ANTENATAL IDA IN MALAYSIA - FMS Conference · 2017-08-21 · ANTENATAL IDA IN MALAYSIA DR ARUKU...
Transcript of ANTENATAL IDA IN MALAYSIA - FMS Conference · 2017-08-21 · ANTENATAL IDA IN MALAYSIA DR ARUKU...
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