MODEL OF GOOD CARE FOR MANAGEMENT OF ANAEMIA JABATAN KESIHATAN WILAYAH PERSEKUTUAN KUALA LUMPUR & PUTRAJAYA 12th JULY 2013

OUTLINE OF PRESENTATIONS Introduction IDA in Pregnancy – Definition, Investigations, Impact Management – colour coding, fetal assessment Treatment – oral, parenteral Flow Chart of Management Referral – FMS, Hospital Practical Tips Of Management When do we investigate further New Practice Points Summary

INTRODUCTION Most common medical disorder in pregnancy Affects nearly ½ of all pregnant women in the world 1 52% in developing countries 23% in the developed world Women often become anaemic during pregnancy because the demand for iron and other vitamins is increased due to physiological burden of pregnancy. Due to inability to meet the required level for these substances either as a result of dietary deficiencies or infection give rise to anaemia 2 1. WHO database 1998-2005 2. Van den Broek N. The Cytology of Anaemia in Pregnancy in West Africa Tropical Doctor. 1996;26:5–7

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

LOCAL STUDY REPORTED The majority was of the mild type. The overall prevalence of anemia 35% (SE 0.02) if the cut off level is 11 g/dL and 11 % (SE 0.03) if the cut-off level is 10 g/dL. The majority was of the mild type. The prevalence was higher in the teenage group, Indians followed by Malays and Chinese Grandmultiparas and from urban residence are at risk Jamaiyah Hanif et al - Asia Pac J Clin Nutr 2007;16 (3):527-536

DEFINITIONS IN PREGNANCY Anemia: Hb <11gm% Iron Deficiency: Ferritin <30g/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 6 July 2013, Kuantan

IRON DEFICIENCY ANAEMIA Iron deficiency can be classified as Mild-moderate 70–100μg/L Severe type < 20–30μg/L Full blood count and MCV value is considered a good screening tool for IDA Many patients do not respond adequately to oral iron therapy due to difficulties associated with ingestion of the tablets and their side effects

INVESTIGATIONS Specific test Basic investigations Full blood count Peripheral blood film Total Iron Study Total Iron binding capacity Total ferritin Total transferrin Vitamins assay Folic acid Vitamin B1, B12 Ascorbic acid Hb Electrophoresis Bone marrow aspiration Lupus anticoagulant antibody Rheumatoid factor antibody LE cells Others – LFT,Renal profile sputum AFB etc Full blood count BFMP Stool ova & cysts

ANTENATAL CARE COLOUR CODING RED Symptomatic anemia regardless of gestational age YELLOW Hb <9.5g/dL (moderate or more severe) GREEN Hb <11g/dL (mild) 6 July 2013, Kuantan

EFFECT ANAEMIA TO PREGNANCY MOTHER FETUS Infection Hypotension Heart failure Renal failure PPH Fetal growth restriction Small for gestational age Prematurity

FETAL ASSESSMENT Fundal height Serial symphysio-fundal height

FETAL ASSESSMENT Ultrasonograph for fetal growth

MANAGEMENT OF ANAEMIA IN PREGNANCY MEDICAL Iron and vitamin supplement Parenteral iron Others – depends on the aetiology OBSTETRIC Antepartum Intrapartum Postpartum

ORAL IRON THERAPY For prophylaxis IDA 30-60 mg elemental iron per day is adequate For treatment IDA 180 mg elemental iron is require For α or β Thalassemia Prescribed folic acid 5mg daily If serum ferritin < 12 µg/dl to treat as IDA

For THALASAEMIA CASES Mild and asymptomatic – no treatment If serum ferritin is low – Iron supplement Moderate – severe type Blood transfusion Iron chelation therapy Splenectomy Bone marrow stem cell transplant

TYPES OF IRON PREPARATION ELEMENTAL IRON (MG/TABLET) Obimin (1tablet) 30 mg Ferrous Sulphate (300mg) 36 mg Ferrous Fumarate (200mg) 66 mg Iberet 500 (1 tablet) 105 mg Zincofer (1 tablet) 115 mg

