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Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 83-88

Study of relation between serum iron and copper levels in pregnant females of Uttarakhand, India


1 Assistant professor, Department of Biochemistry, All Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Research Scholar, Department of Home science (F & N), Swami Purnanand Degree college of Technical education, Muni Ki Reti, Tehri Garhwal,Uttarakhand, India
3 HOD, Department of Home science, Swami Purnanand Degree college of Technical education, Muni Ki Reti, Tehri Garhwal,Uttarakhand, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Manisha Naithani
Assistant professor, Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.5530/ami.2016.1.18

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  Abstract 


Introduction: Copper is an indispensable trace element required for health and also plays a very important role in successful pregnancy completion. There is insufficiency of data on serum levels of copper and its relation with serum Iron levels in pregnant women, especially in India. This loco regional pilot study was done, keeping in mind the limited information about inter relation of these two important minerals and to provide further insight about interaction of these.
Material and Methods: This cross-sectional study comprising of pregnant women, selected by random cluster sampling was conducted in the Rishikesh (Hill regions of Uttarakhand, India). The duration of the study was from 1st Dec, to 31st March 2012. Sixty pregnant women of 18 -35 years age group were included. Serum values of twenty non-anaemic, non-pregnant women volunteers in the age group of 18-35 years with no other accompanying illness were considered as controls. The blood investigations for haemoglobin and serum values of Iron and Copper were done in all these. A Krusskal I-Wallis H test was performed for analysis, followed by a Dunn's test for multiple comparisons and a p- value of <0.05 was taken as statistically significant.
Results: The percentage of anemia among pregnant women of present study was 46.62%. In present study 58.3% of the pregnant women were found to have hypercupremia and 71.42 % of the anemic pregnant women had hypercupremia The relatively increased serum copper in iron deficient anaemic mothers could be a compensatory mechanism to counter-act anemia.
Conclusions: A thorough biochemical analysis of haemoglobin, iron and Copper during pregnancy would therefore help us access the specific nutrient role and corrective measures thereof to deal with iron deficiency anaemia and successful pregnancy completion.

Keywords: Copper, Iron, Pregnancy, Minerals, Micronutrients


How to cite this article:
Naithani M, Bharadwaj J, Garg A. Study of relation between serum iron and copper levels in pregnant females of Uttarakhand, India. Acta Med Int 2016;3:83-8

How to cite this URL:
Naithani M, Bharadwaj J, Garg A. Study of relation between serum iron and copper levels in pregnant females of Uttarakhand, India. Acta Med Int [serial online] 2016 [cited 2019 Jul 19];3:83-8. Available from: http://www.actamedicainternational.com/text.asp?2016/3/1/83/209728






  Introduction Top


Maternal under nutrition remains a challenge globally despite the development and is still somewhat neglected aspect of public wellbeing.[1] Nutrition during pregnancy has been related to fetal body composition and subsequent adult risk of metabolic disorders.[2] Thus the detection of micronutrient deficiency and correction is of utmost importance for the prevention of morbidity and mortality. One of these micronutrients is iron, which has grabbed foremost attention, its deficiency remains as the prime reason of anemia during pregnancy,[3] but studies have also pointed at a varied alternation in the levels of other trace elements as well (including copper, zinc, selenium etc).

Data is surprisingly imprecise on maternal mineral metabolism and requirements mainly due to complexity of maternal metabolism during pregnancy. Requirements for many micronutrients increase during pregnancy. Studies assessing the micronutrient status in pregnant women have found insufficient intakes and low levels even in the developed country like UK.[4],[5] Though it's widely acknowledged but the lacunae is that actual global burden of multiple micronutrient deficiencies during pregnancy has not been estimated.[6],[7]

These deficiencies in maternal micronutrient status are amalgamations of repeated pregnancies, poor nutrition, shorter interval between pregnancies, and augmented physiological requirements, as well as underprivileged population and socio cultural inequities, factors like early marriage and pregnancies.[8] These alterations in the levels of the individual parameters may also be due to an interaction between different minerals or due to the influence of hormones which show wide variations during pregnancy.

Thus we can infer that such multiple micronutrient deficiencies are very common in India and to study this is need of the hour. The present study is a loco regional pilot study to assess the levels of Iron and Copper, keeping in mind the limited information about interrelation of these two important minerals and to provide further insight about interaction of these in pregnant women of Uttarakhand.


  Method Top


This cross-sectional study comprising of 60 pregnant women, selected by random cluster sampling was conducted in the Rishikesh, Uttarakhand from 1st Dec to 31st March 2012. An ethical clearance was taken for the study and a well informed consent for this study was taken from all participants. After routine physical examination their blood samples were collected for the purpose of the present study. The individual's characteristics noted included the age, weight, body mass index (BMI) and gravid status.

