Anaemia in Pregnancy New

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ANAEMIA IN PREGNANCY



ANAEMIA IN PREGNANCY ANAEMIA IN PREGNANCY

Commonest medical disorder in pregnancy Commonest medical disorder in pregnancy

Out of estimated 160 million deliveries occurring annually Out of estimated 160 million deliveries occurring annually

in the world, approx 6,00,000 women die from the in the world, approx 6,00,000 women die from the complications of pregnancy & child birth (W.H.O 1996).complications of pregnancy & child birth (W.H.O 1996).

Anaemia is responsible for 40 Anaemia is responsible for 40- -60% of maternal deaths in 60% of maternal deaths in developing countries. It also increases perinatal mortality developing countries. It also increases perinatal mortality and morbidity rates (W.H.O 1997).and morbidity rates (W.H.O 1997).



D EFINITION D EFINITION

Anaemia is a condition of low circulating haemoglobin in Anaemia is a condition of low circulating haemoglobin in which haemoglobin concentration has fallen below the which haemoglobin concentration has fallen below the

threshold lying at two standard deviations below the threshold lying at two standard deviations below the median value for a healthy matched population.median value for a healthy matched population.

W.H.O defines anaemia in pregnancy as haemoglobin W.H.O defines anaemia in pregnancy as haemoglobin concentration of less than 11 g/dl and haematocrit of less concentration of less than 11 g/dl and haematocrit of less

than 0.33.than 0.33. The cut The cut- -off point suggested by the United States Centers off point suggested by the United States Centers

for disease control is 10.5 gm/dl in the second trimester. for disease control is 10.5 gm/dl in the second trimester.



SEVERITY OF ANAEMIA SEVERITY OF ANAEMIA

ICMR describes four grades of anaemia depending upon ICMR describes four grades of anaemia depending upon the haemoglobin levels as shown:the haemoglobin levels as shown:

Grades of AnaemiaGrades of Anaemia Haemoglobin Value (g/dl)Haemoglobin Value (g/dl)

MildMild 99--10.910.9

ModerateModerate 77--99

SevereSevere < 7< 7

Very SevereVery Severe < 4< 4



ERYTHROPOIESIS ERYTHROPOIESIS

Confined to the bone marrow in adults Confined to the bone marrow in adults

RBCs are formed through stages of pro RBCs are formed through stages of pro- -normoblast normoblast ² ²

normoblast normoblast ² ² reticulocytes reticulocytes ² ² mature non mature non- -nucleated nucleated arithrocyte.arithrocyte.

After a life span of 120 days RBCs degenerate and After a life span of 120 days RBCs degenerate and haemoglobin is broken down into haemosiderin and bi haemoglobin is broken down into haemosiderin and bi- -

pigment. pigment.



ERYTHROPOIESIS (Contd.) ERYTHROPOIESIS (Contd.)

For proper erythropoiesis adequate nutrients are needed:For proper erythropoiesis adequate nutrients are needed:

1.1. Minerals: Iron, traces of copper, cobalt and zinc.Minerals: Iron, traces of copper, cobalt and zinc.

2.2. Vitamins: Folic Acid, Vitamin B12, Vitamin C,Vitamins: Folic Acid, Vitamin B12, Vitamin C,Pyridoxine and riboflavin Pyridoxine and riboflavin

3.3. Proteins: For synthesis of globin moiety.Proteins: For synthesis of globin moiety.

4.4. Hormones: Androgens and thyroxine.Hormones: Androgens and thyroxine.



ERYTHROPOIETIN ERYTHROPOIETIN

Erythropoietin is a hormone produced by kidneys (90%) and Erythropoietin is a hormone produced by kidneys (90%) and

the liver (10%) the liver (10%)

Increased secretion occurs during pregnancy due to Increased secretion occurs during pregnancy due to placental lactogen and progestrone. placental lactogen and progestrone.

Eryhtropoietin increases red cell volume by stimulating Eryhtropoietin increases red cell volume by stimulating stem cells in the bone marrow.stem cells in the bone marrow.

