Anemia in pregnancy &role of parenteral iron therapy

ANEMIA IN PREGNANY AND

ROLE OF PARENTERAL IRON THERAPY

Dr SUSANTA KUMAR BEHERA

SENIOR RESIDENTDEPARTMENT OF O & G

MKCG MEDICAL COLLEGEBRAHMAPUR, ODISHA; INDIA

Most Common Nutritional Disorder in the World Incidence = 40 to 60 % of pregnant women in India Commonest Medical(hematological) disorder during pregnancy 25% of direct maternal deaths Responsible for 40% of maternal deaths in third world countries. India contributes to 80% of maternal deaths due to anemia in South Asia

Pregnancy : Most dangerous journey

of mankind

Anemia begins in childhood, worsens during adolescence in girls and gets aggravated during pregnancy

Quantitative or qualitative

reduction of Hb or circulating RBC’s

or both resulting in a reduced oxygen

carrying capacity of blood to organs

and tissues

Woman Hct 33% or Hb 11g/dl – 1st &

3rd trimester and Hct 32% or Hb 10.5

g / dl in 2nd trimester(CDC/WHO)

Gm% ICMR WHO

Mild 10 – 11 10-10.9

Moderate 7 – 10 7-9.9Severe 4 – 7 <7Very severe < 4

Physiological Acquired

Nutritional deficiency anaemias - Iron deficiency (90%) - Folate deficiency - Vit. B12 deficiency

Infections : Malaria/Hookworm/UTI Hemorrhagic –acute/chronic blood loss

Bone marrow- Aplastic anemiaRenal diseases

Genetic/Haemoglobinopathies: - SCD

- Thalassaemias

COMMON ANEMIAS IN PREGNANCY

PHYSIOLOGICAL ANEMIA

• Plasma volume 50% (by 34weeks) but RBC mass only 25%

• Disproportionate increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy

CRITERIA FOR PHYSIOLOGICAL ANAEMIA• Hb = 10 gm%• RBC = 3.2 million/mm3

• PCV = 30%• Peripheral smear showing normal

morphology of RBC with central pallor

IRON REQUIREMENTS DURING

PREGNANCY

Maternal req. of total Iron -1000mg

500 mg Maternal Hb. Mass

expansion

300 mg Fetus & Placenta

200mg Shed through gut., urine &

skin

2.5mg /day in early pregnancy

5.5mg /day from 20 -32 weeks

Average 4 mg/ day

6 – 8 mg/ day after 32 weeks

Increases from 1-2mg in 1st

trimester to 6-8 mg in 3rd trimester

Absorption of iron depends upon

a)Amount of iron in the diet

b)Bioavailability of iron

c) Physiological requirements

Iron sources are two types

1)Haem iron(5%) : hemoglobin

and myoglobin from red meat,

poultry and fish

2)Nonhaem iron(95%): fibers,

green vegetables

NORMAL IRON CYCLE

Dietary ironUtilization Utilization

Duodenum(average, 1 - 2 mg

per day)

Muscle(myoglobin)

(300 mg)

Liver(1,000 mg)

Bone marrow(300 mg)Circulating

erythrocytes(hemoglobin)

(1,800 mg)

Reticuloendothelialmacrophages

(600 mg)

Sloughed mucosal cellsDesquamation/Menstruation

Other blood loss(average, 1 - 2 mg per day)

Storageiron

Plasmatransferrin

(3 mg)

Iron loss

(Ferritin)

(TIBC)

FACTORS THAT MODIFY IRON ABSORPTION

Heme>Fe2+>Fe3+ Physical State

Vagotomy, pernicious anemia H2 receptor blockers, calcium-based antacids

High Gastric pH

Crohn’s disease, Celiac disease

Intestinal Structure disruption

Phytates, tannins Inhibitors

Cobalt, Lead, Strontium Competitors

Ascorbate, Citrate, Amino acids, Iron deficiency

Facilitators

EFFECTS OF ANAEMA IN PREGNANCY

ANTEPARTUMa) Pre eclampsia b) Intercurrent

infectionc) Cardiac failured) Preterm laboure) APHf) PIH

INTRAPARTUM PPH Cardiac failure Shock

POSTPARTUMa) Puerperal

sepsisb) Subinvolutionc) Failing

lactationd) Puerperal

venous thrombosis

e) Pulmonary embolism

Baby a) IUGRb)Prematurity c) Increased risk of IDA early

infancyd)Still birthse)Congenital malformationsf) ↑ in Neonatal deaths/Perinatal

mortalityg)Intra uterine deaths(severe

maternal anoxemia)h)Abnormal Social and Emotional

behaviourEFFECT OF PREGNANCY IN ANAEMIA• Pt. Mildly anemic progresses to

marked Anaemia• Pt. Who is severely anemic becomes

symptomatic by the end of 2nd trimester

IDA IN PREGNANCYa)Grandmulti b)Hook worm infestationc) Blood loss : Menorrhagia 20-30% d)Increase demand for iron

