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 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 <30g/L Iron Deficiency Anemia: low ferritin & low Hb

Ferritin: First to be abnormal as iron stores decreaseNot affected by recent iron ingestionBut 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

Basic investigations

• Full blood count• BFMP• Stool ova & cysts

Specific test

• 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

ANTENATAL CARE COLOUR CODING

REDSymptomatic anemia regardless of gestational age

YELLOWHb <9.5g/dL (moderate or more severe)

GREENHb <11g/dL (mild)

6 July 2013, Kuantan

EFFECT ANAEMIA TO PREGNANCY

• Infection• Hypotension• Heart failure• Renal failure• PPH

• Fetal growth restriction• Small for gestational age• Prematurity

MOTHER FETUS

FETAL ASSESSMENT• Fundal height • Serial symphysio-fundal height

• Ultrasonograph for fetal growth

FETAL ASSESSMENT

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

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

TYPES OF IRON PREPARATION

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

1. Thalasemia cases2. Severe Anaemia Cases3. Cases not responding to treatment4. Cases that needs referral to hospital

INDICATIONS FOR REFERRAL TO HOSPITAL 1. Severe anaemia (Hb< 7g/dl) more than 32 weeks

gestation2. Moderate anaemia (Hb 7 -8.9) with symptoms and

signs of cardiovascular decompensation e.g. reduced effort tolerance, breathlessness

3. 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

4. Thalassaemia not responding to haematinics. (If they have concomitant IDA, not responding to treatment)

5. Evidence of IUGR

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

PRACTICAL TIPS OF MANAGEMENT

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 FURTHER

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.

WHEN DO WE NEED TO INVESTIGATE FOR THALASSAEMIA

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

• 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

NEW PRACTICE POINTS

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

• 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:? Incorrect diagnosis? Co-existing disease? Malabsorption? Non-compliance? Blood loss

• Be certain of indications before deciding for parenteral iron

6 July 2013, Kuantan

SUMMARY

THANK YOU