IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
-
Upload
nyoman-arya-adi-wangsa -
Category
Documents
-
view
213 -
download
0
Transcript of IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
1/16
ABSTRACT
Nutritional iron-deficiency anaemia (IDA) is the most common disorder in the world,
affecting more than two billion people. The orld !ealth "rgani#ation$s global database on
anaemia has estimated a pre%alence of &' based on a regression-based analysis. ecent data
show that the pre%alence of IDA in pregnant women in industriali#ed countries is &*.' while
the incidence of IDA in de%eloping countries increases significantly up to + . Although oral
iron supplementation is widely used for the treatment of IDA, not all patients respond ade uately
to oral iron therapy. This is due to se%eral factors including the side effects of oral iron which
lead to poor compliance and lac of efficacy. The side effects, predominantly gastrointestinal
discomfort, occur in a large cohort of patients ta ing oral iron preparations. /re%iously, the use
of intra%enous iron had been associated with undesirable and sometimes serious side effects and
therefore was underutilised. !owe%er, in recent years, new type II and III iron comple0es ha%e
been de%eloped, which offer better compliance and toleration as well as high efficacy with a
good safety profile. In summary, intra%enous iron can be used safely for a rapid repletion of iron
stores and correction of anaemia during and after pregnancy.
1. Iron Deficiency in Women Nutritional
Iron deficiency is the most common deficiency disorder in the world, affecting more thantwo billion people worldwide, with pregnant women at particular ris . orld !ealth
"rgani#ation ( !") data show that iron deficiency anaemia (IDA) in pregnancy is a significant
problem throughout the world with a pre%alence ranging from an a%erage of &' of pregnant
women in industriali#ed countries to an a%erage of + (range 1+2*+ ) in de%eloping countries.
3urthermore, IDA not only affects a large number of women and children in the de%eloping
world, but is also considered the only nutrient deficiency that is significantly pre%alent in the
de%eloped world also. The number of patients with ID and IDA is o%erwhelming as more than 4
billion people, appro0imately 15 of the world$s population, are iron deficient with %ariable
pre%alence, distribution, and contributing factors in different parts of the world.
Iron deficiency affects more women than any other condition, constituting an epidemic public
health crisis. It is usually present with subtle manifestations and should be considered as a
chronic slowly progressing disease that is often underestimated and untreated worldwide despite
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
2/16
se%eral warnings and awareness campaigned by the !". The high pre%alence of IDA in
women has substantial health conse uences with subse uent socioeconomic ha#ards, including
poor pregnancy outcome, impaired educational performance, and decreased wor capacity and
producti%ity. 6ecause of the magnitude and conse uences of iron deficiency anaemia in the
world, especially in women in their childbearing period, se%eral international conferences on
nutrition ha%e addressed this issue in order to reduce the pre%alence of iron deficiency in women
of childbearing age without ma7or success. The conse uences of IDA ha%e been widely studied.
!owe%er, there remains a lac of data about its effects on patient$s wellbeing.Targeted iron
supplementation, an iron-rich diet, or both, can impro%e iron deficiency. !owe%er, the %ariability
of bioa%ailable iron compounds limits its %alue against nutritional iron deficiency. Therefore,
laboratory measures of iron stores should be utilised to determine iron deficiency and monitor
therapy.This re%iew highlights the importance of IDA in pregnancy and discusses appropriatetreatment in order to a%oid serious complications of anaemia.
2. Iron Metabolism
The balance of iron metabolism in healthy indi%iduals predominantly reflects three
%ariables8 nutritional inta e, iron loss, and current demand. The nutritional iron inta e relates to
the amount of digested iron in food and the ability to absorb iron from the digesti%e tract. The
amount of iron absorbed depends largely on the presence or absence of pathology of the
gastrointestinal tract or a comorbidity (such as chronic inflammatory diseases) that may result in
e0pression of the iron regulatory proteins and a peptide called hepcidin, which ultimately bloc s
iron absorption. The main source of iron in humans comes from the destruction of erythrocytes
by macrophages of the reticuloendothelial system including the spleen or in other words, a
recycled internal iron supply. ecent studies ha%e shown how the human body up- and
downregulates iron absorption in response to changing iron status %ia intestinal and hepatic
proteins.
