Iron deficiency anemia:Shall we address it once & for all?

Sarawak O&G Update

23 May 2015

Dr Voon Hian Yan

Anemia in Pregnancy= NOT a diagnosis

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

Haniff J et al 2007

Pathophysiology

Nadir in Hb occurs around 28-36 wks

Milman N 2008

IDA: Why is it a problem

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

Absorption - only 10% to 15%

Haem iron more readily absorbed

Dietary advice?

Iron supplementation

• Prophylaxis : 30-100mg/day elemental iron

• Therapeutic: ≥180mg/day elemental iron

(100-200mg/day)

Should Iron supplementation be started in ALL pregnant women?

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

Iberet

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

If not responding

Compliance Dose

Inhibitors

Differentials

Where did the Iron go?

Compliance

Tolerability and GI side effects10-20%

Wrong dose

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

Inhibitors

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

Loss of Iron

Hookworm infestationGI losses

Reconsider differential

PBFStool Ova and CystHb electrophoresis

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

If all else fails............. try cooking this

The Lucky Iron Fish

Declaration of interest

Sponsor for O&G Update

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

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