孕期為何要做好鐵儲(chǔ)備？

1、 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education內(nèi)容Unit 1.孕期鐵儲(chǔ)備減少原因Unit 2.孕期如何做好鐵儲(chǔ)備 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education人體鐵平衡人體每天僅從外界吸收 1-2 mg 的鐵，大多數(shù)鐵由巨噬細(xì)胞吞噬衰老紅細(xì)胞提供 鐵調(diào)素通過(guò)調(diào)節(jié)機(jī)體對(duì)鐵的吸收和排泄來(lái)維持鐵含量在正常范圍，防止體內(nèi)鐵缺乏及鐵過(guò)多*Camaschella C. Iron-deficiency anemia.N Engl J Med 2015;372:

2、1832-43. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕前婦女鐵儲(chǔ)備斯堪的納維亞流行病學(xué)研究顯示非妊娠婦女，總體鐵儲(chǔ)備較差： 42非孕婦女鐵儲(chǔ)備較少，即血清鐵蛋白（SF）30g/l； 只有14-20貯存鐵500毫克，即SF70 g/l 她們鐵儲(chǔ)備多為200-300mg 大約40%非孕婦女骨髓沒有含鐵血黃素顆粒，妊娠時(shí)鐵營(yíng)養(yǎng) 狀況不佳Milman N, Clausen J, Byg K-E (1998) Iron status in 268 Danish women aged 1830 years. Influence of menstruation,

3、method of contraception, and iron supplementation. Ann Hematol 76:1319Milman N, Byg, K-E, Ovesen L (2000) Iron status in Danes updated 1994. II: Prevalence of iron deficiency and iron overload in 1,319 Danish women aged 4070 years. Influence of blood donation, alcohol intake, and iron supplementatio

4、n. Ann Hematol 79:612621 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期鐵的需求增加孕婦鐵需求隨著孕期的進(jìn)展而逐步增加 孕早期為0.8 mg/d 、孕晚期7.5 mg/d整個(gè)孕期平均鐵需求 4.4 mg/dSvanberg B (1975) Absorption of iron in pregnancy. Acta Obstet Gynecol Scand Suppl 48Bothwell TH (2000) Iron requirements in pregnancy and strategies to meet them. Am

5、J Clin Nutr 72:257S64SHallberg L (1988) Iron balance in pregnancy. In: Berger H (ed) Vitamins and minerals in pregnancy and lactation. Nestl Nutr Workshop Ser 16:115127 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期鐵需求增加原因*Bothwell TH. Iron requirements in pregnancy and strategies to meet them. Am J Clin

6、 Nutr. 2000;72:257S-264S.孕期鐵的需求孕期鐵的需求1000mg*基礎(chǔ)丟失:200mg胎兒:300mg血容量擴(kuò)增:500mg 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕婦飲食鐵攝入不足孕婦孕期并未改變飲食習(xí)慣非孕婦女鐵攝入中位數(shù)為：9毫克/天 90%以上孕婦鐵攝入低于推薦值12- 18毫克/天Trygg K, Lund-Larsen K, Sandstad B, Hoffman HJ, Jacobsen G, Bakketeig LS (1995) Do pregnant smokers eat differently from pr

7、egnant non-smokers? Pediatr Perinat Epidemiol 9:307319Andersen NL, Fagt S, Groth MV, Hartkopp HB, Mller A, Ovesen L, Warming DL (1995) Dietary habits in Denmark 1995. Main results. National Food Agency of Denmark, Copenhagen, Publication no. 235Nordic Council of Ministers (2004) Nordic nutrition rec

8、ommendations 2004. Copenhagen 食物 含量吸收率 食物 含量吸收率 食物 含量吸收率鴨血30.512%蟶子33.610%藕粉41.81-7%雞血2512%蛤蜊22.010%黑芝麻22.71-7%瘦豬肉3.010-20%黃豆8.27%雞蛋黃73%鴨肝23.110-20%紫菜54.910%海帶4.710%豬肝22.610-20%紅菇235.11-7%冬菜11.41-7%蚌肉50.010%冬菇10.51-7%苜蓿9.71-7%含鐵較高的食物（mg/100g） 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期Hb、MCV變化Hb最低值在孕期