2.1. Iron Metabolism in Pre nancy
During pregnancy, fetal hepcidin controls the placental transfer of iron from
maternal plasma to the fetal circulation. hen hepcidin concentrations are low, iron
enters blood plasma at a high rate. hen hepcidin concentrations are high, ferroportin is
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
3/16
internali#ed, and iron is trapped in enterocytes, macrophages, and hepatocytes. The daily
re uirement of e0ternal iron remains as little as between & to 9 mg daily :& ;. !owe%er,
more e0ternal iron is re uired to balance increased demand for iron especially with
physiological re uirements during growth, pregnancy, and lactation.This significant
increased demand for iron is re uired to de%elop the fetus and placenta in addition to
support mother$s blood %olume. 3urthermore, pregnant women are sub7ect to iron loss
during and after deli%ery. The total iron loss associated with pregnancy and lactation is
appro0imately &555 mg. Therefore the recommended daily dietary allowance for iron in
pregnancy is 4* mg instead of 9 mg in the adult nonpregnant population.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
4/16
apply for most patients. @easurement of both soluble transferrin receptor and serum
ferritin pro%ides a tool for accurate diagnosis of IDA. !owe%er, transferrin receptor is
not a well-standardi#ed test that can be reliably reproduced with high precision in most
laboratories worldwide. In the meantime, ferritin estimation is an easy automated test to
perform in most laboratories in the world howe%er, its use is limited in cases of
inflammation or infection as it is considered to be influenced by acute phase responses
and hence negati%ely influences its %alue in clinical interpretation of the test results.
The commonly a%ailable laboratory tests that determine iron status, namely,
serum iron, transferrin, total iron-binding capacity (TI6B), transferrin saturation, and
ferritin are widely used in worldwide clinical practice. Coluble Tf (sTf ) is present in
human plasma and is considered as a truncated form of the tissue receptor that e0ists as a
transferrin-receptor comple0 and therefore it reflects tissue iron deficiency. Another protein that plays a crucial role in iron metabolism is hepcidin, which is primarily made
by hepatocytes and secreted into the blood circulation. !epcidin is a small-si#ed
molecule composed of 4+-amino acid peptide, which is renally e0creted and therefore can
be detected and measured in urine. 3urthermore, hepcidins rapid e0cretion suggests that it
is regulation triggered at the le%el of production sites. !epcidin circulates in the
ferroportins plasma and responds to %arious stimuli that regulate iron stores and serum
iron. ecent studies demonstrate that hepcidin le%els are reduced in iron deficiency.
@easurement of blood or urine hepcidin le%els can be achie%ed by mass spectrometry
and immunoassays in serum, plasma, and urine.
!owe%er, the diagnostic utility of serum hepcidin in iron deficiency has not yet
been defined in clinical application. Ne%ertheless, hepcidin estimation seems a potentially
accurate test that reflects the actual iron status with less limitations.Altogether, new
technology such as hypochromic reticulocytes and reticulocyte haemoglobin testing,
sTf , and hepcidin ha%e reportedly been de%eloped with higher sensiti%ity, specificity,
reproducibility, and cost effecti%eness. This may offer a reliable screening tool for iron
deficiency in the future. It is worth noting that there are no specific data addressing the
difference of these mar ers in the pregnant %ersus nonpregnant population. !owe%er, in
principle, no essential change should occur in iron metabolism in the pregnant %ersus
non-pregnant population e0cept for the increased iron demand as discussed before.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
5/16
!.!. Current Strate y to Assess Iron Deficiency $urin Pre nancy
3ull blood count and @B %alue allowing the diagnosis of microcytic anaemia is
considered a good screening tool for IDA. !owe%er, in areas of the world where
haemoglobinopathies are pre%alent and these may be associated with microcytosis, iron
studies, in particular ferritin le%el remains the surrogate mar er for IDA. According to the
ferritin le%el, iron deficiency can be classified as se%ere ID when the ferritin le%el is =15
?g>< or mild-moderate ID if ferritin =&55 ?g>< and E15 ?g>< (there is a wide normal
range between 45 and ' ' and is laboratory and method specific). In cases of ele%ated
ferritin E&55 ?g>< with a concurrent anaemia, a reacti%e common cause such as infection
should be e0cluded and other causes of anaemia should be e0amined accordingly. "ther
complementary tests in iron studies such as serum iron, iron binding capacity, and
transferrin saturation are helpful in confirming the diagnosis of IDA.
