железодефицит во время беременности - британские рекомендации 2011

[Dr.Vad]

Summary of key recommendations
 Anaemia is defined by Hb <110g/l in first trimester, <105g/l in second and
third trimesters and <100g/l in postpartum period
 Full blood count should be assessed at booking and at 28 weeks
 All women should be given dietary information to maximise iron intake and
absorption
 Routine iron supplementation for all women in pregnancy is not
recommended in the UK
 Unselected screening with routine use of serum ferritin is generally not
recommended although individual centres with a particularly high
prevalence of “at risk” women may find this useful
 For anaemic women, a trial of oral iron should be considered as the first
line diagnostic test, whereby an increment demonstrated at two weeks is a
positive result
 Women with known haemoglobinopathy should have serum ferritin
checked and offered oral supplements if their ferritin level is <30 ug/l
 Women with unknown haemoglobinopathy status with a normocytic or
microcytic anaemia, should start a trial of oral iron (1B) and
haemoglobinopathy screening should be commenced without delay in
accordance with the NHS sickle cell and thalassaemia screening
programme
 Non-anaemic women identified to be at increased risk of iron deficiency
should have a serum ferritin checked early in pregnancy and be offered
oral supplements if ferritin is <30 ug/l
 Systems must be in place for rapid review and follow up of blood results
 Women with established iron deficiency anaemia should be given 100-
200mg elemental iron daily. They should be advised on correct
administration to optimise absorption
 Referral to secondary care should be considered if there are significant
symptoms and/or severe anaemia (Hb<70 g/l) or late gestation (>34 weeks)
or if there is failure to respond to a trial of oral iron.
 For nausea and epigastric discomfort, preparations with lower iron content
should be tried. Slow release and enteric coated forms should be avoided
 Once Hb is in the normal range supplementation should continue for three
months and at least until 6 weeks postpartum to replenish iron stores
 Non-anaemic iron deficient women should be offered 65mg elemental iron
daily, with a repeat Hb and serum ferritin test after 8 weeks
 Anaemic women may require additional precautions for delivery, including
delivery in a hospital setting, available intravenous access, blood groupand-
save, active management of the third stage of labour, and plans for
excess bleeding. Suggested Hb cut-offs are <100g/l for delivery in hospital
and <95g/l for delivery in an obstetrician-led unit
 Women with Hb <100g/l in the postpartum period should be given 100-
200mg elemental iron for 3 months
 Parenteral iron should be considered from the 2nd trimester onwards and
during the postpartum period for women with confirmed iron deficiency
who fail to respond to or are intolerant of oral iron
 Blood transfusion should be reserved for those with risk of further
bleeding, imminent cardiac compromise or symptoms requiring immediate
attention. This should be backed up by local guidelines and effective
patient information

[Ссылки доступны только зарегистрированным пользователям ]

[Tuu-Tikki]

Недавно одобряла, поэтому не могу пока. В очередной раз огромное спасибо за информацию.

Все же 110-105-105 у них по триместрам, почти как у ACOG.

Как я понимаю, учитывая частоту анемий при беременности (каждая третья примерно беременная) в отечестве, ферритин в качестве скрининга смотреть все же имеет смысл?
И, учитывая, что ферритин выше 30 у очень и очень немногих, всем, кроме этих счастливиц, имеет смысл назначать препараты железа в профилактических дозах, нет?

По поводу контроля при анемии через две недели от начала терапии - смотрим только гемоглобин? Ретикулоциты интересовать должны?

Есть женщина с анемией (Hb 90-100) в течение всей жизни и абсолютным отсутствием эффекта при попытках лечения препаратами железа. У ее дочери диагностирована талассемия. При консультации гематолога было предположено, что проблема со стороны матери. У матери талассемию не искали. Надо ли во время беременности?

Очень интересно про гемоглобин после родов. Как скоро он должен вернуться к обычным для небеременных людей значениям?

