Iron

deficiency
Anemia in
pregnancy
By Dr
Shanggari
 INTRODUCTION
Anaemia is most common in pregnancy
According to WHO in2011
29 % non pregnant women in reproductive age have anemia
38% of pregnant women have anaemia
50% of anaemia due to iron deficiency

Severe anaemia Increases maternal morbidity and mortality

-maternal fatigue
-poorer quality of life
-postpartum depression
-postpartum haemorrhage
-puerperal sepsis
-Hb <7 g/dl antenatally or postpartum was associated with a two‐fold
increase in mortality, in low‐ and middle‐income countries (Daru et al, 2018)
 INTRODUCTION
Increases perinatal, neonatal and infant mortality and morbidity
- low birth weight
- Pre‐term birth
- stillbirth
- neurodevelopmental impairment
 Prevalence of anemia

World 47% 42% 30%

Malaysia 32% 38% 30%

WHO Global Database on Anemia,2008
TAN AC ET AL-BMC RES 2013 May
The most frequent nutritional
disorder
How many suffer from iron
deficiency anaemia?

2 billion people

1/3rd of the
world’s
population
 DEFINITION OF ANAEMIA (WHO)

WHO defines anaemia in pregnancy as

haemoglobin < 11 g/dL

Severity of anaemia:
Mild Anaemia is Hb 9-10.9 mg/dl
Moderate Anaemia is Hb 7.0- 8.9 mg/dl
Severe Anaemia is Hb < 7 mg/dl
Physiological Anaemia in pregnancy
Haematological changes
Increase plasma volume (40-50%) and hence
hemodilution
Increase in red cell mass (18-25%)
Hematocrit reduced by 10%
Starts at 6 weeks, progressive from 10-12 weeks up
to 36 weeks (FBC should be done at booking and at
least monthly)
Physiological Anaemia in pregnancy
Physiological adaptation to pregnancy
Dilutional anaemia improves uteroplacental
circulation
Hypervolemia allows pregnant women to tolerate
blood loss during vaginal delivery.
 Causes of anaemia
Common types
Nutritional
deficiency
IDA Hemoglobinopathies
Folate Sickle cell disease
Vit B12 Thalassemia

Chronic blood loss

Repeated abortions, poor
spacing, bleeding
tendency, APH, worm
infestation
 Causes of anaemia
RARE types

Myeloproliferative Aplastic Anaemia

Leukemia, lymphoma Drug induced
Idiopatic

Hemolysis
Autoimmune hemolytic,
malaria, drug induced
Iron requirement in pregnancy
9x higher
Iron
100mg/day iron for all requirement
women* during
pregnancy
 Effect of IDA to pregnancy

MOTHER FETUS
Preterm Delivery Fetal growth restriction
PPH SGA

Heart/Renal failure Prematurity

Increase risk of Low birth weight
pre/eclampsia
Increase perinatal morbidity
Increase maternal morbidity and mortality
and mortality
Causes of Maternal Death 1997 &
2007

32.3% potentially stand a

better chance if they DON’T
have Anaemia
 Iron Deficiency Anaemia (IDA)
 Untreated IDA progresses with gestational age
(Haniff J et al. Anemia in pregnancy in Malaysia:
A cross sectional survey.
Asia Pac J Clin Nutr 2007)

 Related to physiological changes in pregnancy

1st. Trimester 2nd. Trimester 3rd. Trimester

Malaysia 12% 32% 43%

SYMPTOMS AND SIGNS OF ANAEMIA

• Fatigue is the most common symptom

• Pallor
• Weakness
• Headache
• Palpitation
• Dizziness
• Dyspnoea
• Irritability
Clinical features
ANAEMIA: Signs & Symptoms

WEAKNESS, COLD
PALE DIZZINESS FATIGUE,
HANDS & HEADACHES
SHORTNESS
SKIN OF BREATH FEET

Mild anemia commonly asymptomatic...

