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Carol Lim Maternal Fetal Medicine Consultant Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang 6 July 2013 17th Malaysian Family Medicine Scientific Conference 2013
IDA in Pregnancy
Cutoff Hb: 11g/dL (WHO)
Prevalence: 14% - developed countries 56% (35-75%) - developing countries 35-38% - Malaysia IDA: most common deficiency disorder in the world; >2 billion people affected worldwide (30%)
WHO
6 July 2013, Kuantan
Impact
Maternal Risks: Maternal morbidity & mortality Risk of PPH Risk of heart failure in severe anemia
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Impact
Fetal Risks:
Low birth weight Preterm delivery Perinatal mortality Behavioral impairment Emotional impairment Cognitive impairment
In cases of Hb <6gm% :
Abnormal fetal oxygenation Non-reassuring fetal heart rate pattern Reduced liquor volume Fetal cerebral vasodilatation Fetal death
Definitions in pregnancy
Anemia: Hb <11gm% Iron Deficiency: Ferritin <30g/L Iron Deficiency Anemia: low ferritin & low Hb
Ferritin: First to be abnormal as iron stores decrease Not affected by recent iron ingestion But also raised in infection / inflammation
Serum Fe & TIBC: unreliable indicators, wide fluctuation due to recent iron ingestion
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Malaysia
Prevalence of anemia in pregnancy Msia 35% if 11g/dL as cutoff 11% if 10g/dL as cutoff Highest among teenagers Indian > Malay > Chinese T3 Mostly 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, myeloproliferative disorders
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Classification of Anemia
Hb level (g/dL)
9.5-10.5 8.0 9.4 6.9 7.9 < 6.9
Severity of Anemia
Mild Moderate Severe Very severe
MOH CPG The Management of Anemia in Pregnancy and Chronic Kidney Disease, 2007 Perinatal Care Manual 2nd Ed , 2010
6 July 2013, Kuantan
Treatment modalities
Diet
Iron therapy
Oral iron Parenteral iron
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)
Combination Preparation
Iberet-Folic 500 (Fe Sulfate)
(105mg elemental iron per tablet)
Iberet-Folic 500
Gradumet Controlled-released dosage form patented Maximise iron absorption Eliminates gastric irritation Improve compliance
6 July 2013, Kuantan
Gradumet reaches the stomach where vitamins & minerals are released
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
6 July 2013, Kuantan
Parenteral Iron
Iron Dextran (Imferon, Cosmofer) Iron Sucrose (Venofer) Iron gluconate (Ferrlecit) Iron Carboxymaltose (Ferinject) Ferumoxytol (Feraheme)
Parenteral Iron
Parenteral Iron Iron Dextran (Imferon) Iron Sucrose (Venofer) Ferinject Elemental iron / ml 50mg 20mg 50mg
12.5mg
30mg
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)
6 July 2013, Kuantan
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 dose not required
INACG* Recommendation
Prevalence of anemia in pregnancy < 40% Dose (elemental iron) 60mg iron + 400g folic acid daily 60mg iron + 400g folic acid daily Duration
40%
WIFS
Intermittent provision: absorption side effects of daily oral iron Blockage of absorption of other mineral due to high iron level in gut lumen & intestinal epithelial cells More acceptable by pregnant women patient compliance
6 July 2013, Kuantan
WIFS
Regime: 120mg elemental iron + 2.8mg Folic Acid weekly Throughout pregnancy Start as early as possible Non-anemic pregnant women For <20% prevalence of anemia in pregnancy
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Blood Transfusion
To be considered for: Symptomatic anemia
Asymptomatic but severe anemia especially >36w
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 <27 Hb analysis
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Establish diagnosis
If Hb <8.5 and MCH <27 - For iron studies / ferritin - Correct IDA - If no improvement in Hb after 1 month or iron studies normal Hb analysis
Intrapartum Management
Aim to keep Hb>8g/dL Hospital delivery Mode of delivery as per obstetric indication Timing of delivery generally allow EDD +10 unless specified PPH prophylaxis be vigilant against PPH GSH on standby
Postpartum Follow Up
Continue iron supplementation Emphasize on contraception (MEC) almost all category 1 or 2 (generally safe)
Pre-pregnancy
For known thalassemia patients / couples Counselling
Summary
All pregnant women must be screened for anemia: - 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 for parenteral iron ?? WIFS
6 July 2013, Kuantan
Instructions for living a life. Pay attention. Be astonished. Tell about it.
~ Mary Oliver
Thank You
carolkklim@yahoo.com
6 July 2013, Kuantan