In addition to common deficiency of folic acid and iron,In addition to common deficiency of folic acid and iron,there is a growing body of evidence to implicate vitamin there is a growing body of evidence to implicate vitamin

A in nutritional anaemia. A in nutritional anaemia.



HAEMATOLOGICAL HAEMATOLOGICAL CHANGES IN PREGNANCY CHANGES IN PREGNANCY

CharacteristicCharacteristic Normal AdultNormal Adult

WomenWomen

3232--34 Weeks34 Weeks

GestationGestation

Increased /Increased /

DecreasedDecreased

Plasma volume (ml)Plasma volume (ml) 26002600 38503850 1250 in1250 in

Red cell mass (ml)Red cell mass (ml) 14001400 16401640--1800*1800* IncreasedIncreased

Haemoglobin (g/dl)Haemoglobin (g/dl) 1212--1414 1111--1212 DecreasedDecreased

Red Blood Cells (10*6 /mm*3)Red Blood Cells (10*6 /mm*3) 44--55 33--44--55 DecreasedDecreased

Packed cell volumePacked cell volume 0.360.36--0.440.44 0.320.32--0.360.36 DecreasedDecreased

Mean corpuscular volumeMean corpuscular volume 8080--9797 7070--9595 DecreasedDecreased

Mean corpuscular haemoglobin (pg)Mean corpuscular haemoglobin (pg) 2727--3333 2626--3131 DecreasedDecreased

Mean corpuscular haemoglobin concentration (%)Mean corpuscular haemoglobin concentration (%) 3232--3636 3030--3535 DecreasedDecreased

Serum Iron (µg/dl)Serum Iron (µg/dl) 6060--175175 6060--7575 DecreasedDecreasedTotal Iron Binding Capacity (µg/100ml)Total Iron Binding Capacity (µg/100ml) 300300--350350 350350--400400 IncreasedIncreased

Percentage Saturation (%)Percentage Saturation (%) 3030 1515 DecreasedDecreased

Requirements of iron (mg/day)Requirements of iron (mg/day) 1.51.5--2.02.0 4.04.0 IncreasedIncreased

Mean corpuscular haemoglobin = MCH Packed cell volume = PCVMean corpuscular haemoglobin = MCH Packed cell volume = PCV

Mean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume = MCVMean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume = MCV

Total iron binding capacity = TIBCTotal iron binding capacity = TIBC



PREVALENCE OF ANAEMIA PREVALENCE OF ANAEMIA

IN PREGNANCY IN PREGNANCY Overall prevalence Overall prevalence ² ² 40% of world·s population 40% of world·s population

Prevalence of anaemia is 3Prevalence of anaemia is 3- -4 times higher in developing 4 times higher in developing countries. Average prevalence being 56%.countries. Average prevalence being 56%.

In industrialized countries approx 18% of women are In industrialized countries approx 18% of women are anaemic during pregnancy.anaemic during pregnancy.

In India alone the prevalence of anaemia in pregnancy is as In India alone the prevalence of anaemia in pregnancy is as high as 88% (W.H.O Global D atabase 1997).high as 88% (W.H.O Global D atabase 1997).



CLASSIFICATION OF CLASSIFICATION OF

ANAEMIA IN PREGNANCY ANAEMIA IN PREGNANCY ACQUIRE D : ACQUIRE D :

Iron deficiency anaemia Iron deficiency anaemia

Anaemia caused by blood loss Anaemia caused by blood loss ² ² Acute (APH) Acute (APH)

² ² Chronic (Hook worm infestation, bleeding piles etc.) Chronic (Hook worm infestation, bleeding piles etc.)

Megaloblastic anaemia (Vitamin B12 and folic acid Megaloblastic anaemia (Vitamin B12 and folic acid deficiency) deficiency)

Acquired hemolytic anaemia Acquired hemolytic anaemia

Aplastic or hypo Aplastic or hypo- -plastic anaemia plastic anaemia



CLASSIFICATION (Contd.) CLASSIFICATION (Contd.)

