update on treatment modalities of anemia in pregnancy_5jul2013_v3

7/27/2019 Update on Treatment Modalities of Anemia in Pregnancy_5Jul2013_v3

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Update on Treatment Modalities

of Anemia in Pregnancy

Carol Lim

Maternal Fetal Medicine Consultant

Hospital Sultan Haji Ahmad Shah,

Temerloh, Pahang6 July 2013

17th Malaysian Family Medicine Scientific Conference 2013


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Iron Deficiency Anemia

An epidemic public health crisis!

6 July 2013, Kuantan


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Bring Home Messages

Dont overlook anemia Dont treat it lightly

Common doesnt mean its not serious

it can be fatal!

Family planning is essential.



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IDA in Pregnancy

Cutoff Hb: 11g/dL (WHO)

Prevalence: 14% - developed countries

56% (35-75%) - developing countries35-38% - Malaysia

IDA:most common deficiency disorder in the world;

>2 billion people affected worldwide (30%)

WHO6 July 2013, Kuantan


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Impact

Maternal Risks:Maternal

morbidity &

mortality Risk of PPH Risk of heart

failure in severeanemia



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Impact

Fetal Risks: Low birth weight

Preterm delivery

Perinatal mortality Behavioral impairment

Emotional impairment

Cognitive impairment


In cases of Hb


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Definitions in pregnancy

Anemia: Hb


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Malaysia

Prevalence of anemia in pregnancyMsia35% if 11g/dL as cutoff

11% if 10g/dL as cutoff

Highest among teenagers

Indian > Malay > Chinese

T3Mostly of mild type



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Malaysia

2 factors:- Gestational age

- Ethnicity

?East Msian

Jamaiyah et al, Asia Pac J Clin Nutr 2007



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Anemia

Causes:Nutritional

Chronic blood loss

Hemolytic anemia thal, malaria, drug

induced

Others eg aplastic, myeloproliferativedisorders



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Classification of Anemia

MOH CPG The Management of Anemia in Pregnancy and Chronic Kidney

Disease, 2007

Perinatal Care Manual 2ndEd , 2010

Hb level (g/dL) Severity of Anemia

9.5-10.5 Mild

8.0 9.4 Moderate

6.9 7.9 Severe

< 6.9 Very severe



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Classification of Anemia for management

purpose : asymptomatic

Symptomatic patients hospital management irrespective of

gestational age

Sabah Obstetric Shared Care Guidelines, 2009

Hb Gestational Age Place ofmanagement

8.0 10.0 Irrespective of

gestational age

Health clinic

< 8.0 < 36 weeks Health clinic

< 8.0 > 36 weeks Hospital



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Antenatal Care Color Coding

RED

Symptomatic anemia regardless of gestational age

YELLOW

Hb


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Treatment modalities

Diet

Iron therapy Oral iron

Parenteral iron



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Food & Drugs that affect Iron absorption:

Impair iron absorption:

Taking oral iron with food (40-60%) Caffeinated beverages especially tea

Calcium containing foods & beverages

Calcium supplements Antacids

H-2 receptor blockers

Proton-pump inhibitors

Enhance iron absorption:

Vitamin C



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Iron Therapy

Oral iron treatment

- Fe Fumarate

- Fe Sulfate

- Fe Gluconate

Parenteral iron

- Iron Dextran

- Iron Sucrose

- Iron Carboxymaltose



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Oral Iron

Oral iron

(100mg)

Elemental iron

(mg)

Ferrous Fumarate 33mg

Ferrous Sulfate 20mg

Ferrous Gluconate 11mg


Ferrous Sulfate most commonly used & cheapest


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Combination Preparation

Iberet-Folic 500 (Fe Sulfate)

(105mg elemental iron per tablet)

Obimin (Fe Sulfate)

(30mg elemental iron per tablet)

Sangobion (Fe Gluconate)(30mg elemental iron per tablet)



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Iberet-Folic 500

GradumetControlled-released dosage form

patentedMaximise iron absorption

Eliminates gastric irritation

Improve compliance



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Gradumet reaches

the stomach wherevitamins & minerals

are released

Gradumet

- iron isreleased in the

duodenum site of

maximum iron

absorption6 July 2013, Kuantan


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Parenteral Iron

Strictly limited for: Absolute non compliance of oral iron

Intractable gastrointestinal intolerance to

oral iron

Proven malabsorption, possible

ulcerative colitis

Hyperemesis in pregnancy



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Parenteral Iron

WHO 2004 report: excessive use of parenteral iron

not justified by indication

does not allow a clear recommendation

in favour of iron sucrose over other

preparation further work & research

required



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Parenteral Iron

Iron Dextran (Imferon, Cosmofer) Iron Sucrose (Venofer)

