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Role of Heme Iron Polypeptide (HIP) for
Preventing & Treating Anemia
Dr Nupur Gupta, Consultant Gynecologist
Is the commonest medical disorder in
pregnancy and has a varied prevalance,
aetiology and degree of severity in different
...
Definition of Anemia in pregnancy
Low circulating haemoglobin with Hb < 2SD of
the median of a healthy population of the s...
Prevalence of Anemia - Global
Iron deficiency
Heavy blood
lossMenorrhagia
Parasite
infections
Acute and
chronic
infections
Pregnancy
Deficiencies
Haemog...
Severity of Anemia
Mild 10 to 10.9gm%
Moderate 7 to 9.9gm%
Severe <7gm%
Very severe <4gm%
Severity of Anemia
Mild to Moderate
• Decreased work capacity
• May go without any
adverse consequences
Moderate
• Substan...
Severe Anemia
Distinct stages recognised
1. Decompensated - Cardiac decompensation due to
low Hb
2. Compensated - cardiac ...
Severe Anemia In pregnancy
Consequences of Anemia in Pregnancy
• Impaired tissue oxygenation
• Impaired organ function
• Increased susceptibility to ...
Anemia is responsible for 40-60% of maternal deaths
(developing countries)
Indirect deaths:
- Cardiac Failure
- Haemorrhag...
Maternal effects of Anemia
1. There may be no effect
2. Increased weakness
3. Lack of energy
4. Fatigue
5. Poor work perfo...
Fetal effects of Anemia
Increased perinatal mortality and morbidity
- Prema et al Nutr. Rep. Int. 1981; Lozoff et al NEJM ...
Agarwal et al Ind. J. Med. Res. 1991; Preziosi et al Am J Clin Nutr 1997
Mean Birth Weight, Apgar & 3 months Hb
was higher...
Iron Deficiency
 Most common micronutrient deficiency in
the world affecting 1.3 billion people i.e.
24% of the world pop...
Causes of Anemia In Pregnancy
1) Acquired - Iron deficiency anemia
- Anemia caused by acute blood loss
- Anemia of inflamm...
Causes of Anemia in Pregnancy
2) Hereditary
-Thalassaemias
- Sickle cell
- Haemoglobinopathies
- Other haemoglobinopathies...
Factors required for erythropoiesis
• Proteins (erythropoietin)
• Minerals (iron)
• Trace elements (Zinc, Cobalt, Copper e...
Enhance Inhibit
Meat Phosphate
Fish Calcium
Poultry Tea (tannic acid)
Seafood Coffee
Gastric acid Colas
Ascorbic acid Soy ...
Bio-availability of Iron
1. High bio-availability diet
Diet rich in meat, poultry, fish
2. Intermediate bio-availability d...
3. Low bio-availability diet
Non-industrialised countries vegetarian
diet low in ascorbic acid with excess of
inhibitors o...
Iron requirements
2.5 mg/day in early pregnancy
5.5 mg/day from 20-32 weeks
6 to 8 mg/day from 32 weeks onwards
Average : ...
Causes of high prevalence of
Iron deficiency Anemia
1. Dietary habits
2. Worm infestations
3. Repeated pregnancies at shor...
Prevention of Iron deficiency
Ideally women should enter pregnancy
with adequate iron stores
As a public health approach, ...
Iron supplementation
during pregnancy
In developed countries like U.K routine Iron
supplementation is not recommended
Howe...
100 mg elemental iron with
500 mg of folic acid
for 100 days in second half of pregnancy
Govt. of India, 2000
GOI & MOH re...
Other effective strategies
1. Treatment of hookworm infestation
Albendazole (400 mg)
Mebendazole 100 mg BD for 3 days
2. I...
Diagnosis
1. Haemoglobin estimation (<11 g/dl)
2. Peripheral blood film : Microcytic hypochromic picture
3. Blood indices ...
Oral Iron Therapy
• 180 mg – 200 mg elemental iron with 500
mg folic acid per day
• Reticulocyte count rises in 5 –10 days...
Side effects of iron
Nausea
Vomiting
Constipation
Abdominal cramping
Diarrhoea
The tablet can be given with meals or
diffe...
For better patient compliance
twice weekly or weekly iron
supplements
have also been recommended
Ridwan et al Am. J. Clin ...
Reasons for failure to respond
1. Non compliance
2. Concomitant folate deficiency
3. Continuous loss of blood through hook...
In India, two or three doses of intramuscular or
IV iron at time of tetanus toxoid injection was
found to be well tolerate...