HERI D ITARY:HERI D ITARY:

Thalassemias Thalassemias

Sickle cell haemoglobinopathies Sickle cell haemoglobinopathies Other haemoglobinopathies Other haemoglobinopathies

Hereditary hemolytic anaemias (RBC membrane defects,Hereditary hemolytic anaemias (RBC membrane defects,

spherocytosis) spherocytosis)



IRON D EFICIENCY IRON D EFICIENCY

ANAEMIA ANAEMIA It is the commonest type of anaemia in pregnancy.It is the commonest type of anaemia in pregnancy.

Food iron is made up of two pool Food iron is made up of two pool

² ²Haem Iron Pool Haem Iron Pool ² ²Non Non- - Haem Iron Pool Haem Iron Pool

Haem Iron Pool includes all food containing iron as Haem Iron Pool includes all food containing iron as haem molecules, such as animal flesh and viscera. Its haem molecules, such as animal flesh and viscera. Its absorption is 15 absorption is 15- -30%, but it can increase to 50% in 30%, but it can increase to 50% in iron deficiency state. Its absorption is usually not iron deficiency state. Its absorption is usually not affected by inhibitors.affected by inhibitors.



IRON D EFICIENCY IRON D EFICIENCY

ANAEMIA (Contd.) ANAEMIA (Contd.) Non Non- -Haem Iron Pool includes cereals, vegetables, milk Haem Iron Pool includes cereals, vegetables, milk

and eggs. Its absorption can be increased by enhancers and eggs. Its absorption can be increased by enhancers

and decreased by inhibitors.and decreased by inhibitors.Enhancers of absorption: Haem iron, proteins, meat,Enhancers of absorption: Haem iron, proteins, meat,

ascorbic acid, ferrous iron, gastric acidity, alcohol, low ascorbic acid, ferrous iron, gastric acidity, alcohol, low iron stores, increased erythropoietic activity.iron stores, increased erythropoietic activity.

Inhibitors of iron absorption: Phytates, calcium, tannins,Inhibitors of iron absorption: Phytates, calcium, tannins,tea & coffee.tea & coffee.



CAUSES OF INCREASE D CAUSES OF INCREASE D

PREVALENCE OF I.D .A PREVALENCE OF I.D .A D ietary habits: Consumption of low D ietary habits: Consumption of low- -bio availability diet bio availability diet

Food Fadism Food Fadism

D efective iron absorption due to intestinal infections,D efective iron absorption due to intestinal infections,hook worm infestation, amoebiasis, giardiasis.hook worm infestation, amoebiasis, giardiasis.

Increased iron loss: Frequent pregnancies, menorrhagia,Increased iron loss: Frequent pregnancies, menorrhagia,hook worm infestation, chronic malaria, excessive hook worm infestation, chronic malaria, excessive sweating, piles.sweating, piles.

Repeated and closely spaced pregnancies and prolonged Repeated and closely spaced pregnancies and prolonged period of lactation. period of lactation.



IRON REQUIREMENT IN IRON REQUIREMENT IN

PREGNANCY PREGNANCY Total iron requirement is 1000 mg.Total iron requirement is 1000 mg.

Fetus and placenta Fetus and placenta -- -- 300 mg 300 mg

in red cell mass in red cell mass ² ² 500 mg 500 mg Basal loss Basal loss ² ² 200 mg 200 mg

Average requirement is 4 Average requirement is 4- -6mg/day.6mg/day. 2.5 mg/day in early pregnancy 2.5 mg/day in early pregnancy

5.5 mg/day from 20 5.5 mg/day from 20- -32 weeks 32 weeks

6 6- -8 mg/day from 32 weeks onwards 8 mg/day from 32 weeks onwards



PREVENTION OF IRON PREVENTION OF IRON

D EFICIENCY D EFICIENCY Prophylaxis of non Prophylaxis of non- -pregnant women pregnant women ² ² 60 mg of elemental 60 mg of elemental

iron daily for 3 months.iron daily for 3 months.

Iron supplementation during pregnancy.Iron supplementation during pregnancy.

