ANTENATAL

IDA IN

MALAYSIA

DR ARUKU NAIDU MD, FRCOG, CU

CONSULTANT O&G ,

UROGYNAECOLOGIST

HOSPITAL RAJA PERMAISURI BAINUN

IPOH

www.arukunaidu.com

Disclosure

NIL

Malaysia – The Millennium

Development Goals at 2010

MDG 5 Improve Maternal Health

MDG 5 has two targets:

Reduce by three quarters, between

1990 and 2015, the maternal mortality

ratio.

Achieve, by 2015, universal access to

reproductive health.

Maternal Mortality Ratio (MMR) of 11

per 100,000 live births by 2015.

Trend of MMR in Malaysia

Target : maternal mortality ratio (MMR) of 11 per 100,000 live births by 2015.

MMR – By State and Ethnicity

MMR – By Age Group and Parity

Causes of Maternal Death, 1997and 2007

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32.3% potentially stand a better chance if they DON’T have Anemia

Anemia

Hemoglobin (Hb) or hematocrit (Hct) value less than the fifth

percentile of the distribution of Hgb or Hct in a healthy reference

population based on the stage of pregnancy1.

1st Trimester 2nd Trimester 3rd Trimester

Hemoglobin (g/dL) < 11 < 10.5 <11

Hematocrit (%) < 33 < 32 < 33

The most frequent nutritional disorder

How many suffer from iron deficiency anemia?

2 billion people

1/3rd of the world’s population

Milman N, Anemia still a major health problem in many parts of the world, Ann Hematol(2011) 90:369–377

Prevalence of anemia

World 47% 42% 30%

Malaysia 32% 38% 30%

Pre-school children Pregnant women

Non-pregnant women during

child bearing age

WHO Global Database on Anemia,2008

Prepartum iron deficiency anemia (IDA)

Among fertile, non-pregnant

women, ∼40% have ferritin of

≤30 μg/L

Prepartum IDA predisposes to

postpartum IDA

Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959

Test Level Remarks

Serum Ferritin (ug/L) < 30 Low iron status

< 15 Iron deficiency

Prevalence of Anemia – Limitation of

Epidemiological Studies in Malaysia

• Different cut off levels of haemoglobin was used

• Rural population vs urban population

• Most study was isolated small-sample

• Most study was hospital based vs population based

• Various method blood sampling (venous vs capillary)

Prevalence of anemia in late pregnancy – different

cut off point, population? Sample saiz?

Ministry of Health Malaysia. Family Health Department Directory Annual Report Year 2000.

Hb 9-11 g/dL

Hb <9 g/dL

1998 1999 2000

%

52.9

4.6

3.6

37.7

30.3

3.1

Prevalence of anemia – Rural vs Urban

1. H Jamaiyah, A Das, TO Lim, WS Chen, MN Noraihan, R Sanjay, et al. Asia Pac J Clin Nutr 2007;16 (3):527-536

2. Zulkifli Ahmad et al Anemia during pregnancy in rural Kelantan. Mal J Nutr. 1997;3:83-90.

Rural

Rural + Urban

19972

% 35

20071 Haemoglobin cut off point 11 g/dL

47.5

Prevalence of anemia by severity

N Prevalence of severity of anemia % (SE)

Mild Moderate Severe

(N=352) (N=19) (N=0)

Overall prevalence 1072 33(0.01) 2 (0.004) 0(0)

Remark: Mild anemia is defined as having a haemoglobin level of 9-<11 g/dL; Moderate anemia is defined as having a haemoglobin level of 7-<9 g/dL; Severe anemia is defined as having a haemoglobin level of <7 g/dL; Note: Since the lowest haemoglobin level is 7.6 g/dL, therefore, there were no severe anemic subjects

H Jamaiyah, A Das, TO Lim, WS Chen, MN Noraihan, R Sanjay, et al. Asia Pac J Clin Nutr 2007;16 (3):527-536

Distribution of Hemoglobin Levels

H Jamaiyah, A Das, TO Lim, WS Chen, MN Noraihan, R Sanjay, et al. Asia Pac J Clin Nutr 2007;16 (3):527-536

Distribution of Hemoglobin Levels

H Jamaiyah, A Das, TO Lim, WS Chen, MN Noraihan, R Sanjay, et al. Asia Pac J Clin Nutr 2007;16 (3):527-536

Iron requirement in pregnancy

Milman N Ann Hematol 2006; 85(9):559-565

Hemoglobin Levels vs Gestational Period

H Jamaiyah, A Das, TO Lim, WS Chen, MN Noraihan, R Sanjay, et al. Asia Pac J Clin Nutr 2007;16 (3):527-536

Can a non-anemic pregnant women have

low iron?

