iron deficiency anaemia in pregnancy

Guidelines on management of

iron deficiency in pregnancy

British Committee for Standards in Haematology

2012.

Aboubakr Elnashar, Egypt

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1. DEFINITION

2. PREVALENCE

3. EFFECTS

4. DIAGNOSIS

5. PREVENTION

6. MANAGEMENT

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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}

Mild Moderate Severe Adam , 2005

9-11 7-9 <7 Hgb g/dl

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2. PREVALENCE

IDA:

Most common cause

30- 40% pregnant women

(WHO, 2008).

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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).

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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).

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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).

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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.

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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.

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H=hypochromic RBC; p=pencil RBC; T=target RBC; M=microcytic RBC The Lancet 2000;355:1260

Iron Deficiency Anemia

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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).

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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

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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.

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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.

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6. MANAGEMENT

1. Dietary Advice

Diet rich in iron

Avoid inhibitors of iron absorption

Poor Medium Rich

milk and its

products, root

vegetables

meat, chicken,

fish, spinach,

banana, apple

liver, egg yolk, dry

beans, dry fruits,

wheat germ, yeast

Enhance Inhibit

Heme Phytates: cereals

Ascorbic acid Tannins: tea –coffee

Ferrous iron(Fe2+) Calcium

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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

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).

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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.

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{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.

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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).

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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},

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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

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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.

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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).

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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.

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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.

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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}.

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Thank you

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