Iron deficiency is the most common deficiency state in the world, affecting more than 2 billion people globally. Iron Depletion affects 20-40% of Egyptian women in childbearing period. Effective management is needed to prevent adverse maternal and pregnancy outcomes, including the need for red cell transfusion. There should be clear and simple recommendations for the diagnosis, treatment and prevention of iron deficiency in pregnancy and the postpartum period. Universal iron supplementation in pregnancy is more suitable for our local protocol. Haemoglopinopathy screening program for pregnant women is awaited.

1. IRON
DEFICIENCY
ANAEMIA
An evidence based
approach
ERC/ELG March 2017
Wafaa B Basta
MRCOG
Consultant Ob/Gyn Mataria Teaching Hospital
ERC Member

2. Declarations of interest
This presentation is Sponsored by GSK for the conference.
– I am not engaged with GSK in any other activities.
– No financial or personal benefit from GSK
UK guidelines on the management of iron deficiency in pregnancy
Biritish Committee for standers in Haematology July 2011

3. Content :
– Size of the problem
– Understanding iron metabolism
– Agreed definitions
– Effects on pregnancy
– Diagnostic tools
– Management& prevention

4. Prevalence
– 1.62 billion people globally (24.8% of the world population)
(McLean et al, 2009)
– 30–40% of pregnant women have Iron depletion
(de Benoist et al, 2008)
75%
25%

6. Body Iron
Distribution &
Storage

7. Iron Deficiency Spectrum
Iron stores Iron transport Functional iron
serum ferritin conc. transferrin
saturation
erthryocyte
protoporphyrin
conc.
haemoglobin
(Hb%)
Iron depletion Reduced Not affected Not affected Not affected
Iron-deficient
erythropoiesis
Reduced Reduced Increased Not affected
Iron D.
anaemia
Reduced Reduced Increased Reduced

8. Definition of IDA in Pregnancy
– A level of 11 g/dl appears adequate in the first trimester
(1B)
– 10.5 g/dl in the second and third trimesters
(1B)
– Postpartum anaemia is defined as Hb <10 g/dl
(2B)
1,3. WHO 2001
2. US Centers for Disease Control and Prevention (CDC) (Dowdle, 1989; Ramsey et al, 2000).
UK guidelines on the management of iron deficiency in pregnancy
British Committee for Standerds in Haematology July 2011

9. Clinical effects of iron
deficiency
Maternal morbidity & mortality
Effects on the fetus & enfant
Effects on pregnancy outcome

10. Maternal morbidity and mortality
– Maternal morbidity:
increased susceptibility or severity of infections
(Ekiz et al, 2005)
poor work capacity and performance.
(Haas & Brownlie, 2001)
disturbances of postpartum cognition and
emotions
(Beard et al, 2005)

11. Effects on the fetus and infant
– Iron deficiency in the first 3 months of life.
(Puolakka et al, 1980; Colomer et al, 1990).
– Impaired psychomotor and/or mental development
(Perez et al, 2005)
– Adult onset diseases.e.g diabetes & cardiac
(Beard, 2008; Insel et al, 2008).

12. Effects on pregnancy outcome
– Preterm delivery
(Scholl & Hediger, 1994)
– Low birth weight
(Cogswell et al, 2003)
– Placental abruption & increased peri-partum
blood loss.
(Arnold et al, 2009)

13. Diagnosis of IDA
• Clinical symptoms & signs
• Lab tests:
-FBC
-Serum ferritin
-Serum (Fe) and (TIBC).
- (ZPP).
-(sTfR).
-Reticulocyte Hb%
reticulocytes
-Bone marrow iron
-Trial of iron therapy

15. FBC, blood film and red cell indices
– FBC routine at booking & 28 weeks.
(1A) (NICE 2008)
– Low Hb%
– Low MCV
– Low MCH
– Low MCHC

16. Trial of iron therapy
– The first line diagnostic test for normocytic or microcytic
anaemia.
– An increase in Hb in 2 weeks, or further tests are needed.
(1B)
– Serum ferritin should be checked prior to starting iron in
patients with known haemoglobinopathy.
(1B)

17. Trial of iron therapy
– Anaemic women with unknown haemoglobinopathy status
should be offered a trial of iron.
(1B)
– and haemoglobinopathy screening should be undertaken
without delay.
(1A)
( NHS sickle cell and thalassaemia screening programme guidelines 2006)

