GUIDELINE FOR ANTENATAL SUPPLEMENTATION IN PREGNANCY

INTRODUCTION

• “ Future health of mankind depends to a very large degree on the nutritional

foundation laid in utero ”
• Barker Hypothesis : In utero malnutrition followed by improved nutrition
after birth leads to Metabolic Syndrome
[Type 2 Diabetes Mellitus, Hypertension & Hyperlipidaemia ]

• For optimal fetal growth & development, the mother needs :

Macro nutrients for energy : Protein / Fat / CHO
Micro nutrients : Iron / Folic Acid / Calcium
Zinc / Iodine / Cu / Mg / Se
Vitamins ( A, B6, B12 C, D, E )
• Globally : Approx 30 % non pregnant women
& 42% pregnant women are anaemic
• Rate of iron deficiency exceeds the rate of iron deficiency anaemia
• Iron deficiency anaemia (IDA) is the commonest complication of pregnancy in
South Asia
• In non industrialized countries : Iron stores may be Nil in 25 – 30 %
• In Sri Lanka: IDA = ?approx. 22% non pregnant women
17% pregnant women
21% Lactating women
• Anaemia + PPH carries a high risk of maternal death

• The effectiveness of the current antenatal supplementation programme is sub

optimal. Taking iron & calcium together, after a dinner of rice & vegetables, or
with tea, is common. This will not result in satisfactory iron absorption.
• The compliance & the manner in which these supplements are taken should be
improved in order to achieve better results
DIAGNOSIS OF ANAEMIA

• WHO Criteria for Diagnosis of Anaemia = Hb< 11g/dl

Severity : Mild = 10- 10.9 g/dl
Moderate = 7 - 9.9 g/dl
Severe = < 7 g/dl

Causes
• Nutritional Deficiencies
Iron - commonest
Protein & energy - common
Folate
Vitamin A, Vitamin C
Vitamin B 12 rare
• Hereditary: Thalassemia, haemolytic anaemias
(spherocytosis & G6PD deficiency)
• Haemorrhagic : heavy menstrual bleeding, helminthiasis or
history of bleeding per rectum
• Chronic conditions - TB / Rhumatoid Arthritis / Bone marrow depression,
malignancies, chronic renal disease
• Malaria
• Higher risk during pregnancy in: Multifetal gestations / Teenage / High parity/
Reduced birth intervals

Diagnosis
• Screen First visit - Full Blood Count ( at least Hb & PCV)
Rpt. at > 28 wks if non anaemic or mildly anaemic
Rpt. at ~ 24 wks after treatment of moderate / severe anaemia
Rpt. Post Partum at 4 - 6 wks in high risk women
(T3 Anaemia / Twins/ PPH)
 • Specific Investigations :

Full Blood Count Haemoglobin < 11 g/dl

PCV < 33 %
MCV < 80 fl (IDA)
>100 fl (Folate/B12 def.)
MCHC < 30 % (IDA)
Serum Ferritin < 20 µg/l (IDA)
Blood Picture Microcytic Hypochromic (IDA)
Macrocytes (Folate / B12 def)
Polymorphic picture ( nutritional def.)
Features of haemolytic anemias

Unreliable indices ( Not recommended)

• Serum Iron (< 60 mcg / dl)
• TIBC (> 400 mcg / dl)
• Transf. Sat. (Ser. Fe. : TIBC <16 %)
• MCH (< 30 pg / L)
• RBC count (< 4.1 mil / mm3 )
• Red cell distribution width

• A single haematological index per se has poor ability of detecting or excluding iron
deficiency in pregnancy. Several indices should be evaluated prior to iron
supplementation or therapy during pregnancy
• As the Hb measurements can vary significantly from one laboratory to another,and
even when repeating the measurement in the same sample in the same laboratory,
a single Hb measurement should be interpreted with caution. The use of the PCV in
addition to Hb may increase the diagnostic accuracy. The measurement should be
repeated if there is any doubt in its validity especially if it does not tally with the
clinical assessment
ANAEMIA : ADVERSE EFFECTS ON MOTHER
• Lethargy
• Poor work tolerance
• Prone to infection
• Poor wound healing
• Post partum debility
• LESS ABLE TO TOLERATE A PPH
• ? Risk of PPH

ANAEMIA : ADVERSE EFFECTS ON FETUS

• L.B.W
• Pre Term Delivery
• Reduced Immunity + prone to infection

• Decreased Iron stores results in anaemia of infancy (Hb - OK at birth)

[:. Delay cord clamping > 2 mins ]

ANAEMIA : ADVERSE EFFECTS ON INFANT

• Anaemia
• Poor growth
• Lethargy & weakness
• Appetite, Irritable
• Food intake

ANAEMIA : ADVERSE EFFECTS ON CHILD

• Abnormal behavior & psychomotor development
• Learning difficulties & educational deficiency

POSSIBLE INTERVENTIONS
• Enrich / Fortify flour, bread, cereals, rice
• Educate / Change diet
• Weekly oral iron (60mg)+ folate (2.8mg) supplements for women of
reproductive age (WRA) - Cyclically X 3 months + 3 months no supplements - if
IDA in WRA >20%
• Appropriate antenatal oral iron + folate supplements during T2 and T3 and
continue 3 months post partum
• Parentaral iron therapy / blood transfusion as per requirements
Food Iron Absorption
- Chemical form more important than content
( Ferrous absorption = 7 to 20 X Ferric :. Ferric→ Ferrous in stomach)
- Haem iron is absorbed best ( red meat / animal proteins)
- ↓by Phytates (Bran) Polyphenolic compounds (Veg)
- 90 % Non haem - Add Vit C ( increases bioavailability)
- Avoid Soya / Tea / Coffee / Ca / Mg
- Only 5 – 15 % usually absorbed
- Increases to 10 – 30 % if Iron Deficient, Pregnant & in infants