 Clinical signs of IDA

PALLOR
ATROPHIC GLOSSITIS

Koilonychia ANGULAR STOMATITIS CHELITIS

+soft systolic murmur

(hyperdynamic circulation)
+basal crepts (if cardiac
failure)
Blood investigations for diagnosis

• FBC
• MCV
• MCH
• MCHC
• RETIC
Lab Findings for IDA

● FBC/FBP – hypochromic, microcytic, target

cells,pencil shaped
poikilocytosis
● Reticulocyte count – low
● Serum ferritin – low
● Se.iron – low, may not be indicative for IDA in
pregnancy due to hemodilution
● TIBC - raised
 SERUM FERRITIN

●Stable glycoprotein - reflect iron store in absence of

inflammatory change
●The best test to assess iron def in pregnancy- more sensitive
indicator of iron deficiency
●Not affected by recent iron ingestion

 UK Guidelines

(specificity 98% & sensitivity 75%)

 Table 4. Laboratory Tests in the Differential Diagnosis of
Microcytosis
Suggested diagnosis
Test Iron deficiency Thalassemia Anemia of chronic disease Sideroblastic anemia
anemia

Serum ferritin level Decreased Increased Normal to increased Normal to increased

Increased
Red bood cell distribution Increased Normal to increased Normal
width
Normal to increased
Serum iron level Decreased Normal to increased Normal to decreased
Normal

Total iron – binding capacity Increased Normal Slightly decreased

Normal to increased
Transferrin saturation
Decreased Normal to increased Normal to slightly decreased

Information from reference 1

 IDA – Treatment & Management

Goals of treatment:
1. To restore normal levels of red blood cells and hemoglobin levels to
normal.
2. To replenish iron stores.

How to treat anemia?

 Increase food intake that are rich in iron

 Take iron supplement
 Blood transfusion
Food that are rich in iron
○ Haem: red meat, chicken &
fish

○ Non haem:
■ grains, cereals, legumes (beans,
peas and lentils)

■ nuts and seeds (sesame, almonds

& pistachios)

■ dried fruits (apricot, prunes &

raisins )
Only 10% to 15% of dietary
■ Eggs (yolk) *Women with iron deficiency in
iron is being absorbed pregnancy should not
■ Dark green leafy vegetables attempt to correct it through
diet alone!
*Mayo Clinic. Iron deficiency anemia. Treatments and drugs.(accesses 7 Sept 2010)
 Food affecting iron absorption

 Iron Absorption Enhancers

1.Vitamin C
1. fruit juices (kiwi, orange, strawberry,
lemon)
2. green leafy vegetables, cabbage,
cauliflower Try to eat food rich
in iron together with
 Iron Absorption Inhibitor orange juice or
1.Phytates (cereal bran, cereal grains, vitamin C tablet
legumes, nut and seeds) as vitamin C
2.Calcium (milk and milk products) *dairy will help increase
products decreases iron absorption by iron absorption !!
40-50% (evidence level B1)
3.Caffein (tea, coffee, and cocoa)
4.Carbonated drinks
●Drugs that reduce iron absorption:
○ Antacids, H2 receptor blocker, PPI
○ Calcium
○ Methyldopa
○ Quinolones (ciprofloxacin)
○ Others: allopurinol, tetracyclines
 Iron Supplement
●WHO recommends – (60mg of elemental iron + 5mg folic acid
OD)

●It is recommended to supplement all pregnant mothers with oral

hematinic at booking and continue in all trimesters.
●Oral iron supplement should be taken on empty stomach
●If not tolerated due to nausea/vomiting, advice to take before
bedtime
 Oral iron treatment
●Prophylaxis 100 mg/day elemental iron and 5mg folic acid
●Treatment at least 180mg/day elemental iron and 5 mg folic acid

●Effectiveness of iron therapy is monitored by:

○ Hb level, retic count and ferritin level

○ Hb is expected to increase in 3 to 4 weeks (Hb rises from 0.3g to 1.0g per week
for those responses to treatment 180mg elemental iron per day)

○ FBC should be repeated after 2 weeks of therapy

(to assess compliance, correct administration and response to treatment)

