Iron deficiency anaemia in pregnancy


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Iron deficiency anaemia in pregnancy

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Iron deficiency anaemia in pregnancy

  1. 1. Guidelines on management of iron deficiency in pregnancy British Committee for Standards in Haematology 2012. Aboubakr Elnashar, Egypt Aboubakr Elnashar
  3. 3. 1. DEFINITION  1st T: <11g/dL (WHO, 2001) 2nd and 3rd T: <10.5 gm Postpartum: <10 gm {relative plasma expansion being particularly marked in the second trimester} MildModerateSevereAdam , 2005 9-117-9<7Hgb g/dl Aboubakr Elnashar
  4. 4. 2. PREVALENCE IDA: Most common cause 30- 40% pregnant women (WHO, 2008). Aboubakr Elnashar
  5. 5. 3. EFFECTS Maternal {immune function} 1. Increased susceptibility or severity of infections (Eliz et al, 2005) 2. Poor work capacity and performance (Haas et al, 2001) 3. Disturbances of postpartum cognition and emotions (Beard et al, 2005). Aboubakr Elnashar
  6. 6. Pregnancy outcome 1. PTD (Scholl et al, 1994) 2. Low birth wt (Cogswell et al, 2003) 3. Placental abruption 4. Increased peripartum blood loss (Arnold et al, 2009). Aboubakr Elnashar
  7. 7. Fetus: protected from the effects of iron deficiency by upregulation of placental iron transport proteins (Gambling et al, 2001) Infant: increases the risk of iron deficiency in the first 3 months of life (Puolakka et al, 1980, Colomer et al, 1990). Aboubakr Elnashar
  8. 8. 4. DIAGNOSIS Clinical usually nonspecific, unless the anaemia is severe. 1. Fatigue: most common symptom. 2. Pallor, weakness, headache, palpitations, dizziness, dyspnoea and irritability. 3. Feel colder than normal {Impair temperature regulation} 4. Rarely pica develops, where there is a craving for non- food items such as ice and dirt. Aboubakr Elnashar
  9. 9.  Laboratory tests 1. CBC: At booking At 28 w (NICE, 2008). low Hb, MCV, MCH, and MCHC Blood film: microcytic hypochromic red cells characteristic ‘pencil cells’. N.B: microcytic, hypochromic indices may also occur in haemoglobinopathies. Aboubakr Elnashar
  10. 10. H=hypochromic RBC; p=pencil RBC;T=target RBC; M=microcytic RBC The Lancet 2000;355:1260 Iron Deficiency Anemia Aboubakr Elnashar
  11. 11. 2. Serum ferritin Accurately reflects iron stores in the absence of inflammatory change. ≤ 15 μg/l: iron depletion ≤ 30 μg/l: early iron depletion which will worsen unless treated: Treatment should be considered (van den Broek et al, 1998). Aboubakr Elnashar
  12. 12. Indications for assessment of serum ferritin I. Anaemic women where estimation of iron stores is necessary 1. Known Haemoglobinopathy 2. Prior to parenteral iron replacement II. Non-anaemic women with high risk of iron depletion 1. Previous anaemia 2. Multiparity >P3 3. Consecutive pregnancy <1year following delivery 4. Vegetarians 5. Teenage pregnancies 6. Recent history of bleeding III. Non-anaemic women where estimation of iron stores is necessary 1. High risk of bleeding 2. Jehovah’s witnesses Aboubakr Elnashar
  13. 13. 3.Trial of Iron therapy Diagnostic and therapeutic for normocytic or microcytic anaemia Ferritin should be checked first In the presence of known haemoglobinopathy, If no improvement in Hb by 2 ws: referral to consider other causes of anaemia, such as folate deficiency. Aboubakr Elnashar
  14. 14. 5. PREVENTION Universal supplementation From booking (WHO) or From 2nd T (INACG) (Stolzfus et al, 1998; WHO, 2001). Cochrane review (2009): Iron supplementation improved birth length Apgar scores infant ferritin at 3 months reduces the need for postpartum maternal transfusion  iron–folic acid supplementation improved birth weight. Aboubakr Elnashar
  15. 15. 6. MANAGEMENT 1. Dietary Advice  Diet rich in iron  Avoid inhibitors of iron absorption PoorMediumRich milk and its products, root vegetables meat, chicken, fish, spinach, banana, apple liver, egg yolk, dry beans, dry fruits, wheat germ, yeast EnhanceInhibit HemePhytates: cereals Ascorbic acidTannins: tea –coffee Ferrous iron(Fe2+)Calcium Aboubakr Elnashar