particularly in 2nd & 3rd trimestere)Higher risk with morning sicknessf) Aspirin/NSAIDSg)Multiple pregnanciesh)Intolerance for red meati) Low dietary intake (Vegetarians, Vit.

C & Calcium)j) Malabsorption (Hypo-or

achlorohydria)k)Losses can increase with colorectal

cancer, polyps

STAGES OF IRON DEFICIENCY

Prelatent(Depletion) :a) Stores are depleted without a change

in hematocrit or serum iron levels .b) Reduced stored iron e.g. serum

ferritin with normal hemoglobin Latent(iron deficient erythropoisis) : c) Serum iron drops and the TIBC

increases without a change in the hematocrit.

d) Reduced stored and transport irone) Increased erythrocyte protoporphyrin

concentrationf) Detected by a routine check of the

transferrin saturation.

Frank IDA :a)Associated with erythrocyte

microcytosis and hypochromia.b)Stage of deficiency of stored,

transport and functional ironc) Reduction of hemoglobin and

serum ferritind)Low serum transferrin saturatione) Increased erythrocyte

protoporphyrin concentrationf) Iron deficiency attracts medical

attention most commonly at this stage.

SYMPTOMS Fatigue Weakness Headache Loss of appetite Dysphagia Palpitations Dyspnea on exertion Ankle swelling Paresthesia Leukoplakia Cold intolerance irritability

CLINICAL FEATURESSIGNS Glossitis Stomatitis Heart murmurs Increased JVP Tachycardia Tachypnea Postural hypotension Pallor Dryness or roughness of the skin Koilonychia Dry & cracked lips & Brittle hair

DIAGNOSIS OF IDA Low hemoglobin Low serum ferritin<15 mcg/dl Microcytic & hypochromic in absence of chronic diseases/hemoglobinopathies Low serum iron content(< 30mcg/dL) Low PCV, MCV, MCH, MCHC High TIBC > 400 mcg/dl

Increased ZPP (>40 mmol/mole heme) Low transferrin saturation(<15%) Increased serum transferrin(>350mg/dL) Increased serum soluble transferrin binding receptors(> 8 mg/L) increased serum neopterin concentration

PENCIL CELLS

INVESTIGATIONS• Haematocrit• RBC Indices: - Low MCV

- Low MCH - Low MCHC - Low PCV• Peripheral blood

• Urine for haemturia(R&M/C&S)

• Stool examination• Hb electrophoresis• X-ray Chest(PA View)

• Serum iron < 50 μgm/dl

• TIBC is increased - > 400 μgm/dl

• Serum ferritin is < 12 μgm/dl

• Serum transferrin saturation<20%

• Red cell Zinc Protoporphyrin

• Stainable iron in the bone marrow is reduced-Gold Standard

• Serum transferrin receptor(TfR) : Increased

• Bone marrow examination.

• Reticulocyte hemoglobin conc. : Count of <26pg/ cell

• LFT, RFT

• Trial of iron therapy-diagnostic & therapeutic

TREATMENT Anaemic gravidas 120 –240mg / per day Supplementation with folic acid + Vit C. Ferrous sulphate 300mg TID daily after meals X 12 months Therapeutic results after 3 weeks – rise in Hb % level of 0.8gm/dl/ week with good compliance Rise in Hb at a rate of 2-4 gm/dl every 3 weeks till normal Hb conc. is normal after 6 wks of therapy

INDICATORS OF IRON THERAPY RESPONSE

1. Increase in Reticulocyte count (Increases 3-5 days after initiation of therapy )

2. Increase in Hb levels. Hb increases 0.3 to 1 g/ week

3. Epithelial changes (esp tongue & nail ) revert to normal

Pregnancy <30wks

Pregnancy 30-36wks

Pregnancy >36wks

IDA FA def. Oral iron Oral FA

Intolerance orNon-compliance

I/M iron I/V iron

IDA FA def.

Parenteral Oral FA

I/M iron I/V iron

Blood transfusion

ORAL IRON THERAPYWHO : 60 mg elemental iron + 250 ug FA OD/BD.