Milman N. Ann Hematol (2008) 87:949–959

Distribution of blood haemoglobin concentrations in non pregnant women with replete iron stores (serum ferritin <30 μg/L) and absent iron stores (serum ferritin<12 μg/L)

Iron Deficiency Anemia1

Test Normal Value

Plasma iron level 40-175 micrograms/L

Plasma total iron-binding capacity 216-400 micrograms/L

Transferrin saturation 16-60%

Serum ferritin2 level More than 10 micrograms/L

1. ACOG Practice Bulletin-Anemia in Pregnancy VOL. 112, NO. 1, JULY 2008

2. Ontario Association of Medical Laboratories. Guidelines for the use of serum tests for iron deficiency. Guidelines

for Clinical Laboratory Practice CLP 002. North York (ON): OAML; 1995. Available at:

http://www.oaml.com/PDF/CLP002.pdf. Retrieved April 4, 2008. (Level III)

Laboratory Test Characteristic of IDA1

• Microcytic and hypochromic RBC

• Low plasma iron levels

• High TIBC

• Low serum ferritin levels

Highest sensitivity and specificity for diagnosing IDA

1. ACOG Practice Bulletin-Anemia in Pregnancy VOL. 112, NO. 1, JULY 2008

Risk factors for IDA in pregnancy

• Diet poor in iron-reach food (vegetarian?)

• Diet poor in iron absorption enhancers

• Diet rich in foods that diminish iron absorption

• Pica (eating non food substances such as clay etc..)

• Gastrointestinal disease affecting absorption

• Short interpregnancy interval

• Antepartum hemorrhage?

Complication of iron deficiency anemia

• Increased risk of1,2 :

Low birth weight

Preterm delivery

Perinatal mortality

• Associated with3,4:

Postpartum depression

Poor results in mental and psychomotor

performance testing in offspring

1. Scholl TO. Iron status during pregnancy: setting the stage for mother and infant. Am J Clin Nutr 2005;81:1218S–22S. (Level III)

2. Rasmussen K. Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth,length of gestation and perinatal mortality? J Nutr 2001;131:590S,601S; discussion 601S–603S. (Level III)

3. Tamura T, Goldenberg RL, Hou J, Johnston KE, Cliver SP, Ramey SL et al. Cord serum ferritin concentrations and mental and psychomotor development of children at five years of age. J Pediatr 2002;140:165–70. (Level II-2)

4. Perez EM, Hendricks MK, Beard JL, Murray-Kolb LE, Berg A, Tomlinson M, et al. Mother-infant interactions and infant development are altered by maternal iron deficiency anemia. J Nutr 2005;135:850–5. (Level I)

IDA During pregnancy

Annet J.C. Roodenburg. Iron supplementation during pregnancy. Eur J Obstet & Gynecol & Reproductive Biology 61 (1995) 65-71

Linsay H Allen. Anemia and iron deficiency: Effects on pregnancy outcome. Am J Clin Nutr 2007; 71(suppl)

Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959

Paul Preziosi et al. Effect of iron supplementation on the iron status of pregnant women: consequences for newborns. AM J Clin Nutr 1997; 66: 1178-82

Post-partum Anemia

1. Jamaiyah Haniffet al.Anemia in pregnancy in Malaysia:a cross-sectional survey.Asia Pac J Clin Nutr

2007;16(3): 527-536.

“More than 80 percent of maternal deaths are caused by haemorrhage,…… Most of these deaths are preventable when there is access to adequate reproductive health service”

1

Post partum anemia

Severe postpartum anemia is a complication of 5% of deliveries1

Following delivery, women lose some amount of iron through

breastfeeding and lactation

IDA has been associated with impaired cognitive function and

behavioral disturbances in postpartum women

Mother’s iron status should be evaluated prior

to discharge to monitor postpartum anemia

1. Bodnar LM,et,al. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J

Epidemiol. 2002 Nov

Post partum 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

Iron supplementation should continue after delivery if iron status

remains low or while the mother is breastfeeding1

1. Bodnar LM,et,al. Who should be screened for postpartum anemia? An evaluation of current recommendations. Am J

Epidemiol. 2002 Nov

Sign & Symptoms of IDA

HEADACHES

COLD

HANDS &

FEET

WEAKNESS,

FATIGUE,

SHORTNESS OF

BREATH

DIZZINESS PALE SKIN

Goals of treatment:

1. To restore normal levels of red blood cells and hemoglobin levels to

normal.