[Dr.Vad]

1. ферритин имеет смысл смотреть у беременных, если имеется высокий риск железодефицита в конкретной популяции;
2. британцы так и рекомедуют - всем с ферритином менее 30 назначать проф. железо;
3. етот пункт непонятен - в самом гайде британцы пишут, что гемоглобин поднимается на ~20 г/л через 3-4 недели (американцы менее оптимистично указывают на 10-20 г/л подьем через месяц), откуда взялся прирост гемоглобина через 2 недели - непонятно, а ретикулоциты могут подняться в етот срок (но опять желательно знать, какие они были до того)

[Dr.Vad]

4. не понял вопроса по талассемии

5. согласно этой статье (таблица 2), большинство женщин с гемоглобином менее 100 восстанавливается уже через 6 недель: с 91 до 125 и сохраняется на этом уровне в послед. полгода, то же происходит и с неанемичными женщинами: гемоглобин со 115 повышаетыся до 132 через 6 недель и пребывает таким в течение полугода; уровень анемизации и длительность коррелирует с обьемом родовой кровопотери:

Postnatal iron status of Hong Kong Chinese women
[Ссылки доступны только зарегистрированным пользователям ]

[Tuu-Tikki]

Спасибо.
Про талассемию - эт я видимо плохо сформулирована.
Есть беременная с хронической анемией, при которой никогда не помогали препараты железа, ждет второго ребенка. У первого ее ребенка после обследования выставлена талассемия. Надо ли искать талассемию у матери?

[Dr.Vad]

у ребенка - альфа или бета талассемия, гомозиготная или гетерозиготная?

если и матери никогда не было еффекта на пероральный пр-т железа, то нужно узнать: есть или нет железодефицита? если есть - усваивается или нет пероральное железо?

[Tuu-Tikki]

Спасибо, в пн подниму карту и созвонюсь с пациенткой на предмет диагноза ребенка, при осмотре спросила, она не помнит.

[Dr.Vad]

тезисы недавних 2 публикаций по послеродовой анемии:

Ann Hematol. 2011 Nov;90(11):1247-53.
Postpartum anemia I: definition, prevalence, causes, and consequences.
Milman N.
Department of Clinical Biochemistry, Næstved Hospital, 4700 Næstved, Denmark.

This review provides a status on the definition, prevalence, causes, and consequences of anemia in women who have given childbirth, i.e., postpartum anemia. The diagnosis of iron deficiency anemia relies on a full blood count including hemoglobin, serum ferritin, and serum soluble transferrin receptor, which appear to be reliable indicators of anemia and iron status 1 week postpartum while serum transferrin saturation is an unreliable indicator several weeks after delivery. It is recommended that postpartum anemia should be defined by hemoglobin <110 g/L at 1 week postpartum and <120 g/L at 8 weeks postpartum. The major causes of postpartum anemia are prepartum anemia combined with acute bleeding anemia due blood losses at delivery. Normal peripartum blood losses are approximately 300 ml, but hemorrhage >500 ml occur in 5-6% of the women. In healthy women after normal delivery, the prevalence of anemia (hemoglobin <110 g/L) 1 week postpartum is 14% in iron-supplemented women and 24% in non-supplemented women. In consecutive series of European women, the prevalence of anemia 48 h after delivery is approximately 50%. In developing countries, the prevalence of postpartum anemia is in the range of 50-80%. Postpartum anemia is associated with an impaired quality of life, reduced cognitive abilities, emotional instability, and depression and constitutes a significant health problem in women of reproductive age.
---

Ann Hematol. 2012 Feb;91(2):143-54.
Postpartum anemia II: prevention and treatment.
Milman N.
Department of Clinical Biochemistry and Obstetrics, Næstved Hospital, Næstved, Denmark.

