الفهرس 
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Abstract
Iron deficiency anemia (IDA) is a very prevalent condition in pregnancy, affecting nearly 18% of all pregnant women during all three trimesters, with as many as 29%of women affected during the third trimester
In twin pregnancies, the maternal iron demands are magnified, estimated at 1.8 times more than in singleton pregnancies due to greater maternal red blood cell mass and plasma volume expansion as well as increased fetal and placental requirements. Thus, maternal hemoglobin (Hgb) in multiple pregnancies is lower in all trimesters compared with singleton gestations, with a rate of IDA estimated to be 2.4 to even 4 times higher.
Adverse outcomes of IDA, including low birth weights, intra-uterine growth restriction, preterm birth, delayed neurodevelopment status, and residual neonatal IDA are therefore also more common in twin pregnancies than in singletons.
With the growing incidence of multifetal gestations this problem becomes even more pertinent. The recommendation of the US Institute of Medicine is that women bearing more than one fetus consume a daily supplement containing 30mg of elemental iron from the 12th week of gestation onward.
Expert opinion relying on the increased risk for micronutrient deficiency in twin pregnancies recommends supplementation of iron beyond that contained in a typical prenatal vitamin. Moreover, some experts support doubling the dose of multivitamins containing 30 mg of elemental iron during the second and third trimesters of a twin pregnancy, regardless of maternal Hgb and ferritin concentrations.
With a lack of randomized controlled trials assessing the adequacy of iron supplements on twin pregnancy, various recommendations are based on level 3 clinical expert opinions at most. The purpose of our study was to assess the efficacy of a single versus a double daily iron supplement dose in iron deficient women with twin pregnancies. Determining the effect of this intervention on maternal iron stores and immediate neonatal outcome measures will assist in defining evidence-based recommendations for prenatal care.
Aim of the study:
The purpose of our study was to assess the efficacy of a single versus a double daily iron supplement dose in prevention of iron deficiency anemia in women with twin pregnancies.
Methodology:
• Randomized controlled clinical trial.
• All enrolled women will provide informed consent for participation in this research. All women with a twin gestation fulfilling the inclusion criteria will be randomized by Randomizer (http://www.randomizer.org) to receive either one (group A) or two (group B) capsules of Feroglobin capsules (containing Ferrous Fumarate 17mg, Zinc sulphate, Vitamin B6, vitamin B12, and Folic acid). Company: Vitabiotics.
• A total of 466 healthy women aged 20 – 35 years with twin pregnancies, at 14 weeks of gestation presented to Ain Shams University Maternity Hospital Outpatient clinic.
Inclusion criteria
Age: 20 - 35 years old.
Twin pregnancy.
Hgb ≥ 10.5 gm/dl.
Exclusion criteria
Continuous hyperemesis gravidarum lasting beyond 20 weeks of gestation.
Thalassemia minor (alpha or beta).
Malabsorption disorders (such as inflammatory bowel diseases, Crohn’s disease, ulcerative colitis, previous bowel resection).
Anemia from chronic illness.
Any use of multi-vitamin supplements containing iron.
Any chronic blood loss. e.g.: hemorrhoids.
Autoimmune disorders.
Primary outcome parameters
• Hgb concentration at 32 weeks, and at delivery > 10.5gm/dl.
• We chose this outcome as opposed to Hgb concentration at delivery. Due to the likely possibility of preterm delivery in twins, 32 weeks will be deemed representative of Hgb at or near delivery.
Secondary outcome parameters
• Mean Hgb concentration during the study.
• Need for intravenous iron administration during the study (administered in cases of Hgb <9 g/dL with ferritin <8 ng/mL at 24 weeks of gestation of beyond).
• Blood products at delivery or postpartum (administered in cases of Hgb <7 g/dL or symptomatic anemia).
• Incidence of gastrointestinal side effects.
• Compliance with drug regimen.
• Newborn birth weights in NICU (Neonatal intensive care unit).
• Preterm birth rate (<37 weeks).
Ethical approval was obtained by the ethical committee of Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University.
Results:
During the study period, 589 twin pregnant women were assessed for eligibility at our center. Of these, 123 women were excluded from the study, 101 did not meet the inclusion criteria and 22 refused to participate in the study. Four hundred and sixty-six patients were eligible for participation, having met inclusion criteria, and were available for randomization to either group A (receiving 1 capsule of iron) or group B (receiving 2 capsules of iron).
No significant difference between the studied groups regarding cervical length. Cervical length did not significantly change from week-14 to each of week-24 and week-32 in both groups.
No significant difference between the studied groups regarding hemoglobin at week-14. Hemoglobin was significantly higher in double group at further follow ups (week-24, week-32 and labour). Hemoglobin significantly increased from week-14 to each of week-24, week-32 and labour in both groups.
Vomiting and constipation were significantly more frequent in double group.
No significant difference between the studied groups regarding Mode of delivery.
No significant difference between the studied groups regarding Neonatal condition.