² ² Routine iron supplementation is debatable in western Routine iron supplementation is debatable in western countries countries

² ² It has to be given in non It has to be given in non- -industrialized countries industrialized countries

² ² W.H.O RECOMMEN D ATION:W.H.O RECOMMEN D ATION: Universal oral iron Universal oral iron supplementation for pregnant women (60 mg of supplementation for pregnant women (60 mg of elemental iron and 250 µg of folic acid) for 6 months elemental iron and 250 µg of folic acid) for 6 months in pregnancy and additional of 3 months post in pregnancy and additional of 3 months post- -partum partum

where the prevalence is more than 40%.where the prevalence is more than 40%.



PREVENTION OF IRON PREVENTION OF IRON D

EFICIENCY (Contd.) D

EFICIENCY (Contd.) ² ² MINISTRY OF HEALTH, GOVT. OF IN D IA MINISTRY OF HEALTH, GOVT. OF IN D IA

RECOMMEN D ATION:RECOMMEN D ATION: 100 mg of elemental iron with 100 mg of elemental iron with 500 µg of folic acid in second half of pregnancy for atleast 500 µg of folic acid in second half of pregnancy for atleast

100 days. 2 injections of iron dextran (250 mg each) given 100 days. 2 injections of iron dextran (250 mg each) given IMI at 4 weeks interval with TT injection.IMI at 4 weeks interval with TT injection.

Treatment of hook worm infestation Treatment of hook worm infestation

² ² Single albendazole (400 mg) or mebendazole (100 mg x B D

x Single albendazole (400 mg) or mebendazole (100 mg x B D

x 3 days) 3 days)

² ² Change in defecation habits and avoidance of walking bare Change in defecation habits and avoidance of walking bare footed. footed.



PREVENTION OF IRON PREVENTION OF IRON D

EFICIENCY (Contd.) D

EFICIENCY (Contd.) Improvement of dietary habits and improving bio Improvement of dietary habits and improving bio

availability of food iron availability of food iron

Iron fortification of food.Iron fortification of food.



EFFECTS OF ANAEMIA ON EFFECTS OF ANAEMIA ON

PREGNANCY PREGNANCY Maternal effects:Maternal effects:

ANTE NATAL ANTE NATAL INTRA NATAL INTRA NATAL POST NATAL POST NATAL

Poor weight gain Poor weight gain D ysfunctional labour D ysfunctional labour Puerperal Sepsis Puerperal Sepsis

Preterm labour Preterm labour Haemorrhage & shock Sub Haemorrhage & shock Sub- -involution involution

Pre Pre- -eclampsia eclampsia Cardiac failure Cardiac failure Embolism Embolism

Abruptio placentae Abruptio placentae Inter current infections Inter current infections

PROM PROM



EFFECTS OF ANAEMIA ON EFFECTS OF ANAEMIA ON

PREGNANCY (Contd.) PREGNANCY (Contd.) Fetal effects:Fetal effects:

² ² Risk of pre Risk of pre- -maturity maturity

² ² IUGR, LBW, poor apgar score IUGR, LBW, poor apgar score ² ² D epleted iron store in neonates and anaemia in D epleted iron store in neonates and anaemia in

infancy period infancy period

² ² High prevalence of failure to thrive and poor High prevalence of failure to thrive and poor intellectual development.intellectual development.

² ² Cardiovascular morbidity and mortality in adult lives.Cardiovascular morbidity and mortality in adult lives.



INVESTIGATIONS INVESTIGATIONS

Haemoglobin estimation Haemoglobin estimation

Peripheral blood smear Peripheral blood smear ² ² microcytosis, hypochromia microcytosis, hypochromia

anisocytosis, poykilocytosis and target cells anisocytosis, poykilocytosis and target cells RBC indices RBC indices ² ² MCV, MCH, MCHC, MCV is the MCV, MCH, MCHC, MCV is the

most sensitive indicator most sensitive indicator

Serum ferritin Serum ferritin ² ² first abnormal laboratory test first abnormal laboratory test

Transferrin saturation Transferrin saturation ² ² second to be affected second to be affected

FEP FEP ² ² third test to become abnormal third test to become abnormal

Serum transferrin receptor Serum transferrin receptor ² ² best indicator best indicator



INVESTIGATIONS (Contd.) INVESTIGATIONS (Contd.)