This review focuses on the prevention and treatment of anemia in women who have just given childbirth (postpartum anemia). The problem of anemia both prepartum and postpartum is far more prevalent in developing countries than in the Western societies. The conditions for mother and child in the postpartum, nursing, and lactation period should be as favorable as possible. Many young mothers have a troublesome life due to iron deficiency and iron deficiency anemia (IDA) causing a plethora of symptoms including fatigue, physical disability, cognitive problems, and psychiatric disorders. Routine screening for postpartum anemia should be considered as part of the national maternal health programs. Major causes of postpartum anemia are prepartum iron deficiency and IDA in combination with excessive blood losses at delivery. Postpartum anemia should be defined as a hemoglobin level of <110 g/l at 1 week postpartum and <120 g/l at 8 weeks postpartum. Bleeding exceeding normal blood losses of approximately 300 ml may lead to rapid depletion of body iron reserves and may, unless treated, elicit long-standing iron deficiency and IDA in the postpartum period. The prophylaxis of postpartum anemia should begin already in early pregnancy in order to ensure a good iron status prior to delivery. The most reliable way to obtain this goal is to give prophylactic oral ferrous iron supplements 30-50 mg daily from early pregnancy and take obstetric precautions in pregnancies at risk for complications. In the treatment of slight-to-moderate postpartum IDA, the first choice should be oral ferrous iron 100 to 200 mg daily; it is essential to analyze hemoglobin after approximately 2 weeks in order to check whether treatment works. In severe IDA, intravenous ferric iron in doses ranging from 800 to 1,500 mg should be considered as first choice. In a few women with severe anemia and blunted erythropoiesis due to infection and/or inflammation, additional recombinant human erythropoietin may be considered. Blood transfusion should be restricted to women who develop circulatory instability due to postpartum hemorrhage.

[Dr.Vad]

Профилактика железодефицита во время беременности с позиции датских реалий:

J Pregnancy. 2012;2012:514345. Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much!

[Ссылки доступны только зарегистрированным пользователям ]

NB!

Новый журнал, посвяшенный проблемам беременности в полной версии (содержание):

[Ссылки доступны только зарегистрированным пользователям ]

попадаются и интересные обзоры, напр.:

Preeclampsia 2012 [Ссылки доступны только зарегистрированным пользователям ]

Periconceptional Folate Deficiency and Implications in Neural Tube Defects
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Вот такой 3-летнее наблюдение за беременными с ЖДА из Австралии, у которых ее лечение было исключительно препаратом железа внутрь или же вначале одна в/в иньекция аналога Венофера, а затем прием железа внутрь:

Two hundred women matched for haemoglobin concentration and serum ferritin level were recruited. Patients were randomized to daily oral ferrous sulphate 250 mg (elemental iron 80 mg) with or without a single intravenous iron polymaltose infusion...
Prior to delivery, the intravenous plus oral iron arm was superior to the oral iron only arm as measured by the increase in haemoglobin level (mean of 19.5 g/L vs. 12 g/L; P < 0.001); the increase in mean serum ferritin level (222 microg/L vs. 18 ug/L; P < 0.001); and the percentage of mothers with ferritin levels below 30 microg/L (4.5% vs. 79%; P < 0.001). A single dose of intravenous iron polymaltose was well tolerated without significant side effects.//J Intern Med. 2010 Sep;268(3):286-95.

через 3 года:

Patients who received intravenous iron demonstrated significantly higher haemoglobin and serum ferritin levels (p<0.001). There were strong associations between iron status and a number of the HRQoL parameters, with improved general health (p<0.001), improved vitality (physical energy) (p<0.001), less psychological downheartedness (p=0.005), less clinical depression (p=0.003) and overall improved mental health (p<0.001). The duration of breastfeeding was longer (p=0.046) in the intravenous iron group. The babies born in both groups recorded similarly on APEG growth chart assessments...
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BMJ Open. 2012 Oct 18;2(5). Three-year follow-up of a randomised clinical trial of intravenous versus oral iron for anaemia in pregnancy.

[Dr.Vad]

Кокрэйн (подбил бабки - зачеркнуто) собрал весь эвиденс по теме: Daily oral iron supplementation during pregnancy

