3. IDA=Problem
How common is the problem? (Epidemiology)
Why is it a problem? (Pathophysiology)
How to recognize? (Diagnosis)
What can we do about it? (Management)
4. 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
5. Epidemiology
Anemia – most common medical
disorder in pregnancy worldwide
1 in 3 pregnant mothers in Malaysia are
anemic
95% of them have iron deficiency anemia
10. IDA: Why is it a problem?
Intrapartum: Severe iron deficiency
Poor maternal Hb reserve
Predisposes to atony: Depleted myoglobin
impairs uterine contraction
11. ?Screening for IDA
Hb to be taken at booking
20-24wks
36wks
Microcytic hypochromic
? Ferritin/TIBC?/Serum Iron
Sarawak Guidelines Prevention & Management of
Anemia in Pregnancy
12. 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
13. Absorption - only 10% to 15%
Haem iron more readily absorbed
Dietary advice?
16. Harms of routine Iron
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)
17. Intermittent supplementation in
non-anemic pregnant women
Rationale = Intestinal cells have limited
iron absorption capacity andturn over every 5-6 days
Intermittent supplementation exposes iron to only
new intestinal cells,in theory improving absorption
18. Fewer GI side effects
or Hb >13g/dL
Intermittent vs Daily
No difference in maternal
anemia/ Preterm/ LBW
21. 1st line "Investigation"
Treat with 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
25. Elemental Iron
Products Elemental Iron
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. 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
28. Enhancer of absorption
• Ascorbic acid
• Fermentation (Reduces phytate content)
• Ferrous iron
• Gastric acidity
34. 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
35. 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
36. 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
37. Postpartum
Hb < 10g/dL
• Treatment dose for 3/12
• 2wks to raise Hb BUT 3/12 to replenish
iron stores
38. If all else fails.............
try cooking this
41. References
1 Haniff J et. 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