ANTENATAL MANAGEMENT

• Appropriate antenatal oral iron /folate supplementation

(and continue 3 months post partum)
- 60mg elemental iron + 400µg folic acid daily if IDA in pregnancy >40%

- 30mg elemental iron + 400µg folic acid daily if IDA in pregnancy <40%
- 120mg elemental iron + 2.8mg folic acid weekly in
non anemic pregnant women if IDA in pregnancy <20%
- 120mg elemental iron + 400µg folic acid daily if Hb <10g/dI in T2

• If ≥ 38 wks with Hb ≤ 9 g/dl –Blood Transfusion

• If 36-38 wks with ↓ Hb – IV iron sucrose therapy

• Benefits of antenatal oral iron supplements in T2 + T3

- Anemia and iron deficiency in mother
(RBC increased /No effect on Plasma Vol.)
- Main effects on iron deficient subjects
(replenishes maternal iron stores)
- Fetal growth improved
- Birth Weight improved
- Pre-Term labour reduced
- ? Reduced maternal infections during pregnancy, blood transfusion after
delivery , congenital anomalies and neonatal death
• Daily oral iron supplementation results in high iron levels in the gut lumen &
intestinal mucosal cells, produces oxidative stress, reduces iron absorption by a
mucosal block, & increases severity & frequency of undesirable GIT side effects.
:. Weekly supplementation, based on mucosal cell turnover of 5 – 6 days, may
improve iron absorption & patient compliance and have less adverse effects.
Common practice of giving iron supplements after meals reduces GIT side
effects but absorption is also significantly reduced.

Oral Iron Therapy

• Mild – Moderate Anemia : 2 wks therapeutic trial of oral Fe 120 mg + 400 µg folic
acid daily if Hb < 10 g/dI in T2 (↑in Hb level > 0.5 g/dl is reliable)
Inquire about dietary habits & chronic blood loss/antihelminthic treatment
If no response – refer to specialist for FBC, Blood picture, S.ferritin etc.
• Severe anemia – refer to specialist
• Continue oral iron therapy for a minimum of 3 months after correction of anaemia

How should oral iron be given ?

• Empty stomach (eg. 11 AM) - Not after meal (of rice/ bread & veg.)
• No Ca / Mg / tea / coffee
• Add Vit C ( 50 - 100 mg)
• Reduce dose / Intermittent doses – If GIT Side Effects +

Parenteral Iron Therapy

• Intravenous Iron sucrose - if poor compliance, failure to respond to oral
supplements or proven malabsorption
- 2 X 100 mg IV EOD
- Max. 600 mg IV / wk
- “ 1 wk therapy often adequate?? “
- “ 200 mg ~ Hb of 1 g/dl ??”
- Bolus 1 ml / min X 20 min ( 200 mg)
or 5 ml vials x 2 in 100 ml N. Saline: 25 ml x 30 min
75 ml x 30 min
• Contraindications : T1, h/o allergy, chronic liver disease, ongoing systemic
infection
ANAEMIA : MANAGEMENT IN LABOUR
• Adequate analgesia in first stage
• O2 inhalation sos
• Prevent prolonged second stage
• Prevent PPH
• Hb should be > 10 g / dl at delivery

ANAEMIA : POST PARTUM MANAGEMENT

• Blood transfusion if Hb < 8 g / dl after delivery

• FBC prior to discharge : anaemia in pregnancy, multiple pregnancy, PPH

CALCIUM SUPPLEMENTATION

• Milk & Yogurt are the best sources of calcium. Good bioavailability of calcium in
Soya products. Small fish with bones is a good source of calcium
• Oxalates inhibit calcium absorption
• Calcium Supplements
- Calcium carbonate is absorbed well ( = Calcium citrate)
& is most cost effective
- Calcium absorption is increased in T3
- High dose calcium (1.5 – 2 g in divided doses after meals ) is recommended
for women with an increased risk of pre-eclampsia and women with a low
intake of dietary calcium
• Recommendation for Sri Lanka= Calcium Lactate (300mg) tabs twice daily after
meals

FOLIC ACID SUPPLEMENTATION

• Folic Acid supplements ( 0.4 mg / day) commenced pre conceptionally and

continued during T1 are recommended. [Available tablet strength is 1mg]
• Reduces the occurrence of neural tube defects in the fetus and severe language
delay in children at age of 3 years.
• Improves birth weight and reduces small for gestational age infants
• Folic Acid supplements commenced after diagnosis of pregnancy will have
minimal/no benefits
DIETARY ADVICE
• Nutritional advice & balanced energy / protein supplements are recommended
• High protein supplements are not recommended
• Energy / protein restriction is not recommended for overweight women

Expected Maternal
Weeks
Weight Gain
10 0.5 kg
20 4.5 kg
30 8.5 kg
40 12.5 kg
> 20 wks ~ 0.4 kg / week

Professor Malik Goonewardene

MBBS (Cey) , MS(Col) , FSLCOG, FRCOG (Gt. Brit ), Hon. MGS (Poland)
Senior Professor and Head, Dept. of Obstetrics & Gynaecology
University of Ruhuna 26th May 2015