Definition

Anemia - insufficient Hb to carry out O2 requirement by

tissues.

WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester

For developing countries : cut off level suggested is 10 gm %

- WHO technical report Series no. 405, Geneva 1968

Centre for disease control, MMWR 1989;38:400-4

Anemia - insufficient Hb to carry out O2 requirement by

tissues.

WHO definition : Hb conc. 11 gm %

CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester

For developing countries : cut off level suggested is 10 gm %

- WHO technical report Series no. 405, Geneva 1968

Centre for disease control, MMWR 1989;38:400-4

ANEMIA DEFISIENSI BESI PADA KEHAMILAN

Magnitude of ProblemMagnitude of Problem

Globally, is about 30 % In developing countries & India,

incidence is around 40 – 90%.

Responsible for 40% of maternal deaths in third world countries.

Important cause of direct and indirect maternal deaths

- Vitere FE Adv Exp Med Biol 1994;352:127

Globally, is about 30 % In developing countries & India,

incidence is around 40 – 90%.

Responsible for 40% of maternal deaths in third world countries.

Important cause of direct and indirect maternal deaths

- Vitere FE Adv Exp Med Biol 1994;352:127

Infection

Lack of Concentration

Weakness

Irritability

Palpitation

Fatigue

Dizziness

SymptomsSymptoms

Clinical FeaturesClinical Features

Signs

Pallor of skin And m/m

Edema

PlatynychiaKoilonychia PlatynychiaKoilonychia

Glossitis

Stomatitis

Tachycardi

a

Soft ejectionsystolic murmur

Physiological

Pathological

Causes of Anaemia Causes of Anaemia

Nutritional

Haemorrhagic

Haemolytic

Nutritional

Haemorrhagic

Haemolytic

Iron RequirementIron Requirement

Iron Absorption Iron Absorption 11 Amount of iron in the

body Amount of iron in the

body

Iron Loss

Skin

Urine

Feces

Menstruation

1-2mg/d1-2mg/d

20-30mg/c20-30mg/c

Early Pregnancy

2.5 mg / day

32 to 40 weeks

6.8 mg / day

TOTAL800 – 1000

mg

20 to 32 weeks

5.5 mg / day

RBC =500mgFetus+Placenta =450mgThird stage blood loss=200mgTotal = 1150mg

Iron Requirement During PregnancyIron Requirement During Pregnancy

HbHb 13.5 – 14 gm %13.5 – 14 gm %

R.B.C.R.B.C. 4.5 – 4.7 million/cu mm4.5 – 4.7 million/cu mm

Serum IronSerum Iron 50 – 150 μg / dL50 – 150 μg / dL

TIBCTIBC 300 – 360 μg / dL300 – 360 μg / dL

Transferrin saturationTransferrin saturation 25 – 50 %25 – 50 %

S. Ferritin levelS. Ferritin level 30 μg / Lit30 μg / Lit

Red Cell protoporphyrinRed Cell protoporphyrin 30 μg / dL30 μg / dL

ErythropoietinErythropoietin 15.20 U / Lit15.20 U / Lit

MCVMCV 76 – 100 fL76 – 100 fL

MCHMCH 27 – 33 pg27 – 33 pg

MCHCMCHC 33.37 gm / dL33.37 gm / dL

PCVPCV 32 – 40 %32 – 40 %

Normal LevelsNormal Levels

Laboratory Diagnosis of AnaemiaLaboratory Diagnosis of Anaemia

IDAIDA ThalassemiaThalassemia Chronic DiseasesChronic Diseases

Serum IronSerum Iron Decreased Decreased Normal / Increased Normal / Increased DecreasedDecreased

TIBCTIBC IncreasedIncreased NormalNormal Decreased or NDecreased or N

TransferrinTransferrin

SaturationSaturation

DecreasedDecreased N or IncreasedN or Increased N or DecreasedN or Decreased

Serum FerritinSerum Ferritin DecreasedDecreased N or IncreasedN or Increased NN

Marrow IronMarrow Iron Decreased / Decreased / absentabsent

N or IncreasedN or Increased NN

Therapeutic test with Therapeutic test with oral ironoral iron

Rise in HbRise in Hb No rise in HbNo rise in Hb No riseNo rise

National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)

National Nutrition Anaemia Prophylaxis Programme (NNAPP 1971 - 72)

Anaemia continues – Major health problem

Nutritional Anaemia :Major Health ProblemsNutritional Anaemia :

