Maternal and Cord Blood Serum Levels
of Zinc, Copper, and Iron in
Healthy Pregnant Jordanian Women
S.M. Awadallah,1* K.H. Abu-Elteen,2A.Z. Elkarmi,2
S.H. Qaraein,3N.M. Salem,4and M.S. Mubarak5
1Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences,
Hashemite University, Zarqa, Jordan
2Department of Biological Sciences, Faculty of Science and Arts,
Hashemite University, Zarqa, Jordan
3Obstetrics and Gynecology Private Clinic, Amman, Jordan
4Department of Chemistry, Faculty of Science and Arts, Hashemite University,
5Department of Chemistry, Faculty of Science, University of Jordan, Amman, Jordan
Altered plasma levels of zinc, copper, and iron during pregnancy are known to have
profound effects on pregnant women and their neonates. The status of these elements is
not known in pregnant women in Jordan. During the three trimesters of pregnancy,
blood specimens were collected from 186 healthy pregnant women aged 17?45 years
and from cord blood of 92 of their neonates. The mean neonatal birth weight was 3.34
± 0.44 kg. Maternal and cord blood serum levels of zinc, copper, and iron were de-
termined by atomic absorption spectrophotometry, and hemoglobin concentration was
determined by hematology cell counter. The results indicate significantly lower serum
zinc levels and higher copper and iron levels in cord blood than in maternal blood.
During the three trimesters of pregnancy, the serum levels of zinc and copper signifi-
cantly decreased and increased, respectively, whereas the levels of serum iron were
unchanged. Significant positive correlation was observed only between zinc levels of
cord blood and birth weight. During third trimester, the mean serum levels of zinc and
iron were significantly lower in anemic pregnant women (group I: Hb less than 11.0 g/
= 56). There was no noticeable difference between group I and group II regarding cord
blood parameters on one hand and neonatal birth weight on the other hand. Similar
significant positive correlation was observed between serum zinc levels of cord blood
and birth weight in both groups. These results indicate that Jordanian women during
pregnancy follow a well-balanced and adequate diet regime. J. Trace Elem. Exp. Med.
? 2004 Wiley-Liss, Inc.
Key words: trace elements; birth weight; hemoglobin; Jordan
*Correspondence to: Dr. Samir Awadallah, Department of Medical Technology, Faculty of Allied
Health Sciences, The Hashemite University, P.O. Box 330077, Zarqa, 13133, Jordan. E-mail:
Received 24 July 2002; Accepted 15 June 2003
? ? 2004 Wiley-Liss, Inc.
The Journal of Trace Elements in Experimental Medicine 17:1–8 (2004)
Minerals and trace elements, such as zinc, copper, iron, selenium, calcium,
magnesium, and other micronutrients, have significant influence on the health of
pregnant women and the growing fetus . In developing countries, the preva-
lence of iron deficiency anemia in pregnant women ranges from 35% to 75%, and
is recognized as the most common nutritional problem in the world [2,3]. During
pregnancy, iron needs are usually very high to meet the requirements for the
fetus, placenta, and maternal red cell expansion. Such demands cannot be met by
diet alone, particularly in developing countries where diet is usually low in
bioavailable iron; therefore, iron supplements are commonly recommended
during pregnancy. Worldwide, poor pregnancy outcome has been most com-
monly associated with anemia caused by low plasma levels of iron [4,5]. Re-
cently, the importance of zinc and other micronutrients in relation to pregnancy
outcomes and fetal health have been the concern of many studies [1,6].
Severe maternal zinc deficiency has been associated with spontaneous abortion
and congenital malformation, whereas milder forms of zinc deficiency have been
associated with low birth weight, intrauterine growth retardation, and preterm
delivery [7,8]. Additionally, low plasma zinc has also been reported to correlate
with pregnancy complications, such as prolonged labor, hypertension, and
postpartum hemorrhage . Because pregnant women, especially in developing
countries, are considered as a high-risk group for iron and zinc deficiency, ma-
ternal zinc supplementation has been suggested by several groups as one possible
nutritional intervention during pregnancy to improve pregnancy outcome .
Although most of the studies were mainly focused on maternal iron and zinc
and their correlation with poor pregnancy outcome, others were concerned with
copper and its correlation with pregnancy and birth defects [11,12]. The im-
portance of copper for prenatal development was first demonstrated by studies
of diseases in lambs and other animals called enzootic ataxia, which is charac-
terized by various neurological, skeletal, and connective tissue abnormalities .
