg/m²) or control group (n=33, 23.2 kg/m², p<0.05). The prepregnancy nutritional status revealed significantly more women classified as underweight in the SS hemoglobinopathy group (15.4%) than in the SC hemoglobinopathy group (4.4%) and control group (1.6%, p=0.009). In the second trimester, maternal protein intake was significantly lower in SS hemoglobinopathy (73.2 g/day) and SC hemoglobinopathy (68.8 g/day) than in the control group (95.7 g/day, p=0.004). In the third trimester, only SS hemoglobinopathy mothers showed dietary intake of protein significantly lower than that of the controls (67.5 g/day vs. 92.8 g/day, p=0.02). Vitamin A and E consumption was also reduced in the third trimester in the SS hemoglobinopathy group (p<0.05).

CONCLUSION:

The nutritional status of pregnant women with SS hemoglobinopathy is characterized by a state of undernutrition. The lower protein intake in the second and third trimesters of pregnant women with SS hemoglobinopathy may contribute to this condition. Undernourishment is a serious complication of sickle cell disease, primarily during pregnancy, and it should be addressed during the prenatal period.

KEYWORDS:
Nutrition disorders; Sickle cell disease; Pregnancy complication; Anemia

Characteristics		HbSS (n=26)	HbSC (n=23)	Control (n=63)	p
Maternal age, years		25.5 (17–34)	25.0 (19–44)	28.0 (18–39)	0.367
Nulliparous women		16 (61.5)	13 (56.5)	38 (60.3)	0.626
Education
	Elementary school	14 (53.8)	8 (34.8)	26 (41.3)	0.376
	High school/college	12 (46.2)	15 (65.2)	37 (58.7)
Prepregnancy BMI (kg/m²)		20.3 (16.4–26.3)	22.7 (17.4–27.6)	23.2 (18.0–37.2)	<0.001^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Prepregnancy nutritional status
	Underweight	4 (15.4)	1 (4.4)	1 (1.6)
	Eutrophic	20 (76.9)	15 (65.2)	38 (60.3)	0.009
	Overweight/obese	2 (7.7)	7 (30.4)	24 (38.1)
BMI in late pregnancy (kg/m²)^b b 25 cases of HbSS and 22 cases of HbSC (one case of miscarriage was excluded in each group).		23.1 (19.1–31.1)	26.1 (22.1–34.8)	28.5 (22.2–41.5)	<0.001^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Nutritional status in late pregnancy^b b 25 cases of HbSS and 22 cases of HbSC (one case of miscarriage was excluded in each group).
	Underweight	15 (60.0)	4 (18.2)	7 (11.1)
	Eutrophic	8 (32.0)	10 (45.5)	26 (41.3)	<0.001
	Overweight/obese	2 (8.0)	8 (36.4)	30 (47.6)
Weight gain during pregnancy, kg^b b 25 cases of HbSS and 22 cases of HbSC (one case of miscarriage was excluded in each group).		8.0 (–1 to 17.7)	11.9 (3.1–18.5)	13.7 (0.2–28)	<0.001^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Hemoglobin electrophoresis
	A2	2.8 (0–5)	0 (0–4.1)	–
	Fetal	11.4 (1–24)	1.3 (0–8.3)	–
	S	83.5 (67.2–96)	50.2 (38.7–83)	–	–
	C	0 (0)	46.7 (27.8–53.3)	–
Hemoglobin, g/dL		7.7 (5.8–9.5)	9.8 (6.5–11.5)	12.2 (11.2–14.7)	<0.001^c c HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
Hematocrit, %		22.5 (16.7–28.6)	28.2 (19.2–36.4)	36.3 (32.7–41.3)	<0.001^c c HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
White blood cell count, n.10³/mL		16.9 (3.5–31.9)	12.4 (4.9–24.2)	9.3 (5.5–14.5)	<0.001^c c HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
Platelets, n.10³/mL		322 (36–896)	176 (59–561)	225 (158–357)	0.010^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.