(. )ral *ersus Intra*enous Iron for Treatment of Iron Deficiency in Women orRe%ro$ucti*e A e an$ Pre nancy
"ral iron therapy is the most widely prescribed treatment for iron deficiency anaemia,
howe%er, there are many issues that may pre%ent oral iron supplementation from successfully
managing IDA. 3or instance, many patients do not respond ade uately to oral iron therapy due to
difficulties associated with ingestion of the tablets and their side effects. Cide effects may play a
significant role in rates of compliance. 3urthermore, the presence of bowel disease may affect the
absorption of iron and thereby minimi#e the benefit recei%ed from oral iron therapy.
The side effects of oral iron therapy include gastrointestinal disturbances characteri#ed by
colic y pain, nausea, %omiting, diarrhoea, and>or constipation, and occur in about +5 of
patients ta ing iron preparations.
3urthermore, the most widely prescribed oral iron is mainly composed of ferrous salts.3errous salt is characteri#ed by low and %ariable absorption rates. Its absorption can be limited
by ingestion of certain foods as well as mucosal luminal damage. Therefore, ferric compounds
were introduced to a%oid such obstacles. !owe%er, these compounds are generally less soluble
and ha%e poor bioa%ailability.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
6/16
The usual recommended oral iron sulphate dose for the treatment of iron deficiency is at least 95
mg daily of elemental iron, which is e ui%alent to 4+5 mg of oral iron sulphate tablets (Abbott,
Australasia /ty
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
7/16
gluconate reported. There were no life-threatening reactions recorded as a result of iron
gluconate infusion. "n the other hand, there were 1& fatalities among &F
allergic>anaphylactic reactions, which were reported for iron de0tran. The high incidence
of ad%erse reactions to iron de0tran, including serious ad%erse e%ents ha%e limited its
application in pregnancy. hilst the application of iron gluconate is considered safe, it
remains impractical in theory as it re uires multiple infusions with huge implications on
the often limited health system resources as well as on patientsG compliance. @ore
recently new forms of intra%enous iron that ha%e been de%eloped and are a%ailable, are
permitting treating physicians to safely administer relati%ely high doses of iron in a single
dose treatment.
(.2. Intra*enous *ersus )ral Iron T-era%y in Pre nancy
Intra%enous iron, including iron sucrose, was employed in randomised controlled
trials with impro%ed effecti%eness of intra%enous iron only or in combination with oral
iron, compared to oral iron only, based on !b le%els. A single I iron sucrose dose has
been reported to be associated with an increased incidence of thrombosis (F>'&, 44 ). In
contrast, small doses of intra%enous iron sucrose administered o%er a three-wee period
were without infusion-associated thrombosis, with intra%enous iron sucrose administered
in + daily doses to '+ pregnant women, also well tolerated. In the first study utilising
intra%enous iron sucrose, there was no significant difference in !b le%els at any time
measured at days 9, &+, 4&, and 15 and at deli%ery between intra%enous iron sucrose or
oral iron sulphate. In contrast, in another trial, with small doses of iron sucrose, there
was a significant difference in !b le%els in fa%our of the intra%enous iron sucrose group
as measured at 4 and ' wee s after administration of I iron and at deli%ery. !owe%er,
both trials administered I iron sucrose at the e0pense of a %astly greater effort from the
patients to present to the hospital for infusions in a short period of time as well as the
e0tra demands on hospital resources.
3urthermore, relati%ely older and established iron preparations such as
intra%enous iron polymaltose (3errosig, Cigma /harmaceuticals, Australia) demonstrated
a high safety profile in the treatment of IDA in both obstetric and general populations
without a ma0imum dose of treatment. The total dose of I iron polymaltose is
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
8/16
calculated according to the patientGs body weight and entry !b le%el with reference to the
product guidelines as follows8 iron dose in mg (+5 mg per & m< constant factor (5.4') K iron
depot (+55). Iron polymaltose infusion showed high efficacy and safety profile during
pregnancy in the largest, recently published trial.
