Establishment of discrete reference interval and next-generation reference interval for copper and zinc during pregnancy using real-world data

Background: Copper and zinc are two trace elements that are essential to maintain normal pregnancy and fetal development. But only few research established specific reference intervals (RIs) for pregnant women. In this study, we aim to establish discrete RIs and next-generation RIs for copper and zinc during pregnancy by real-world data.

Method: We retrospectively collected 710 healthy pregnant women and 300 age-matched non-pregnant women attending the hospital and compared copper and zinc levels among them. Further, we analyzed multiple factors (gestational age, maternal age, and parity) that may affect copper and zinc during pregnancy by multivariate regression. Two types of reference intervals (RIs) of copper and zinc for pregnant women were established: discrete reference intervals (RIs) by non-parametric method and next-generation RIs by Generalized Additive Models for Location, Scale, and Shape (GAMLSS) model.

Result: Copper levels were higher (median: 1st trimester: 1203.00 μg/L, 2nd trimester: 1818.00 μg/L, 3rd trimester: 1795.00 μg/L) than in non-pregnant women (median: 900.00 μg/L, p＜0.001), whereas zinc levels were lower in pregnant women (median: 1st trimester: 836.00 μg/L, 2nd trimester: 639.00 μg/L, 3rd trimester: 618.00 μg/L) than in non-pregnant women (median: 767.00 μg/L, p＜0.001). Additionally, copper and zinc levels varied among trimesters. Moreover, copper and zinc were affected significantly by gestational age but maternal age only had a weak effect on them. Based on the effect of gestational age, we established discrete RIs partitioned by trimesters and next-generation RIs for copper and zinc respectively during pregnancy.

Conclusion: Taken together, this research elucidated the remarkable effect of gestational age on copper and zinc during pregnancy. The next-generation RIs visualized trends and subtle changes in copper and zinc levels during pregnancy. The discrepancy between discrete RIs and next-generation RIs suggested a more detailed continuous RIs could be considered for pregnant women.