Govt. of India : 100 mg Fe + 500 ug FA during 2nd half of pregnancy X 100 days.

Drawbacks: - Intolerance - Unpredictable absorption

rate. - Not suitable for patients with GI diseases/ significant bleeding

- Non Compliant patient. - Long time for improvement

Side effectsa) Nausea & Vomitingb) Gastric irritationc) Constipationd) Abdominal crampe) Diarrhoea

Response to therapy: - Sense of well being/Increased

appetite. - Increase in Hb approximately

2gm% per every 3-4 wk - Reticulocytosis with in 5-10

days - hematocrit returning to normal

.

Enteric coated/sustained release preparations to be avoided as they are carried past duodenum limiting absorption

Once hemoglobin is normal therapy is continued for further 3 months /at least 6 wks postpartum to replenish stores.

IRON SUPPLEMENTS

Taking iron tablets

Absorption helped by vitamin-C(take the tablets with glass of orange juice)

Take before or after 1 hr of meal

Don't take tea/coffee/milk

Calcium based antacids will reduce the absorption

NEW THERAPEUTIC ALTERNATIVES

• CARBONYL Iron

• Iron ascorbate

ADVANTAGES a) Outstanding GI Tolerance

b) Very safe with no poisoning even in high doses

c) No interaction with food stuffs

d) Delicious with non-metallic taste and don’t stain the patients’ teeth

e) Compliance is very high

INDICATIONSa) Failure to oral iron therapy.b) Non compliance/intolerance to oral

ironc) 1st time seen during last 8-10 wks with

severe anemiad) Malabsorbtion/IBDe) Small bowel resectionf) When hemorrhage is likely to continueg) C/I to blood transfusionh) Combination with recombinant human

erythropoietini) C/I to oral therapy

PARENTRAL THERAPY

Intravenous preparationa) Iron dextran (Imferon)b) Iron sucrose c) Sodium ferric gluconate

(ferrlecit)

Intramuscular preparationd) Iron Sorbitol Citrate in

dextrin(Jectofer)

e) Iron Dextran (imferon) Iron dextran: 50 mg/mL. Iron

sucrose: 20 mg/mL. Ferric gluconate: 12.5 mg/mL

Contraindications a)h/o anaphylaxis to

parenteral iron therapyb)1st trimester of

pregnancyc) Active acute/chronic

infectiond)Chronic liver diseases

Advantages: - Certainty of

admission. - Hb rises @1gm/wk.Disadvantage

a) Nausea and Vomitingb) Metallic taste on

tongue

IM ROUTEIron Dextran (1ml contains 50mg elemental iron

& 1amp=2ml)Dose : 100 mg IM OD/AD till the total dose overDrawbacks:

a) Painful injection (less with jactofer).b) Skin discolorationc) Local abscessd) Allergic reactione) Fe over load.f) Category C drugg) Gluteal sarcomah) Test dose needed

AdvantageCan be given in primary care set upAbsolute reticulocyte count increases in 7 daysHemoglobin increases within 1-2 wksWhole dose can be given in single setting

I/V Route :

a)Repeated Injections

b)Total dose infusion

Side effects:

- Anaphylactic reaction.

- Chest pain, rigors, chills, fall in BP, dyspnoea, hemolysis.

Treatment:

a) Stop infusion.

b) Give antihistaminics, corticosteroids & epinephrine.

IRON DEXTRANa)Colloidal solution of ferric

oxyhydroxide complexed with polymersised dextran

b)Advantage : patients total iron requirement is given in one administration

c) Higher rate of adverse effects like delayed hypotension/ arthralgia/abdominal pain

d)Test dose is necessarye)Patients should be monitored 1

hr following a test dose of 25 mgf) Can given as IV infusion with rate

less than 50 mg/ming)Category B drug

TDI – TOTAL DOSE INFUSION

I/V : (IRON DEXTRAN)

TDI=(Normal Hb - Patients Hb) X Blood Volume(65ml/kg)X3.4

100

TDI= (Normal Hb – Pt. Hb) X Wt in Kg X 2.21+1000

TDI=[10 × (target Hb-actual Hb ) × (0.24 × bodyweight )] +0/500

Dose given I/V by slow push 100mg / day or the entire dose given in 500 ml N/S slow I/V infusion over 1-6 hours