In this study, two hundred Baucasian pregnant women aged &9 years or abo%e
were identified with moderate IDA, defined as !b L&&+ g>< (reference range ( ) &452
& 5 g>< ( 152''5 g>
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
9/16
5.5') in those women who had recei%ed I iron polymaltose %ersus oral iron. omen
with better iron status were less downhearted ( P H 5.55+) and less li ely to de%elop
postnatal clinical depression ( P H 5.551). This would indicate that it is worthwhile
considering the !b and iron status as a surrogate mar er for assessment of womenGs
wellbeing, not only during pregnancy but also during the postnatal period. !owe%er,
further studies are warranted to confirm and e0tend these findings.
3urthermore, recent reports demonstrate the feasibility of rapid iron polymaltose
infusion o%er 4 hours. !owe%er, a test dose of iron polymaltose (&55 mg) should be first
administered o%er 15 minutes, and premedication with antihistamine and>or low-dose
steroids is recommended prior to iron treatment for better toleration. A recent
comprehensi%e meta-analysis and re%iew by e%ei# et al. of the literature between &F*5
till present on different treatments for IDA of pregnancy showed paucity of good ualitytrials assessing clinical maternal and neonatal effects of iron administration in women
with IDA in spite of the high incidence and burden of disease associated with IDA.
During this period, there was only one prospecti%e randomi#ed trial of the effect of I
iron %ersus oral iron in the treatment of IDA during pregnancy that fulfils the stringent
independent re%iewer uality criteria.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
10/16
. Recent Data on Treatment of IDA in t-e Post%artum Perio$
The new preparations of intra%enous iron are see ing appro%al for use during pregnancy
in phase II and III clinical trials from the authorised organisational bodies in Murope and the
CA. Ne%ertheless, they can be potentially used currently in the non-pregnant female populationfor the treatment of postpartum, pre-further, and postmenopausal iron deficiency anaemia
according to the regional health authority appro%al.
Table 1
ecently a%ailable intra%enous (I ) iron preparations.
Name of the IV ironpreparation
Status ofregistration
Indications Testdose
Duration of
infusion
Max dosein singleinfusion
Ferumoxytol(Feraheme, AMAGPharmaceuticals, Inc.,USA)
FDA appro e!
"reatment o#iron$!e#iciencyanaemia in a!ultpatients %ith&'D
one * minute +* m-
Ferric car oxymaltose(Ferin/ect, 0i#orPharma, Glatt ru--,S%it1erlan!)
Appro e! in2urope,FDA$appro al issou-ht
"reatment o#iron$!e#iciencyanaemia in a!ultpatients
one*+
minutes
3 m-45-%ith max
!ose o#* m-
Iron isomaltosi!e(MonoFer,Pharmacosmos A4S,6ol ae5, Denmar5)
Appro e! in2urope FDA$appro al issou-ht
"reatment o#iron$!e#iciencyanaemia in a!ultpatients %ith&'D
one7
minutes
o max!ose -i en
at rate o#3 m-45-
3DA, 3ood and Drug Administration BOD, chronic idney disease @a0, ma0imum. No a%ailable data in pregnancy howe%er, if the benefit of treatment is 7udged to outweigh the
potential ris to the fetus, the treatment should be confined to second and third trimester of
pregnancy. M0tended appro%al is sought.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
11/16
In a randomised trial to assess safety and efficacy of intra%enous ferric carbo0ymaltose in
the treatment of postpartum IDA, 44* women were assigned to I ferric carbo0ymaltose with
&555 mg ma0imum dose (up to 1 wee ly doses) %ersus &&* women who recei%ed oral ferrous
sulphate &55 mg twice daily. Intra%enous iron carbo0ymaltose was as effecti%e as oral ferrous
sulfate with no statistically significant differences between groups at any time point despite the
shorter treatment period and a lower total dose of iron (mean &.1 g I iron %ersus & .9 g oral
iron). 3urthermore, in the I iron carbo0ymaltose group, the increases in ferritin le%els were
significantly greater than in the ferrous sulphate ( P = 5.555&) indicating a successful repletion of
iron stores and accessibility for erythropoiesis.
