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Anaemia in pregnancy ICOG guidelines


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Anaemia in Pregnancy

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Anaemia in pregnancy ICOG guidelines

  1. 1. National Nutrition Consensus, ICOG Guidelines 2015-2016 Dr Meenakshi Sharma
  2. 2. Iron deficiency anaemia  WHO defines anaemia in pregnancy as Hb <11gm/dl WHO, 2001  ICMR classification  8-11 g% - mild,  5-8 g % - moderate  <5 g% - severe anaemia.  Serum ferritin <12-15μg/l is considered as iron deficiency  56 million women globally, two thirds in Asia  Prevalence of anaemia in India – 58% (NFHS-3, 2007)  78% lactating and 75% pregnant women are anaemic  Anaemia – 20% direct maternal death and 50% indirect maternal deaths
  3. 3. Aetiology of IDA  Inadequate Iron intake-Poor iron content of diet -10- 20 mg/day  Poor absorption- 1-2mg iron absorbed in SI  Increased iron requirement -Total Pregnancy iron requirement -1000mg  Increased blood loss-Worm infestation, menorrhagia  Poor iron stores – frequent childbirth, inadequate spacing
  4. 4. Outcome of iron deficiency • Reduced work capacity, intellectual capacity • Increased maternal mortality • Affect immune function and increases risk of infections Maternal morbidity and mortality • Decreased weight on delivery • Greater risk of anaemia after birth • Long term deficit in physical and mental health • Negatively contribute to infant and social emotional behaviour Effect on foetus and infant • Preterm delivery, LBW and Possibly, placental abruption and increased peripartum blood loss • Further research necessary to establish a clear causal relationship Effects on pregnancy outcome
  5. 5. Investigations • FBC • Serum Ferritin • Serum iron • Total iron binding capacity • Zinc protoporphyrin • Soluble Transferrin Receptor • Reticulocytes & Bone Marrow Iron (not applicable in routine practice) • Iron Therapy - diagnostic whilst being therapeutic at the same time Signs and symptoms • Fatigue, weakness, pallor, palpitations, dizziness and dyspnea • May develop pica • Temperature regulation may also be affected, leading to cold intolerance. Diagnosis & Investigations
  6. 6. Prevention of anaemia in pregnancy  Pre-pregnancy counselling and dietary advice  Rich sources of iron include haeme iron (in meat, poultry, fish and egg yolk), dry fruits, dark green leafy vegetables (spinach, beans, legumes, lentils) and iron fortified cereals.  Using cast iron utensils for cooking and taking iron with vitamin C (orange juice) can improve its intake and absorption.  Avoid foods which may inhibit iron absorption - polyphenols (in certain vegetables, coffee), tannins (in tea), phytates (in bran) and calcium (in dairy products)  CBC at the booking and at 28 weeks in pregnancy to screen for anaemia.  Repeat Hb near term in high risk mothers and multiple pregnancies
  7. 7. Prevention of anaemia in pregnancy  Iron supplementation weekly iron (60 mg) and folic acid (2.8 mg) should be given.  Deworming  Delayed clamping of the umbilical cord at delivery (by 1–2 min) is important step in prevention of neonatal anemia.
  8. 8. Treatment of anaemia in pregnancy • A course of iron therapy is simultaneously diagnostic and therapeutic • Ferritin levels should be checked if the patient has a known haemoglobinopathy • Microcytic or normocytic anaemia can be assumed to be caused by iron deficiency anaemia until proven otherwise • Response to iron is both quick and cost effective; a rise in Hb should occur within 2 weeks to confirm the diagnosis. • Furthermore, if there has been no improvement in Hb by 2 weeks a referral should be made to secondary care.