Iron gluconate (Ferrlecit)

Iron Carboxymaltose (Ferinject)

Ferumoxytol (Feraheme)



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Parenteral IronParenteral Iron Elemental iron / ml

Iron Dextran

(Imferon)

50mg

Iron Sucrose

(Venofer)

20mg

Ferinject 50mg

Iron gluconate(Ferrlecit)

12.5mg

Feraheme 30mg



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Parenteral Iron

hematological response

Restore feritin faster then oral iron

Possible side effects & adverse events:


Intravenous (IV):

venous thrombosis

allergic reaction

Metallic taste (Venofer)Headache (Ferinject)

Intramuscular (IM):

pain

discoloration

Allergic reaction


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Parenteral Iron

IM preferably at hospital, may be administered

at health clinic after a test dose in hospital

IV must be in hospital

*Venofer :

hypersensitivity reaction

test dosenot required



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INACG* Recommendation

Prevalence of

anemia inpregnancy

Dose

(elemental iron)

Duration

< 40% 60mg iron +

400g folic aciddaily

6 months in

pregnancy

40% 60mg iron +

400g folic acid

daily

6 months in

pregnancy and

continuing to 3months

postpartum


*International Nutritional Anemia Consultative Group


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INACG Recommendation (cont)

If 6 mths duration cannot be achieved in pregnancy

continue to supplement during postpartum

period x 6mth

Or increase to 120mg iron in pregnancy

International Nutritional Anemia Consultative Group (INACG)



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WHO 2012 Recommendation

Daily oral iron & folic acid supplementation aspart of antenatal care

30-*60mg elemental iron + 0.4mg FA daily

throughout pregnancy, starting as early aspossible

*60mg for countries >40% prevalence anemia in

pregnancy

Once anemia is diagnosed: 120mg elemental

iron + 0.4mg FA



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Cochrane 2012 Recommendations

Prenatal supplementation is effective:

Low birth weight baby

Prevent maternal anemiaPrevent iron deficiency in pregnancy


WIFS: Weekly Iron Folic Acid


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WIFS: Weekly Iron-Folic Acid

Supplementation

For non-anemic pregnant women With adequate antenatal care

In countries with


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WIFS

Intermittent provision:absorption

side effects of daily oral iron

Blockage of absorption of other mineral dueto high iron level in gut lumen & intestinal

epithelial cells

More acceptable by pregnant womenpatient compliance



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WIFS

Regime:

120mg elemental iron + 2.8mg Folic Acid weekly

Throughout pregnancy

Start as early as possible

Non-anemic pregnant women

For


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Blood Transfusion

To be considered for:

Symptomatic anemia

Asymptomatic but severe anemia

especially >36w



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Interventions to prevent IDA

Iron supplementation

Fortification of food with iron

Health & nutrition education

Control of parasitic infection

Improvement in sanitation

Delayed cord clamping to prevent iron

deficiency among infants and young children



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Screening

FBC

- Booking

- Monthly through out pregnancy

If anemic

- Iron studies- if MCH


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Establish diagnosis

If Hb


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Intrapartum Management

Aim to keep Hb>8g/dLHospital delivery

Mode of delivery as per obstetric indication

Timing of delivery generally allow EDD +10unless specified

PPH prophylaxis be vigilant against PPH

GSH on standby



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Postpartum Follow Up

Continue iron supplementation

Emphasize on contraception (MEC) almost all

category 1 or 2 (generally safe)



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Pre-pregnancy

For known thalassemia patients / couples

Counselling



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Summary

All pregnant women must be screened foranemia:

- Hb, MCV

Countries with Hemoglobinopathies /Thalasemia prevalence:

- Ferritin / Iron Studies

- Hb analysis



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Summary

IDA to be treated

Anemia other than IDA to be further evaluated Failure to respond to iron therapy:

? Incorrect diagnosis

? Co-existing disease

? Malabsorption

? Non-compliance

? Blood loss

Be certain of indications before deciding forparenteral iron

?? WIFS



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Bring Home Messages

Dont overlook anemia Dont treat it lightly

Common doesnt mean its not serious

it can be fatal!

Family planning is essential.



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Instructions for living a life. Pay attention. Be astonished. Tell about it.

~ Mary Oliver


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Thank You

[email protected]

update on treatment modalities of anemia in pregnancy_5jul2013_v3

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