In human adults, severe copper deficiency is relatively rare, whereas signs of
moderate copper deficiency were observed in human infants under a variety of
conditions . Copper deficiency caused by inadequate maternal dietary intake
is very rare, whereas moderate copper deficiency attributed to secondary causes,
such as disease states, drug interactions, and nutritional genetic factors, are more
common and may result in pregnancy complications .
In Jordan, iron deficiency anemia is considered a major health problem be-
cause it has been reported to occur at a rate of about 35% among pregnant and
lactating women [14?16]. Reports from the World Health Organization and the
Ministry of Health of Jordan have shown that the high prevalence of iron de-
ficiency anemia in pregnant women and in their infants was most commonly seen
in Palestinian refugees camps and in those attending government-provided ma-
ternal and child health clinics throughout Jordan [14?16]. The status of trace
elements in Jordanian pregnant women attending private maternity clinics is not
known. In this work, we present data pertaining to the blood levels of zinc,
copper, and iron in healthy Jordanian pregnant women in addition to their
2 Awadallah et al.
MATERIALS AND METHODS
27 ± 4.9 who were attending private obstetric and gynecology clinics in Amman
city were investigated for analysis of plasma levels of trace elements. A history
sheet was completed where data pertaining to personal and demographic factors
women explaining the purpose of the study and the confidentiality of collected
data and results. Pregnant women on modified diet or on zinc supplements were
excluded from the study. All investigated women were on folate supplementation
as a routine measure to prevent the development of neural tube defects. Iron and
multivitamins, however, were given to those who had hemoglobin levels below
delivered by participating women were obtained from their clinical chart.
Blood specimens were collected from participating women during each of the
three trimesters; 52 samples from pregnant women in their first trimester, 42
samples from pregnant women in their second trimester, and 92 samples from
pregnant women in their third trimester. At term, 92 cord blood specimens were
collected from neonates of the third-trimester mothers. Blood specimens were
collected in metal-free plain tubes (Royal blue, Becton-Dickinson, Rutherford,
NJ, USA) and in EDTA tubes. Plain tubes were centrifuged (1100 · g) for 15 min
at 3500 rpm and the serum was separated and kept in trace elements-free tubes
and stored at )20?C until analysis. Hemoglobin (Hb) concentrations were de-
termined on all EDTA specimens using a hematology cell counter. Pregnant
women investigated during their third trimester were divided into two groups
according to their Hb results; group I were those with Hb values less than 11.0 g/
dL and group II were those with Hb values equal to or more than 11.0 g/dL.
Maternal and cord blood serum levels of zinc, copper, and iron were determined
by atomic absorption spectrophotometry.
Data were analyzed by means of one-way analysis of variance and by multiple
comparison using computer statistical analysis software (STATISTICA for
Windows, 1995; Stat Soft Inc, OK). Data are expressed as the mean ± SD, and
P < 0.05 was considered statistically significant.
This study was conducted on a group of healthy Jordanian pregnant women
who gave birth to healthy neonates through normal vaginal delivery. The mean
age of studied pregnant women was 27 ± 4.9 years, and the mean birth weight of
neonates was 3.34 ± 0.44 kg. The mean values of serum levels of zinc, copper,
Trace Elements in Pregnant Women from Jordan3
and iron in each of the three trimesters of pregnant women and in cord blood are
presented in Table I. As shown in the table, serum zinc levels during the third
trimester were significantly lower than that during the first and second trimesters
(P < 0.05). There was no significant difference between the first and second
trimesters in terms of zinc levels. Zinc levels of cord blood were higher than that
of maternal blood (P < 0.01). Serum copper levels of the second and third
trimesters were higher than that in the first trimester (P < 0.001). No significant
difference was observed between the second and third trimesters in terms of
copper levels. Copper levels in cord blood were lower than that of the maternal
blood (P < 0.001). No significant difference was observed between serum iron
levels among the three trimesters; however, cord blood iron levels were higher
than that of the maternal blood (P < 0.01). Hb concentrations in the second
trimester were significantly lower than that of the first and third trimesters (P <
0.01 and < 0.05, respectively). No significant correlation was observed between
serum levels of iron, zinc, or copper of the pregnant women studied at their third
trimester on the one hand and their neonatal birth weight on the other hand.
However, Figure 1 demonstrates a statistically significant positive correlation
between cord blood level of zinc and birth weight (r = 0.7225 and P < 0.001).