Amount of elemental iron
 Prophylaxis Iron Supplement
1st Trimester
 At least 30 mg/day of elemental iron:

 Eg Obimin 30 mg

 Eg Ferrous Fumarate 60 mg

2nd and 3rd Trimester

 At least 100 mg/day of elemental iron:

 Eg Zincofer 115 mg

 Eg Iberet 105 mg

 Eg Maltofer 100 mg

 Eg Ferrous Fumarate x 2 120 mg

CARTA
SAMPEL PIL
ZAT BESI
 Anaemia Management (Hb < 11)
●Double oral haematinics (equivalent to at
least 200 mg elemental iron)
●In moderate to severe anemia, monitor for
IUGR by serial symphisis fundal height ± serial
ultrasound scan monthly plotted on the growth
chart
 Parenteral iron indication
●Severe malabsorption
●Insufficient or no response to oral iron
●Poor compliance
●Severe intolerance of oral iron
○ Confirm there is no contraindication to parenteral
iron eg iron hypersensitivity or iron overload.
○ Can be given in Thalassaemic patients with
concurrent iron deficiency
 Type of parenteral iron
Iron dextran 50mg
Iron Sucrose
FE/ML injection
Preparation cosmofer (IM or IV) Preparation venofer (IV only)
Elemental 50MG per ML Elemental 20MG per ML

Ganzoni formula, Dose elemental iron Dose elemental iron needed

needed (mg)=
(normal HB-Patient HB)x
weight(kg)x10x0.24+500 VS (mg)=(normal HB-Patient HB)x
weight(kg)x10x0.24+500

IV slow injection:total single dose not

more than 200mg, up to 3 times in 1
IV infusion for multiple doses (30-
week (max 600mg/week)
60minute) or total dose over 3-4 hours.
IV infusion:max single tolerated dose
not more than 200mg, up to 3 times in
1 week(max 600mg/week)
 Blood transfusion
Consider when:
●Hb < 8 g/dl and POA > 36 weeks
●Hb < 6 g/dl
●Moderate and severe anaemia in patient with known
heart disease or severe respiratory disease
●Symptomatic anaemia
●Placenta Praevia with Hb < 10g/dl
●Patient who develop severe side effect to both oral
and parenteral iron therapy
 Folate & B12 deficiency
●Uncommon
●May be due to vegetarian diet, pernicious anemia
●B12 deficiency can be corrected with IM
cyanocobalamin 1000ug for 10 doses
●Hb should be repeated after 2 weeks (Hb level ↑ by
1g/dL)
●If anemia still not corrected, consider further
investigations – Hb electrophoresis
 THALASSEMIA – overview

●Thalassemias are a heterogenous group of genetic disorders

●Decreased or absent production of one or more globin chains that
make up a hemoglobin molecule.
●Each hemoglobin molecule is composed of 4 globin chains; normally
2 from the α family and 2 from the β family of globin chains.
●Each hemoglobin molecule also has a heme group containing iron.
●The thalassemias are broadly categorized according to the globin
chain that is defective
 Treatment
●Mild and asymptomatic thalassemia – no treatment
●If there is concurrent IDA– Iron supplement
●Moderate – severe type

○ Blood transfusion

○ Iron chelation therapy

○ Splenectomy

○ Bone marrow stem cell transplant

 When to admit or refer HOSPITAL

●Symptomatic anemia regardless of Hb level

●When Hb < 7g/dl – risk of heart failure
●Hb < 8g/dl at > 36 weeks
 Post partum anemia
● Postpartum Hb may ↓ by 3.5g/dL during 1st 4 days even without
clinical PPH
● The risk is higher in women with antenatal anemia
 Iron deficiency persists beyond the 4-6 weeks postpartum period