FERRIC GLUCONATE COMPLEX IN SUCROSE

1)Given as IV injection/infusion

2)Standard dose of 125 mg may be given IV injection over 10 min

3)Rate should be < 12.5mg/min

4)Dose can be repeated if ferritin < 100ng/ml or saturation < 20%

5)Can be safely given to Dextran sensitive patients

IRON SUCROSE• Commonly used in chronic kidney

diseases• MW 34,000-60,000 D• Iron hydroxide sucrose complex in

water• Given as IV injection/infusion• Each ml contains 20 mg of Fe• After IV administration it

dissociates into iron & sucrose• T 1/2 is 6hrs

• Category B drug

• Total iron deficit = Body weight x (Target Hb – Actual Hb) x 2.4 + Iron stores [mg]

• Administered 100 mg IV over 5 minutes, thrice weekly until 1000 mg

• 200mg max dose per Sitting• Rate of administration should not

more than 20 mg/min• Infusion : 50 mg to be injected

slowly over 2 minutes, wait for 2-3 min ,then give another 50 mg over 2 min

• 100mg-200 mg to be diluted with 100ml NS, infuse at least 15 min

• Marked increase in reticulocyte count expected in 7-14 days

Advantages of IRON SUCROSE over othersa)All iron preparations were capable of

causing tissue peroxidation except iron sucrose

b)Less oxidative injuryc) Less risk of tissue parenchymal injury by

free iron.d)Higher availability for erythropoiesis

than iron Dextran e) IV iron supplementation increases the

erythropoiesis 5 timesf) Safe in dextran sensitive patientsg)Minimal side effects

The Hb rise will be evident in as early as 5 days IV iron sucrose is safe & effective Iron sucrose is given both bolus push & infusionDisadvantage

a)Total dose administered in multiple infusions

b)Needs a set up where anaphylactic reaction can be managed.

NEWEST FAST ACTING IV MOLECULES

Iron III Carboxymaltose (FERRINJECT) :

a)Ferric hydroxide carbohydrate complex which allows for control delivery of iron within cells of the RES (primarily bone marrow) and subsequently delivery to the iron binding proteins ferritin and transferin

b)T1/2 : 16 hrc) Dose : Single dose of 1000 mg

over 15 minutes (maximum 15mg/kg by injection or 20 mg/kg by infusion)

IRON III ISOMALTOSE(MONOFER)

a)Strongly bound iron in spheroid iron-carbohydrate particle providing slow release of bioavailale iron to iron binding proteins

b)Rapidly up taken by RES and little risk of free iron for tissue damage

c) Dose : 1000 mg in a single infusion

d)Erythropoietic response seen within days

e)Serum ferritin returns to normal by 3 wks

FERUMOXYTOL

USA FDA approved this drug in 2009 for iron replacement in patients with IDA & CKD

No test dose required

Can be given as large dose (510 mg/vial) in <20 Seconds in single settings

No significant side effects

Not approved in Europe

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 TRANSFUSION

Decision based on • Needs and risk of developing

complications of inadequate oxygenation

• Both clinical and hematological grounds

Indications a) Severe anemia, especially after

36 weeksb) Risk of further hemorrhage c) Associated infectionsd) Imminent cardiac compromise

Patient factors Type of surgery

Preg Preg Elective

Emergency<36wks > 36wks C/S

C/S

-Hb ≤ 5gm% - Hb ≤ 6gm% - with H/o -assess

without CHF without CHF APH,PPH, according

-Hb 5-7gm%,if -Hb 6-8gm%,if previous to situation

CHF, hypoxia, CHF, hypoxia, LSCSInfection infection

Hb 8 – 10 gm%, confirm BG & cross-matching Hb <8 gm%, 2 units to be kept ready in OT

MANAGEMENT DURING LABOUR

• Consideration for delivery in well equipped hospital.

• Avoid sympathetic stimulation and hyperventilation; prevent rightward shift of ODC.

• Supplemented with oxygen therapy

• Prophylactic forceps/Vaccum to cut short 2nd stage

• Decreased blood loss by active management of 3rd stage of labors.

• Avoid maternal stress, patient can go into CHF.

• PPH should be emergently treated(uterotonics)

ANAETHETIC CONSIDERATIONS

Pre oxygenation is mandatory with 100% O2

Oxygen supplementation should be given in peri and postoperative periods

Blood arrangements prior to surgery is must

Airway maintenance to prevent fall of PO2 due to airway obstruction

Hyperventilation to be avoided to minimize respiratory alkalosis

General/spinal anaesthesia can be given after platelet count and excluding h/o spontaneous hemorrhage.