Table II demonstrates the biochemical findings and birth weight in the two
Hb-based groups of pregnant women studied during their third trimester. Group
I included 36 (39%) pregnant women with Hb concentrations below 11.0 g/dL
and group II included 56 (61%) with Hb concentrations equal or above 11.0 g/
dL. The table demonstrates that maternal serum levels of iron and zinc in group I
were lower than those in group II (P < 0.05). No significant difference was
observed for maternal serum copper levels in both groups. Additionally, no
statistically significant difference was detected between group I and group II
regarding all parameters of cord blood and average birth weight. However, a
statistically significant positive correlation was observed between cord blood
levels of zinc and birth weight in both groups (group I: r = 0.6060, P < 0.001;
group II: r = 0.7115, P < 0.001; Fig. 1).
It is well-established that physiologic, metabolic, and hormonal changes
during pregnancy affect the metabolism and body needs for micronutrients and
TABLE I.Mean Serum Levels of Zinc, Copper, Iron, and Hb Concentration in Maternal and Cord Blood
(n = 52)
(n = 42)
(n = 92)
(n = 92)
77 ± 16
175 ± 42
69 ± 26
11.4 ± 1.1
73 ± 14
226 ± 51
68 ± 19
10.8 ± 1.0
68 ± 10
236 ± 36
74 ± 21
11.2 ± 1.4
114 ± 23
49 ± 24
116 ± 17
15.7 ± 2.6
4 Awadallah et al.
minerals. Deficiency or decreased levels of various minerals and trace elements,
such as iron, zinc, and copper, have been shown to be associated with many
complications related to pregnancy outcome [1,6].
attributed to several factors, such as increased zinc uptake by the fetus and pla-
volume, and decreased serum albumin availability for zinc binding during preg-
mothers with Hb values less than 11.0 g/dL at term and to mothers with Hb values equal to or greater than
11.0 g/dL at term, respectively. Solid and open circles represent cord blood zinc levels versus neonatal
birth weights in groups I and II, respectively.
Scatterplot of cord blood zinc levels versus neonatal birth weights. Groups I and II refer to
Women at Third Trimester
Hemoglobin, Trace Elements, and Neonatal Birth Weight in Anemic and Nonanemic Pregnant
Group I (Hb < 11.0 g/dL) (n = 36)Group II (Hb ? 11.0 g/dL) (n = 56)
Third trimester Third trimesterCord blood Cord blood
Birth weight (kg)
10.2 ± 0.6
67 ± 19
65 ± 11
230 ± 33
15.1 ± 2.0
141 ± 17
111 ± 24
48 ± 20
3.322 ± 0.43
12.2 ± 1.2
80 ± 22
72 ± 8
234 ± 38
15.8 ± 2.3
142 ± 13
113 ± 23
46 ± 16
3.371 ± 0.46
Trace Elements in Pregnant Women from Jordan5
nancy . Furthermore, zinc transporters, such as ZnT, that are localized in
placenta  may play an important role in accelerating zinc uptake from the
be higher in cord blood than that in maternal blood. The observed higher levels of
copper in maternal blood than that in cord blood may be caused by increased
mobilization of stored copper in tissues, especially the liver, for its use by the
developing fetus. Additionally, the concentration of ceruloplasmin, which is a
blood is much greater than that in cord blood [21,23]. Therefore, the expected
to the much higher concentration of ceruloplasmin in the maternal serum.
Correlations between maternal zinc levels and neonatal birth weight were
among the most commonly studied parameters for the evaluation of birth out-
come . Whereas some previous investigators observed positive correlations
[25,26], results reported by this study and by others [27?29] could not find any
correlation. However, the only positive correlation that was observed in this
study is between serum zinc levels of cord blood and birth weight (P < 0.001),
which is consistent with results reported by others [25,26,29]. This correlation
might be considered a better indicator for the adequacy of zinc for fetal growth
and development, because physiologic and metabolic factors that influence
maternal zinc levels are not active in the fetus blood.
Results of this study demonstrate that the status of serum iron in maternal
and cord blood are in close agreement with previous reports [30?32]; the levels
were not altered significantly during pregnancy and no correlation with birth
weight was observed. Despite the fact that serum iron levels below 50 lg/dL were
observed in 28 (30%) of pregnant women studied during their third trimester;
none of them suffered from any complications or symptoms related to iron
deficiency, and their birth outcome was normal. Additionally, the mean serum
iron levels in cord blood were significantly higher than that of the corresponding
maternal blood levels even in mothers having iron levels less than 50 lg/dL.
Similar results have been observed by other investigators [33?35]. The high
serum iron in cord blood compared with maternal blood, even in anemic mothers
(iron less than 50 lg/dL), suggests that the process of active transfer of iron from
the mother to the fetus is adequately maintained.