In a multicenter randomi#ed, controlled study, 4F& women directly after deli%ery with
haemoglobin L&55 g>< were randomi#ed to recei%e &555 mg I iron carbo0ymaltose (&'1
women), repeated wee ly to a calculated replacement dose (ma0imum dose 4.+ g), or ferroussulfate (&'9 women) 14+ mg orally three times daily for wee s (total dose '5.F g). 3erric
carbo0ymaltose-treated women achie%ed a haemoglobin E&45 g>< in a shorter period of time
with a sustained haemoglobin E&45 g>< at day '4. 3urthermore, the achie%ed haemoglobin rise of
P15 g>< was significantly more rapid in the I iron group than the oral group in achie%ing higher
serum ferritin le%els. Drug-related ad%erse e%ents occurred less fre uently with ferric
carbo0ymaltose. In a phase 1 randomised trial &*' women who recei%ed I ferric
carbo0ymaltose with a mean total dose of &.' g %ersus &*9 women who recei%ed 14+ mg ferrous
sulfate three times daily for wee s (total dose '5.F g) were assessed. /atients assigned to I
ferric carbo0ymaltose achie%ed a haemoglobin rise E45 g>< faster than the oral iron group (*
days compared with &' days in the oral iron group, P = 5.55&). The I iron group significantly
achie%ed a haemoglobin rise E15 g>< at any time (9 .1 compared with 5.' in the oral iron
group, P = 5.55&), and were more li ely to achie%e a haemoglobin E&45 g>< (F5.+ compared
with 9. , P = 5.55&). In the meantime, there were no serious ad%erse drug reactions in both
groups.
In a large randomi#ed, controlled phase 1 multicentre trial, '** women with IDA and
hea%y uterine bleeding were assigned to recei%e either I ferric carbo0ymaltose (415 women)
with a ma0imum dose of &555 mg repeated wee ly to achie%e a total calculated replacement
dose, or 14+ mg of oral ferrous sulphate ( + mg elemental iron) three times daily for wee s
with a total dose of '5.F g in 44 women. Twenty-one patients did not recei%e the assigned
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
12/16
treatment in this study. About 94 of the I iron arm achie%ed haemoglobin rise P45 g>< %ersus
4 in the oral iron P = 5.55&. omen who achie%ed a haemoglobin rise P15 g>< were +1 in
the I iron group %ersus 1 in the oral iron group ( P = 5.55&). Also, more women (*1 )
achie%ed normal haemoglobin E&45 g>< in the I iron group compared to +5 in the oral iron
group ( P = 5.55&). There were no serious ad%erse drug e%ents. This trial demonstrated that
patients with IDA due to hea%y uterine bleeding who recei%ed I iron carbo0ymaltose, are more
li ely to ha%e normal haemoglobin with replenished iron stores.
Altogether, the new intra%enous iron preparations represent a medical re%olution in
effecti%e, rapid, and safe iron repletion in the management of iron deficiency anaemia. This will
positi%ely reflect on the treatment of IDA in different populations by application of a single high-
dose intra%enous iron treatment with effecti%e subse uent repletion of iron stores and hence
impro%ement of sub7ecti%e and ob7ecti%e outcomes of the IDA. Although iron deficiency is a precursor of IDA, many clinical studies treat it similarly to IDA.
/. A*oi$in Bloo$ Transfusion
In the case of se%ere IDA, a blood transfusion has been the traditional efficient approach
to correct anaemia, especially if patients did not respond to oral iron therapy or when a rapid
correction of anaemia is clinically re uired. Although there is a lac of data regarding thea%oidance of blood transfusion during pregnancy, a recent trial in%estigating treatment of IDA
with oral %ersus I iron in pregnancy demonstrated that none of both treatment arm participants
recei%ed blood transfusion for correction of anaemia during pregnancy. !owe%er two patients
(5.F ) in the oral iron arm recei%ed blood transfusion in the postpartum period.
