1. GUIDELINES ON PREVENTION AND MANAGEMENT OF ANAEMIA IN PREGNANCY)
2. Rountine Haemoglobin Assessment Should be done at booking If normal, to be repeated during mid trimester ( 20-24/52) and around 36/52
3. Iron Supplements In PregnancyT. Folic Acid 5mg OD in the first trimester ( 13/52) T Ferrous Fumarate 200mg -400mg OD + T Folid Acid 5mg OD or T Obimin 1 tablet/ day
4. If Haemoglobin < 11g/dl(a) Low MCV and MCH ( result available on the same day), no history/ family history of haemoglobinopathy and clinically no apparent medical illness: Empirically treat as Iron Deficiency Anaemia Investigation: FBC with PBF Treatment: 1. T Ferrous Fumarate 400mg BD + T Folic Acid 5mg OD 2. Recheck Hb after 2-4 weeks – Hb expected to rise by 0.3g to 1g per week – If Hb rises as expected, continue with the same for the rest of the pregnancy
5. If Hb does not rise,- Ask about compliance and review full blood picture- If patient compliant, perform the followinginvestigations:serum ferritinHb electrophoresis Stool for ova and cyst Stool for occult blood BFMP if patient from an endemic area
6. (b) If MCV and MCH not available on the same day ( i.e. in KD orsmall MCH/ KK), no history/ family history ofhaemoglobinopathy and clinically no medical illnesses: Empirically treat as iron deficiency anaemia Investigation: FBC with PBF Treatment: o T Ferrous Fumarate 400mg BD + T folic Acid 5mg OD o Recheck Hb after 2-4 weeks ( Hb expected to rise by 0.3g -1g per week)
7. o If FBP shows microcytic hypochromic anaemia ( iron deficiency), – If Hb rises as expected, continue the same treatment for the rest of pregnancy – If compliance not an issue, perform the following investigations: Serum Ferritin Hb electrophoresis Stool for ova and cyst Stool for occult blood BFMP if patient from an endemic area
8. o IF MCV and MCH is normal or high, Refer to Antenatal Combined Clinic/ Antenatal Specialist Clinic for further assessement and management
9. 4. Categorization of Women Using HaemoglobinAnd Serum Ferritin Serum Ferritin Haemoglobin Diagnosis ( microgram/ l) (g/dl)1 >12 >11 Normal, IDA excluded2 <12 >11 Storage iron depletion3 <12 <11 Iron deficiency anaemia4 >12 <11 Other causes of anaemia
10. 5. Women with IDA and unable to tolerate or non compliance to Ferrous Fumarate, Options include:a. Change to different preparation ( i.e. T Iberet 1 tab BD)b. Parenteral iron therapyc. blood transfusion
11. 6. Elemental Iron Doses: For prophylaxis against IDA, 30-100mg/day is enough For the purpose of treatment, at least 180mg/day is required
12. Amount of elemental iron in differentpreparations: Preparation Elemental iron (mg/ tab) 1. Ferrous Fumarate 60mg 2. Iberet 105mg of ferrous sulphate 3. Obimin/ Obimin plus/ 30mg of ferrous fumarate/ New Obimin ferrous sulphate
13. 7. Parenteral Iron Therapy No advantage over oral iron if the latter is well tolerated Only indicated in patients who cannot absorb iron, non compliant or developed serious side effect with oral iron Preparations: Iron Dextran ( Imferan) –Intramuscularly Dose: elemental iron needed (mg)= ( desire Hb – patient’s Hb) x weight(kg)x2.21+1000 Example: 60kg patient with Hb 7g/dl Elemental iron needed for her: (10-7)x60x2.21+1000= 1398mg Caution: small risk of hypersensitivity, should only given in hospital setting. Test dose of 50mg of IM Imferan given followed by 100mg daily until total dose meet
14. 8. Haemoglobin <11g/dl in patient known to bealpha or beta thalassemia trait:a. Prescribe Folic Acid 5mg dailyb. Check serum ferritin – If serum ferritin < 12 microgram/l, to treat as concurrent IDA
15. 9. Indications for blood transfusion duringantenatal period: Hb < 6g/dl Hb <8g/dl and POA >36/52 Moderate and severe anaemia in patient with known heart disease or severe respiratory disease Symptomatic anaemia Placenta praevia with Hb <10g/dl Patient who develops severe side effect to both oral and parenteral iron therapy
16. 10. Anaemic patient in labour: To transfuse if Hb <8g/dl and transfer to the hospital with specialist in high risk patient High risk patient with Hb between 8-10g/dl require at least 2 pint of blood ( GXM) AND transfer to the hospital with specialist if possible Patient with risk of PPH and anaemic is best delivered in the hospital with specialist In the event of advance labour where transfer is not possible, specialist input is required regarding the need for blood transfusion. GXM of at least 2 pint of blood must be made available in such patient
17. Prophylactically, can start IV infusion of pitocin ( 20 unit in 500ml Hartman’s saline) to run over 4-6 hours after delivery of the babyIn grandmultipara, to start on 40 unit pitocin in 500mls Hartman’s infusion over 4-6 hoursClose maternal monitoring immediate postnatal period to be able to diagnose PPH early
18. Antenatal management Hb < 11g/dl, POA < 28 week No indication for blood transfusion, no apparent medical illness Empirically treat as iron deficiency anaemia -Investigation : Full blood picture (FBP) -Tab ferrous fumarate 400mg bd + Folic acid 500mcg od -Recheck Hb after 4 weeks (Hb expected to rise by 0.3g-1.0g per week) Review Hb and FBP
19. Microcytic hypocromic anaemia Not microcytic and but Hb not rises as expected Microcytic hypocromic hypochromic anaemia but Hb rises as anaemia expected Perform following investigation • Serum ferritin • Hb electrophoresis -Continue same treatment for Refer to combined or antenatal the rest of the pregnancy • Stool for ova and cyst specialist clinic – repeat Hb at 20-24/52 and • Stool for occult blood 36/52 • BFMP if patient coming from an endemic area Change FF with T. Iberet 1 tab BD Diagnosis: IDA but Hb did not Review Patient in 4/52 (if POA rise as expected <28/52 ) or 2/52 (if POA > 28/52) • Non compliantDiagnosis: Not IDA-Manage accordingly • Unable to tolerate oral preparation-Refer toCombined/Specialist Deworming/treatantenatal clinic malaria/address issue of occult blood loss if indicated Parenteral iron therapy ( IM Imferon)
20. Antenatal management Hb < 11g/dl, POA 28-36 weeks No indication for blood transfusion, no apparent medical illness To follow above flow chart but follow- up every 2/52 instead of 4/52
21. Antenatal management Hb < 11g/dl, POA 36 weeks No indication for blood transfusion, no apparent medical illness Empirically treat as iron deficiency anaemia -Investigation : Full blood picture -Tab Iberet 1 tab bd + Folic acid 500mcg od -Recheck Hb after 2 weeks or /and during labour (Hb expected to rise by 0.3g-1.0g per week)
