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ANEMIA IN PREGNANCY. Background. Anaemia is the commonest medical disorder during pregnancy Iron deficiency anaemia is the most common type of anaemia during pregnancy NFHS 2003-06: 57.9% of pregnant women 25% direct maternal deaths. Effects of Anemia on Mother. Antepartum

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background
Background
  • Anaemia is the commonest medical disorder during pregnancy
  • Iron deficiency anaemia is the most common type of anaemia during pregnancy
  • NFHS 2003-06: 57.9% of pregnant women
  • 25% direct maternal deaths
effects of anemia on mother
Effects of Anemia on Mother
  • Antepartum
    • Preterm labor
    • Pre eclampsia
    • Sepsis
    • IUGR
  • Intrapartum
    • Uterine inertia
    • PPH
    • Cardia failure
  • Postpartum
    • Puerperal sepsis
    • Subinvolution
    • Pulmonary embolism
    • Failure of lactation
    • Delayed wound healing
    • Cardiac failure
fetal effects
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
physiological changes in pregnancy
Physiological changes in pregnancy
  • Plasama volume 50% (by 34weeks)
  • But RBC mass only 25%
  • Results in haemodilution :
  • Hb, Haematoc, RBC count
  • No change in MCV or MCH
iron requirement in pregnancy
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
  • 2-3 fold increase in Fe requierment.
  • 10-20 Fold increase in folate requirement
  • 1000mg extra elemental iron required in pregnancy
  • Cannot be met by diet alone
  • 1.Iron supplementation during pregnancy According to WHO 60 mg elemental iron and 250mg folic acid daily for 6 months and additional 3 months in postpartum period in low prevalence countries
during pregnancy anemia is defined as
During pregnancy, anemia is defined as
  • Normal hemoglobin by gest age in pregnant women taking iron supp
  • 12 wks 12.2 [11.0-13.4]
  • 24wks 11.6 [10.6-12.8]
  • 40 wks 12.6 [11.2-13.6]
  • 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
clinical features symptoms
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
  • Signs
  • Pallor
  • Nail changes
  • Cheilosis, Glossitis, Stomatitis
  • Edema
  • Hyperdynamic circulation (short & soft systolic murmur)
  • Fine crepitations
etiology
ETIOLOGY

There are 3 main causes:

1- Erythrocyte production: (hypo proliferative anemia )

. Fe deficiency

. Folic acid

. Vitamin B12

2- RBC destruction:

3- RBC loss:

90% anemia in pregnancy is due to Fe deficiency

common anaemias in pregnancy
Common Anaemias in pregnancy
  • Common types:
  • Nutritional deficiency anaemias
  • - Iron deficiency

- Folate deficiency

- Vit. B12 deficiency

  • Haemoglobinopathies:
  • - Thallassemias

- SCD

  • Rare types:
  • - Aplastic
  • - Autoimmune hemolytic
  • - Leukemia
  • - Hodgkin’s disease
  • - Paroxysmal nocturnal haemoglobinurea
diagnosis baseline presumptive
Diagnosis – Baseline/ Presumptive
  • Haemoglobin Measurement
  • Peripheral blood smear
  • Reticulocyte count
  • Hematocrit
  • Blood indices
    • MCV, MCHC, MCHC
  • Stool Examination
  • Urine Examination
  • Proteins, LFT, RFT
  • Diagnosis - Additional
  • Serum Fe
  • Total iron binding capacity
  • Serum Ferritin
  • Saturation
  • Hb electrophoresis
  • Bone marrow examination
anemia morphologic classification
Anemia- Morphologic Classification

Microcytic anemia : (MCV < 80)

: iron deficiency, lead toxicity and thalasemia

Normocytic anemia :(80 < MCV < 100)

: blood loss, hemolysis, chronic disease, infiltrative, sequestration

Macrocytic anemia: (MCV > 100

: Vit B12 and folate def, liver disease, uremia, dilanton, hypothyroid, aplastic anemia, dyserythropoeisis

mentzer index
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
lab findings in ida
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
newer investigations
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
management
MANAGEMENT
  • Objectives:

1- To achieve a normal Hb by end of pregnancy

2- To replenish iron stores

  • Two ways to correct anaemia:

I- Iron supplementation . Oral Fe

. Parenteral Fe

II- Blood transfurion

  • Choice of method:

It depends on three main factors:

