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Anaemia in Pregnancy Guidelines

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Sarawak guidelines for prevention and management of anaemia in pregnancy.
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  • Added: February, 11th 2012
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Content Preview
GUIDELINES ON PREVENTION AND MANAGEMENT OF ANAEMIA IN PREGNANCY:

1. Routine Haemoglobin assessment should be done at booking
If normal to be repeated during mid-trimester (20-24/52) and around 36/52

2. Iron Supplements in pregnancy
- Tablet folic acid 0.5mg od in first trimester (13 weeks)
- Tablet ferrous fumarate 200-400 mg od + folic acid 0.5mg od (or)
- Tablet Obimin 1 tablet /day

3. If Haemoglobin is < 11g%
a. Low MCV and MCH (result available on the same day), no history/family history
of haemoglobinopathy and clinically no apparent medical il ness.
- Empirically treat as iron deficiency anaemia
- Investigation : full blood picture (FBP)
- Tab ferrous fumarate 400mg bd + Folic acid 500mcg od
- Recheck Hb after 2-4 weeks (Hb expected to rise by 0.3g-1.0g per week)
- If Hb rises as expected continue the same for the rest of the pregnancy
- If Hb do not rise
o Ask about compliance and review ful blood picture
o If the patient is compliant, perform the fol owing investigation:
Serum ferritin
Hb electrophoresis
Stool for ova and cyst
Stool for occult blood
BFMP if patient coming from an endemic area

b. If MCV and MCH not available on the same day (i.e. in KD or smal MCH/KK), no
history/family history of haemoglobinopathy and clinical y no medical il nesses.
- Empirically treat as iron deficiency anaemia
- Investigation : full blood picture(FBP)
- Tab ferrous fumarate 400mg bd + Folic acid 500mcg od
- Recheck Hb after 2-4 weeks (Hb expected to rise by 0.3g-1.0g per week)
- If FBP shows microcytic hypochromic anaemia (iron deficiency)
o If Hb rises as expected continue the same treatment for the rest
of the pregnancy
o If not a compliance problem, perform following investigation:
Serum ferritin
Hb electrophoresis
Stool for ova and cyst
Stool for occult blood
BFMP if patient coming from an endemic area
- If MCV and MCH is normal or high
o Refer combined clinic/ antenatal specialist clinic for further
assessment and management
1


4. Categorization of women using haemoglobin and serum ferritin


Serum ferritin
Haemoglobin
Diagnosis
(g/l)
(g/dl)
1
>12
>11
Normal, IDA excluded
2
<12
>11
Storage iron depletion
3
<12
<11
Iron deficiency anaemia
4
>12
<11
Other causes of anaemia


5. Women with IDA and unable to tolerate or non-compliance to Ferrous Fumarate
Options Include:
a.
Change to different preparation ( i.e Tab Iberet 1 tablet BD)
b.
Parenteral iron therapy
c.
Blood transfusion
6. Elemental iron doses:
For prophylaxis against IDA, 30-100 mg /day of elemental iron is enough, but for the purpose
of treatment at least 180 mg/day of elemental iron is required.

Amount of elemental iron in different preparations

Preparation
Elemental iron (mg/tablet)
Ferrous fumarate (200mg)
60 mg
Iberet
105 mg of ferrous sulphate
Obimin/Obimin plus/
30 mg of ferrous
New obimin
fumarate/ferrous sulphate


7. Parenteral iron therapy:
It has no advantage over oral iron if the latter is well tolerated. It is only indicated in patients
who cannot absorb iron, non-compliant or developed serious side effect with oral iron.

Preparation: Iron Dextran (Imferon) - Intramascularly
Dose: Elemental iron needed (mg) = (Desired HB- Patient's Hb) x Weight (kg) x 2.21 + 1000

Example: (60 kg patient with Hb 7.0g/dl)
Elemental iron needed= (10-7) x 60 x 2.21 + 1000 =1398 mg

Caution:
There is small risk of hypersensitivity towards IM Imferon, it should only should only be
given in a hospital. An initial test dose of 50 mg of IM Imferon is given fol owed by 100 mg
daily until the total dose met.

2


8. Haemoglobin < 11g/dl in patient known to be or -thalassemia trait:
a.
Prescribe folic acid 5 mg daily
b.
Check serum ferritin

- if serum ferritin < 12g/l, to treat as concurrent IDA
9. Indications for blood transfusion during antenatal period:

- Hb < 6 g/dl
- Hb < 8 g/dl and POA > 36 weeks
- Moderate and severe anaemia in patient with known heart disease or
severe respiratory disease
- Symptomatic anaemia
- Placenta Praevia with Hb < 10g/dl
- Patient who develop severe side effect to both oral and parenteral iron
therapy

10. Anaemic patient in labour:

- To Transfuse if Hb < 8 g/dl and transfer to the hospital with specialist if
high risk patient.
- High risk patient with Hb between 8-10g/dl require GXM of at least 2
pint of blood 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 transfusion. GXM of at least 2
pint of blood must be available for such patient.
- Prophylactically, can start intravenous infusion of Pitocin (20 units in
500mls of Hartman's saline) to run over 4 to 6 hours after the delivery of
the baby. In grand multiparas start on 40 units Pitocin in 500mls
Hartman's infusion over 4 to 6 hours.
- Closer maternal monitoring immediate postnatal period to be able to
diagnose PPH early






3





Hb > 11 g/dl














Routine Hb Check at 20-24/52 and 36/52


Tab Ferous fumarate 200mg daily or


Tab Obimin 1 tablet daily


Tab Folic acid 5 mg daily





















4


Hb < 11g/dl, POA < 28 week


No indication for blood transfusion, no apparent

medical il ness



Low MCV and MCH
MCV and MCH not

available on the same day



Empirical y treat as iron deficiency anaemia

-Investigation : Ful blood picture

-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 ful blood

picture




Not microcytic and
Microcytic hypocromic
Microcytic hypocromic

hypochromic
anaemia but Hb not rises as
anaemia but Hb rises as

anaemia
expected
expected





Refer to combined
Perform fol owing investigation
-Continue same
or antenatal
treatment for the rest of

-Serum ferritin
specialist clinic
the pregnancy

-Hb electrophoresis

- repeat Hb at 20-24 /52

-Stool for ova and cyst
and 36/52

-Stool for occult blood


-BFMP if patient coming from
an endemic area
Change FF with T. Iberet 1 tab BD
5

Review Patient in 4/52 If POA
<28/52 and 2/52 if POA > 28/52




Diagnosis: IDA but Hb did not rises
Diagnosis: Not IDA

as expected
- Manage accordingly
-Non compliant

- Refer to
- Unable to tolerate to oral
Combined/Specialist

preparation
antenatal clinic
Deworming/treat malaria/address

issue of occult blood loos if

indicated




Parenteral iron therapy ( IM
Imferon)















6




Hb < 11g/dl, POA 28-36 weeks

No indication for blood transfusion, no apparent

medical il ness






To fol ow above flow chart but fol ow-up every
2/52 instead of 4 weeks


















7





Hb < 11g/dl, POA 36 weeks

No indication for blood transfusion, no apparent
medical il ness





Low MCV and MCH
MCV and MCH not
available on the same day





Empirical y treat as iron deficiency anaemia

-Investigation : Ful 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)






Prepared by:
Dr. Rafaie Amin
O&G Specialist (Maternal Fetal Specialist)
Department of Obstetrics & Gynaecology
SGH
30.3.2011
8


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