Open Access Study protocol

Accuracy of erythrogram and serum ferritin for the maternal anemia diagnosis (AMA): a phase 3 diagnostic study on prediction of the therapeutic responsiveness to oral iron in pregnancy

Cristiane Campello Bresani12*, Maria Cynthia Braga34, Daniel Falcão Felisberto5, Carlos Eduardo Lopes Tavares-de-Melo5, Debora Bresani Salvi1 and Malaquias Batista-Filho13

Author Affiliations

1 Nutrition Research Group at Instituto de Medicina Integral Prof Fernando Figueira – IMIP, Rua dos Coelhos, 300, Boa Vista, Recife, PE CEP: 50.070-550, Brazil

2 Instituto Nacional do Seguro Social/Ministério da Previdência Social – INSS/MPS, Av Jorn Mário Melo, 343, Santo Amaro, Recife, PE CEP: 50.040-010, Brazil

3 Postgraduate Program in Maternal and Child Health of IMIP, Rua dos Coelhos, 300, Boa Vista, Recife, PE CEP: 50.070-550, Brazil

4 Postgraduate Program in Public Health at Centro de Pesquisas Aggeu Magalhães – Fundação Oswaldo Cruz – CPQAM/FIOCRUZ, Av. Professor Moraes Rego, s/n - Campus da UFPE - Cidade Universitária, Recife, PE CEP: 50.670-420, Brazil

5 Faculdade Pernambucana de Saúde – FPS, Av. Jean Emile Favre, 422 Imbiribeira, Recife, PE CEP: 51.200-060, Brazil

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BMC Pregnancy and Childbirth 2013, 13:13  doi:10.1186/1471-2393-13-13

Published: 16 January 2013



Pregnancy anemia remains as a public health problem, since the official reports in the 70’s. To guide the treatment of iron-deficiency anemia in pregnancy, the haemoglobin concentration is the most used test in spite of its low accuracy, and serum ferritin is the most reliable test, although its cutoff point remains an issue.


The aim of this protocol is to verify the accuracy of erythrocyte indices and serum ferritin (studied tests) for the diagnosis of functional iron-deficiency in pregnancy using the iron-therapy responsiveness as the gold-standard. This is an ongoing phase III accuracy study initiated in August 2011 and to be concluded in April 2013. The subjects are anemic pregnant women (haemoglobin concentration < 11.0 g/dL) attended at a low-risk prenatal care center in the Northeast of Brazil. The sample size (n 278) was calculated to estimate sensitivity of 90% and 80% of specificity with relative error of 10% and power of 95%. This study has a prospective design with a before-after intervention of 80 mg of daily oral iron during 90 days and will be analyzed as a delayed-type cross-sectional study. Women at the second trimester of pregnancy are being evaluated with clinical and laboratorial examinations at the enrollment and monthly. The ‘responsiveness to therapeutic test with oral iron’ (gold-standard) was defined to an increase of at least 0.55 Z-score in haemoglobin after 4 weeks of treatment and a total dose of 1200 mg of iron. At the study conclusion, sensitivities, specificities, predictive values, likelihood ratios and areas under the ROC (Receiver Operating Characteristic) curves of serum ferritin and erythrocyte indices (red blood cell count, haematocrit, haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red blood cell distribution width, reticulocyte count) will be tested. The compliance and adverse effects are considered confounding variables, since they are the main obstacles for the iron-therapy responsiveness.


This study protocol shows a new approach on iron-deficiency anemia in pregnancy from a functional point of view that could bring some insights about the diagnostic misclassifications arising from the dynamic physiologic changes during the gestational cycle.

Trial registration

WHO International Clinical Trials Registry Platform U1111-1123-2605.

Anemia; Iron-deficiency; Diagnosis; Pregnancy; Erythrocyte indices; Ferritins; Sensitivity; Specificity; Adverse effects; Patient compliance; Ferrous sulfate