Iron Deficiency Treatment in Pregnancy at [INSERT LOCAL HOSPITAL NAME HERE]

1. Disclaimer: This presentation has been designed for UK Healthcare Trusts using guidelines available by February 2018. If you wish to use this presentation for your own trust, please make any changes necessary to comply with your local guidelines, and ensure the references used are still valid at the date you are training. Please note, this presentation follows the local guidance in the Trust it was first designed for, which involved taking a haematinic screen in the first instance of anaemia in pregnancy. Current national guidance states that iron deficiency anaemia in pregnancy can be confirmed by administering a trial of oral iron in microcytic or normocytic anaemia (unless the woman is know to have a haemoglobinopathy).If this is your local policy you will need to edit the slides accordingly.

2. IRON DEFICIENCY TREATMENT IN PREGNANCY Bringing Patient Blood Management to Maternity at [INSERT LOCAL HOSPITAL NAME HERE]

3. WHAT IS PATIENT BLOOD MANAGEMENT? PBM is an evidence based, multi-disciplinary approach to optimising the care of patients who may need a transfusion https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management

4. WHY DOES PBM MATTER? Patient Benefit Blood Supply Sustainability Cost to the NHS https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management

5. HOW CAN PBM HELP OUR WOMEN? • Anaemia in pregnancy affects more than 56 million women globally • Iron deficiency in pregnancy is a well known risk for adverse maternal and foetal outcome • Correction of anaemia, even late in pregnancy, may reduce these adverse events • Other options to use PBM include the appropriate use of cell salvage for caesarean sections • Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005, Mc Lean et al, Public Health Nutrition: page 1-11

7. AUDIT RESULTS FOR ‘Local Hospital’ ?% of women were anaemic at booking ?% of women were anaemic at 28 weeks ?% of women were anaemic pre delivery ?% of women were anaemic post delivery ?% of women had a transfusion ?% of women were prescribed oral iron post delivery ?% of women who had a caesarean section had a EBL of 500 ml or more ? = replace with local hospital data

8. FIRST TRIMESTER • Offer empirical trial of oral iron – ferrous sulphate 200mg tds • Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects • Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected. • Review Hb and thalasaemia screen at booking • If Hb result of <110g/l add on a haematinics screen • Check patient history to find out if they’ve ever had oral iron before and if it was effective RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

9. WEEKS 13-34 • Educate the women about the most effective way of taking oral iron, and encourage them to seek further advice if they suffer from side effects • Check Hb 4 weeks after they start oral iron, an increase of 20g/L can be expected. • If Hb doesn’t improve after 4 weeks, discuss with women. If there is compliance with taking oral iron, or compliance can’t be improved, refer for IV iron • Women with multiple pregnancy should have an additional FBC at 20-24 weeks • Check patient history to find out if they’ve ever had oral iron before and if it was effective • Offer empirical trial of oral iron – ferrous sulphate 200mg tds • If Hb <105g/L, schedule haematinics screen to confirm iron deficiency RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

10. AFTER 34 WEEKS • If Hb <105g/dl, schedule haematinics screen to confirm iron deficiency • If iron deficiency is confirmed, refer directly for IV iron RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018 Munoz M et al (2018) Patient Blood Management in obstetrics: management of anaemia and haematic deficiencies in pregnancy and in the post-partum period: NATA Consensus statement Transfusion Medicine, 28, 22-30

11. STRAIGHT TO IV IRON AFTER 34 WEEKS?! • RCOG Green-top guidelines state that oral iron should be the preferred first line treatment for iron deficiency • However, parental iron is indicated if the women is approaching term and there if insufficient time for oral supplementation to be effective RCOG Greentop Guidelines – Blood Transfusion in Obstetrics – May 2018

12. When else might IV iron be used in pregnancy? • As well as if the patient has iron deficiency anaemia and is >34 weeks, IV iron may also be considered if: • There are significant symptoms of anaemia • Oral iron is not showing a response • Anaemia is severe (Hb <70g/L) • In these cases, the woman should be referred to secondary care. Pavord et al (2012) UK guidelines on the management of iron deficiency in pregnancy British Journal of Haematology , 158 , 588-600

13. WHEN IS IV IRON CONTRAINDICATED? • The first trimester • During cases of sepsis (but can be given post sepsis) • Chronic liver disease • Iron overload or haemochromatosis • Known serious hypersensitivity to any parenteral iron products • Non iron deficiency anaemia • The risk is enhanced for patients with known allergies including drug allergies, including patients with a history of severe asthma, eczema or other atopic allergy • There is an increased risk of hypersensitivity reactions to parenteral iron complexes in patients with immune or inflammatory conditions (e.g. systemic lupus erythematosus, rheumatoid arthritis).

14. NOT SURE IF IV IRON IS APPROPRIATE? Contact the woman’s obstetrician for advice