The most commonly used method for the assessment of anemia during preg-
nancy is the measurement of Hb concentration [36?38]. According to World
Health Organization recommendations, anemia in pregnant women is likely to be
present when the Hb concentration is below 11.0 g/dL, and severe anemia is
recognized when the Hb values are less than 7.0 g/dL [2,3,39]. The correlation
between maternal Hb levels and birth weight is also conflicting [36?38,40]; some
investigators reported higher infant’s birth weight in association with higher
maternal Hb levels, others reported higher birth weight in association with lower
maternal Hb concentration, whereas others reported no significant association
[40,41]. Results of this study demonstrate no significant association of either cord
blood or maternal Hb levels with birth weight. Of the 36 anemic pregnant women
observed at the third trimester (group I), only 7 (19%) had Hb levels between 9.0
and 10.0 g/dL, one (3%) had Hb value less than 9.0 g/dL, and none had Hb values
6Awadallah et al.
below 7.0 g/dL. None of these women suffered from any complications during
pregnancy and none delivered infants of low birth weight. The observed lower
values of maternal iron and zinc, in addition to Hb concentration in group I,
probably reflects a larger expansion of maternal plasma volume that usually
occurs at the third trimester. A significant association between zinc levels of cord
blood and birth weight was observed in both groups, indicating that the low
maternal hemoglobin levels or the anemia observed during the third trimester has
no effect on the adequacy of zinc available for fetal growth and development.
In conclusion, our results are consistent with previous reports and showed that
maternal and neonatal serum levels of zinc, copper and iron were adequate in the
studied group of healthy Jordanian pregnant women. The mild anemia observed
in some of the pregnant women included in this study had no significant effect on
maternal or cord blood parameters or neonatal birth weight. The observed sig-
nificant correlation between neonatal serum zinc levels and birth weight in both
normal and anemic mothers reflects the adequacy of zinc during pregnancy.
1. Black RE. Micronutrients in pregnancy.
2. World Health Organization. The prevalence of anemia in women: a tabulation of available
information. 2nd ed. Geneva: WHO; 1992 (WHO/MCH/MSM 92.2)
3. Royston E. The prevalence of nutritional anemia in women in developing countries. A critical
review of available information. World Health Stat Q 1982;35:52?91.
4. Scholl TO, Hediger ML, Fischer RL, Shearer JW. Anemia vs iron deficiency: increased risk of
preterm delivery in a prospective study. Am J Clin Nutr 1992;55:985?988.
5. Murphy JF, Newcombe RG, O’Riordan J, Coles EC, Pearson JF. Relation of hemoglobin levels
in first and second trimesters to outcome of pregnancy. Lancet 1986;1:992?995.
6. Ladipo OA. Nutrition in pregnancy: mineral and vitamin supplements. Am J Clin Nutr 2000;
7. Jameson S. Zinc status in pregnancy: the effect of zinc therapy on perinatal mortality, prema-
turity, and placenta ablation. Ann NY Acad Sci 1993;678:178?192.
8. Scholl TO, Hediger ML, Scholl JI, Fisher RL, Khoo C. Low zinc intake during pregnancy:
its association with preterm and very preterm delivery. Am J Epidemiol 1993;137:1115?1124.
9. Gibson RS. Zinc nutrition in developing countries. Nutr Res Rev 1994;7:151?173.
10. Caulfield LE, Zavaleta N, Figueroa A. Adding zinc to prenatal iron and folate supplements
improves maternal and neonatal zinc status in a Peruvian population. Am J Clin Nutr 1999;
11. Keen CL, Uriu-Hare JY, Hawk SN, Jankowski MA, Daston GP, Kwik-Uribe CL, Rucker RB.
Effect of copper deficiency on prenatal development and pregnancy outcome. Am J Clin Nutr
12. Uauy R, Olivares M, Gonzalez M. Essentiality of copper in humans. Am J Clin Nutr 1998;
14. Jilani I, Qazq HS, Al-Arabi ZA. A study on anemia among pregnants at Mother and Childhood
(MCH) Centers in Jordan for the year 1990 and the first half of 1991. Ministry of Health,
15. Mawajdeh S, Badran O, Haddadin A, Abu-Laban A, Idris M. Prevalence and determinants of
anemia and iron deficiency among Jordanian women 15?49 years of age: a national study.
UNICEF, Jordan Country Programme and Ministry of Health, Jordan; 1996.
16. Faqih A, Hijazi S, Qazaq H. Prevalence of iron deficiency anemia in Jordan. In: Musaiger A,
Miladi S, editors. Proceedings of the workshop on Micronutrient deficiencies in the Arab
Middle East Countries, Amman, Jordan, 1996;52?55.
Br J Nutr 2001;85(suppl):193S?197S.