      • Severity of the anaemia
      • Gestational Age.
      • Presence of additional risk factor
management 32w
MANAGEMENT <32w
  • Recommended supplementation for non-anaemiac 30 - 60mg /day of elemental iron
  • Anaemic gravidas 120 –240mg / per day
  • In tolerance to iron tablets – enteric coated tablet / liquid suspension
  • Supplementation with folic acid + Vit C.
  • Therapeutic results after 3 weeks – rise in Hb % level of 0.8gm/dl/ week with good compliance.
  • Treatment continued in the postpartum period to fill the stores
  • FACTROS DECREASES IRON ABSORBTION
  • Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements
side effects of oral iron
Side effects of Oral iron
  • Nausea
  • Vomiting
  • Constipation
  • Abdominal cramping
  • Diarrhoea
  • FACTROS DECREASES IRON ABSORBTION
  • Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements

The tablet can be given with meals or different brand may be tried

new therapeutic alternatives
New Therapeutic Alternatives
  • The side effects Nausea
  • Vomiting
  • Constipation
  • Abdominal cramping
  • Diarrhoea

The tablet can be given with meals or different brand may be tried

  • Newer preparations are better tolerated, have less side effects with better compliance
  • Carbonyl Iron
  • Iron ascorbate
management 32 36w
MANAGEMENT 32-36w
  • Parenteral iron therapy
  • * INTRAVENOUS IRON Indication
  • * Non compliant GI problems
  • * Pregnancy >32-36wks Advantages Certainty of its administration Raise Hb/wk(rapid raise)
  • * Alternate to blood transfusion when oral treatment fails.8
preparation dosage
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
dose calculation
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–ptHb) + 500
disadvantages
Disadvantages
  • Pain
  • Nausea, vomiting, headache
  • Skin discolouration
  • Abscess formation
  • Fever
  • Lymphadenopathy
  • Allergic reaction
  • Anaphylaxis
reasons for failure to respond
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
blood transfurion
Blood transfurion
  • Choice of method:

It depends on three main factors:

      • Severity of the anaemia
      • Gestational Age.>36w
  • Presence of additional risk factor [infection] .hemorrage
  • Packed cells preferred ,Exchange transfusion rare
  • ,
megaloblastic anemia
Megaloblastic Anemia
  • Due to impaired DNA synthesis, derangement in Red Cell maturation
  • It may be due to Def. of VitB12 or Folic Acid or both.
  • Megaloblastic anemia in pregnancy is almost always due to Folic Acid def.
  • Vit B12 def is rare in Pregnancy becoz its need is less in amount and amount is met with any diet that contains animal products.
folate deficiency anaemia
FOLATE DEFICIENCY ANAEMIA

Folic acid deficiency more likely if

. Woman taking anticonvulsants.

. Multiple pregnancy.

. Hemolytic anemia; thalasemia H.spherocytosis

Maternal risk:

Megaloblastic anemia

Fetal risk:

Pre-conception deficiency cause neural tube defect and cleft palate etc.

sign and symptoms
Sign and symptoms
  • Insidious onset, mostly in last trimester
  • Anorexia and occasional diarrhoea
  • Pallor of varying degree
  • Ulceration in mouth and tongue
  • Hemorrhagic patches under the skin and conjunctiva
  • Enlarged liver and spleen
blood values
Blood values
  • Hb<10gm%
  • Hypersegmentation of neutrophils
  • Megaloblast
  • MCV>100micrometer3
  • Serum Fe is Normal or high TIBC is low
  • Folic acid<3ng/ml
  • B12<80pg/ml
treatment
Treatment
  • Prophylactic- all woman of reproductive age should be given 400mcg of folic acid daily
  • Curative DOSE-daily administration of Folic acid 4mg orally for at least 4 wks following delivery
  • B12 defeciency
  • 1,000 micrograms of intramuscular cobalamin once daily for 10 days (after 10 days, the dose was changed to once per week for four weeks
management in labor
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
sickle cell disease
Sickle cell DISEASE
  • Pre pregnancy
  • Counseling against conception until disease status assesses (Renal and liver function).
  • Avoid (IUD)
  • Counseling about risks of pregnancy, maternal mortality, IUGR, PLD
  • Screen partner and if trait → prenatal diagnosis
  • Prenatal
  • Regular Transfusion (6w interval) to keep Hb at 9-12 g/dl
  • Treatment of crises (hydration .oxygen .screen infection)
  • Avoid Tourniquets
  • Prenatal fetal surveillance
  • Screen for- UTI- pre-eclampsia-liver and renal function.
  • IUGR -Hemolytic disease of new born (Ab)
  • Labor/delivery (-Post partum)
  • Ensure adequate hydration
  • Avoid hypoxia-Sepsis- acidosis-prolonged labor.
  • Continuous Monitoring
  • Contraception counseling → IUD

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