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  1. ANEMIA IN PREGNANCY

  2. Dr AnahitaChauhan Associate Professor & Unit Head Seth G S Medical College & KEM Hospital Honorary Consultant, Saifee & St. Elizabeth Hospital

  3. Background • Anaemia is the commonest medical disorder during pregnancy • Greek meaning “without blood” • Iron deficiency anaemia is the most common type of anaemia during pregnancy • NFHS 2003-06: 57.9% of pregnant women • 25% direct maternal deaths

  4. Definitions of Anemia in Pregnancy • WHO - Hemoglobin concentration <11gm/dl & hematocrit of <33% • CDC definition- Hb <11gm/dl during the first and third trimesters and <10.5gm/dl in th second trimester (to allow for the physiological fall due to hemodilution in second trimester) • FOGSI - a cut off of 10 gm/dl for India

  5. Classification Based on Severity

  6. Causes of Anemia in Pregnancy • Physiological anemia • Nutritional anemia – IDA, megaloblastic • Anemia of chronic illness • Blood loss • Hemolysis and hemolytic anemias • Hemoglobinopathies • Other hereditary anemias • Aplastic anemia

  7. Increased Iron Demands • 1000mg extra elemental iron required in pregnancy • Cannot be met by diet alone • Undernutrition compounds the problem

  8. Normal Reference Ranges

  9. Morphological Classification • By the size of the RBCs • Macrocytic anemia (MCV > 100) • Normocytic anemia (80 < MCV < 100) • Microcytic anemia (MCV < 80)

  10. Clinical Features - Symptoms • Mild anemia is usually asymptomatic • Moderate anemia - weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness • Severe anemia - palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema

  11. Clinical Features - Signs • Pallor • Nail changes • Cheilosis, Glossitis, Stomatitis • Edema • Hyperdynamic circulation (short & soft systolic murmur) • Fine crepitations

  12. Effects of Anemia on Mother • Antepartum • Preterm labor • Pre eclampsia • Sepsis • IUGR • Intrapartum • Uterine inertia • PPH • Cardia failure

  13. Effects of Anemia on Mother Postpartum • Puerperal sepsis • Subinvolution • Pulmonary embolism • Failure of lactation • Delayed wound healing • Cardiac failure

  14. Fetal Effects • Prematurity and LBW • IUGR • IUFD • Increased perinatal mortality • Iron Deficiency Anemia due to lower iron stores can cause poor mental performance or behavioral abnormalities in later life

  15. Diagnosis – Baseline/ Presumptive • Haemoglobin Measurement • Peripheral blood smear • Reticulocyte count • Hematocrit • Blood indices • MCV, MCHC, MCHC • Stool Examination • Urine Examination • Proteins, LFT, RFT

  16. Therapeutic Trial of Iron

  17. Diagnosis - Additional • Serum Fe • Total iron binding capacity • Serum Ferritin • Saturation • Hb electrophoresis • Bone marrow examination

  18. Lab findings in IDA • Hb < 11 gm/dl • Peripheral smear - microcytic, hypochromic • MCV and MCHC are low • Serum iron is low - < 50 μgm/dl (N 60 -175) • TIBC is increased - > 400 μgm/dl • Tests of iron stores • Serum ferritin is < 12 μgm/dl (N 40-200) • Stainable iron in the bone marrow is reduced

  19. Newer investigations • Serum transferrin receptors • Transferrin receptor/ ferritin index • Reticulocyte indices • automated counting of reticulocytes, count of <26pg/ cell is a strong predictor of IDA • Reticulocyte production index • Red cell zinc protoporphyrin level

  20. Mentzer Index • Calculation that may (or may not) be useful in differentiating thalassemia minor from IDA • Mentzer Index = MCV/RBC Count • <13 – Thalassemia minor • >13 – Iron Deficiency • Useful in children

  21. Folic Acid Deficiency Anemia • Deficiency of folate or B12 • Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals • Folate is essential for normal growth and development • Coexists with IDA

  22. Diagnosis • Macrocytes on peripheral smear • Hypersegmentation of neutrophils • Pancytopenia • Low Hb and high MCV • Megablastosis on bone marrow • Serum folate <3ng/ ml

  23. Prevention • Dietary advice and modification • Iron supplementation of adolescent & non pregnant women • Treatment of hookworm Infestation • Iron supplementation in pregnant women • Food fortification • Antenatal care for early recognition

  24. Management of Anemia • Oral Iron Therapy • Prophylactic Iron therapy- 100mg elemental iron daily with 500 mcg of folic acid • Deworming of all anemic patients • Treatment of Anemia- 200mg of elemental iron & folate 5mg/d