INDICATION OF PARENTERAL IRON Cannot tolerate side effects of oral iron Suffers from inflammatory bowel disease Patient does not comply Patient near term

FLOW CHART MANAGEMENT OF ANEMIA

DISCUSS WITH FMS Thalasemia cases Severe Anaemia Cases Cases not responding to treatment Cases that needs referral to hospital

INDICATIONS FOR REFERRAL TO HOSPITAL Severe anaemia (Hb< 7g/dl) more than 32 weeks gestation Moderate anaemia (Hb 7 -8.9) with symptoms and signs of cardiovascular decompensation e.g. reduced effort tolerance, breathlessness Asymptomatic moderate anaemia (Hb 7 -8.9) in the third trimester with risk of post-partum haemorrhage (if poor response to initial management) Grandmultiparity, Multiple pregnancy Past history of PPH Polyhydramnios

INDICATIONS FOR REFERRAL TO HOSPITAL Thalassaemia not responding to haematinics. (If they have concomitant IDA, not responding to treatment) Evidence of IUGR

PRACTICAL TIPS OF MANAGEMENT NOT COST EFFECTIVE to religiously investigate mild anemia Our resources and facilities are limited A known fact: Iron deficiency anemia is the most common type of anemia and a FULL BLOOD COUNT will reveal reduced MCV, MCHC and MCH. These patients can be empirically treated with therapeutic dosage of iron supplementations.

PRACTICAL TIPS OF MANAGEMENT A full blood picture is NOT routinely required to confirm a hypochromic microcytic anemia UNLESS the classical features of iron deficiency anemia are absent. Is it NOT COST EFFECTIVE to perform a battery of investigations for all anemia cases (eg FBP, Se Ferritin, TIBC, stool ova & cyst, HB electrophoresis, Hb analysis). Be SELECTIVE in your approach

WHEN DO WE NEED TO INVESTIGATE FURTHER All moderate or severe anemias need to be investigated (Hb<9g/dl). In these instances, do a serum ferritin and confirm the diagnosis of iron deficiency anemia if it is low.

WHEN DO WE NEED TO INVESTIGATE FURTHER If compliance in not an issue but there is no response to iron supplementations after at least 3 weeks of treatment (haemoglobin increases by 0.3g/week), that is indication for further investigations. These patients would need a: Serum Ferritin Iron Profile Stool for ova & cyst for hookworm infestations Thalasemia screen.

WHEN DO WE NEED TO INVESTIGATE FOR THALASSAEMIA In patients who have a significant family history of thalassemia MCH is the most important screening parameter for thalassaemia. (low MCH < 27) Even with a normal haemoglobin levels is an indication to screen for thalasemia. (Normal Hb, MCH <27) Iron deficiency anemia which does not respond to iron supplementations.

NEW PRACTICE POINTS ALL cases of anaemia should be discussed with the medical officer To do FBC at booking, 28 wks ±1 wk and 35wk±1wk For anaemia cases treated with oral iron, monitor Hb every 2 weekly (Expected Hb increased of 1 gm% in 2 weeks) Zincofer/Iberet will be made available at the stand alone KKIA

NEW PRACTICE POINTS Medical officers can start Zincofer/Iberet BUT 1st line of management is still Ferrous Fumarate (please adhere to the flowchart of management) Prescription of Zincofer/Iberet MUST be countersigned by FMS Nurses CANNOT start Zincofer/Iberet, but once initiated, they can continue till the treatment is reviewed by the doctor IM Imferon will be initiated at health clinics/KKIA which are equipped with emergency facilities

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 Establish diagnosis IDA to be treated Anemia other than IDA to be further evaluated 6 July 2013, Kuantan

SUMMARY Failure to respond to iron therapy: ? Co-existing disease ? Incorrect diagnosis ? Co-existing disease ? Malabsorption ? Non-compliance ? Blood loss Be certain of indications before deciding for parenteral iron 6 July 2013, Kuantan

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