19. Serum ferritin
– Levels below 15 lg/l are diagnostic of established iron
deficiency.
– A level below 30 lg/l in pregnancy should prompt
treatment.
(2A)
– Unselected screening with routine use of serum
ferritin is generally not recommended.
(2B)

20. Indications for assessment of serum ferritin
Anaemic women where estimation of iron stores is necessary:
• Known haemoglobinopathy
• Prior to parenteral iron replacement
Non-anaemic women with high risk of iron depletion:
• Previous anaemia
• Multiparity ‡P3
• Consecutive pregnancy <1 year following delivery
• Vegetarians
• Teenage pregnancies
• Recent history of bleeding
Non-anaemic women where estimation of iron stores is necessary:
• High risk of bleeding
• Jehovah’s witnesses

21. Serum ferritin
– Accurately reflects iron stores.
– It is not affected by recent iron ingestion.
However,
– It is an acute phase reactant and levels will rise
when there is active infection or inflammation.

22. Serum (Fe) and (TIBC)
Unreliable indicators:
-- recent ingestion of Fe
– diurnal rhythm
– infection.
(Adams et al, 2007).

23. Zinc protoporphyrin (ZPP)
– not influenced by the plasma dilution in the 3rd
trimester.
– affected by inflammation and infection less than ferritin.
– has greater sensitivity and specificity but is rarely
performed.
(Schifman et al, 1989)

24. Soluble transferrin receptor (sTfR)
– Sensitive, not an acute-phase reactant
(Choi et al, 2000).
– expensive test
– little data on its use in pregnancy.

25. Reticulocyte haemoglobin content
& Reticulocytes
– Iron deficiency --------- reduction in reticulocyte
number and reticulocyte haemoglobin
concentration.
– not widely available
– no data in pregnancy.

26. Bone marrow iron
– the gold standard for assessment of iron stores
– too invasive and not practical

27. Management of iron
deficiency
Dietary advice
Oral supplementation
Parenteral Iron
Blood transfusion

28. Dietary advice
– iron rich food sources.
– factors that inhibit or promote iron absorption
– Importance of maintaining adequate iron stores
in pregnancy .
(1A)

29. Dietary advice
– Daily iron intake from food for women in Great Britain is 10.5 mg
(Gregory et al, 1990)
– The recommended daily intake (RDA) for the 2nd half of pregnancy is 30 mg.
– iron requirements are 3 times higher in pregnancy
(Tapiero et al, 2001)
– Iron requirements increasing from 1–2 mg to 6 mg per day
(Bothwell, 2000)..
– Only 15% of dietary iron is absorbed. Absorption increases 3-fold by the
third trimester.

30. Factors influencing iron absorption
Factors that inhibit iron absorption Factors that enhance iron absorption
• Foods rich in calcium
• Tannins in tea& coffee
• Phytates in cereals
• Haem iron(2-3 folds)
• Ferrous iron (Fe2+)
• Ascorbic acid
• Germination & fermentation of
cereals and legumes (↓phytate)

32. Oral iron supplements
– Dietary changes alone are insufficient to
correct IDA.
– Ferrous iron salts are the preparation of choice.
– The oral dose for IDA: 100–200 mg of elemental iron
daily.
(1A)

33. Oral iron supplements
– Oral iron should be taken:
on an empty stomach
 1 h before meals
 with a source of vitamin C
 Not with other medications or antacids
(1A)

34. Dose and elemental iron content per tablet
Table adapted from the British National Formulary 2010

35. Indications for oral iron
– Anaemic women .
(1B)
– Women with known haemoglobinopathy with ferritin is
<30 lg/l
(1B)
– In non-anaemic women, high risk . If the ferritin is
<30 lg/l, 65 mg elemental iron once a day.
(1B)

36. Indications for oral iron
– Referral to secondary care:
– sever anaemia (Hb <7 g/dl)
– significant symptoms
– advanced gestation (>34 weeks)
– no rise in Hb% 2weeks after start of treatment
(2B)
– starting dose 200 mg elemental iron daily.