We included 61 trials. Forty-four trials, involving 43,274 women, contributed data and compared the effects of daily oral supplements containing iron versus no iron or placebo.Preventive iron supplementation reduced maternal anaemia at term by 70% (risk ratio (RR) 0.30; 95% confidence interval (CI) 0.19 to 0.46, 14 trials, 2199 women, low quality evidence), iron-deficiency anaemia at term (RR 0.33; 95% CI 0.16 to 0.69, six trials, 1088 women), and iron deficiency at term by 57% (RR 0.43; 95% CI 0.27 to 0.66, seven trials, 1256 women, low quality evidence). There were no clear differences between groups for severe anaemia in the second or third trimester, or maternal infection during pregnancy (RR 0.22; 95% CI 0.01 to 3.20, nine trials, 2125 women, very low quality evidence; and, RR 1.21; 95% CI 0.33 to 4.46; one trial, 727 women, low quality evidence, respectively), or maternal mortality (RR 0.33; 95% CI 0.01 to 8.19, two trials, 12,560 women, very low quality evidence), or reporting of side effects (RR 1.29; 95% CI 0.83 to 2.02, 11 trials, 2423 women, very low quality evidence). Women receiving iron were on average more likely to have higher haemoglobin (Hb) concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130 g/L during pregnancy, and at term.Compared with controls, women taking iron supplements less frequently had low birthweight newborns (8.4% versus 10.3%, average RR 0.84; 95% CI 0.69 to 1.03, 11 trials, 17,613 women, low quality evidence), and preterm babies (RR 0.93; 95% CI 0.84 to 1.03, 13 trials, 19,286 women, moderate quality evidence). They appeared to also deliver slightly heavier babies (mean difference (MD) 23.75; 95% CI -3.02 to 50.51, 15 trials, 18,590 women, moderate quality evidence). None of these results were statistically significant. There were no clear differences between groups for neonatal death (RR 0.91; 95% CI 0.71 to 1.18, four trials, 16,603 infants, low quality evidence), or congenital anomalies (RR 0.88, 95% CI 0.58 to 1.33, four trials, 14,636 infants, low quality evidence).Twenty-three studies were conducted in countries that in 2011 had some malaria risk in parts of the country. In some of these countries/territories, malaria is present only in certain areas or up to a particular altitude. Only two of these studies reported malaria outcomes. There is no evidence that iron supplementation increases placental malaria. For some outcomes heterogeneity was higher than 50%.

[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

FIGO recommends the following:
>Anemia is defined as hemoglobin less than 11.0 g/dL during pregnancy and postpartum.
>Full blood count should be assessed at least at booking and at 28 weeks.
>All women should be given dietary information to maximize iron intake and absorption.
>Routine iron supplementation for all women in pregnancy is recommended, according to the health policies of the countries, especially in areas with a high prevalence of anemia. The minimum dosage should be 30 mg of elemental iron a day.
>Unselected screening with routine use of serum ferritin is generally not recommended although individual centers with a particularly high prevalence of at‐risk women may find this useful.
>Women with iron deficiency anemia should be given 100–200 mg elemental iron daily. They should be advised on correct administration to optimize absorption.
>Referral to secondary care should be considered if there are significant symptoms and/or severe anemia (hemoglobin <7.0 g/dL), late gestation (>34 weeks), or if there is failure to respond to a trial of oral iron.
>Once hemoglobin is in the normal range, supplementation should continue for 3 months and at least until 6 weeks postpartum to replenish iron stores.
>Pregnant women with anemia may require additional precautions for delivery, including delivery in a hospital setting, available intravenous access, active management of the third stage of labor, and preparation for excess bleeding. Suggested hemoglobin cutoffs are less than 10.0 g/dL for delivery in hospital and less than 9.5 g/dL for delivery in an obstetrician‐led unit. Women with hemoglobin less than 10.0 g/dL in the postpartum period should be given 100–200 mg elemental iron for 3 months.
>Parenteral iron should be considered from the second trimester onward and during the postpartum period for women with confirmed iron deficiency who fail to respond or who are intolerant to oral iron.
>Blood transfusion should be reserved for those with risk of further bleeding, imminent cardiac compromise, or symptoms requiring immediate attention.
[Ссылки доступны только зарегистрированным пользователям ]

[Babyborner]

Всем добрый день.
Что скажете по поводу препарата Сантеферра?
В частности интересует компонент железа полифосфат -375мг.

Целесообразно ли назначать при железодефицитной анемии?

[Dr.Vad]

лучше железа бисглицинат 18-30 мг

[Babyborner]

Сообщение от Dr.Vad

лучше железа бисглицинат 18-30 мг

Спасибо
На практике Ваша рекомендация лучше привычных - мальтофер, сорбифер и гинотардиферрон?