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anaemia in pregnacy

this topic provide brief description about the anemia and its type ,and how it affects pregnancy's

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anaemia in pregnacy

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  1. HAEMOTOLOGICAL DISORDERS IN PREGNANCY DEEPMALA PAUL GOVT COLLEGE OF NURSING GWALIOR

  2. Alterations in Erythrocyte Function • Anemias • reduction in the total number of circulating erythrocytes or a decrease in the quality or quantity of hemoglobin • Etiology • Impaired Erythrocyte Production • Blood Loss • Increased Erythrocyte Destruction • Combination of the Above Causes

  3. HAEMOTOLOGICAL DISORDERS IN PREGNANCY ANAEMIA PLATELET DISORDERS HAEMOGLOBINOPATHIES INHERITED COAGULATION DEFECTS

  4. ANAEMIA Commonest haematological disorder occur in preg. Prevalance in pregnant women – 14 % - Developed 51% - Developing countries 65-75% - India 80 % leading to maternal deaths

  5. DEFINITION Reduction in circulating Hb mass < 12g/dl in non-pregnant women <10 g/dl in pregnant women CDC Anaemia in iron supplemented preg. Woman Hct 33% & Hb 11g/dl – 1st & 3rd trimester Hct 32% & Hb 10.5 g / dl - 2nd trimester

  6. WHO grading of anemia • Mild 10g/dl • Moderate 7- 10 g/dl • Severe < 7 g/dl

  7. ICMR GRADING

  8. Hemotological Changes in preg.

  9. Physiological Anemia of pregnancy Plasma volume s 40-50% RBC mass s 30 % As a result Hb concentration decreases by 2g/dl Decreased Hb concn. Is due to haemodilution Criteria of Physiological Anemia 1) Hb 10 gm % 2)RBC 3.2 million cells / cu mm 3)PCV 32% 4)Peripheral Smear – Normal morphology

  10. Classification of Anaemia

  11. Classification …….

  12. Classification …….

  13. Classification …….

  14. Classification …….

  15. ERYTHROPOISES

  16. IRON METABOLISM

  17. IRON Requirements during Pregnancy • Maternal req. Of total Iron -1000mg • 500 mg  Mat. Hb. Mass expansion • 300 mg Fetus & Placenta • 200mg  Shed through gut urine, skin

  18. DEVELOPMENT OF Iron def. anemia Iron Deficiency Anemia – 3 stages • a)Depletion of Iron stores • b)Iron deficient erythropoiesis • c)Frank Iron deficiency Anemia

  19. Symptoms of IRON DEFICIENCY ANEMIA • Fatigue • Weakness • Headache • Loss of appetite • Dysphagia • Palpitations • Dyspnea on exertion • Ankle swelling • Paresthesias • Leukoplakia

  20. Physical examination • Pallor of varying degrees (Mucous membranes , nail beds – Koilonychia or Platynychia • Glossitis • Stomatitis • Heart murmurs • Increased JVP • Tachycardia • Tachypnea • Postural hypotension • Crepitations- due to lung congestion

  21. Depletion of Iron stores • Ferritin <20 ng/ml • Hb / Hct. Normal • RBC INDICES normal Iron deficient erythropoiesis • Ferritin <20 ng/ml • Transferrin saturation<25% • Hb –Normal • Serum Iron < 60mg/dl

  22. c)Frank Iron deficiency Anemia • ferritin <20 ng/ml • Transferrin saturation<25 % • Serum iron <60 mg/dl • Hb <10g/dl, Hct.<28%

  23. Microcytic Hypochromic

  24. PROPHYLAXIX • WHO - 60 mg Elemental iron + 400 micro gram Folic acid / day * 6 months & 3 months postpartum • National Nutritional Anemia Control Programme of India - 60 mg elemental Iron + 500 mcg Folic acid & Prophylactic supplementation * 100 days in 2nd trimester

  25. Iron Supplements

  26. Ferrous sulphate 300mg Tid orally daily after meals • To be contd for 12 months after anemia is corrected • Indicators of iron therapy response • Increase in Reticulocyte count (Increases 3-5 days after initiation of therapy ) • Increase in Hb levels. Hb increases 0.3 to 1 g/ week 3 .Epithelial changes (esp tongue & nail ) revert to normal • Hb concn. Is normal after 6 wks of therapy

  27. PARENTERAL ADMINISTRATION • INDICATIONS • Intolerance to oral iron • Non compliance pt. • Inflammatory bowel disease • Pt. unable to absorb iron orally • Patients near term

  28. TDI – Total Dose Infusion Amount of iron needed to restore Hb conc to normal & additional allowance to provide adequate replenishment of iron stores • Formulae 1 Total Dose ( mg ) = ( normal Hb – Pts Hb ) * (body wt. in kg ) * 2.21 2 Total Iron Dose (mg ) = 2.3 * wt. kg before preg * D (Target Hb) + 500 mg for body store

  29. MEGALOBLASTIC ANAEMIA • Incidence – 0.2 – 5 % • Caused by folic acid deficiency & Vit B12 deficiency

  30. Folic Acid Defciency Pathophysiology • Preg. Causes 20 -30 fold increase in Folate requirement (150-450 microgram / day ) to meet needs of fetus & placenta. • Placenta transports folate actively to fetus even if the mother is deficient. • This cause decreased plasma folate levels.