Bone marrow examination Bone marrow examination ² ² no response to treatment after no response to treatment after 4 weeks of therapy 4 weeks of therapy

² ² Aplastic anaemia Aplastic anaemia ² ² D iagnosis of kala D iagnosis of kala- -azar azar

² ² Urine examination Urine examination

² ² Stool examination Stool examination ² ² for three consecutive days for three consecutive days

² ² Other tests Other tests ² ² RFT, LFT, TSP A:G, chest x RFT, LFT, TSP A:G, chest x- -ray,ray,sputum examination, etc.sputum examination, etc.

² ² For response For response ² ² haemoglobin and PBS, reticulocyte haemoglobin and PBS, reticulocyte

count count



MANAGEMENT OF IRON MANAGEMENT OF IRON D

EFICIENCY ANAEMIA D

EFICIENCY ANAEMIA AIM AIM

To correct iron deficiency To correct iron deficiency

To restore iron reserve To restore iron reserve To correct associated complicating factor To correct associated complicating factor

CHOICE OF THERAPY CHOICE OF THERAPY

D epends on severity of anaemia D epends on severity of anaemia D uration of pregnancy D uration of pregnancy

Associated complicating factor Associated complicating factor



MANAGEMENT (Contd.) MANAGEMENT (Contd.)

GENERAL TREATMENT GENERAL TREATMENT

D ietary advice D ietary advice

Treatment of associated complicating factor Treatment of associated complicating factor IRON THERAPY IRON THERAPY

Oral Oral

Parenteral Parenteral





IN D ICATIONS OF RESPONSE IN D ICATIONS OF RESPONSE

TO THERAPY TO THERAPY Sense of well being Sense of well being

Improved outlook of patient Improved outlook of patient

Increased appetite Increased appetite

haemoglobin, haematocrit, reticulocytosis within 5 haemoglobin, haematocrit, reticulocytosis within 5- -10 10 days days

If no significant clinical or haematological improvement If no significant clinical or haematological improvement within 3 weeks, diagnostic re within 3 weeks, diagnostic re- -evaluation is needed.evaluation is needed.



IN D ICATIONS OF RESPONSE IN D ICATIONS OF RESPONSE

TO THERAPY (Contd.) TO THERAPY (Contd.) RATE OF IMPROVEMENT:RATE OF IMPROVEMENT:

After a lapse of few days haemoglobin concentration is After a lapse of few days haemoglobin concentration is expected to rise at a rate of 0.7 g/dl/week.expected to rise at a rate of 0.7 g/dl/week.

CAUSES OF FAILURE OF ORAL THERAPY CAUSES OF FAILURE OF ORAL THERAPY

² ² Incorrect diagnosis Incorrect diagnosis

² ² Malabsorption syndrome Malabsorption syndrome

² ² Presence of chronic infection Presence of chronic infection

² ² Continuous loss of iron Continuous loss of iron

² ² Poor patient compliance Poor patient compliance

² ² Concomitant folate deficiency.Concomitant folate deficiency.



PARENTRAL IRON THERAPY PARENTRAL IRON THERAPY

IN D ICATIONS:IN D ICATIONS:

In tolerance to oral iron In tolerance to oral iron

Poor patient compliance Poor patient compliance Unpredictable absorption Unpredictable absorption

Patient near term Patient near term

A D VANTAGE A D VANTAGE

No added advantage over oral iron except for certainty of No added advantage over oral iron except for certainty of its administration.its administration.



