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MODEL OF GOOD CARE FOR MANAGEMENT OF ANAEMIA
JABATAN KESIHATAN WILAYAH PERSEKUTUAN KUALA LUMPUR & PUTRAJAYA
12th JULY 2013
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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
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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
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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
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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
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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
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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
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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
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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
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EFFECT ANAEMIA TO PREGNANCY
• Infection• Hypotension• Heart failure• Renal failure• PPH
• Fetal growth restriction• Small for gestational age• Prematurity
MOTHER FETUS
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FETAL ASSESSMENT• Fundal height • Serial symphysio-fundal height
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• Ultrasonograph for fetal growth
FETAL ASSESSMENT
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MANAGEMENT OF ANAEMIA IN PREGNANCY
• MEDICAL• Iron and vitamin supplement• Parenteral iron• Others – depends on the aetiology
• OBSTETRIC • Antepartum• Intrapartum• Postpartum
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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
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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
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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
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INDICATION OF PARENTERAL IRON
• Cannot tolerate side effects of oral iron• Suffers from inflammatory bowel disease• Patient does not comply• Patient near term
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• FLOW CHART MANAGEMENT OF ANEMIA
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DISCUSS WITH FMS
1. Thalasemia cases2. Severe Anaemia Cases3. Cases not responding to treatment4. Cases that needs referral to hospital
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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
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INDICATIONS FOR REFERRAL TO HOSPITAL
4. Thalassaemia not responding to haematinics. (If they have concomitant IDA, not responding to treatment)
5. Evidence of IUGR
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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
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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
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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
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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
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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
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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
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• 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
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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
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• Establish diagnosis
• IDA to be treated
• Anemia other than IDA to be further evaluated
6 July 2013, Kuantan
SUMMARY
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• 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
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THANK YOU