Inclusion Criteria

Sixty (60) pregnant women, in the age group of 18–35 years, visiting the outpatient department of Nirmal Ashram Hospital, Rishikesh and seeking antenatal advice for the first time were selected, and a thorough history was noted and routine physical examination by gynecologist was performed. Twenty (20) non-anaemic, non-pregnant volunteer women in the age group of 18–35 years with no other illness at present were considered as controls.

Exclusion criteria

  1. Pregnant women with associated diseased conditions like bleeding piles, previous history of tuberculosis, cardiac, respiratory, renal, gastrointestinal, thyroid and neoplasm.
  2. Pregnant Women with complications such as hyperemesis gravidarum, diabetes, lupus erythematosis, convulsion, or had abnormal BMI.


Fasting blood samples were taken on the day after first visit with about 6 ml of venous blood being drawn from median cubital vein using vacutainers. Out of this 2ml was collected in EDTA tubes and 4 ml was collected in plain vials. The investigations done on each sample includes:

EDTA- Hemoglobin in g/d1 (the automated cell counter was used for the estimation of hemoglobin).

Plain vial: For Iron (Fe), Copper(Cu). The collected sample was left to stand for about 1 hour and then centrifuged. Serum was separated after optimum time and used for analyzing the above mentioned parameters on the same day by spectrophotometeric method using colorimetric kits.

On the basis of heamoglobin (Hb) concentration (<11g/dl) and iron levels (<50 microg./dl), the pregnant women will be sub-grouped as having Iron deficient anemic pregnancy, non-iron deficient anemic pregnancy and non-anemics. The data is presented and compiled. A Krusskal I-Wallis H test was performed for analysis, followed by a Dunn's test for multiple comparisons. A p- value of <0.05 was taken as significant.


  Results Top


In 20 non pregnant women, the Hb level was found to be >11 g/dl. They were thus grouped as non-anaemic non-pregnant women (NANP) and considered as control.

Hemoglobin was estimated in 60 pregnant women, of whom 32 pregnant women had a Hb level >11g/d1. They were grouped as non-anaemic pregnant women (NAP). Of the 60 pregnant women, 28 were found to have a Hb level of <11g/d1. They were grouped as anaemic pregnant.

In control cases and according to international standards, reference ranges in healthy adult women were considered as:

  • Serum Iron:- 50-170 μg/dl
  • Serum Copper:- 70-150 μg/dl


Patient above and below these ranges are considered as having high and low levels of the respective micronutrient.

On the basis of the level of Iron in serum, the anaemic pregnant women were further classified [Table 1] as:
Table 1: Group wise distribution of cases on the basis of the serum Iron level in the anaemic pregnant women

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  1. Iron deficient anaemic pregnancy (IDAP) (iron<50 μg/d1: 25 pregnant women).
  2. Non-iron deficient anaemic pregnancy (NIDP) (iron >50 μg/dl: 03 pregnant women).


On the basis of their Hb concentration, 28 anaemic pregnant women, were further classified into: Mild (Hb = 9-11 g/d1), moderate (Hb = 7- 9g/dl) and severe anaemic (Hb= <7g/d1).

In 25 cases of Iron deficient anaemic pregnant women, 08 iron deficient anaemic pregnant women were found to have mild anaemia (Hb=9-11g/d1); 11 iron deficient pregnant women were found to have moderate anaemia (Hb=7-9g/d1); 06 iron deficient pregnant women were found to have severe anaemia (Hb= <7g/d1) [Table 1].

The anaemic pregnant women who had mean Iron level > 50 μg/d1 were grouped as non-iron deficient anaemic pregnancy. 02 women in this group had a mean Hb level of > 8g/d1. These 02 cases had mild anaemia and remaining One (01) case had severe anaemia [Table 1].

On Comparison of iron status amongst the groups i.e., non-aneamic non-pregnant, non-anaemic pregnant, mild IDA pregnancy, moderate IDA pregnancy, severe IDA pregnancy and non-IDA pregnancy (NIDP), it was also found that there was no significant difference in the iron levels between those having mild, moderate or severe anaemia. Though there is no significant reduction in the level of iron in mild anaemia, in comparison to NIDP; but it differs significantly from NAP and NANP. There is a significant reduction in the level of iron in moderate and severe anaemia when each is compared with NIDP, NAP, NANP. The level of Iron is significantly lower in NIDP when it is compared with NAP or NANP (p<0.05).

Comparison of copper status amongst the groups i.e., non-anaemic non-pregnant, non-anaemic pregnant, mild IDA pregnancy, moderate IDA pregnancy, severe IDA pregnancy and non-IDA pregnancy (NIDP) is shown in [Table 2].
Table 2: Group wise distribution of cases according to serum copper level

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The cases with higher level of copper are more in each of these cases with anaemia when compared individually to NIDP and NANP. The serum levels of copper are significantly higher (p< 0.05) in NAP when compared to NANP.