37. Response to oral iron
– The Hb% rise by 2 g/dl over 3–4 weeks
(British National Formulary, 2010)
– Repeat Hb test 2 weeks after start treatment
(1B)
– Once the Hb% normal , continue for 3 months , 6 weeks postpartum
(1A)
– In non-anaemic repeat Hb% and ferritin after 8 weeks.
(2B)
– If response is poor, exclude : folate deficiency, anaemia of chronic disease
(1A)

38. Response to oral iron
– For nausea and epigastric discomfort, lower iron content .
– Slow release and enteric- coated forms should be avoided
(1A)
– Titration of dose, trial of an alternative preparation.
– The relation between dose and altered bowel habit
(diarrhoea and constipation) is less clear.
(Tapiero et al, 2001)

39. Postnatal anaemia
– FBC should be checked within 48 h of delivery:
 blood loss >500 ml
 uncorrected anaemia in ANC
 symptoms of anaemia.
(1B)
– Elemental iron 100–200 mg daily for 3 months, repeat FBC and ferritin .
(1B)
Hb <10 g/dl (WHO definition)

40. Parenteral iron therapy
– from 2nd, 3rd trimester and postpartum.
– failure to respond, intolerant to oral iron
(1A)
– calculated dose on pre-pregnancy weight, aiming
for a target Hb of 11 g/dl
(1B)

41. – faster increases in Hb and better replenishment of
iron stores. (Al et al, 2005; Bhandal &
Russell, 2006)
– fewer postpartum transfusions. (Broche et al, 2005)
– However, there is a paucity of good quality trials
that assess clinical outcomes and safety.
(Reveiz et al, 2007)
Parenteral iron therapy

42. Parenteral iron therapy
– Contraindications include:
– a history of previous anaphylaxis or reactions
– first trimester of pregnancy
– active acute or chronic infection
– chronic liver disease
(Perewusnyk et al, 2002)

43. Management of delivery in women with IDA
– Delivery in an hospital ( Hb cut-offs are 9.5-
10 g/dl)
– IV access
– Blood group-and-save
– Active management of the third stage
– Plans to deal with excessive bleeding
(ecobolics )
(2B)

44. Indications for blood transfusion
– blood transfusions in postpartum period
inappropriate, with under-utilization of iron
supplements.
(Butwick et al, 2009; Parker et al, 2009; So-Osman et al, 2010).
– In fit, healthy, asymptomatic patients there is little
evidence of the benefit of blood transfusion
(American Society of Anesthesiologists Task Force, 1996).

45. Indications for blood transfusion
– Massive obstetric
haemorrhage .
– Intra- operative cell
salvage.
(1A)

46. Indications for blood transfusion
– in the postpartum period, if risk of bleeding, cardiac
compromise or symptoms requiring urgent attention.
(1A)
– Prompt recognition of iron deficiency in the
antenatal period & iron therapy may reduce the
subsequent need for blood transfusions
(1A)

47. Prevention of iron
deficiency
Universal Supplementation
Intermittent regimens
Low daily dose regimens

48. Universal supplementation
– WHO recommend 60 mg/d of elemental iron, from booking
(Stolzfus & Dreyfuss, 1998; WHO, 2001)
– The International Nutritional Anemia Consultative Group (INACG) recommend 60 mg/d of
elemental iron, from the second trimester.
(INACG)
– Routine iron supplementation for all women in pregnancy is not recommended in the UK
(1B)
– An individual approach is preferable, based on results of blood count screening tests
as well as identification of women at increased risk
(1A)
UK guidelines on the management of iron deficiency in pregnancy

49. Clinical hazards of routine supplementation
– raised Hb with risk of placental insufficiency
– secondary haemochromatosis .
– However,
– Theoretical rather than practical not for short-
term iron administration.

50. Alternative regimens
– Intermittent regimes, taken weekly or on
alternate days.
(Anderson, 1991; Institute of Medicine, 1993).
– low dose daily regimes, such as 20 mg elemental
iron
(Makrides et al, 2003) .

51. Conclusion
– Iron deficiency is the most common deficiency state in
the world, affecting more than 2 billion people globally.
– Iron Depletion affects 20-40% of Egyptian women in
childbearing period.
– Effective management is needed to prevent adverse
maternal and pregnancy outcomes, including the need
for red cell transfusion.

52. Conclusion
– There should be clear and simple recommendations for
the diagnosis, treatment and prevention of iron
deficiency in pregnancy and the postpartum period.
– Universal iron supplementation in pregnancy is more
suitable for our local protocol.
– Haemoglopinopathy screening program for pregnant
women is awaited.

53. Thank You