  9. 9. Management of Iron deficiency Dietary advice  Physiological iron requirements are three times higher in pregnancy compared to non-pregnant stage with increasing demand as pregnancy advances.  Iron absorption depends upon the amount of iron in diet, its bioavailability and requirements of the body.  The main source of dietary haem iron are haemoglobin and myoglobin from red meat, fish and poultry.  Haem iron is absorbed more readily than non-haem iron sources.  Vitamin C significantly enhances iron absorption from non -haem foods.  Germination and fermentation of cereals and legumes improve the bioavailability of non-haem iron by reducing the content of phytate, a food substance that inhibits iron absorption.  Tannins in tea inhibit iron absorption when consumed with a meal or shortly after.
  10. 10. Oral iron supplementation  Daily oral iron (60 mg) and folic acid (4 mg) should be started, and continued up to 6 months' postpartum. The aim is to achieve a hemoglobin of at least 10 g/dL at term.  The recommended therapeutic dose of iron is 100- 200mg daily.  It is recommended to take iron with orange juice to enhance its absorption.  Oral ferrous salts are the treatment of choice (ferric salts are less well absorbed).
  11. 11. Oral iron supplementation  Ferrous sulphate 200 mg 2– 3 times daily (each tablet provides 60 mg elemental iron) is the most common preparation used.  First week of iron therapy – only reticulocytosis  Second week –Hb starts rising 1g/dl/week  Side effects - nausea, constipation and occasionally diarrhoea which can be reduced by taking tablets after meals.
  12. 12. Parenteral Iron  Indications of parenteral iron  Intolerance oral iron  Severe anaemia in near term  Failure of oral therapy  Parenteral iron -intramuscular (IM) or intravenous (IV). The main drawbacks of IM route are pain, staining of skin, myalgia, arthralgia and injection abscess.  Intravenous iron can be administered as total dose infusion; however, utmost caution is needed as anaphylaxis can occur.  Iron dextran and iron polymaltose preparations can be used by both IM and IV routes.
  13. 13. Parenteral Iron  Newer IV preparations – iron sucrose and ferric gluconate are associated with reduced side-effects.  Iron sucrose- 50 mg elemental iron in one ampoule.  It may be administered undiluted by slow I/V @ 1 mL/mt (20 mg iron) not exceeding 100 mg iron per injection.  I/V infusion – 2.5ml (50mg) iron sucrose in 100ml NaCl @100mg/15 minutes, 200mg alternate days  Unused diluted solution must be discarded.  Ferrinject (ferric hydroxide carbohydrate complex), IV as a single dose of 1000mg over 15 minutes (max 15mg/kg by injection or 20mg/kg by infusion)
  14. 14. Blood Transfusion Packed red cell transfusion may be indicated for pregnant women with  Severe anemia (Hb of 6 g/dL or less) close to due date or less than 8 g/dL if they have increased risk of blood loss at delivery
  15. 15. Intrapartum Management  IV cannula and blood should be cross-matched in case of significant hemorrhage at the time of delivery.  Strict asepsis is very important.  Active management of third stage  In case of severe anemia with congestive cardiac failure, active management of third stage (with methyl ergometrine) is contraindicated.
  16. 16. Postpartum management  Close monitoring should be done to look for signs of decompensation, infection or thrombosis. Appropriate thromboprophylaxis and contraceptive advice should be provided and haematinic supplementation should continue
  17. 17. Overview of treatment of IDA Pre-pregnancy Antenatal Delivery Dietary advice and iron therapy Iron therapy without iron studies with 60mg in second trimester. Cross match blood in case of severe anaemia Folic Acid supplement (which also prevent NTDs) Hb <10, Oral 100-200mg elemental iron with Vit C, deworming, treatment for malaria Active management of third stage of labour Blood transfusion if Hb is <6g/dl Intolerance to oral iron, Malabsorption, non compliance/poor, follow up Continue iron for three months in post natal period
  18. 18. Simplified flow chart for the iron deficiency anaemia
  19. 19. Recommendations There is variation in definition of normal Hb levels in pregnancy. A level of ≥ 11g/dl appears adequate in the first trimester and ≥ 10.5g/dl in the second and third trimesters (1B). Postpartum anaemia is defined as Hb <10g/dl (1B Full blood count should be assessed at booking and at 28 weeks. For anaemic women, a trial of oral iron should be considered as the first line diagnostic test, increase demonstrated in two weeks is a positive result. All women should be counselled regarding diet in pregnancy including details of iron rich food sources and factors that may inhibit or promote iron absorption and why maintaining adequate iron stores in pregnancy is important. This should be consolidated by the provision of an information leaflet in the appropriate language (1A).