  31. Causes of Folic acid deficiency 1.Diet- Poor intake, prolonged cooking. 2. Malabsorption – Coeliac disease. 3.Increased demand – Pregnancy, cell proliferation (hemolysis ) 4.Drugs – anticonvulsants, contraceptive pill, cytotoxic drugs (Methotrexate ) 5.Diminished storage – Hepatic disorders & Vit C deficiency

  32. Diagnostic features of Folic acid deficiency 1.Serum Folate levels – Low <3 ng/ml 2.Erythrocyte Folate levels - <20 ng/ml 3.Peripheral smear – Hypersegmented neutrophils,Oval macrocytes,Pancytopenia

  33. Treatment • Pregnancy induced megaloblastic anaemia- Folic acid, nutritious diet & Iron . • Supplementation of 1mg of folic acid daily can improve MA by 7 to 10 days • Folic acid should be given with iron • Ascorbic acid 100mg Tid enhances action • In other conditions • Recommended folic acid dose – 5mg /day orally daily • Prophylaxis • WHO – 400 micrograms folic acid daily to prevent neural tube defects

  34. Vit – B12 Deficiency

  35. Pathophysiology • Vit B12 absorption is unaltered during pregnancy • Tissue uptake is increased  Decreased serum B12 • Recommended B12 intake – 3 microgram /day. CAUSES of Vit B12 def. • Strict Veg. diet • Use of proton pump inhibitors • Metformin. • Gastritis • Gastrectomy • Ileal bypass • Crohn’s • H. Pylori infection

  36. Pathogenisis of PERNICIOUS ANEMIA  Gastric juice IF Antibody

  37. Clinical manifestations • Macrocytic Megaloblastic Anemia • Glossitis • Peripheral neuropathy • Subacute combined degeneration of the Spinal cord

  38. DIAGNOSIS Ser.Vit B12 levels ,100 pg /ml Radio active Vit B12 absorption test . ( Schilling Test ) Treatment 1000 microgram parenteral cyanocobalamin every wk * 6 weeks Pernicious Anaemia – Oral Vit B12 Total Gastrectomy – 1000 microgram Vit B12 im every month. Partial gastrectomy – Ser. Vit B12 levels measured.

  39. Pernicious Anemia cont • Etiology • Defective gastric secretion of Intrinsic factor (IF) from parietal cells of gastric mucosa • Congenital • Following partial or complete gastrectomy • Autoimmune gastric atrophy • Chronic atrophic gastritis • Heavy alcohol, hot tea, smoking • More common in elderly

  40. Pernicious Anemia • Clinical Manifestations • Classic signs of anemia • Neurologic manifestations with severe anemia (<7 g/dl) • Vitamin B12 is necessary for the synthesis of myelin • Parasthesias of feet and fingers • Ataxia • Loss of position and vibration sense • Spasticity • Sore tongue, beefy red (unknown cause) • Hyperbilirubinemia • Jaundice/icterus • “Lemon yellow” skin – combination of pallor and jaundice • Hepatosplenomegaly – enlarged liver and spleen

  41. Pernicious Anemia • Evaluation • CBC analysis • Clinical manifestation analysis • B12 levels • Schilling test – Vit B12 absorption is measured by administering radioactive Vitamin B12 and measuring its excretion in the urine • Intrinsic factor evaluation • Bone marrow aspiration and analysis

  42. Pernicicous Anemia • Treatment • Vitamin B12 administration • Injection if IF deficiency is the problem • Orally, IF deficiency is not the problem • Dietary adjustments • Blood transfusion • Monitor reticulocyte count for evidence of response to therapy

  43. Vitamin B12 • Cyanocobalamin • Routes: PO, Intranasally, IM, SC • Oral Preferred • Adverse effects: hypokalemia • PO: 1000-10,000 micrograms/day tx 6 micrograms/day dietary supplement • IM, SC: typically 30 micg/day x 5-10days then 100 to 200 micg/month • Intranasal 500 micg/spray once a week

  44. B12 Treatment Considerations • Monitor B12 levels • Monitor Hemogram and reticulocytes • Give Folic acid with B12 for severe anemia • Folic acid caution

  45. Folate Deficiency • Megaloblastic anemia • Etiology low folic acid levels • Sources: liver, yeast, fruits, leafy vegetables, eggs, milk • Absorbed in upper small intestine and is not IF dependent • Circulates through the liver with very little storage • Deficiency is most common with select groups • Pregnancy and lactation (increased need) • Fad diets with decreased intake of folate • Alcoholic persons (ETOH interferes with folate metabolism) • Chronically malnourished • Sprue

  46. Folate deficiency anemia • Clinical Manifestations • Classic signs of anemia • No neurologic manifestations • Manifestations related to malnourishment • painful ulcerations of cheeks and tongue • fissuring of lips and mouth • Gastrointestinal symptoms • Dysphagia • Flatulence • Watery diarrhea

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