Intakes/day		Second trimester				3rd trimester
Intakes/day		HbSS (n=22)	HbSC (n=21)	Control (n=30)	p	HbSS (n=22)	HbSC (n=20)	Control (n=33)	p
GA at FFQ, weeks		11.1 (2.9)	21.8 (2.8)	21.9 (3.2)	0.202	33.1 (2.3)	33.6 (2.1)	35.0 (3.0)	0.031^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
Energy, kcal		1,518 (653–2,828)	1,562 (841–2,440)	1,694 (955–3,577)	0.165	1,648 (853–2,721)	1,530 (835–2,357)	1,829 (1,304–3,823)	0.037^b b HbSS vs. control: p=NS; HbSS vs. HbSC: p=NS; HbSC vs. control: p<0.05.
Macronutrients
Carbohydrates
	g	200 (95–440)	223 (102–361)	220 (115–643)	0.403	210 (126–410)	191 (88–350)	228.1 (129.3–464.5)	0.125
	% of energy	51.7 (41.1– 73.5)	53.4 (36.9–69.3)	51.3 (40.3–72.0)	0.491	55.8 (40.9–72.5)	50.9 (31.9–61.3)	48.9 (38.4–73.4)	0.097
Proteins
	g	73.2 (36.3–111.3)	68.8 (38.2–113.3)	95.7 (53.7–143)	0.004^c c HbSS vs. control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p<0.05.	67.5 (37.9–127.8)	81.7 (42.6–149.6)	92.8 (51.6–253.3)	0.020^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
	% of energy	18.8 (10.4–31.5)	16.6 (12.6–26.1)	20.0 (11.6–33.4)	0.066	18.4 (10.5–30.9)	23.4 (10.4–29.3)	22.0 (9.3–31.9)	0.010^d d HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Fat
	g	40.0 (14.3–133.7)	47.9 (25.9–105.3)	54.9 (26.4–117.5)	0.235	50.4 (17.6–103.2)	51.6 (21.8–71.2)	58.3 (38.4–121.0)	0.090
	% of energy	28.0 (15.6–42.6)	27.1 (17.1–41.6)	27.6 (16.4–39.1)	0.861	28.0 (14.8–40.0)	27.8 (20.2–38.9)	28.9 (15.1–36.7)	0.626
Fiber, g		18.0 (9.9–42.3)	23.0 (10.7–33.0)	21.0 (13.0–37.8)	0.094	16.4 (8.4–32.9)	23.3 (10.4–50.6)	18.4 (6.7–36.0)	0.036^e e HbSS vs. control: p=NS; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Micronutrients
Calcium, mg		409.9 (91.0–1,247.5)	575.3 (88.1–1,086.9)	747.6 (166–1,208)	0.021^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.	607.2 (91.9–1,974.1)	590.6 (112.0–1,558.4)	734.4 (244–1,726)	0.117
Iron, mg		13.1 (6.7–17.9)	10.1 (6.0–18.4)	12.2 (7.2–25.0)	0.177	10.5 (6.0–25.3)	14.3 (6.2–21.5)	12.7 (6.0–42.2)	0.468
Zinc, mg		10.3 (4.5–25.5)	9.2 (0.8–17.2)	13.0 (4.5–22.0)	0.103	9.4 (3.3–21.6)	13.6 (3.4–25.9)	13.0 (4.0–55.7)	0.063
Vitamin A, μg		538 (58–2,224)	575 (171–1,926)	897 (243–6,330)	0.075	447 (64–3,093)	730 (250–2,441)	940 (232–5,150)	0.005^a a HbSS vs. control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
Vitamin E, mg		5.3 (2.5–17.9)	5.3 (2.1–11.5)	6.7 (2.5–24.7)	0.102	5.6 (1.9–10.9)	9.5 (3.4–14.1)	6.7 (3.0–20.2)	0.007^d d HbSS vs. control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p=NS.
Vitamin C, mg		96.6 (19.2–936.9)	85.1 (13.5–315.3)	150.6 (32.0–656.6)	0.078	145.2 (40.6–696.7)	108.6 (14.2–291.0)	128.8 (49.6–548.7)	0.417
Folate, μg		93.9 (56.7–162.3)	99.3 (28.8–169.2)	125.6 (51.7–316.8)	0.072	97.6 (35.5–205.0)	130.6 (76.2–213.8)	136.6 (69.9–400.1)	0.053

		HbSS	HbSC	Control	p
Maternal complication
	Arterial hypertension	6 (23.1)	6 (26.1)	-	0.930
	Pain crisis	15 (57.7)	10 (43.5%)	-	0.480
	Alloimmunization	10 (38.5)	5 (21.7)	-	0.300
	Pulmonary infection	9 (34.6)	2 (8.7)	-	0.070
	Antenatal blood transfusion	8 (30.8)	2 (8.7)	-	0.008
	Urinary infection	8 (30.8)	4 (17.4)	-	0.451
	Blood transfusion at childbirth/postpartum	5 (19.2)	3 (13.0)	-	0.707
Total of deliveries		n=25	n=22	n=63	P
	Gestational age at delivery, weeks	37.4(25.6–39.3)	37.9 (25.7–40.1)	39.9 (36.0–41.3)	<0.001^a a HbSS vs. Control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p<0.05.
	Prematurity (<37 weeks)	10 (40.0)	5 (22.7)	2 (3.2)	<0.001^a a HbSS vs. Control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p<0.05.
Delivery mode
	Cesarean	21 (84.0)	18 (81.8)	37 (58.7)	0.024^b b HbSS vs. Control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
	Vaginal	4 (16.0)	4 (18.2)	26 (41.3)
Total of newborns		n=26 ^e e One twin pregnancy.	n=22	n=63	P
Birth weight, g		2,220(292–3,390)	2,865(378–3,820)	3,220(2,450–4,520)	<0.001^c c HbSS vs. Control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
Birth weight <2.500 g		18 (69.2)	7 (31.8)	1 (1.6)	<0.001^c c HbSS vs. Control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
Small-for-gestational age infant		16 (61.5)	6 (27.3)	3 (4.8)	<0.001^c c HbSS vs. Control: p<0.05; HbSS vs. HbSC: p<0.05; HbSC vs. control: p<0.05.
1st min Apgar <7		8 (30.8)	3 (13.6)	2 (3.2)	0.001^b b HbSS vs. Control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
5th min Apgar <7		1 (3.8)	2 (9.1)	0 (0)	0.071
Perinatal result
	Fetal death	1 (3.8)	1 (4.5)	0	0.029^b b HbSS vs. Control: p<0.05; HbSS vs. HbSC: p=NS; HbSC vs. control: p=NS.
	Neonatal death	2 (7.7)	1 (4.5)	0
	Alive	23 (88.5)	20 (90.9)	63 (100)

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[1] *Corresponding author: roseli.nomura@hotmail.com