  20. 20. Recommendations Women should be counselled as to how to take oral iron supplements correctly. This should be on an empty stomach, 1 hour before meals, with a source of vitamin C (ascorbic acid) such as orange juice to maximise absorption. Other medications or antacids should not be taken at the same time (1A). Women with known haemoglobinopathy should have serum ferritin checked and offered oral supplements if ferritin level is <30 ug/l. Women with unknown haemoglobinopathy status with a normocytic or microcytic anaemia, should start a trial of oral iron and screening should be commenced without delay. Women should undergo specialist assessment if there is a lack of response (increase of less than 2 g/100 mL in the haemoglobin level) after 2–4 weeks. Once haemoglobin concentration and red cell indices are normal, iron treatment should be continued for 3 months to aid replenishment of iron stores, and then stopped. The person's full blood count should be monitored every 3 months for 1 year.
  21. 21. Vitamin B12 deficiency anaemia  SYMPTOMS • Anaemia can result in many complications, including cardiovascular symptoms, reduced physical and mental performances, reduced immune function and fatigue. • For the foetus consequences include growth retardation, prematurity, amnion rupture, neural tube defects, low birth weight and even intrauterine death. • The association between B12 deficiency and neural defects has been noted multiple times. • Very low B12 can cause anencephaly, due to its use in the metabolism of neural tissue, resulting in demyelination, axonal degeneration and neuronal death.
  22. 22. Vitamin B12 deficiency anaemia  INVESTIGATIONS • B12 deficiency leads to megaloblastic anaemia, leading to vomiting, diarrhoea and pyrexia, with oedema and albuminuria occurring at later stages. • Neurological involvements may be present, including mental slowness, memory defects, hallucinations and numbness/tingling in the extremities. • The diagnosis of anaemia occurs fist by determining Hb levels, with a threshold of 110 g/L. • If the MCV is above 100fl, and the peripheral blood picture suggests B12 deficiency appropriate investigations should be carried out.
  23. 23. Treatment  B12 deficiency can be prevented with a rich B12 diet, thus avoiding the need for supplementation.  However, if Vitamin B12 deficiency is suspected (caution in interpreting B12 levels as lower in pregnancy), therapy should be started if neurologic signs are present.  Cyanocobalamin or hydroxycobalamin 1mg is given three times a week for 2 weeks and then every 3 months. Prenatal Labour and postpartum 2.6mcg of vitamin B12 is the recommended daily intake in pregnancy. Continuation of maintenance therapy is needed In strict vegetarians oral supplementation might be necessary.
  24. 24. Folate Deficiency Investigations  The clinical features of folate deficiency include symptoms of anaemia, hyperpigmentation and low grade fever, falling after vitamin therapy.  Neuropsychiatric symptoms may be present in conjunction with B12 deficiency. Laboratory investigations include serum folate, red cell folate assay, serum B12, serum homocyestein and methylmalonic acid.  Bone marrow aspiration may be considered for megaloblastic changes suggestive of B12 or folate deficiency, and liver/thyroid function tests to find causes of macrocytosis.  The criteria for folate deficiency is serum folate below 2.0 ug/L and red cell folate concentration below 160 ug/L.  Due to their close relation, it is important to rule out B12 deficiency as a cause of any neuropsychiatric symptoms, as they will not improve with folic acid therapy.
  25. 25. Management of folate deficiency anaemia Prenatal Labour Post natal 5mg of folic acid daily No specific management apart from the previously mentioned is needed. WHO recommends 400mcg folic acid along with 60mg iron for 6 months in pregnancy and for 3 months postpartum in areas with poor nutrition Women with haemolytic anaemia require high doses (5-10mg)