Parenteral Iron therapy
• Indicated when the pregnant women is unable
to take iron due to side effects or is non
compliant...
Parenteral Iron Therapy
It has no advantage over oral iron if the
latter is well tolerated
Indicated only for non-complian...
Dose calculation of Parenteral Iron
Prema K 1992
Basu J. Obstet Gynaecol Br. Cwith 1965
Elemental iron (mg) =
(Normal Hb –...
1. Carbonyl Iron (very effective and well
tolerated, better compliance)
2. Iron ascorbate
3. Iron Polymaltose complex (not...
Role of blood transfusion
1. Severe anaemia beyond 36 weeks
2. Associated infection
3. To replenish blood loss due to ante...
Management of labour
1. Comfortable position
2. Sedation and pain relief
3. Oxygen for dyspnoea
4. Use betamimetics & ster...
Puerperium
1. Adequate rest
2. Continue iron and folate for at least 3 months
3. Energetic treatment of any infection
4. W...
Maternal Mortality
It can happen in severe anaemia due to cardiac
failure or pulmonary embolism at following times:
1. Las...
Contraception
Minimum spacing for 2 yrs to make up for iron
stores
Sterilization is preferred if family is complete
Intrau...
Types of Iron
Heme Iron
• Animal tissue (red meat,
poultry & fish)
• More bioavailable
• Better absorption
Inorganic Iron ...
HEME IRON POLYPEPTIDE– PP26
HEME IRON POLYPEPTIDE
• Oral tablet containing 6/12 mg of elemental iron as
heme iron polypeptide (HIP),
– With polypeptid...
Mechanism of Absorption & Metabolism
1. Absorbed over several hours after oral administration
2. Heme attaches to apical b...
Advantages of Heme Iron
Heme Iron Uses
• GI tolerability comparable
to IV iron,
• Reduced GI distress
• Higher Bioavailabi...
Iron & Oxidative Stress Trial
• Production of superoxide & NO plays a role in cellular
signaling & metabolic regulation
• ...
Oral
administr
ation
leads
High
transferrin
saturation
levels
Formation
of non-
transferrin-
bound iron
Potentially
toxic ...
Ferrous
Sulfate
Therapy
Heme Iron
Polypeptide
1. Serum iron
2. Transferrrin
saturation (TSAT)
3. Non-transferrin-
bound ir...
9.37 9.63
10.29
11.26
0
2
4
6
8
10
12
Baseline Hb Hb after 4 weeks Hb after 8 weeks Hb after 12 weeks
HbLevel(gm/dL)
Week
...
Why L-methylfolate?
• It is the biologically active isomer
of folate and the primary form of
folate in circulation.
• It i...
Megaloblastic anemia,
Neural tube defects,
Homocysteinemia
Cleft lip & palate
Dietary supplementation with L-Methylfolate ...
Making Pregnancy Safer
Targeting Anemia Eradication during Adolescence
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Newer Iron therapy for Anemia in pregnancy

  1. 1. Role of Heme Iron Polypeptide (HIP) for Preventing & Treating Anemia Dr Nupur Gupta, Consultant Gynecologist
  2. 2. Is the commonest medical disorder in pregnancy and has a varied prevalance, aetiology and degree of severity in different populations being much more common in non- industrialised nations - Schwartz et al. Clin Obstet Gynaecol 1995 ANEMIA
  3. 3. Definition of Anemia in pregnancy Low circulating haemoglobin with Hb < 2SD of the median of a healthy population of the same age and stage of pregnancy WHO: Hb < 11 g/dl (7.45 mmol/l), PCV < 0.33, CDC < 10.5 g/dl during the second trimester
  4. 4. Prevalence of Anemia - Global
  5. 5. Iron deficiency Heavy blood lossMenorrhagia Parasite infections Acute and chronic infections Pregnancy Deficiencies Haemoglob- inopathies General Causes of Anemia
  6. 6. Severity of Anemia Mild 10 to 10.9gm% Moderate 7 to 9.9gm% Severe <7gm% Very severe <4gm%
  7. 7. Severity of Anemia Mild to Moderate • Decreased work capacity • May go without any adverse consequences Moderate • Substantial reduction in work capacity • Morbidity rates are higher • Susceptible to infections • Premature/LBW • Unable to bear blood loss (antepartum & post-partum haemorrhage)