9、24-32w安慰劑組顯示MCV在孕晚期顯著下降孕期血容量增加不同，Hb變異較大，Hb不能反映機(jī)體鐵營(yíng)養(yǎng)狀況（ROC曲線）Williams MD, Wheby MS (1992) Anemia in pregnancy. Med Clin North Am 76:631647Milman N, Byg K-E, Graudal N, Agger AO (2000) Reference values for hemoglobin and erythrocyte indices during normal pregnancy in 206 women with and without iron su

10、pplementation. Acta Obstet Gynecol Scand 78:8998Rev Panam Salud Publica. 2014 Aug;36(2):110-6. Rev Panam Salud Publica. 2014 Aug;36(2):110-6. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期鐵營(yíng)養(yǎng)狀況變化*孕期14-18w至產(chǎn)后8w口服補(bǔ)鐵與安慰劑相比，鐵營(yíng)養(yǎng)狀況變化：Serum ferritin concentration (geometric meanSEM) during pregnancy and postpar

11、tum in women taking placebo or iron supplement, 66 mg ferrous iron/day from 1418 weeks gestation to 8 weeks postpartum* Milman N, Agger OA, Nielsen OJ (1991) Iron supplementation during pregnancy. Effect on iron status markers, serum erythropoietin and human placental lactogen. A placebo controlled

12、study in 207 Danish women. Dan Med Bull 38:471476 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education產(chǎn)后貧血的原因*產(chǎn)后貧血的主要原因：產(chǎn)前鐵缺乏/貧血、伴有分娩時(shí)失血過(guò)多 出血量超過(guò)正常分娩失血250-300毫升可能會(huì)導(dǎo)致體內(nèi)鐵儲(chǔ)備迅速枯竭，除非治療，否則會(huì)引起產(chǎn)后長(zhǎng)期缺鐵和IDA*Milman N. Postpartum anemia II: prevention and treatment. Ann Hematol. 2012 Feb;91(2):143-54. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Me

13、dical Education孕期常規(guī)補(bǔ)鐵可減少產(chǎn)后貧血孕期14-18周至產(chǎn)后八周口服補(bǔ)鐵與安慰劑比較產(chǎn)后貧血： 鐵劑組：3.2鐵缺乏、1.6缺鐵性貧血安慰劑組：15.5鐵缺乏、12.1的缺鐵性貧血Iron deficiency (ID), low haemoglobin (Hb) and iron deficiency anaemia (IDA) during pregnancy and postpartum in women taking placebo or iron supplement from 1418 weeks gestation to 8 weeks postpartumMi

14、lman N, Byg K-E, Graudal N, Agger AO (2000) Reference values for hemoglobin and erythrocyte indices during normal pregnancy in 206 women with and without iron supplementation. Acta Obstet Gynecol Scand 78:8998Milman N, Agger OA, Nielsen OJ (1991) Iron supplementation during pregnancy. Effect on iron

15、 status markers, serum erythropoietin and human placental lactogen. A placebo controlled study in 207 Danish women. Dan Med Bull 38:471476 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education脆弱的婦女-脆弱的鐵營(yíng)養(yǎng)狀況*1.育齡婦女鐵儲(chǔ)備不足2.孕婦飲食習(xí)慣難以改變、鐵攝入不足3.孕期鐵需求增加：自身血容量增加、發(fā)育中胎兒血紅蛋白合成以及胎盤發(fā)育4.孕期常規(guī)補(bǔ)鐵可減少產(chǎn)后缺鐵性貧血發(fā)病率*Nils Milman. Iron and

16、 pregnancya delicate balance. Ann Hematol. (2006) 85: 559565 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education認(rèn)識(shí)鐵缺乏鐵缺乏三階段：鐵減少期（ID) 缺鐵性紅細(xì)胞生成期(IDE) 缺鐵性貧血期(IDA)Skikne BS (2008) Serum transferrin receptor. Am J Hematol 83, 872875.Goddard AF, James MW, McIntyre AS, Scott BB on behalf of the British Society of Gast

17、roenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:13091316.IDIDEIDA體內(nèi)儲(chǔ)存鐵下降血清鐵蛋白20 g/L轉(zhuǎn)鐵蛋白飽和度和Hb正常紅細(xì)胞攝入鐵降低血清鐵蛋白20 g/L轉(zhuǎn)鐵蛋白飽和度15%Hb正常紅細(xì)胞內(nèi)Hb明顯減少血清鐵蛋白20 g/L轉(zhuǎn)鐵蛋白飽和度15%Hb濃度110 g/L 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education鐵缺乏癥狀癥狀為非特異性，容易被忽視缺鐵性貧血發(fā)展的三個(gè)階段階段階段名稱機(jī)體變化外在表現(xiàn)第一階段鐵減少期存儲(chǔ)

