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Iron Deficiency Anaemia
The document discusses iron deficiency anemia (IDA) in pregnancy, emphasizing its prevalence and the need for awareness and management. It outlines the definition, epidemiology, implications, screening, diagnosis, and treatment options, including dietary advice and iron supplementation strategies. The text also covers guidelines for when to refer patients for more intensive care and the importance of monitoring and managing IDA to prevent complications during and after pregnancy.
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Iron Deficiency Anaemia
- 1. Iron deficiency anemia: Shallwe address it once & for all? SGH O&G Update 7th May 2016 Dr Chai Ming Cheng
- 2.
- 3. Anemia in Pregnancy=NOT a diagnosis
- 4. IDA=Problem How common isthe problem? (Epidemiology) Why is it a problem? (Pathophysiology) How to recognize? (Diagnosis) What can we do about it? (Management)
- 5. Definition WHO & CDC: Haemoglobin <11.0g/dL + Ferritin <12ug/L British Committee of Standards in Hematology (BCSH) : 1st trimester <11g/dL : 2nd & 3rd trimester <10.5g/dL : Post partum < 10g/dL
- 6. Epidemiology Anemia – mostcommon medical disorder in pregnancy worldwide 1 in 3 pregnant mothers in Malaysia are anemic 95% of them have iron deficiency anemia
- 7.
- 8. Pathophysiology Nadir in Hboccurs around 28-36 wks
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- 11. IDA: Why isit a problem
- 12. IDA: Why isit a problem? Intrapartum: Severe iron deficiency Poor maternal Hb reserve Predisposes to atony: Depleted myoglobin impairs uterine contraction
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- 14. Screening for IDA Hbto be taken at • Booking • 20-24wks • 36wks Microcytic hypochromic Ferritin/TIBC?/Serum Iron Sarawak Guidelines Prevention & Management of Anemia in Pregnancy
- 15. Serum Ferritin <12-15ug/L : Sensitivity 90%, Specificity 85% : Glycoprotein; Acute phase reactant : 1st test to be abnormal when iron stores reduced : Not affected by recent iron ingestion BCSH 2011
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- 17. Absorption - only10% to 15% Haem iron more readily absorbed Dietary advice?
- 18. Iron supplementation • Prophylaxis: 30-100mg/day elemental iron • Therapeutic: ≥180mg/day elemental iron (100-200mg/day)
- 19. Should Iron supplementationbe started in ALL pregnant women?
- 20. Harms of routineIron supplementation • ?Observational studies shown increase risk of LBW, perinatal death, preterm Hb>13.2 @<20wks • ?Oxidative stress due to free radical formation (intestinal mucosa/placenta)
- 21. Intermittent supplementation in non-anemicpregnant women Rationale = Intestinal cells have limited iron absorption capacity and turn over every 5-6 days Intermittent supplementation exposes iron to only new intestinal cells,in theory improving absorption
- 22. Fewer GI sideeffects or Hb >13g/dL Intermittent vs Daily No difference in maternal anemia/ Preterm/ LBW
- 23. Types of OralIron
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- 26. Elemental Iron Products ElementalIron Iberet-Folic 500 105mg Obimin 30mg Ferrous Fumarate 200mg 60mg Iron dextran (IM or IV) 50mg per ml Iron sucrose (IV) 20mg per ml
- 27. Elemental Iron Products ElementalIron Ferrous Fumarate 200mg 60mg (33%) Ferrous Sulphate 200mg 65mg (32%) Ferrous Gluconate 60mg (12%)
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- 29. 1st line "Investigation" Treatwith oral iron ≥180 mg/day Expected increment of 1g/2weeks Clues: Low MCV/MCH currently BUT Normal baseline Hb & MCV/MCH esp booking bloods in 1st trimester
- 30. If not responding ComplianceDose Inhibitors Differentials Where did the Iron go?
- 31. Compliance Tolerability and GIside effects10-20%
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- 34. Inhibitor of absorption •Phytates (Cereals) • Calcium • Tannins (Tea) To take between meals/bedtime Up to 40% reduction of absorption if taken with meals USPSTF 2015
- 35. Enhancer of absorption •Ascorbic acid • Fermentation (Reduces phytate content) • Ferrous iron • Gastric acidity
- 36. Loss of Iron Hookworminfestation GI losses
- 37. Reconsider differential PBF Stool Ovaand Cyst Hb electrophoresis
- 38. Mentzer Index IDA vsThalassemia >13 RBC (106 /mcL) MCV (fL) RBC (106 /mcL) = MCV (fL) <13
- 39. Special groups Thalassemia -Folate 3/12prepregnancy -Iron if Ferritin< 30ug/L Renal impairment -Recombinant human erythropoietin
- 40. When to referto tertiary hospital? • Symptomatic patients • Moderate anemia & failure to response to oral iron • Severe anemia after 24 weeks
- 41. Indication for parenteral •Malabsorption • Moderate anemia with non-compliance • Severe anemia 24-36weeks
- 42. Parenteral iron •1) Dextran(IM/IV) •2) Sucrose (IV)- less side effects •Need test dose (0.5mls, wait for 1 hour) •Risk of anaphylaxis (1%) •Increase in 0.8-1.5g/dl/week •RCT – postpartum – not any superior then oral
- 43. Indications for antenatal transfusion •Patients who are symptomatic • Hb<6g/dL • Hb<8g/dL @>36wks • Placenta Praevia Major Hb<10g/dL • Moderate-Severe anemia in patients with cardiac/severe respiratory ds • Intolerant oral/Parenteral Iron
- 44. IDA: Intrapartum management •Transfuse and transfer to tertiary hospital if Hb<8g/dL • Crossmatch 2 pints if Hb 8-10g/dL and transfer to specialist hospital • 2 large branulas in labour • Active management of third stage • Delayed cord clamping
- 45. Postpartum Hb < 10g/dL •Treatment dose for 3/12 • 2wks to raise Hb BUT 3/12 to replenish iron stores
- 46.
- 47. References 1 Haniff Jet. al. Anemia in pregnancy in Malaysia: a cross-sectional survey. Asia Pac J Clin Nutr 2007;16 (3):527-536 2 Nils Milman. Prepartum anaemia: prevention and treatment. Ann Hematol (2008) 87:949–959. 3. Nils Milman. Iron and pregnancy—a delicate balance. Ann Hematol (2006) 85: 559–565 4. Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Pregnant Women: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation March 2015 5. UK guidelines on the management of iron deficiency in pregnancy British Committee for Standards in Haematology 2011
- 48. Declaration of interest Sponsorfor O&G Update