Trace Elements in Pregnant Women from Jordan7
17. Martin-Lagos F, Navarro-Alarcon M, Terres-Martos C, Lopez-Garcia de la Serrana H, Perez- Download full-text
Valero V, Lopez-Martinez MC. Zinc and copper concentrations in serum from Spanish women
during pregnancy. Biol Trace Elem Res 1998;61:61?70.
18. Al-Bader A, Hussein T, Al-Mosawi M, Otaibi M, Abul H, Khalifa D, Dashti H. Serum zinc and
19. Iqbal AS, Shahidullah M, Islam MN, Akhter S, Banu S. Serum zinc and copper in maternal
blood and cord blood of neonates. Indian J Pediatr 2001;68:523?526.
20. Vir SC, Love AGG, Thompson W. Zinc concentration in hair and serum of pregnant women in
Belfast. Am J Clin Nutr 1981;34:2800?2807.
21. Vir SC, Love AGG, Thompson W. Serum and hair concentrations of copper during pregnancy.
Am J Clin Nutr 1981;34:2382?2388.
22. Cousins RJ, McMahon RJ. Integrative aspects of zinc transporters. J Nutr 2000;130:1384S?
23. Henkin RI, Marshall JR, Meret S. Maternal-fetal metabolism of copper and zinc at term. Am J
Obstet Gynecol 1971;110:131?134.
24. Tamura T, Goldenberg RL, Johnston KE, DuBard M. Maternal plasma zinc concentrations
and pregnancy outcome. Am J Clin Nutr 2000;71:109?113.
25. Frkovic A, Medugorac B, Alebic-Juretic A. Zinc levels in human milk and umbilical cord blood.
Sci Total Environ 1996;192:207?212.
26. Ghebremeskel K, Burns L, Burden TJ, Harbige L, Costeloe K, Powell JJ, Crawford M. Vitamin
A and related essential nutrients in cord blood: relationship with anthropometric measurements
at birth. Early Hum Dev 1994;39:177?188.
27. Okonofua FE, Isinkaye A, Onwudiegwu U, Amole FA, Emofurieta WA, Ugwu NC. Plasma
zinc and copper in pregnant Nigerian women at term and their newborn babies. Int J Gynecol
28. Leo TT, Loong EP, Chin RK, Lam CW, Lam YM. Zinc and birth weight in uncomplicated
pregnancies. Acta Obstet Gynecol Scand 1990;69:609?611.
29. Jeswani RM, Vani SN. A study of serum zinc levels in cord blood of neonates and their mothers.
Indian J Pediatr 1991;58:683?686.
30. Zamorano AF, Arnalich F, Sanchez Casas E, Sicilia A, Solic C, Vazquez JJ, Casalla R. Levels of
iron, vitamin B12, folic acid and their binding proteins during pregnancy. Acta Haematol
31. Singhal U, Mohsin S, Saini K, Singhal KC. Serum levels of iron and transferrin in neonatal and
anemic pregnant women. Indian J Physiol Pharamacol 1993;37:71?74.
32. Gaspar MJ, Ortega RM, Moreiras O. Relationship between iron status in pregnant women and
their newborn babies. Investigation in a Spanish population. Acta Obstet Gynecol Scand
33. Singla PN, Chand S, Agarwal KN. Cord serum and placental iron status in maternal hypo-
ferremia. Am J Clin Nutr 1979;32:1462?1465.
34. Rougereau A, Gore J, N’diaye M, Person O. Ferritin and iron status in Senegalese women. Am
J Clin Nutr 1982;36:314?318.
35. Agrawal RM, Tripathi AM, Agrawal KN. Cord blood hemoglobin, iron and ferritin status in
maternal anemia. Acta Paediatr Scand 1983;72:545?548.
36. Steer PJ, Alam MA, Wadsworth J, Welch A. Relation between maternal hemoglobin concen-
trations and birth weight in different ethnic groups. BMJ 1995;310:489?491.
37. Steer PJ. Maternal hemoglobin concentration and birth weight. Am J Clin Nutr 2000;71
38. Scholl TO, Reilly T. Anemia, Iron and pregnancy outcome. J Nutr 2000;130:443S?447S.
39. De Maeyer EM. Preventing and controlling iron deficiency anemia through primary health care.
Geneva: World Health Organization; 1989.
40. Rasmussen KM. Is there a causal relationship between iron deficiency or iron-deficiency anemia
and weight of birth, length of gestation and perinatal mortality. J Nutr 2001;131(Suppl):
41. Yip R. Significance of an abnormally low or high hemoglobin concentrations during pregnancy:
Special consideration of iron nutrition. Am J Clin Nutr 2000;72(Suppl):272S?279S.
8Awadallah et al.