OGCO-C2.6 Management of iron deficiency anemia in pregnancy

Question 1

Define anemia in 1st trimester, from 13 weeks and in the post partum period?
When is CBC tested?
Indications for assessing serum ferritin?

Answer 1

• Hb<11/gL in the 1st trimester (first 12 weeks), <10.5/dL from 13 weeks (2nd and 3rd trimester) and 10g/dL in the post partum period
• CBC routinely checked at booking and at 28 weeks. Women with known anemia should have CBC rechecked at 36 weeks.
• Serum ferritin level <68pmol/L is diagnotic criteria for iron deficiency. However in the presence of acute inflammation a serum ferritin level <225pmol/L may indicate iron deficiency

Question 2

What is Mx of iron deficiency anemia?

Answer 2

Oral iron supplement: ferrous sulpahte (FeSO4) 300mg daily is the 1st line of oral iron therapy. Ferrum hausmann chewable tablet or ferrum Hausmann drops can be given if women cannot tolerate ferrous sulphate
An expected rise in hemoglobin by >=1g/dL after taking oral iron for 14 days or more indicates a positive response to iron therapy.
Once Hb level has normalized, supplementation should continue for 3 months and at least 6 weeks postpartum. Women with Hb<10g/dL in the postpartum period should be prescribed iron supplement for 3 months.
* Multivitamin preparations not recommended as sole therapy for IDA because the calcium, phosphours and Mg salts contained in multivits can impair absorption of elemental iron and iron content in such preparation is insufficient to replenish iron deficiency
* Avoid intake within 1-2 hours of antacids or reven longer after intake of H2 blockers (famotidine, ranitidine)
* Consider prescribing stool softener (lactulose) to alleviate constipation, which is a common AE of oral iron

IV oral therapy

Question 3

What are the indications for IV iron?

Answer 3

• Does not respond to oral iron therapy (have to rule out on going blood loss/haemolysis)
• Cannot tolerate oral iron (significant GI side effects)
• Cannot absorb oral iron (IBD, atrophic gastritis)
• Has problems complying to oral iron
• IV iron also considered in women with severe iron deficiency in 3rd trimester of pregnancy or severe anemia in women with high risk for bleeding (major placenta previa, placenta accretia)

Question 4

What are the contraindications to IV iron?

Answer 4

• History of anaphylactic reactions upon using IV iron
• Non iron deficiency anemia (haemolytic anemia)
• Iron overload or disturbanves in utilization of iron (haemochromatosis, haemosiderosis)
• 1st trimester of pregnancy
• Active bacteremia
• Decompensated liver cirrhosis or hepatitis

Question 5

What is dosage of IV irone>

Answer 5

Ferinject: single IV infusion of 1000mg in 250ml sterile 0.9% NS over 1 hour infusion

Question 6

What should be monitored during adminsitration of IV iron?

Answer 6

• BP, pulse, spO2, RR monitored regularly every 15 mins for the hour during IV iron infusion and subsequent hour after
• Observe and document any SZS of AE. Complement activation related pseudoallergy encountered 1:200 patients. It consistis of minor infusion reactions including arthralgia, myalgia, flushing but without associated tachypnea, tachycardia, hypotension, wheezing, stridor, or periorbital edema.
• Infiltration/extravasation of IV iron can result in permanent skin damage and requires immediate action.

Question 7

How to Mx hypersensitivity/intolerance and its SS during administration of IV iron?

Answer 7

Question 8

How to Mx infiltration/extravasation and its SS during administration of IV iron?

Answer 8

Question 9

How to asses treatment response to IV iron?

Answer 9

Check CBC at least 4 weeks after IV iron to monitor treatment response (maximum haemoglobin response is observed at 3 weeks post treatment)
Patient unresponsive to IV iron should be assessed for any on-going bleeding and be referred to haematologist to look for any underlying causes if poor response to IV iron is suspected.