Uk. GuideLines Flashcards
What is the prevalence of iron deficiency globally?
2 billion people
What is the definition of anaemia in pregnancy?
< 110 g/L in the first trimester
< 105 g/L in 2nd & 3rd trimester
< 100 g/L in postpartum period
When CBC should be assessed in normal pregnancy?
At booking
At 28 weeks
Is routine iron supplementation recommended for all women in pregnancy in UK?
NO
What is the first line diagnostic test for anaemic pregnant women?
A trial of oral iron
An increment demonstrated at 2 weeks is a positive result
When to check ferritin in non anaemic pregnant women who are identified to be at increased risk of iron deficiency?
Early in pregnancy
Offer iron supplements if ferritin < 30 mg /L
What is the dose of iron supplements in women with iron deficiency anemia?
100 - 200 mg / daily of elemental iron
When to consider referral anaemic women to secondary care ?
1- significant symptoms
2- severe anaemia ( Hb < 70)
3- late gestation ( > 34 weeks)
4- there is a failure to respond to a trail of oral iron ( no rise in Hb at 2 weeks)
❤🌷the starting dose should be 200 mg of elemental iron daily 🌷❤
What cautions should be taken if nausea and epigastric discomfort happened?
❤ preparation with lower iron content should be tried
What is the period of time that iron supplementation should be continued after Hb is in normal range?
For 3 months and at least 6 weeks postpartum
What is the iron dose In non anaemic pregnant women with iron deficiency ?
65 mg / daily
Repeat Hb / ferritin after 8 weeks
What is the iron dose for women with Hb < 100g / L in the postpartum period?
❤ 100-200 mg / daily for 3 months
🔴 check Hb & ferritin at the end of the therapy
When to consider parenteral iron in women with confirmed iron deficiency?
- fail to respond to oral iron
- intolerant of oral iron
- proven malabsorption
What is the definition of :
Iron depletion/ iron deficiency?
❤ Iron depletion: ⬇️ ferritin
Normal transport & functional iron
No iron to mobilize if the body needs more iron
❤ iron deficiency: ⬇️ ferritin
⬇️ transport iron (⬇️ transferrin)
⬇️ Hb
What is the prevalence of iron deficiency anemia in pregnancy?
30- 40 %
What are the maternal effects of iron deficiency anemia?
1- severe infections
2- poor work capacity
3- disturbances in postpartum cognition and emotions
What is the Hb threshold below which maternal mortality increases?
8.9 g / dl
Associated with doubling of maternal death
What are the fetal effects of iron deficiency anemia?
Fetus is protected by upregulation of placental iron transport protein
What is the effect of iron deficiency anemia on pregnancy outcomes?
1- preterm delivery
2- low birth weight
3- placental abruption
4- peripartum blood loss
What are the clinical symptoms of iron deficiency anemia?
1- Fatige ( most common symptom)
2- pallor / weakness / dizziness
3- headache/ palpitations
4- dyspnoea
5- pica ( ice - dirt )
6- feeling cold
What are the symptoms of iron deficiency that may occur even without anaemia?
1- fatigue
2- irritability
3- poor concentration
4- hair loss
What are the laboratory tests findings in iron deficiency anemia?
1- CBC: ⬇️ Hb / ⬇️ MCV / ⬇️ MCH
2- Blood film : microcytic hypochromic red cells ( pencil cells)
3- ⬇️ ferritin
4- ⬆️ ZPP ( Zn protoporphyrin)
5- ⬆️ sTfR ( soluble transferrin receptor )
6- ⬇️ reticulocyte number
What is the first laboratory test to become abnormal as iron stores decrease?
Serum ferritin
Not affected by recent iron ingestion
How serum ferritin concentrations varies during pregnancy?
- initially rises
- fall by 32 weeks (to about 50 % prepregnancy levels)
- mildly increase in 3rd trimester.
What is the ferritin concentration that is diagnostic of established iron deficiency in pregnancy?
When to treat?
< 15 mg / L
Treatment should be prompt in pregnancy if :
Ferritin < 30 mg / L
Why are (serum fe / TCBI / transferrin ) unreliable indicators of iron depletion?
Because of wide fluctuation in levels due to 1- recent ingestion of Fe
2- diurnal rythm
3- infection
What is the gold standard for assessment of iron stores?
Bone marrow sample stained for iron
In a trail of iron therapy when to check Hb ?
After 2 weeks
A rise confirms iron deficiency
Hb should rise by 20 g/L over 3-4 weeks
In anaemic women with known haemoglobinopathy what to check prior to starting iron?
Serum ferritin
( iron deficiency can cause some lowering of HbA2 percentage)
❤ offer oral supplements if ferritin < 30 mg/L
How much of dietary iron is absorbed?
15%
What is the recommended iron daily intake in pregnancy?
30 mg / d
The requirements in pregnancy are 3 times higher than menstruating women.
What are the iron daily requirements in pregnancy?
Early pregnancy: 1-2 mg / d
3rd trimester: 6 mg / d
Which one is better absorbed ferrous or ferric salts?
Ferrous salts is better absorbed
What are the factors that enhance iron absorption?
Haem iron
Ferrous iron ( Fe+2)
Ascorbic acid
What are the factors that inhibit iron absorption?
Food rich in ca
Tannins in tea
Phytates in cereals
What are the variations of elemental iron in each salt?
Fumarate/ sulphate:
200 mg 👉 65 mg
Gluconate :
300 mg 👉 35 mg
How to take iron supplements correctly?
On an empty stomach 1 hour before meals with a source of vit c
When to offer iron supplements in pregnancy?
Hb < 11 up until 12 weeks
Hb< 10.5 beyond 12 weeks
What are the indications for assessment of serum ferritin in non anaemic women?
Previous anaemia
Multiparty > 3
Consecutive pregnancy < 1 year
Vegetarians
Teen pregnancies
Recent history of bleeding
High risk of bleeding
Jehovah’s witnesses
What kind of iron preparations should be avoided?
Enteric coated/ sustained release
( the majority of iron is carried past the duodenum
When to check Hb in the postpartum period ?
Within 48 hours of ⏰
In : 1- estimated blood loss > 500 ml
2- uncorrected anaemia detected in the antenatal period
3- symptoms suggestive of anaemia.
What are the contraindications of parenteral iron therapy?
1- history of anaphylaxis
2- 1st trimester of pregnancy
3- acute or chronic infection
4- liver disease
What is the most commonly used IV iron preparation in pregnancy?
Iron sucrose / iron dextran
🌷Sucrose has a higher availability for erythropoiesis
🛑 require multiple infusions
What is the only IM iron preparation available?
Iron dextran
What are the fast acting IV iron preparations ?
Iron ³ carboxymaltose
Iron ³ isomaltoside
☀️ dose for carboxymaltose:
Single dose 1000 mg / 15 minutes
What are the recommendations for women who are still anaemic at the time of delivery?
Cut-off: Hb< 10 👉 delivery in the hospital
Hb< 9.5 👉obstetric led unit
1- IV access
2- blood group and save
3- active management of the third stage of labour
4- IM syntocinon / syntometrine
5- ( prolonged labour/ instrumental delivery) : IV high dose of syntocinon
6- misoprestol may be used
What is the relative risk reduction of anaemia at term if universal supplementation with 60 mg / d from 2nd trimester is applied?
30 - 50 %