  25. Iron Requirement in Pregnancy • 2.5mg /day in early pregnancy • 5.5mg /day from 20 -32 weeks • 6 – 8 mg/ day after 32 weeks • Average 4 mg/ day

  26. Side effects of Oral iron • Nausea • Vomiting • Constipation • Abdominal cramping • Diarrhoea The tablet can be given with meals or different brand may be tried

  27. Reasons for Failure to Respond • Non compliance • Concomitant folate deficiency • Continuous loss of blood through hookworm infestation or bleeding haemorrhoids • Co-existing infection • Faulty iron absorption • Inaccurate diagnosis • Non iron deficiency microcytic anaemia

  28. New Therapeutic Alternatives • The side effects of older Iron preparations & their poor compliance even on providing free tablets are the most important reasons of failure of anaemia control programmes • Newer preparations are better tolerated, have less side effects with better compliance • Carbonyl Iron • Iron ascorbate

  29. Merits of New Preparations • Outstanding GI Tolerance in contrast to 20% severe side effects with conventional therapy • Very safe with no poisoning even in high doses • No interaction with food stuffs • The newer preparations are delicious with non-metallic taste and don’t stain the patients’ teeth • Hence the compliance is very high

  30. Parenteral Iron therapy • Indicated when the pregnant woman is unable to take iron due to side effects or is non compliant • Its main advantage is certainty of administration • Rise in hemoglobin is similar to oral iron (upto 1gm per wk)

  31. Preparation & dosage • Iron Dextran IM and IV – high molecular wt stable complexes release iron slowly, can cause anaphylaxis • Iron citrate sorbitol IM – less stable, rapid release of iron • Iron sucrose IV – intermediate stability, rapid metabolism hence readily available iron. Since they do not form biological polymers, there are no reactions

  32. Precaution • Oral Iron to be suspended 48 hours before parenteral therapy • Emergency measures like inj hydrocortisone adrenaline, oxygen cylinder to be kept ready • Look for reaction while giving infusion

  33. Dose calculation • Older preparations: each 1ml = 50mg elemental iron • 0.3 x Wt in lb x (100 – Hb%) + 500 • Iron sucrose: each ml = 20mg elemental iron • Dose: 200mg slow IV alternate day • 0.24 x wt in kg x (target Hb–pt Hb) + 500

  34. Disadvantages • Pain • Nausea, vomiting, headache • Skin discolouration • Abscess formation • Fever • Lymphadenopathy • Allergic reaction • Anaphylaxis

  35. Blood Transfusion • Severe anemia, especially after 36 weeks • Hemorrhage • Associated infections • Packed cells preferred • Exchange transfusion rare

  36. Use of Erythropoetin • Used in severe anemia & renal failure for significant increase in Hb and to avoid blood transfusion • Gynaecological surgeries - preop use of erythropoietin and Iron Dextran has been shown to avoid the need for blood tranfusion later

  37. Dosage Regimen Erythropoetin • Injerythropoetin can be given subcut or iv 100-15 iu/kg • On day 1, 3 & 5 along with parenteral iron or day 1, 3 & 5 6000units s/c erythropoetin and iron dextran 100mg deep im daily for 5 day • First dose given after subcut sensitivity test • Adrenaline, hydrocortisone, oxygen to be kept ready • Produces 3gm% rise in Hb over a 2wk period

  38. Management in Labor • Make patient comfortable, oxygen • Sedation and analgesia • Prevent cardiac failure • Aim to deliver vaginally • Antibiotics • Cut short second stage • Active management of third stage

  39. Clinical Case Scenarios • A primigravida presents at 28 wks of gestation with pallor, hemoglobin 7.8g%, no other medical comorbidity, good functional status. Most pragmatic first line therapy in cases with assured compliance would be • a. blood transfusion • b. parenteral iron • c. oral iron • d. oral plus parenteral iron Answer: c

  40. Clinical Case Scenarios • Foodstuff with highest available iron is • a. Red meat • b. Figs • c. Groundnut • d. Soyabean Answer b

  41. Clinical Case Scenarios • A lady at 32 weeks gestation with hemoglobin 8.9, red cell width is increased, taking iron supplements. Least likely situation is • a. non compliance • b. intestinal parasites • c. thalassemia trait • d. anti epileptic medication Answer: c

  42. Clinical Case Scenarios • Single most important set of investigations in a recently diagnosed case of anaemia in pregnancy is • a. Red cell indices • b. Retic count and peripheral smear • c. Iron studies • d. Hemoglobin electrophoresis Answer: b

  43. Clinical Case Scenarios • G5P2L0A2 at 35 weeks gestation in early preterm labor. Hb is 8.8g%. All can be part of management except • a. Steroids • b. Frusemide • c. Blood transfusion • d. Intra partum antibiotics Answer: c