18、鐵耗竭，血清鐵蛋白濃度下降食欲下降，頭暈，易疲倦，注意力不集中第二階段紅細(xì)胞生成缺鐵期轉(zhuǎn)鐵蛋白飽和度下降第三階段貧血期血紅蛋白和紅細(xì)胞比積下降貧血癥狀 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education診斷鐵缺乏（ID）、缺鐵性貧血（IDA）診斷*妊娠期鐵缺乏和缺鐵性貧血診治指南.中華圍產(chǎn)醫(yī)學(xué)雜志2014年第7期鐵缺乏指血清鐵蛋白濃度20 g/L妊娠期IDA是指妊娠期因鐵缺乏所致的貧血，Hb濃度110 g/L 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education血清鐵蛋白(SF)檢測(cè)SF30 g/l意味著鐵耗盡早期，如果不干預(yù)就會(huì)惡化 Va

19、n den Broek 等認(rèn)為SF是鐵貯存最佳單項(xiàng)指標(biāo)，截止值30 g/l，靈敏度90%,特異度85%UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012 Mar;156(5):588-600.van den Broek et al, Iron status in pregnant women: which measurements are valid? Br J Haematol. 1998 Dec;103(3):817-24. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Me

20、dical Education各國(guó)孕期常規(guī)補(bǔ)鐵與篩查現(xiàn)階段各國(guó)孕期常規(guī)補(bǔ)鐵或篩查措施妊娠期鐵缺乏和缺鐵性貧血診治指南.中華圍產(chǎn)醫(yī)學(xué)雜志2014年第7期2012 UK guidelines on the management of iron deficiency in pregnancyPostpartum anemia II: prevention and treatment. Ann Hematol (2012) 91:143154 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education預(yù)防補(bǔ)鐵具體措施一般孕婦一級(jí)預(yù)防：包括攝入足夠的膳食鐵、妊娠早期口服小劑量元素鐵

21、（30 mg/d）的鐵補(bǔ)充劑 孕婦高危人群預(yù)防：補(bǔ)充 元素鐵60-100 mg/d 高危因素存在高危因素的孕婦，即使Hb110g/L也應(yīng)檢查是否存在鐵缺乏曾患過(guò)貧血多次妊娠在1年內(nèi)連續(xù)妊娠素食Pe a-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Intermittent oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2012;7:CD009997. World Health Organization. Iron and Folate Suppleme

22、ntation. Standards for Maternal and Neonatal Care. Integrated Management of Pregnancy and Childbirth (IMPAC). Volume 1.8. Geneva: World Health Organization; 2006.妊娠期鐵缺乏和缺鐵性貧血診治指南.中華圍產(chǎn)醫(yī)學(xué)雜志2014年第7期 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期常規(guī)補(bǔ)鐵的循證醫(yī)學(xué)證據(jù)*WHO（2012）強(qiáng)烈推薦：孕婦每日補(bǔ)充口服鐵劑和葉酸被推薦為產(chǎn)前保健工作之一，以減少低出生體重，產(chǎn)婦

23、貧血和鐵缺乏癥孕婦補(bǔ)鐵與未補(bǔ)鐵比較低出生體重，早產(chǎn)，產(chǎn)婦孕期貧血和鐵缺乏循證醫(yī)學(xué)證據(jù)等級(jí)為中等質(zhì)量的* Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva: World Health Organization; 2012. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical EducationWHO妊娠缺鐵性貧血防治方案*預(yù)防（強(qiáng)烈推薦）：孕婦每日補(bǔ)鐵（30-60mg元素鐵）和葉酸、且越早越好 治療妊娠IDA：120mg元素鐵+葉酸400 g * Guideline: Daily

24、Iron and Folic Acid Supplementation in Pregnant Women. Geneva: World Health Organization; 2012. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education國(guó)內(nèi)防治方案*診斷明確的IDA孕婦應(yīng)補(bǔ)充元素鐵100200 mg/d，治療2周后復(fù)查Hb評(píng)估療效（1B）治療至Hb恢復(fù)正常后，應(yīng)繼續(xù)口服鐵劑36個(gè)月或至產(chǎn)后3個(gè)月（1A）非貧血孕婦如果血清鐵蛋白30g/L，應(yīng)攝入元素鐵60mg/d ，治療8周后評(píng)估療效（2B）*妊娠期鐵缺乏和缺鐵性貧血診治指南.中華圍產(chǎn)醫(yī)學(xué)雜志2014年第7期