 12% of women are iron deficient up to 12 months after delivery

 8% of women are iron deficient 13-24 months after delivery

● Supplement with hematinics/dietary advice
● Iron supplementation should continue after delivery until anemia
corrected and maintain for 3 months to replenish iron stores
● Offer contraception.
MANUAL PENGENDALIAN ANAEMIA NEGERI
PERAK 2020
JIKA HB NORMAL
JIKA ANEMIA TERUK ATAU ADA SIMPTOM
ANAEMIA RINGAN DAN SEDERHANA Hb ≫7≪11
200 MG ELEMENTAL IRON “Double haematinic”

●Contoh:
1. Zincofer 1 tab OD(115mg) + FeSO4 2 tab OD(66x2
mg)=247 mg
2. Iberet 1 tab OD (105 mg) + FeSO4 2 tab OD(66x2
mg)= 237 mg
3. Maltofer 2 tab OD (105x2)= 210 mg
4. FeSO4 2 tab BD (66x4)= 264 mg

Maltofer dan FeSO4 perlu diambil bersama Vit C

ANAEMIA RINGAN DAN SEDERHANA Hb
≫7≪11
UJIAN DARAH

HB ANALYSIS SERUM FOLATE /B12

ANAEMIA RINGAN DAN SEDERHANA Hb ≫7≪11
JIKA MASIH ANAEMIA ATAU HB<9 SEMASA
28-32 MINGGU POA :
KONTRAINDIKASI PEMBERIAN PARENTERAL IRON:
 PARENTERAL ZAT BESI (DIBERI SELEWAT-
LEWATNYA PADA 28-32 MINGGU JIKA
PERLU):
●IV COSMOFER (IRON DEXTRAN)
●IV VENOFER (IRON SUCROSE)
●BERHENTI PENGAMBILAN ORAL HEMATINIK SEMASA
PARENTERAL IRON.
●MULA PENGAMBILAN ORAL HEMATINIK SEMINGGU
SELEPAS PARENTERAL IRON.
 INDICATIONS
○ Where there is a clinical need for rapid iron
supply
○ In patients who cannot tolerate oral iron
therapy or who are non-compliant
○ In active inflammatory bowel disease where
oral iron preparations are ineffective
 CONTRAINDICATIONS

●Hypersensitivity to parenteral iron

preparations
●Anaemia which is not caused by iron
deficiency
●Evidence of iron overload
●First trimester of pregnancy
 SELEPAS PARENTERAL IRON

●ULANG HB 2 MINGGU

●JIKA HB NAIK 1GM/2 MINGGU, TERUSKAN ELEMENTAL

IRON 200 MG.

●JIKA TIDAK, LAKUKAN UJIAN MAKMAL CNTH: FULL BLOOD

PICTURE, FOLATE, B12, STOOL OVA&CYST DAN BFMP
 In conclusion
 IDA is the most frequent form of anemia in pregnant women

 Dietary measures are inadequate to reduce the frequency of IDA

 Pregnant women should be given 100mg/day iron regardless of iron status in

2nd and 3rd trimester, prophylactically

 Treatment of IDA should aim at replenishing body iron deficits

 Treating and preventing IDA can reduce maternal mortality

 DISCUSS WITH FMS

1. Still anaemic at 28-32 weeks POG and above

2. Require parenteral iron
3. Thalassemia cases
4. Moderate and Severe anemia cases
5. Cases not responding to treatment
6. Cases that need referral to hospital
7. High risk mother eg Grandmultiparity, Multiple
pregnancy, Past history of PPH, and evidence of IUGR
References

●THE MALAYSIAN CPG 2007: MANAGEMENT OF

ANEMIA IN PREGNANCY AND CHRONIC KIDNEY
DISEASE
●HILIR PERAK ANAEMIA MODEL OF GOOD CARE 2005
●MALAYSIAN MINISTRY OF HEALTH PERINATAL CARE
MANUAL 2013 (3RD EDITION)
●KINTA ANAEMIA MODEL OF GOOD CARE 2016
●PERAK ANAEMIA FLOW CHART (NUTRITIONIST
INITIATIVES) 2019
●PERAK MODEL OF GOOD CARE OF ANAEMIA 2020
THANK YOU