  8. 8. Severe Anemia Distinct stages recognised 1. Decompensated - Cardiac decompensation due to low Hb 2. Compensated - cardiac output is raised even at rest 3. Circulatory failure - anaerobic metabolism & lactic acid accumulation occurs
  9. 9. Severe Anemia In pregnancy
  10. 10. Consequences of Anemia in Pregnancy • Impaired tissue oxygenation • Impaired organ function • Increased susceptibility to thrombocytopenic bleeding • Increased post operative morbidity • Increased probability of blood transfusion • Impaired quality of life
  11. 11. Anemia is responsible for 40-60% of maternal deaths (developing countries) Indirect deaths: - Cardiac Failure - Haemorrhage - Infection - Pre-eclampsia - Viteri. Adv. Exp Med Biol 1994, Bhatt J. Obstet Gynaec Ind. 1997 Maternal effects of Anemia
  12. 12. Maternal effects of Anemia 1. There may be no effect 2. Increased weakness 3. Lack of energy 4. Fatigue 5. Poor work performance ICMR 1989, Lops et al Am Fam Physician 1995 Severe anemia: 1. Palpitation 2. Tachycardia 3. Breathlessness 4. Cardiac Stress 5. Decompensation 6. Cardiac Failure 7. Pre-Term labour 8. Pre-eclampsia 9. Sepsis
  13. 13. Fetal effects of Anemia Increased perinatal mortality and morbidity - Prema et al Nutr. Rep. Int. 1981; Lozoff et al NEJM 1992 • Preterm deliveries • Intra-uterine growth retardation (IUGR) • Low fetal iron stores • Fetal iron deficiency anemia • Cognitive and affective dysfunction in the infant
  14. 14. Agarwal et al Ind. J. Med. Res. 1991; Preziosi et al Am J Clin Nutr 1997 Mean Birth Weight, Apgar & 3 months Hb was higher Fetal effects of Anemia Babies of iron supplemented mothers
  15. 15. Iron Deficiency  Most common micronutrient deficiency in the world affecting 1.3 billion people i.e. 24% of the world population.  Defined as hemoglobin below the 5th percentile of healthy population.  Iron deficiency can range from sub-clinical state to severe iron deficiency anemia.
  16. 16. Causes of Anemia In Pregnancy 1) Acquired - Iron deficiency anemia - Anemia caused by acute blood loss - Anemia of inflammation or malignancy - Megaloblastic anemia - Acquired haemolytic anemia - Aplastic or hypoplastic anemia - Thalassaemias - Sickle cell haemoglobinopathies - Other haemoglobinopathies - Hereditary haemolytic anemias
  17. 17. Causes of Anemia in Pregnancy 2) Hereditary -Thalassaemias - Sickle cell - Haemoglobinopathies - Other haemoglobinopathies - Hereditary haemolytic anemias
  18. 18. Factors required for erythropoiesis • Proteins (erythropoietin) • Minerals (iron) • Trace elements (Zinc, Cobalt, Copper etc) • Vitamins : Folic acid, Cyanocobalamin (B12), Vitamin C, Pyridoxine (B6), Riboflavin, Vitamin A • Hormones : Androgens & Thyroxine Letsky E. 1995 Prasad AS. J. Am. Coll. Nutr. 1996
  19. 19. Enhance Inhibit Meat Phosphate Fish Calcium Poultry Tea (tannic acid) Seafood Coffee Gastric acid Colas Ascorbic acid Soy protein Malic acid High doses of minerals Citric acid Bran/fiber Source: Compiled from Provan D.Mechanisms and management of iron deficiency anaemia. Br J Haematol 1999; 105 Suppl 1:19-26; Wharton B. Iron deficiency in children: detection and prevention. Br J Haematol 1999; 106:270-280; Cook JD. The measurement of serum transferring receptor. Am J Med Sci 1999;318:269-276. Dietary Factors That Affect absorption
  20. 20. Bio-availability of Iron 1. High bio-availability diet Diet rich in meat, poultry, fish 2. Intermediate bio-availability diet Cereals, roots, tubers with some animal foods like meat, fish and ascorbic acid. Hallberg et al Scand J Haemat
  21. 21. 3. Low bio-availability diet Non-industrialised countries vegetarian diet low in ascorbic acid with excess of inhibitors of iron absorption (phytates), cereals, roots, tubers, maize, rice , beans, whole wheat, flour, sorghum Iron bio-availability
  22. 22. Iron requirements 2.5 mg/day in early pregnancy 5.5 mg/day from 20-32 weeks 6 to 8 mg/day from 32 weeks onwards Average : 4mg/day Sharma JB, The Obstet Protocol, 1998