MEGALOBLASTIC ANAEMIA

• Incidence – 0.2 – 5 %• Caused by folic acid deficiency &

Vit B12 deficiencyPathophysiologyPreg. 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.

Vit.B12 deficiency : Occurs in patients with gastrectomy , ileitis, ileal resection, pernicious anaemia, intestinal parasites

FOLATE DEFICIENCY ANAEMIA

Folic acid reduced to DHFA then THFA, used in nucleic acid synthesis, is required for cell growth & division.

So more active tissue reproduction & growth more dependant on supply of folic acid.

So bone marrow and epithelial lining are therefore at particular risk.

Coexists with IDA

Folic acid deficiency more likely if. Woman taking

anticonvulsants.. Multiple pregnancy.. Hemolytic anemia,

thalassemia & cleft palateDiagnosis :

-Increased MCV ( > 100 fl)-Peripheral smear : -

Macrocytosis, hypochromia - Hypersegmented

neutrophils(> 5 lobes)

- Neutropenia - Thrombocytopenia

-Low Serum folate level.(<3ng/ ml)

-Low RBC folate (<20 ng/ml)

CLINICAL FEATURES• Insidious onset, mostly in last

trimester• Anorexia and occasional diarrhea• Pallor of varying degree• Ulceration in mouth and tongue• Glossitis• Enlarged liver and spleen• Hemorrhagic patches under the

skin and conjunctiva• Macrocytic Megaloblastic Anemia• Peripheral neuropathy• Subacute combined degeneration

of the Spinal cord

a)Hb < 10gm%b)Hypersegmentation of neutrophilsc)Megaloblast, Howell-Jolly bodiesd)MCV > 100 fle)MCH > 33pg, but MCHC is Normalf) Serum Fe is Normal or high, TIBC is

lowg)Serum Vit B12 levels < 100 pg /mlh)Radio active Vit B12 absorption

test (Schilling Test)

DIAGNOSIS

MEGALOBLASTIC ANEMIA(PS)

MEGALOBLASTIC ANEMIA(BM)

TREATMENT

• Replace iron and treat underlying disease.

• Oral route is preferred for replacement.

• Response can be followed by retic. increase in 1-2 weeks (5-7 days)

• Hb response to treatment– half normal by a month– returns to normal by 2-4 months

• Replacement therapy is prolonged by 6-12 months to replenish stores of iron.

• 1000 microgram Parenteral Cyanocobalamin every wk X 6 weeks

• Prophylactic : All woman of reproductive age should be given 400mcg of folic acid daily

• Curative : Daily administration of Folic acid 4mg orally up to at least 4 wks following delivery

HAEMOGLOBINPATHIESSickle cell disease a)Sickle cell anaemia (most

common & severe) b)Sickle cell beta

thalassemia,c) Haemoglobin SC diseaseThalassemia - Alpha thalassaemia. - Beta thalassaemia: .

Major .

Minor

SICKLE CELL ANAEMIA

• Valine substituted for glutamic acid at 6th position on β chain of Hb molecule

• Common variants - SS ( sickle cell anemia)

- SA ( sickle cell trait) Hb SS Hb SA

Cell trait Homozygous HeterozygousHbS 70 – 90%,

rest HbF10 – 40%, 40-60% HbA

Hb (g/dl) 6 - 9 13 -15Life expectancy

30 yrs normal

Propensity for sickling

++++ + (O2 falls < 40%)

SIGNS & SYMTOMSVaso-occlusive

complications a)Painful episodes-most

common(50%) b) Acute chest

syndrome(20%) c) Strokes d) Renal insufficiency e) Splenic sequestration f) Proliferative

retinopathy g) Priapism h) Spontaneous abortion i) Bone pains, leg ulcers,

Osteonecrosis

Complications related to hemolysis a) Anemia (Hct 15 – 30%) b) Cholelithiasis c) Acute aplastic episodesInfectious complications a) Streptococcus pneumonia

sepsis b) E.coli sepsis c) OsteomyelitisDIAGNOSIS• Hb solubility test-specific, cheap,

rapid and simple.• Sickling test• Hb electrophoresis,

MANAGEMENT Multidisciplinary approch Routine BP measurement and urinalysis

to detect hypertension and proteinuria Retinal screening/fundoscopy for

prliferative retinopathy Screening for iron overload(serum

ferritin) Screening for PAH by echocardiography Antibiotic

prophylaxis-penicillin/eruthromycin Termination planned for homozygous

state

Folic acid-5 mg should be given OD preconceptually and throughout the pregnancy

Hydroxurea if taking should be stopped 3 months prior conception

ACE inhibitors & angiotensin receptor blockers stopped before conception

Early detection and treatment of malaria and infections

Low dose Aspirin from 12 wks of gestation

Thromboprophylaxis with LMWH NSAIDS between 12 to 28 weeks Fluid and oxygen therapy(oxygen

saturation > 95%) in painful crisis BT indicated only during

complications like acute anemia/ACS/twin pregnancies, preeclampsia, septicemia, renal failure