2. To replenish iron stores.

IDA – Treatment & Management

How to treat anemia? Increase food intake that are rich in iron Take iron supplement parenteral route-im/iv infusion Blood transfusion

How to increase iron bioavailability?

Dietary enhancers -Bioavailability of iron is increased with these foods

1. Ascorbic acid present in citrus fruits

2. Fruit juices

3. Green leafy vegetables, cabbage, cauliflower

Dietary inhibitors

1. Phytates present in cereal bran, cereal grains

2. Legumes, nut and seeds

3. Calcium, particularly in milk and milk products

4. Tannins present in tea, coffee, and cocoa

Food that are rich in iron

Only 10% to 15% of dietary

iron is being absorbed.

IDA – Treatment & Management

*Women with iron deficiency in pregnancy should not attempt to correct it through means of diet alone.

*Mayo Clinic. Iron deficiency anemia. Treatments and drugs.(accesses 7 Sept 2010)

Iron Supplementation:

Simple and effective to treat & prevent IDA.

Ferrous iron salts (ferrous fumarate, ferrous sulfate and ferrous gluconate) are

the preferred oral preparations of iron as it gives better bioavailability of

elemental iron.

Slow-release tablet are preferred as it is better tolerated and absorption is 29%

greater than standard preparation

Iron supplements should be taken at bedtime or between meals to ensure

optimum absorption (Milman.N,2000).

Oral iron treatment

WHO recommendation 120 mg/day elemental iron

RNI Malaysia 2005 recommendation 100mg/day elemental iron

High-dose iron therapy

preferably administered as sustained release iron preparations

to optimize absorption and reduce GI side effects

Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959

RNI Malaysia 2005, National Coordinating Committee on Food and Nutrition (NCCFN), Ministry of Health Malaysia

Iron supplementation reduces IDA

Paul Preziosi et al. Effect of iron supplementation on the iron status of pregnant women: consequences for newborns. AM J Clin

Nutr 1997; 66: 1178-82

Treatment of IDA in pregnancy

In women with slight to moderate IDA

(Hb 90–105 g/L)

Rx : oral ferrous iron of ∼100 mg/day

Hb checked after 2 weeks

Increase > 10g/l

Continue oral iron

Milman N ,Prepartum anemia:prevention and treatment, Ann Hematol(2008) 87:949–959

Oral iron prophylaxis

Would be convenient for the woman if iron supplements could be taken as combined multivitamin–mineral preparations

Should be given as early as 10 weeks gestation or upon first visit to the clinic, when red blood cell mass begins increasing

For ID women, supplementation should begin at the time pregnancy is planned.

should continue after delivery if iron status remains low, or

while the mother is breastfeeding.

Slow-release tablets are better tolerated and absorption is 29% greater compared with standard ferrous sulphate preparations

Oral iron prophylaxis

Iron prophylaxis should be tailored according to serum ferritin levels

- 2007 Danish Advisory National Board of Nutrition

In Southeast Asia, where the prevalence of ID is estimated to be

>90%, dosages of 100 mg/day are needed for the majority of

pregnant women

Impact of intervention

Restore personal health and raise national productivity levels by as much as 20%

Reduction in maternal deaths : Anaemia contributes to 20% of all maternal deaths

Iron deficiency anemia. https://apps.who.int/nut/ida.htm accessed on May 2011

Maternal Iron & Folic Acid Supplementation Improve Lives !!

In conclusion

IDA is the most frequent form of anaemia in pregnant women

Dietary measures are inadequate to reduce the frequency of

prepartum IDA

Pregnant women should be given 100mg/day iron regardless of ID

status in 2nd and 3 rd trimester, prophylactically

Treatment of IDA should aim at replenishing body iron deficits

Treating and preventing IDA can improve national productivity by

20% and reduce maternal mortality

Thank you