  23. 23. Causes of high prevalence of Iron deficiency Anemia 1. Dietary habits 2. Worm infestations 3. Repeated pregnancies at short intervals
  24. 24. Prevention of Iron deficiency Ideally women should enter pregnancy with adequate iron stores As a public health approach, prolonged oral iron supplementation even before pregnancy is a better strategy (PRECONCEPTION COUNSELING) Sloan et al Mother Care Project, 1992
  25. 25. Iron supplementation during pregnancy In developed countries like U.K routine Iron supplementation is not recommended However, it is mandatory in non-industrialized countries WHO recommends 60 mg elemental iron with 250 mg folic acid for 6 months in pregnancy and additional 3 months postpartum Sloan et al, Mother care project, 1992
  26. 26. 100 mg elemental iron with 500 mg of folic acid for 100 days in second half of pregnancy Govt. of India, 2000 GOI & MOH recommendation
  27. 27. Other effective strategies 1. Treatment of hookworm infestation Albendazole (400 mg) Mebendazole 100 mg BD for 3 days 2. Improving dietary habits 3. Food fortification Atukorala et al. Am. J. Clin Nutr 1994 Viteri et al Am. J. Clin Nutr 1995
  28. 28. Diagnosis 1. Haemoglobin estimation (<11 g/dl) 2. Peripheral blood film : Microcytic hypochromic picture 3. Blood indices are lower 4. Low serum ferritin (<12 mg/l) 5. Elevated Total Iron Binding Capacity (TIBC) ( > 350 mg/dl) 6. Low serum iron ( < 60 mg/dl) 7. Low transferrin saturation ( < 15 % ) 8. Raised Free Erythrocytic Protoporphyrin (FEP) (>50 mg/dl) 9. Raised serum transferrin receptor 10. Bone marrow examination
  29. 29. Oral Iron Therapy • 180 mg – 200 mg elemental iron with 500 mg folic acid per day • Reticulocyte count rises in 5 –10 days • Hb rises 0.3 to 1 g per week
  30. 30. Side effects of iron Nausea Vomiting Constipation Abdominal cramping Diarrhoea The tablet can be given with meals or different brand may be tried
  31. 31. For better patient compliance twice weekly or weekly iron supplements have also been recommended Ridwan et al Am. J. Clin Nutr. 1996 Compliance Issues
  32. 32. Reasons for failure to respond 1. Non compliance 2. Concomitant folate deficiency 3. Continuous loss of blood through hookworm infestation or bleeding haemorrhoids 4. Co-existing infection 5. Faulty iron absorption 6. Inaccurate diagnosis Non iron deficiency microcytic anaemia a. Thalassaemia b. Pyridoxine deficiency c. Lead poisoning d. Sideroblastic anaemia e. Atransferrinaemia Prema K. Obst. & Gynaecol 1992 Sharma JB, In Progress in Obst. & Gynaec, 2002
  33. 33. In India, two or three doses of intramuscular or IV iron at time of tetanus toxoid injection was found to be well tolerated, safe and effective regimen. Bhatt J. Obstet Gynecol Ind. 1997 Sharma and Jain (MD thesis 2002) IM Iron with Tetanus
  34. 34. Parenteral Iron therapy • Indicated when the pregnant women is unable to take iron due to side effects or is non compliant • Its main advantage is certainity of administration • Rise in haemoglobin is similar to oral iron (upto 1gm per wk) Sharma J.B. Progress in Obst. & Gynae. (Studd) 2003
  35. 35. Parenteral Iron Therapy It has no advantage over oral iron if the latter is well tolerated Indicated only for non-compliance or serious side effects with oral iron Sharma JB, In Progress in Obst. & Gynaec, 2002
  36. 36. Dose calculation of Parenteral Iron Prema K 1992 Basu J. Obstet Gynaecol Br. Cwith 1965 Elemental iron (mg) = (Normal Hb – Patients Hb) x Wt (Kg) x 2.21 + 1000
  37. 37. 1. Carbonyl Iron (very effective and well tolerated, better compliance) 2. Iron ascorbate 3. Iron Polymaltose complex (not used any more due to lack of efficacy) 4. Heme Iron Polypeptide New Therapeutic Alternatives
  38. 38. Role of blood transfusion 1. Severe anaemia beyond 36 weeks 2. Associated infection 3. To replenish blood loss due to antepartum or postpartum haemorrhage 4. Patients not responding to oral or parenteral iron. Packed cells are preferred.
