ida o&g update2015
TRANSCRIPT
Iron deficiency anemia:Shall we address it once & for all?
Sarawak O&G Update
23 May 2015
Dr Voon Hian Yan
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)
DefinitionWHO & 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
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
IDA: Why is it a problem?
Intrapartum: Severe iron deficiency
Poor maternal Hb reserve
Predisposes to atony: Depleted myoglobin
impairs uterine contraction
?Screening for IDAHb to be taken at booking 20-24wks 36wks
Microcytic hypochromic ? Ferritin/TIBC?/Serum Iron Sarawak Guidelines Prevention & Management
of Anemia in Pregnancy
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
Iron supplementation
• Prophylaxis : 30-100mg/day elemental iron
• Therapeutic: ≥180mg/day elemental iron
(100-200mg/day)
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)
Intermittent supplementation in non-anemic pregnant women
Rationale = Intestinal cells have limitediron absorption capacity andturn over every 5-6 days
Intermittent supplementation exposes iron to only new intestinal cells,in theory improving absorption
Fewer GI side effects
or Hb >13g/dL
Intermittent vs Daily
No difference in maternal anemia/ Preterm/ LBW
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
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
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
Enhancer of absorption
• Ascorbic acid• Fermentation (Reduces phytate content)• Ferrous iron• Gastric acidity
Special groups
Thalassemia
-Folate 3/12 prepregnancy
-Iron if Ferritin< 30ug/L
Renal impairment
-Recombinant human erythropoietin
When to refer to tertiary hospital?
• Symptomatic patients• Moderate anemia & failure to response
to oral iron• Severe anemia after 24 weeks
Indication for parenteral
• Malabsorption• Moderate anemia with non-compliance• Severe anemia 24-36weeks
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
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
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
Postpartum
Hb < 10g/dL
• Treatment dose for 3/12
• 2wks to raise Hb BUT 3/12 to replenish iron stores
References1 Haniff J et. al. Anemia in pregnancy in Malaysia: a cross-sectional survey. A
sia Pac J Clin Nutr 2007;16 (3):527-5362 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: 559–5654. Routine Iron Supplementation and Screening for Iron Deficiency Anemia in Pregnant Women: A Systematic Review to Update the U.S. Preventive Servi
ces Task Force Recommendation March 20155. UK guidelines on the management of iron deficiency in pregnancy British Committee for Standards in Haematology 2011