Burrently, the de%elopment of new intra%enous iron formulations that offer higher doses
in a single administration has pro%ided the treating physicians with the opportunity to employ
intra%enous iron as an effecti%e, rapid, and safe treatment for IDA, a%oiding the use of blood
transfusion with its nown ha#ards. There is increasing e%idence-based research that supports the
safety and efficacy of I iron in IDA. There is also increasing e%idence for inade uacy of oral
iron in terms of ad%erse effects, lac of compliance as well as lac of absorption and slow and
often uestionable effect in IDA patients.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
13/16
A common re uirement across the range of clinical situations is the need for safe, effecti%e,
higher, and less fre uent doses to achie%e optimal clinical outcomes. The ma7or goals of such
strategies include o%erall cost reduction, relief to o%erstretched health system(s), impro%ed
patient con%enience, impro%ed compliance, preser%ation of %enous access, and reduced blood
transfusion. This will ultimately reduce the demand for blood transfusions, especially in the case
of short supply. 3urthermore, some of the new iron preparations such as ferric carbo0ymaltose
and iron isomaltoside do not re uire a test dose and therefore, ease the application of intra%enous
iron in a timely and cost-effecti%e fashion. This certainly will enhance the use of intra%enous iron
in clinical practice.
0. Summary
The !" has recognised the problem of IDA in the general population as the most debilitatingnutritional deficiency worldwide in the twenty-first century, noting women to be at particularly
high ris . Cuch a problem, if ignored and not addressed properly, can ha%e a de%astating effect
on entire populations with serious conse uences. Therefore, the use of intra%enous iron should
be considered as an effecti%e, rapid, and safe treatment option in some clinical situations. An
algorithm for the treatment of iron deficiency anaemia in pregnancy and postpartum period based
on different prospecti%e randomised trials is proposed in. The intra%enous iron is increasingly
employed to a%oid or reduce the demand for blood transfusions or for effecti%e rapid repletion of
iron stores. Treatment options for IDA should consider the recently de%eloped intra%enous iron
formulations, which are considered a milestone in the management of IDA ( 3igure &).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389687/figure/fig1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389687/figure/fig1/ -
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
14/16
i ure 1
/roposed treatment for anaemia in pregnancy and postpartum period based on different
randomi#ed and non-randomi#ed trials
"%erall, the de%eloping world is most %ulnerable, especially the poorest and the least
educated populations that are disproportionately affected by iron deficiency, and therefore ha%e
the most to gain by eradication of IDA. 3urthermore, awareness of the magnitude and scale of
the IDA problem during pregnancy and also in the non-pregnant female population will help
health practitioners in recognising the most appropriate methods of diagnosis and treatment,which are crucial in o%ercoming such a de%astating health problem. A consensus guideline set by
world e0perts in managing IDA in women and in the general population, incorporating new
intra%enous iron therapies with a global approach of the health and economy aspects of IDA,
should be considered. It is worthwhile considering a uni%ersal comprehensi%e IDA management
algorithm that offers different e%idence-based treatment options and addresses local conditions.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389687/figure/fig1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389687/figure/fig1/ -
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
15/16
!owe%er, de%eloping countries with pre%alent IDA often ha%e lac of resources. Therefore, it is
crucial to adapt a %iable programme with the aim of utilising the local a%ailable resources
effecti%ely. /erhaps prioritising the treatment of IDA and increasing the awareness among the
community of such a chronic de%astating problem of paramount importance is the ey for
success and sustainability of such a programme. Bertainly, successful eradication of IDA will
result in huge benefits for community health and producti%ity with a ma7or health sa%ing not
only in the de%eloping world but also in de%eloped nations.
-
8/14/2019 IRON DEFISIENSI ANEMIA IN PREGANANCY TIPE 1.doc
16/16
References
&. orld !ealth "rgani#ation : !"; The /re%alence of Anaemia in omen8 a tabulation
of a%ailable information. Di%ision of 3amily !ealth, @aternal !ealth and Cafe
@otherhood /rogramme, Di%ision of !ealth /rotection and /romotion, Nutrition/rogramme !", 4nd ed. orld !ealth "rgani#ation, Qene%a, Cwit#erland, &FF4.
4. ABB>CBN ( nited Nations Administrati%e Bommittee on Boordination>Ctanding
Bommittee on Nutrition) 3ifth report on the world nutrition situation8 Nutrition for
impro%ed de%elopment outcomes. Qene%a, Cwit#erland, accscnRwho.org, 455'.
1. @aberly Q3, Trowbridge 3