  39. 39. Management of labour 1. Comfortable position 2. Sedation and pain relief 3. Oxygen for dyspnoea 4. Use betamimetics & steroids with caution in preterm labour 5. Digitalisation for cardiac failure of severe anaemia 6. Aim to deliver vaginally 7. Antibiotic prophylaxis 8. Avoid prolongation of second stage 9. Active management of third stage 10. Neonatologist should attend to the baby Sharma JB, The Obstetic Protocol, 1998
  40. 40. Puerperium 1. Adequate rest 2. Continue iron and folate for at least 3 months 3. Energetic treatment of any infection 4. Watch and energetically treat puerperal sepsis, failing lactation, sub involution of uterus and thromboembolism Sharma JB, The Obstetic Protocol, 1998
  41. 41. Maternal Mortality It can happen in severe anaemia due to cardiac failure or pulmonary embolism at following times: 1. Last trimester (maximum blood volume) 2. During labour 3. Immediately after delivery 4. During puerperium Sharma JB, The Obstetic Protocol, 1998
  42. 42. Contraception Minimum spacing for 2 yrs to make up for iron stores Sterilization is preferred if family is complete Intrauterine device can be inserted if no menorrhagia Barrier methods can be offered but high failure rate is the disadvantage Sharma JB, In progress in Obst & Gynae, 2002
  43. 43. Types of Iron Heme Iron • Animal tissue (red meat, poultry & fish) • More bioavailable • Better absorption Inorganic Iron (iron salts) • Vegetables & cereals • Less bioavailable (altered absorption by food – tannins, phytates, soy & dairy products) • Inadequate absorption
  44. 44. HEME IRON POLYPEPTIDE– PP26
  45. 45. HEME IRON POLYPEPTIDE • Oral tablet containing 6/12 mg of elemental iron as heme iron polypeptide (HIP), – With polypeptides of varying molecular weights, porphyrin rings • Peptides & amino acids are cleaved during processing to increase the concentration of the bioavailable iron. • Heme moiety remains covalently bound to the polypeptide chain – Enhancing solubility in aqueous solutions at a wide range of pH levels; pH less than 3 and pH > 6 46
  46. 46. Mechanism of Absorption & Metabolism 1. Absorbed over several hours after oral administration 2. Heme attaches to apical brush border of the absorptive enterocyte. 3. Heme moiety binds to transferrin 4. Carried across brush border into the cytosol intact 5. Peak change in serum iron from a single dose is seen in 2 -4 hours & gently slopes thereafter for up to ten hours
  47. 47. Advantages of Heme Iron Heme Iron Uses • GI tolerability comparable to IV iron, • Reduced GI distress • Higher Bioavailability • Higher serum Fe, Ferritin Recommended Use • One tab three times daily • With or without meals Ideal alternative to traditional iron therapy
  48. 48. Iron & Oxidative Stress Trial • Production of superoxide & NO plays a role in cellular signaling & metabolic regulation • Iron is involved in both formation & scavenging of these species • Iron deficiency (anemia) associated with oxidative stress • Iron preparations also induce oxidative & nitro-sative stress 04-08-2015 49
  49. 49. Oral administr ation leads High transferrin saturation levels Formation of non- transferrin- bound iron Potentially toxic form of iron Propensity to induce oxidative stress High serum iron & transferrin saturation levels observed Iron & Oxidative Stress Trial
  50. 50. Ferrous Sulfate Therapy Heme Iron Polypeptide 1. Serum iron 2. Transferrrin saturation (TSAT) 3. Non-transferrin- bound iron (NTBI) 04-08-2015 51 Iron & Oxidative Stress Trial
  51. 51. 9.37 9.63 10.29 11.26 0 2 4 6 8 10 12 Baseline Hb Hb after 4 weeks Hb after 8 weeks Hb after 12 weeks HbLevel(gm/dL) Week Hb rise using 0.3mg BD (0.26, 0.66, 0.97) Series1 Linear (Series1) Efficacy of Heme Iron Polypeptide 04-08-2015 52
  52. 52. Why L-methylfolate? • It is the biologically active isomer of folate and the primary form of folate in circulation. • It is the only form of folate to cross the blood-brain barrier. • Folic acid (Vit B9) is required for the nucleic acid metabolism, red blood cell maturation and for cell division and growth.
  53. 53. Megaloblastic anemia, Neural tube defects, Homocysteinemia Cleft lip & palate Dietary supplementation with L-Methylfolate at the time of conception is known to reduce the risk of neural tube defects in the offspring. Deficiency of L-methylfolate
  54. 54. Making Pregnancy Safer Targeting Anemia Eradication during Adolescence
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Role of heme iron polypeptide for treating and preventing anemia

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