Remembering iron in heavy menstrual bleeding and pregnancy

MIMS Doctor speaks to Dr Carol Lim, head of obstetrician and gynaecologist department, and Dr Jameela Sathar, head and senior consultant haematologist, both of Hospital Ampang, Kuala Lumpur, about the incidence of iron deficiency anaemia (IDA) during pregnancy and heavy menstrual bleeding.  

The incidence of IDA among pregnant women in Malaysia is close to 40 percent, noted Jameela and Lim. IDA in pregnancy can occur at any stage. A woman may already have IDA before pregnancy without her knowledge and also experience postpartum IDA due to postpartum haemorrhage. [J Preg Child Health 2015;2:168]

Similar to IDA due to malnutrition, IDA in pregnancy and heavy menstrual bleeding is treated with iron therapy or a trial of oral iron. Lim and Jameela noted that if the response is suboptimal—<1 g rise in haemoglobin after 2 weeks of therapy, or <2 g in 4 weeks of therapy, intravenous (IV) iron supplementation should be considered.

The best way to prevent IDA during pregnancy is to ensure that a woman already has sufficient iron store before embarking on pregnancy. During pregnancy, it is paramount for a woman to consume a balanced diet and take prophylactic iron supplements even if she is not anaemic. If IDA is diagnosed at this time, IV iron supplementation  may be necessary.

While IDA doesn’t look like a serious condition, noted Lim and Jameela, there is a possible risk of severe morbidity and mortality to the mother. This comes in the form of the inability to tolerate blood loss, increased risk of heart failure, reduced milk production and shorter lactation periods, increased risk of perinatal mental health conditions, impaired physical functions, and overall reduced quality of life. IDA may also cause premature delivery, low birth weight, IDA in the newborn, autistic spectrum disorder, intellectual disability and more.

Therefore, IDA should be treated early before or early in pregnancy to prevent the possible detrimental effects on both mother and baby.

Heavy menstruation contributes to IDA, too
Pregnancy isn’t the only contributing factor to IDA, as heavy menstrual bleeding is also a major contributor. About 20 to 25 percent of women suffer from menorrhagia or heavy menstrual bleeding. While not everyone with heavy menstrual bleeding is negatively affected, those who are suffering from the effects of IDA should seek medical help.

Treatment of heavy menstrual bleeding begins with determining the cause ie, gynaecological or haematological (bleeding disorders). Once the aetiology is determined, the patient is usually treated with hormonal therapy, contraceptives, tranexamic acid, iron therapy, or medical therapy in the case of bleeding disorders.

More serious cases would necessitate surgical procedures that are tailored towards specific causes of heavy menstrual bleeding. These include dilation and curettage, hysteroscopy, endometrial ablation, hysterectomy, among others. 

As GPs are the first point of contact for many patients, they can help by being on the lookout for IDA, due to any cause, said Lim and Jameela. They can recommend the use of oral contraceptives to prevent heavy menstrual bleeding, they added.