25、醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education孕期補(bǔ)鐵的顧慮有關(guān)出生體重，新生兒死亡，先天畸形，產(chǎn)婦死亡，產(chǎn)婦在懷孕期間嚴(yán)重貧血和感染的證據(jù)等級(jí)是低質(zhì)量的;而有關(guān)藥物副作用的證據(jù)等級(jí)是極低的人們常將治療失敗的原因歸罪于口服鐵的副作用，或婦女不喜歡藥片的氣味或味道，但有篇文獻(xiàn)綜述發(fā)現(xiàn)鐵的副作用僅占不能堅(jiān)持用藥的10。 相反，多數(shù)情況下，婦女不服藥片是因?yàn)樗齻儚奈吹玫竭^(guò)這種藥或得到的量不夠Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva: World Heal

26、th Organization; 2012.Galloway R, McGuire J. Determinants of compliance with iron supplementation: supplies, side effects, or psychology. Social science and medicine 1994;39:381-390. 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education食物補(bǔ)鐵？每日飲食中含鐵10-15mg，吸收率僅為10%，請(qǐng)問(wèn)僅僅從食物中每日能獲取多少鐵？ （10mg-15mg）10%=1-1.5mg 是否能夠滿足妊娠

27、需求？ 1mg-1.5mg遠(yuǎn)遠(yuǎn)4.4mg 孕婦飲食習(xí)慣難以改變丹麥非孕女性鐵攝入日均為 9mg/day，意味著90%女性低于日推薦攝入量 18 mg/dayTrygg K, Lund-Larsen K, Sandstad B, Hoffman HJ, Jacobsen G, Bakketeig LS (1995) Do pregnant smokers eat differently from pregnant non-smokers? Pediatric Perinatal Epidemiology 9:307319Lyhne N, Christensen T, Groth MV et al

28、 (2005) Dietary habits in Denmark 20002002. Main results. Publication no. 11. National Food Agency of Denmark, CopenhagenNordic Council of Ministers (2004) Nordic nutrition recommendations 2004. Nordic Council of Ministers, Copenhagen 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education口服鐵劑為主，食物補(bǔ)充為輔鐵缺乏和輕、中度貧血者以口

29、服鐵劑治療為主，并改善飲食，進(jìn)食富含鐵的食物孕婦咨詢包括：富含鐵的食物、抑制和促進(jìn)鐵吸收的因素以及妊娠期保持合理鐵儲(chǔ)備的重要性 (1A). 一旦儲(chǔ)存鐵耗盡，僅通過(guò)食物難以補(bǔ)充足夠的鐵，通常需要補(bǔ)充鐵劑?？诜a(bǔ)鐵有效、價(jià)廉且安全妊娠期鐵缺乏和缺鐵性貧血診治指南.中華圍產(chǎn)醫(yī)學(xué)雜志2014年第7期UK guidelines on the management of iron deficiency in pregnancy.British Journal of Haematology, 2012, 156, 588600. 富含鈣的食物 茶（單寧） 谷物（植酸鹽）抑制鐵吸收的因素 血紅素鐵 二價(jià)鐵鹽

30、維生素C促進(jìn)鐵吸收的因素鐵吸收影響因素 醫(yī)學(xué) 繼續(xù)教育（CME）Continued Medical Education妊娠婦女補(bǔ)充多種微量營(yíng)養(yǎng)素？該Cochrane評(píng)價(jià)*更新于2006年、評(píng)價(jià)納入九項(xiàng)試驗(yàn)含15378名婦女。 所有試驗(yàn)都是在低收入國(guó)家進(jìn)行的，而且方法學(xué)上可靠 該評(píng)價(jià)提供的證據(jù)表明，與單獨(dú)補(bǔ)充鐵和葉酸相比，補(bǔ)充多種微量營(yíng)養(yǎng)素并無(wú)更多益處。 在得到更多信息前，應(yīng)執(zhí)行世界衛(wèi)生組織孕期補(bǔ)充鐵和葉酸的建議2012年丹麥產(chǎn)后貧血：預(yù)防和治療指南： 多種維生素礦物質(zhì)補(bǔ)充劑的鐵吸收率很低，因此補(bǔ)充鐵劑必須是單 一成分的片劑、且在兩餐之間服用，確保最佳吸收率 Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during preg