Major Health Problems

FS + FA

Pregnancy

Lactating mothers

Family planning acceptors

Children – 1 to 11 years

Reason For Increased Incidence Of AnemiaReason For Increased Incidence Of Anemia

Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual disorders

Improper supplementation of iron in pregnancy ( late registration and poor follow up)

Repeated childbearing Lack of awareness and illiteracy

Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual disorders

Improper supplementation of iron in pregnancy ( late registration and poor follow up)

Repeated childbearing Lack of awareness and illiteracy

Reason For Increased Incidence Of AnemiaReason For Increased Incidence Of Anemia

Low socioeconomic status and poor hygiene

Chronic malnutrition

Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos

GI infections and infestations (e.g. Kala azar, worm infestations)

Low socioeconomic status and poor hygiene

Chronic malnutrition

Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos

GI infections and infestations (e.g. Kala azar, worm infestations)

IUGR

IUD IUH

CCFCCF

INFECTIONINFECTION

PRETERM LABOUR

PRETERM LABOUR

PIHPIH

Medical DisorderMedical Disorder

Complications - PregnancyComplications - PregnancyComplications - PregnancyComplications - Pregnancy

Instrumental delivery

PPH

FoetalDistressCCF

MATERNALPERINATAL

MorbidityMortality

Complications - LabourComplications - LabourComplications - LabourComplications - Labour

Management Options Management Options

Pre – pregnancy :

Treat the cause before conception

Pre-pregnancy balanced diet, education and

health support.

Build up iron stores during adolescent phase

Pre – pregnancy :

Treat the cause before conception

Pre-pregnancy balanced diet, education and

health support.

Build up iron stores during adolescent phase

Oral Iron

Blood transfusionParenteral

Injectable IronInjectable IronHuman Recombinant

Erythropoietin

Modalities of ManagementModalities of ManagementModalities of ManagementModalities of Management

100 mg elemental Iron ------- ↑ 0.18 gm % day100 mg elemental Iron ------- ↑ 0.18 gm % day

Iron stores poor

-ve-ve

Iron absorption

↓ Bioavailability

of Iron

-ve-ve-ve-ve

Phosphate phytate

Worm infestation

Oral IronOral IronOral IronOral Iron

Oral Iron Therapy Oral Iron Therapy Ideal dose – 100mg per day (prophylactic)

Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate

Rise in Hb – 0.8 gm / dl / week

Side effects -G I upset most common

Pt. compliance not guaranteed

Ineffective in pts with worm infestations

Inconclusive evidence on benefit of controlled release Iron preparation

Ideal dose – 100mg per day (prophylactic)

Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate

Rise in Hb – 0.8 gm / dl / week

Side effects -G I upset most common

Pt. compliance not guaranteed

Ineffective in pts with worm infestations

Inconclusive evidence on benefit of controlled release Iron preparation

Iron salts are dissociated into bivalent or trivalent iron salts

Diffuses as free iron ions through the upper part of the gastrointestinal mucosa

Taken up by transferrin and incorporated into ferritin.

For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation

Highly reactive free radicals are produced during this process

All ionic iron including carbonyl iron are absorbed similarly

Iron salts are dissociated into bivalent or trivalent iron salts

Diffuses as free iron ions through the upper part of the gastrointestinal mucosa

Taken up by transferrin and incorporated into ferritin.

For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation

Highly reactive free radicals are produced during this process

All ionic iron including carbonyl iron are absorbed similarly

• Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67

• Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.

• Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67

• Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8.

Absorption of Ferrous SaltsAbsorption of Ferrous SaltsUncontrolled Passive AbsorptionUncontrolled Passive Absorption

↑ Hb – 0.21 gm %

Fractionated Irondextran[Iron hydroxide dextran

complex]

Les s

Les s

Les

s Les

s

Parenteral TherapyParenteral Therapy

100 mg elemental Iron

Anaphylactic Anaphylactic reactionreaction

Anaphylactic Anaphylactic reactionreaction

I.M. I.V.

Parenteral Therapy : Traditional IndicationsParenteral Therapy : Traditional Indications

Intolerance to oral iron

Poor compliance to oral iron

Gastrointestinal disorders

Malabsorption syndromes

Rapid blood loss

Intolerance to oral iron

Poor compliance to oral iron

Gastrointestinal disorders

Malabsorption syndromes

Rapid blood loss