1. Disclaimer: This presentation has been designed for UK Healthcare Trusts using guidelines available by February If you wish to use this presentation for your own trust, please make any changes necessary to comply with your local guidelines, and ensure the references used are still valid at the date you are training.
Please note, this presentation follows the local guidance in the Trust it was first designed for, which involved taking a haematinic screen in the first instance of anaemia in pregnancy.
Current national guidance states that iron deficiency anaemia in pregnancy can be confirmed by administering a trial of oral iron in microcytic or normocytic anaemia (unless the woman is know to have a haemoglobinopathy).If this is your local policy you will need to edit the slides accordingly.

2. IRON DEFICIENCY TREATMENT IN PREGNANCY
Bringing Patient Blood Management to Maternity at
[INSERT LOCAL HOSPITAL NAME HERE]

3. WHAT IS PATIENT BLOOD MANAGEMENT?
PBM is an evidence based, multi-disciplinary approach to optimising the care of patients who may need a transfusion

4. WHY DOES PBM MATTER? Patient Benefit Blood Supply Sustainability
Cost to the NHS

5. HOW CAN PBM HELP OUR WOMEN?
Anaemia in pregnancy affects more than 56 million women globally
Iron deficiency in pregnancy is a well known risk for adverse maternal and foetal outcome
Correction of anaemia, even late in pregnancy, may reduce these adverse events
Other options to use PBM include the appropriate use of cell salvage for caesarean sections
Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005, Mc Lean et al, Public Health Nutrition: page 1-11

7. AUDIT RESULTS FOR ‘Local Hospital’
?% of women were anaemic at booking
?% of women were anaemic at 28 weeks
?% of women were anaemic pre delivery
?% of women were anaemic post delivery
?% of women had a transfusion
?% of women were prescribed oral iron post delivery
?% of women who had a caesarean section had a EBL of 500 ml or more
? = replace with local hospital data
Note that there is full record sets for most patients, so portionel percentage of women that are anaemic post delivery is likely skewed up – because they are more likely to have an FBC at this point if they are suspecting anaemia.

8. FIRST TRIMESTER
Offer empirical trial of oral iron – ferrous sulphate 200mg tds
Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects
Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected.
Review Hb and thalasaemia screen at booking
If Hb result of <110g/l add on a haematinics screen
Check patient history to find out if they’ve ever had oral iron before and if it was effective
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

9. WEEKS 13-34
Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects
Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected.
If Hb doesn’t improve after 4 weeks, discuss with women. If there is compliance with taking oral iron, or compliance can’t be improved, refer for IV iron
Women with multiple pregnancy should have an additional FBC at weeks
Check patient history to find out if they’ve ever had oral iron before and if it was effective
Offer empirical trial of oral iron – ferrous sulphate 200mg tds
If Hb <105g/L, schedule haematinics screen to confirm iron deficiency
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

10. AFTER 34 WEEKS
If Hb <105g/dl, schedule haematinics screen to confirm iron deficiency
If iron deficiency is confirmed, refer directly for IV iron
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018
Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

11. STRAIGHT TO IV IRON AFTER 34 WEEKS?!
RCOG Green-top guidelines state that oral iron should be the preferred first line treatment for iron deficiency
However, parental iron is indicated if the women is approaching term and there if insufficient time for oral supplementation to be effective
RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018

12. When else might IV iron be used in pregnancy?
As well as if the patient has iron deficiency anaemia and is >34 weeks, IV iron may also be considered if:
There are significant symptoms of anaemia
Oral iron is not showing a response
Anaemia is severe (Hb <70g/L)
In these cases, the woman should be referred to secondary care.
Pavord et al (2012) UK guidelines on the management of iron deficiency in pregnancy British Journal of Haematology , 158 ,

13. WHEN IS IV IRON CONTRAINDICATED?
The first trimester
During cases of sepsis (but can be given post sepsis)
Chronic liver disease
Iron overload or haemochromatosis
Known serious hypersensitivity to any parenteral iron products
Non iron deficiency anaemia
The risk is enhanced for patients with known allergies including drug allergies, including patients with a history of severe asthma, eczema or other atopic allergy
There is an increased risk of hypersensitivity reactions to parenteral iron complexes in patients with immune or inflammatory conditions (e.g. systemic lupus erythematosus, rheumatoid arthritis).

14. NOT SURE IF IV IRON IS APPROPRIATE?
Contact the woman’s obstetrician for advice