The cases with higher level of copper are significantly higher in IDAP, when compared to NIDP and NANP. There is also a significant increase in the level of copper in NAP women when compared to NANP women (p<0.05).

The Results and differences between the parameters in the different groups may be compiled as follows:

  1. Non-anaemic pregnant women (NAP) versus non- anaemic non-pregnant women (NANP): There is a statistically significant increase in the value of copper in NAP when compared to NANP (p<0.05). The other parameters do not show any significant increase or decrease when the two groups are compared.
  2. Iron deficient pregnant women (IDAP) versus non- iron deficient pregnant women (NIDP): The cases with higher level of copper level are significant in IDAP, as compared to NIDP.
  3. Mild versus moderate versus severe anaemia in iron deficient pregnant women (IDAP): There is no significant difference in the level of any parameter between mild, moderate, and severe anaemia in pregnancy. Results are correlating as a whole group.
  4. Mild, Moderate and Severe iron deficient anaemic pregnant women (IDAP) versus Non iron deficiency anaemic pregnancy (NIDP): There is no significant reduction in the level of Iron in mild anaemia compared to NIDP (p0.05). However, the reduction in the level of iron in moderate and severe anaemia is significantly lower when compared to non-iron deficient anaemia (p<0.05). The cases with higher level of copper are significantly higher in mild, moderate and severe anaemia in iron deficient pregnancy (IDAP) when each is compared separately with NIDP (p<0.05).
  5. IDA pregnancy versus non-anaemic pregnant (NAP): The level of iron is significantly lower in IDA when compared to NAP or NANP (p<0.05). The level of copper is significantly higher in IDAP when it is compared to NAP, NANP (p<0.05).
  6. IDA pregnancy versus non anaemic non-pregnant (NANP): The level of iron is significantly lower in IDA when compared to NANP (p<0.05). The level of copper is significantly higher in IDAP when it is compared to NANP (p<0.05).


Overall results of this study are:

  • 46.6% of the pregnant women were found to be suffering from anaemia (28 out of 60).
  • 88.2% of the anaemic pregnant women (25 out of 28) were suffering from iron deficiency while the rest had anaemia due to other causes.
  • 16.7% of pregnant women had mild anaemia (IDAP-8 + NIDP- 02)=10/60
  • 18.4% (11/60) of pregnant women had moderate anaemia.
  • 11.7% of the pregnant women were (07/60) found to be suffering from severe anaemia.
  • 58.3% of the pregnant women included in the present study (35 out of 60) had hypercupremia.
  • In the present study, 71.42 % of the anaemic pregnant women (20 out of 28) had hypercupremia.



  Discussion Top


Copper (Cu) is one of the vital trace elements whose history is dated back to as early as 400 B.C., with mention of Hippocrates using copper compounds to treat diseases. There is a plethora of information regarding role of copper in the human body is still being uncovered till date.[9],[10] Human Body's copper is mostly in the cupric form, though it has an ability to change from the cuprous and cupric forms making it important in scavenging free radicals and in oxidation-reduction (redox) reactions.

The biochemical role for copper is primarily to assist in catalysis. There are many copper containing enzymes as Cytochrome-c oxidase, Amine oxidases, Lysyl oxidase, Dopamine β monooxygenase, Superoxide dismutase, Tyrosinase found in humans. It is substantially documented from animal studies that diets low in copper reduces activities of many of these copper metalloenzymes.[11],[12],[13]

The copper metabolism is very complexly linked to iron metabolism. Two copper-containing enzymes ferroxidase I and ferroxidase II have the capability to oxidize ferrous (Fe2+) to ferric (Fe3+) form of iron. Ferric form is used for transport of iron. Ceruloplasmin (having ferroxidase I), is the predominant copper protein in plasma having antioxidant functions. Defects in ceruloplasmin function produce cellular iron accumulation, supporting its ferroxidase role. Ferroxidase II is found in human plasma, but it may have a role in iron metabolism in specific cellular sites. A transmembrane copper containing protein (hephaestatin) with ferroxidase activity has been described. Iron mobilization from storage sites is hampered in state of copper deficiency, thus making it probable that it has a important role in iron metabolism.[14],[15],[16]

Copper is an indispensable micronutrient required for fetal growth and its deficiency may affect fetal growth, chances of complications in pregnancy and delivery. Copper is essential for life being involved in the functions of several metalloenzymes. This micronutrient is being delivered to the developing fetus via specific transporters present in the placenta. These receptors are known to be regulated by the mother's hormonal status including estrogen and insulin levels.[17],[18] Various studies comparing healthy pregnant women with their non-pregnant counterparts have reported significantly higher mean serum copper levels.[19],[20],[21],[22] Thus, hypercupremia in pregnancy is known phenomenon, with incremental increase in trimesters. During pregnancy, the serum copper levels escalate from 80 to 155 μg/dl to about 118 to 302 μg/dl in third trimester of gestation.[23],[24]

