Anemia in Pregnancy

1. Jeopardy Anemia in Pregnancy

2. Physiology Screening Treating 100 100 100 200 200 200 300 300 300 400 400 400 500 500 500

3. Row 1, Col 1 Name three reasons pregnant women get anemic? 1.Dilutional or physiologic 2. Iron Deficiency Anemia 3. Thalassemias

4. 1,2 USPSTF gives a ___ recommendation to screening asymptomatic pregnant women for iron deficiency anemia? B The USPSTF recommends that clinicians provide screening to eligible patients. The USPSTF found at least fair evidence that screening improves important health outcomes and concludes that benefits outweigh harms.

5. 1,3 What does the USPSTF say about routine iron supplements in pregnancy? (non-anemic women) I Evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women.

6. 2,1 Name at least two protective roles of maternal hypervolemia Decreased blood viscosity results in reduced resistance to flow, facilitating placental perfusion and lowering cardiac work. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. To safeguard the mother against the adverse effects of blood loss associated with parturition. Williams 2006 & UTD

7. 2,2 Why screen? Iron deficiency anemia is associated with what adverse outcomes in and around pregnancy? • The USPSTF reports in it’s screening recommendation: • increased risk for low birth weight • preterm delivery • perinatal mortality • postpartum depression • poor performance on mental & psychomotor tests in offspring. 

8. 2,3 How do you counsel patients about taking iron, regarding dose, timing, and side effects? 325mg PO TID is standard, evidence lacking Most can absorb enough iron with BID dosing Take 30 minutes before meals to allow maximum absorption Side effects dyspepsia and nausea

9. 3,1 What are the Hb cutoffs (by trimester) we use to define anemia in pregnancy? 1st 2nd 3rd 11 10.5 11 Normal Hb levels at 12, 24, and 40 weeks gestation 12 Weeks: 12.2 [11.0-13.4] 24 Weeks: 11.6 [10.6-12.8] 40 Weeks: 12.6 [11.2-13.6]

10. 3,2 If anemic by Hb/HCT, what’s the best confirmatory test to get? Ferritin <15mcg/dl = iron deficiency It is also recommended to get cbc, smear, and iron levels

11. 3,3 What are the advantages of parenteral iron? • Single dose (iron dextran) • Effective: ↑iron, ↑ ferritin • Good for pts who can’t take PO iron • Well-tolerated, generally

12. 4,1 True or False: Pregnant women can get enough iron from diet. False The amount of iron absorbed from diet, together with that mobilized from stores, is usually insufficient to meet the maternal demands imposed by pregnancy Williams 2006

13. 4,2 Who gets screened for hemoglobinopathies in pregnancy? Individuals of African, Southeast Asian, and Mediterranean ancestry are at a higher risk for being carriers of hemoglobinopathies and should be offered carrier screening.

14. 4,3 How is sickle cell disease managed in pregnancy? Folate 4mg daily Pain management High risk OB referral NICU available post-delivery

15. 5,1 When should we see a resolution of pregnant hemo-bizarro-weirdness? Six weeks post-partum

16. 5,2 True or False: you should worry about a pregnant woman who’s Hct/Hb never drops. • True • Plasma volume expansion is important for fetal growth and well being • High hematocrits likely represent failure of plasma volume expansion • Results persist even when controlled for HTN and preeclampsia

17. 5,3 True or False: women with β-thalassemia should not get pregnant? False...mostly Recommended only for those with normal cardiac funtion, s/p prolonged hypertransfusion therapy & Hb>10, and iron chelation therapy c deferoxamine (discontinued during pregnancy)