PARENTERAL IRON THERAPY PARENTERAL IRON THERAPY

Intra muscular Intra muscular

Intra venous Intra venous Two preparations Two preparations ² ² Iron dextran Iron dextran ² ² IM/IV IM/IV

Iron sorbitol citrate Iron sorbitol citrate ² ² IM IM

IRON D EFICIT IRON D EFICIT

Elemental iron needed (mg) = (Normal Hb Elemental iron needed (mg) = (Normal Hb ² ² Patient·s Hb) x Patient·s Hb) x Weight (kg) x 2.21 + 1000 Weight (kg) x 2.21 + 1000


(Contd.) (Contd.)




(Contd.) (Contd.) Simple method is to give 250 mg elemental iron for each gm Simple method is to give 250 mg elemental iron for each gm of haemoglobin below normal. Another 50 % is to be added of haemoglobin below normal. Another 50 % is to be added

to replenish store.to replenish store.Oral Iron Oral Iron should be stopped atleast 24 hrs prior to therapy should be stopped atleast 24 hrs prior to therapy to avoid toxic reaction.to avoid toxic reaction.

Iron injections are given daily or on alternate day by deep Iron injections are given daily or on alternate day by deep

IMI using ¶Z· technique.IMI using ¶Z· technique.I.V. ROUTE I.V. ROUTE

Total dose in fusion (T D I) Total dose in fusion (T D I) ² ² D ose calculated by same D ose calculated by same

formula formula



PRE PRE- -REQUISITES FOR T D I:REQUISITES FOR T D I:

Correct diagnosis of iron deficiency anaemia.Correct diagnosis of iron deficiency anaemia.

Adequate supervision in hospital setting. Adequate supervision in hospital setting.

Facility for management of anaphylactic reaction.Facility for management of anaphylactic reaction.

Sensitivity test done by 1ml test dose prior to infusion:Sensitivity test done by 1ml test dose prior to infusion:

If no reaction iron dextran is diluted in normal saline or If no reaction iron dextran is diluted in normal saline or 5% dextrose and given over 4 5% dextrose and given over 4- -6 hrs.6 hrs.

If total dose is more than 2500 mg infusion is given in 2 If total dose is more than 2500 mg infusion is given in 2 doses on consecutive days.doses on consecutive days.

Look for reaction Look for reaction ² ² Chest pain, rigor chills, hypotension,Chest pain, rigor chills, hypotension,dyspnoea, haemolysis & anaphylactic reaction.dyspnoea, haemolysis & anaphylactic reaction.



IN D ICATION OF BLOO D IN D ICATION OF BLOO D

TRANSFUSION TRANSFUSION Severe anaemia beyond 36 weeks Severe anaemia beyond 36 weeks

Refractory anaemia Refractory anaemia

To correct anaemia due to blood loss To correct anaemia due to blood loss Associated infection Associated infection



MANAGEMENT D URING MANAGEMENT D URING

LABOUR LABOUR Iron and folate therapy for 3 months Iron and folate therapy for 3 months

Infection if any should be treated energetically Infection if any should be treated energetically

Careful watch for puerperal sepsis, failing lactation; sub Careful watch for puerperal sepsis, failing lactation; sub involution of uterus and thromboembolism involution of uterus and thromboembolism

First stage First stage ² ² Comfortable position Comfortable position

² ² Adequate analgesia Adequate analgesia

² ² Arrangement for oxygen, Arrangement for oxygen,

² ² D igitalization maybe required in cardiac failure due to D igitalization maybe required in cardiac failure due to severe anaemia severe anaemia

² ² Antibiotic prophylaxis Antibiotic prophylaxis



MANAGEMENT D URING MANAGEMENT D URING

LABOUR (Contd.) LABOUR (Contd.) Second stage Second stage ² ² Cut short by forceps application.Cut short by forceps application.

Active management of third stage Active management of third stage

D uring puerperium D uring puerperium ² ² Adequate rest Adequate rest

² ² Iron and folate therapy for 3 months Iron and folate therapy for 3 months

² ² Infection if any should be treated energetically Infection if any should be treated energetically ² ² Careful watch for puerperal sepsis, failing lactation; Careful watch for puerperal sepsis, failing lactation;

sub involution of uterus and thromboembolism sub involution of uterus and thromboembolism



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Anaemia in Pregnancy New