  16. 16. 2. Oral Iron Patil et al, 2012: I J Med Pharmaceutical Sci I. Conventional iron preparations Fe sulfate, Fe fumarate. Cheap. No scientific evidence that any particular brand is better . Should not be given with food {salts bind the iron: impair absorption} Side effects 40% Nausea, vomiting, heart burn, metallic taste, constipation, abdominal cramps, diarrhea. 10%: Discontinue Aboubakr Elnashar
  17. 17. Extended (slow) release capsules or enteric coated capsules Less side effect {slow/decreased iron absorption, absorbed lower parts of the GI} {Iron absorption occurs at the duodenum and proximal jejunum} Not very effective Should be avoided {majority of the iron is carried past the duodenum: limiting absorption} (Tapiero, 2001). Aboubakr Elnashar
  18. 18. II. New iron preparations Multi Amino Acid Chelated iron, Carbonyl iron, Iron polymaltose, others………. Multi Amino Acid Chelated iron Vs iron salt (Pineda et al, 1994; Sofia et al, 2001) Low GIT intolerance Increase Hbg level faster with significant low doses High bioavailability and regulation Better improve iron stores Higher cost. Aboubakr Elnashar
  19. 19. {Higher stability of amino acid chelate: prevents the molecule from being destroyed in the gut}: less GI irritation {Atomic structure and chemistry}: protects the ferrous iron from undesirable chemical reactions in the stomach and intestine that limit iron absorption. Absorption not reduced in presence of phytates. Aboubakr Elnashar
  20. 20. Oral iron should be taken On an empty stomach, 1 h before meals With a source of vitamin C: orange juice {maximise absorption}. Other medications or antacids should not be taken at the same time (1A). Aboubakr Elnashar
  21. 21.  Response to oral iron Hgb should rise by 2.0 g/l over 3-4w (British National Formulary, 2010). Oral therapy should be continued for 3 months after anemia has been corrected {replenish iron stores}, Aboubakr Elnashar
  22. 22. Failure to respond to oral iron  Incorrect diagnosis: thalassemia  Presence of a coexisting disease interfering with response: anemia of chronic disease, renal failure  Patient is not taking the medication  Medication is not being absorbed: enteric coated tablets, concomitant use of antacids, malabsorption  Iron (blood) loss or need is in excess of the amount ingested: severe continuous GI bleeding, dialysis patient Aboubakr Elnashar
  23. 23. 3. Parenteral Iron Therapy Indication From the 2nd T onwards and postpartum period 1. Failure to respond 2. Intolerant of oral iron (1A). 3. Proven malabsorption Dose calculated based on Pre-pregnancy wt, Target Hb of 11.0 g/l (1B). Potential side effects written information. Skin discoloration Local abscess Allergic reaction Iron over load. Aboubakr Elnashar
  24. 24. Parenteral Vs oral iron: Faster increases in Hbg Better replenishment of iron stores, particularly iron sucrose (Al et al, 2005; Bhandal et al, 2006) and iron (III) carboxymaltose (Van Wyk et al, 2007; Breymann et al, 2007, Shafi et al, 2012) Equivalent increases in Hbg (Bayouneu and colleagues, 2002; Sharma and co-workers, 2004). Aboubakr Elnashar
  25. 25. 4. Blood transfusion:  Red cells (preferred) or whole blood  Indications: rare 1. Severe anemia near term { maximum rise in hgb achievable with either oral or parenteral iron is 0.8 g/ dL/wk}. 2. Other complication: placenta previa 3. Hypovolemia from blood loss 4. Emergency operation on a severely anemic woman. Aboubakr Elnashar
  26. 26. Anaemia at the time of delivery 1) Delivery in an hospital setting 2) Available intravenous access 3) Blood group-and-save 4) Active management of 3rd stage of labour 5) Plans to deal with excessive bleeding. Aboubakr Elnashar
  27. 27. Postnatal anaemia WHO: Hb <10g/dl. CBC should be checked within 48 h of delivery in 1. Estimated blood loss≥ 500ml 2. Uncorrected anaemia in ANC 3. Symptoms suggestive of postpartum anaemia.  Oral iron: for at least 3 months Repeat CBC and ferritin {ensure Hb and iron stores are replete}. Aboubakr Elnashar
  28. 28. Thank you Aboubakr Elnashar