Goals : Hb > 8gm/dl & HbA > 40% of total Hb

Iron therapy to be given if there is evidence of iron deficieny

• Vaccine : H influenza type b, conjugated menigococcal C vaccine, peneumococcal vaccine & Hepatitis-B vaccine

• Timing of deliver : 38 -40 wks of gestation either by induction of labour/elective CS

• Factors to be avoided favouring sickling

- Dehydration - Hypotension - Hypothermia - Acidosis - High conc. of HbS

CS is preferred over vaginal delivery when labour is not progressing well.

Continuous FHR monitoring due to increases rate of still births/abruption/compromosed placental reserve

Counseling the parents regarding partner screening for carrier detection.

Contraceptivesa) Porgesterone only pillb) Injectable contraceptivesc) LNG-IUS d) Barrier methodse) Sterilization

THALASSAEMIAS• The synthesis of globin chain is

partially or completely suppressed resulting in reduced Hb. content in red cells,which then have shortened life span.

• TYPES: - Alpha thalassaemia. - Beta thalassaemia: Major &

Minor• Microcytic haemolytic anaemias• Reduced synthesis of one or more

of polypeptide globin chains.• Higher transfusion requirements in

pregnancy worsen haemosiderosis & cardiac failure.

CLINICAL FEATURES• Usually asymptomatic

• Weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness

• Palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema

a) Pallorb) Nail changesc) Cheilosis, Glossitis, Stomatitisd) Edemae) Hyperdynamic circulation (short & soft

systolic murmur)f) Fine crepitations

Women with hemoglobinopathy should be offered oral iron therapy if serum ferritin<30 mcg/L

Referral to secondary/tertiary care to be done if

a)Severe anemia

b)Significant symptoms

c) Late gestation(34 wks)

d)Failure to respond to oral iron

TREATMENT

WHO - 60 mg Elemental iron + 400 micro gram Folic acid / day up to 3 months postpartum

GOI - 60 mg elemental Iron + 500 mcg Folic acid as Prophylactic supplementation x 100 days in 2nd trimester up to 3 months postpartum

ANAEMIA ASSOC. WITH CHRONIC INFECTIONS / DISEASE

• Common in developing countries• Poor response to Haematinics

unless primary cause is treated• Worm infestations is common

( Diagnosed by stool examination )• Urinary tract inf, & asymptomatic

bacteriuria in preg. is assoc. with refractory anaemia

• Chronic renal disorders = due to erythropoietin def.

• Identifying the etiology and treat accordingly

• Deworming with mebendazole/albendazole/levamisole

• Treated with recombinant Erythropoietin for renal disease.

• ATT to a patients with tuberculosis

• Antibiotics to treat UTI according to sensitivity

TREATMENT

PREVENTION

• Dietary advice and modification(red meat/ poultry/fish)

• Germination and fermentation of cereals and legumes improve the bioavailability of iron in food

• Green peas/Whole wheat/Green vegetables/Jaggery

• Iron supplementation of adolescent girls & non pregnant women

• A nutritious diet in a pregnant woman should be providing about 40 mg elemental iron daily.

• Food fortification

a)Fortification of staple food like wheat flour which is technically simple(USA)

b)Fortification of curry powder, salt and sugar, dried and liquid milk(SA)

c) Fortification of infant foods (INDIA)

d)Fortification of complimentary foods (USA)

Treatment of hookworm Infestation, malaria,TB

Avoidance of Hypoxia, Acidosis, Infection, Dehydration Stress , Exercise, Extreme, Temperature

Avoidance of frequent child birth.

Supplemented Viamin-C (250-500mg/day) with iron

Adequate treatment for any infection like UTI

Early detection of falling Hb level, levels should be estimated at 1st A/N visit, 30th & finally 36th week

Mandatory monthly screening for anemia should be done in all antenatal clinics(especially at booking and at 28 wks with FBC)

Screening and effective management of obstetric and systemic problems in all pregnant women

THANK Q