Ida o&g update2015
- 1. Iron deficiency anemia: Shall we address it once & for all? Sarawak O&G Update 23 May 2015 Dr Voon Hian Yan
- 2. Anemia in Pregnancy= NOT a diagnosis
- 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
- 6. Haniff J et al 2007
- 7. Pathophysiology Nadir in Hb occurs around 28-36 wks
- 9. IDA: Why is it a problem
- 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?
- 14. Iron supplementation • Prophylaxis : 30-100mg/day elemental iron • Therapeutic: ≥180mg/day elemental iron (100-200mg/day)
- 15. Should Iron supplementation be started in ALL pregnant women?
- 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
- 19. Iberet
- 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
- 22. If not responding Compliance Dose Inhibitors Differentials Where did the Iron go?
- 23. Compliance Tolerability and GI side effects10-20%
- 24. Wrong dose
- 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
- 26. Inhibitors
- 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
- 29. Loss of Iron Hookworm infestation GI losses
- 30. Reconsider differential PBF Stool Ova and Cyst Hb electrophoresis
- 31. Special groups Thalassemia -Folate 3/12 prepregnancy -Iron if Ferritin< 30ug/L Renal impairment -Recombinant human erythropoietin
- 32. When to refer to tertiary hospital? • Symptomatic patients • Moderate anemia & failure to response to oral iron • Severe anemia after 24 weeks
- 33. Indication for parenteral • Malabsorption • Moderate anemia with non-compliance • Severe anemia 24-36weeks
- 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
- 39. The Lucky Iron Fish
- 40. Declaration of interest Sponsor for O&G Update
- 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
- 42. www.sgh-og.com