However, very high copper levels in pregnancy have been linked with fetal growth retardation and increased chances of developing preeclampsia and neurological diseases in mother. Persistently high levels are known to contribute towards development of postpartum complications including depression. The postpartum depression is due to the effects of metals on nervous tissue, altering the equilibrium of two mood-regulating neurotransmitters viz dopamine and norepinephrine.[25],[26],[27]

Thus a delicate balance of copper is required in pregnancy but the interaction of copper with iron presents a very baffling picture with very similar presentation in deficiency. The important role of copper in iron metabolism is more obvious when we look at the clinical manifestations of copper deficiency. One of the clinical signs of copper deficiency is an anemia unresponsive to iron therapy but responding to copper supplementation.[28],[29],[30] This anemia results from defective iron mobilization due to decreased ferroidaes activity of caeruloplasmin. Abnormally low numbers of white blood cells are also one of the outcomes of copper deficiency. Abnormalities of bone development are the most frequently recorded manifestation of copper deficiency in infants, especially those who were low birth weight. Relatively less common features may include neurological symptoms, impaired growth and loss of pigmentation.[31]

As described that Copper is necessary for the conversion of the ferrous to the ferric state of iron, and its incorporation into haemoglobin resulting in microcytic, hypochromic anemia. The increase in copper in iron deficient anaemic mothers could possibly be an offseting mechanism to counter-act anemia, and this is complemented by a surge in ceruloplasmin synthesis, which is having ferroxidase activity. Several human and animal studies have shown, that increased iron intake is associated with decreased serum copper concentrations and decreased activity of corresponding copper enzymes, and vice versa, probably as a result of competitive absorptive mechanisms for iron and copper. The present study is in accordance with several studies, which predict an increase in copper during pregnancy. Several human and animal studies have shown, that increased iron intake is associated with decreased serum copper concentrations and decreased activity of corresponding copper enzymes, and vice versa, probably as a result of competitive absorptive mechanisms for iron and copper.[32],[33],[34] In the present study, 71.42 % of the anaemic pregnant women had hypercupremia and overall, 58.3% of the pregnant women had hypercupremia.

The cause of hypercupremia of pregnancy is still a subject of controversy. As already pointed out it may be due to increase of ceruloplasmin which results due to elevated level of estrogen during pregnancy. Elevation in serum copper levels has been ascribed to increased estrogen and progesterone concentrations as has been proved by studies done on effects of estrogen containing oral contraceptive pills. Plethora of possibilities are there including decreased diffusion of serum Cu through the placenta in mothers[35],[36],[37]or maternal tissues copper mobilization under influence of estrogen may lead to hypercupremia. In addition to the hormonal influence, elevation in serum copper during pregnancy has been suggested to be a result of resistance reaction of the maternal organism against the continuously invading metabolic products from the fetus into the maternal circulation.[38],[39]

There are no data which can be used for establishing an estimated adequate response (EAR) for pregnancy; therefore, the EAR given in literature is based on estimates of the amount of copper that must be accumulated during pregnancy to account for the fetus and products of pregnancy. Due to no studies done involving supplemental copper intake by pregnant or lactating women, it is recommended that the upper limit for pregnant and lactating females be the same as that for the nonpregnant and nonlactating females.[40],[41]

For the success of a supplementation programme of micronutrients during pregnancy, there has to be a proper evaluation of data on the prevalence of micronutrient deficiencies, their adverse effects and the potential for reversing these through supplementation.[42],[43]


  Conclusion Top


Hypercupremia in pregnancy is known phenomenon but very high copper levels in pregnancy have been found to be associated with preeclampsia in mother and growth retardation in fetus. The present study emphasizes the changes in serum copper concentration during pregnancy, but the exact mechanism and physiological significance of these remain obscure. Further studies appear desirable to investigate the exact mechanism and implications of these changes on well being of women during pregnancy and its effect on the developing fetus.

Though ideally micronutrient deficiencies should be prevented before a woman becomes pregnant but in developing country like India such an ideal scenario does not exist. This makes a thorough biochemical analysis of haemoglobin, iron and other trace elements like copper during pregnancy essential and imperative not only to diagnose the specific nutrient deficiency but to timely institute ideal therapeutic measures. A rational approach to achieving a situation very near to ideal one would be giving multiple micronutrient supplements and/or food fortification to women capable of becoming pregnant and follow-up with regular serum level testing of minerals in pregnant.


  Limitations Top


  1. Gestation specific cut off values taking into account the hemodilution effects are not available for these micronutrients, this is the first limitation of this study.
  2. The second limitation is that the variations in dietary intakes and within subject variations, effect of serum iron level being altered by inflammation have not been considered.




 
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