Update on Treatment Modalities of Anemia in Pregnancy

Carol Lim Maternal Fetal Medicine Consultant Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang 6 July 2013 17th Malaysian Family Medicine Scientific Conference 2013

Iron Deficiency Anemia An epidemic public health crisis!

6 July 2013, Kuantan

Bring Home Messages

Dont overlook anemia Dont treat it lightly Common doesnt mean its not serious it can be fatal! Family planning is essential.

6 July 2013, Kuantan

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
6 July 2013, Kuantan

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

Consider maternal transfusion for fetal indication

6 July 2013, Kuantan

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

Classification of Anemia for management purpose : asymptomatic

Hb 8.0 10.0 < 8.0 < 8.0 Gestational Age Irrespective of gestational age < 36 weeks > 36 weeks Place of management Health clinic Health clinic Hospital

Symptomatic patients hospital management irrespective of gestational age

6 July 2013, Kuantan

Sabah Obstetric Shared Care Guidelines, 2009

Antenatal Care Color Coding

RED Symptomatic anemia regardless of gestational age
YELLOW Hb <9.5g/dL (moderate or more severe) GREEN Hb <11g/dL (mild)
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Treatment modalities
Diet

Iron therapy
Oral iron Parenteral iron

6 July 2013, Kuantan

6 July 2013, Kuantan

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
6 July 2013, Kuantan

Iron Therapy
Oral iron treatment - Fe Fumarate - Fe Sulfate - Fe Gluconate Parenteral iron - Iron Dextran - Iron Sucrose - Iron Carboxymaltose
6 July 2013, Kuantan

Oral Iron
Oral iron (100mg) Elemental iron (mg)

Ferrous Fumarate 33mg Ferrous Sulfate 20mg

Ferrous Gluconate 11mg
Ferrous Sulfate most commonly used & cheapest

6 July 2013, Kuantan

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)
6 July 2013, Kuantan

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

Gradumet - iron is released in the duodenum site of maximum iron absorption

6 July 2013, Kuantan

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)

6 July 2013, Kuantan

Parenteral Iron
Parenteral Iron Iron Dextran (Imferon) Iron Sucrose (Venofer) Ferinject Elemental iron / ml 50mg 20mg 50mg

Iron gluconate (Ferrlecit) Feraheme

6 July 2013, Kuantan

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

Intramuscular (IM): pain discoloration Allergic reaction

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

6 July 2013, Kuantan

INACG* Recommendation
Prevalence of anemia in pregnancy < 40% Dose (elemental iron) 60mg iron + 400g folic acid daily 60mg iron + 400g folic acid daily Duration

6 months in pregnancy 6 months in pregnancy and continuing to 3 months postpartum

40%

*International Nutritional Anemia Consultative Group

6 July 2013, Kuantan

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)

6 July 2013, Kuantan

WHO 2012 Recommendation

Daily oral iron & folic acid supplementation as part of antenatal care 30-*60mg elemental iron + 0.4mg FA daily throughout pregnancy, starting as early as possible *60mg for countries >40% prevalence anemia in pregnancy Once anemia is diagnosed: 120mg elemental iron + 0.4mg FA
6 July 2013, Kuantan

Cochrane 2012 Recommendations

Prenatal supplementation is effective: Low birth weight baby Prevent maternal anemia Prevent iron deficiency in pregnancy

6 July 2013, Kuantan

WIFS: Weekly Iron-Folic Acid Supplementation

For non-anemic pregnant women With adequate antenatal care In countries with<20% prevalence anemia in pregnancy Compared to daily oral iron: Similar maternal & infant outcome Less gastrointestinal side effects Rationale: Intestinal cell turn over every 5-6d limited iron absorptive capacity
6 July 2013, Kuantan

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
6 July 2013, Kuantan

Blood Transfusion
To be considered for: Symptomatic anemia
Asymptomatic but severe anemia especially >36w

6 July 2013, Kuantan

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 <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

If Hb >8.5 and MCH <27 - For Hb analysis

6 July 2013, Kuantan

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

6 July 2013, Kuantan

Postpartum Follow Up
Continue iron supplementation Emphasize on contraception (MEC) almost all category 1 or 2 (generally safe)

6 July 2013, Kuantan

Pre-pregnancy
For known thalassemia patients / couples Counselling

6 July 2013, Kuantan

Summary
All pregnant women must be screened for anemia: - Hb, MCV Countries with Hemoglobinopathies / Thalasemia prevalence: - Ferritin / Iron Studies - Hb analysis
6 July 2013, Kuantan

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

Bring Home Messages

Dont overlook anemia Dont treat it lightly Common doesnt mean its not serious it can be fatal! Family planning is essential.

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