ANEMIA IN PREGNANCY

BACKGROUNDBACKGROUND

Anaemia is the commonest medical disorder Anaemia is the commonest medical disorder during pregnancyduring pregnancy

Iron deficiency anaemia is the most common Iron deficiency anaemia is the most common type of anaemia during pregnancytype of anaemia during pregnancy

NFHS 2003-06: 57.9% of pregnant womenNFHS 2003-06: 57.9% of pregnant women

25% direct maternal deaths25% direct maternal deaths

EFFECTS OF ANEMIA ON EFFECTS OF ANEMIA ON MOTHERMOTHER

•AntepartumAntepartum

• Preterm laborPreterm labor

• Pre eclampsiaPre eclampsia

• SepsisSepsis

• IUGRIUGR

•Intrapartum Intrapartum

• Uterine inertiaUterine inertia

• PPHPPH

• Cardia failureCardia failure

Postpartum Postpartum • Puerperal sepsisPuerperal sepsis

• Subinvolution Subinvolution

• Pulmonary embolismPulmonary embolism

• Failure of lactationFailure of lactation

• Delayed wound Delayed wound healinghealing

• Cardiac failureCardiac failure

FETAL EFFECTS

Prematurity and LBWPrematurity and LBW

IUGRIUGR

IUFDIUFD

Increased perinatal mortalityIncreased perinatal mortality

Iron Deficiency Anemia due to lower iron stores Iron Deficiency Anemia due to lower iron stores can cause poor mental performance or can cause poor mental performance or behavioral abnormalities in later lifebehavioral abnormalities in later life

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 IRON REQUIREMENT IN PREGNANCYPREGNANCY

2.5mg /day in early pregnancy2.5mg /day in early pregnancy

5.5mg /day from 20 -32 weeks5.5mg /day from 20 -32 weeks

6 – 8 mg/ day after 32 weeks6 – 8 mg/ day after 32 weeks

Average 4 mg/ dayAverage 4 mg/ day

2-3 fold increase in Fe requierment.

10-20 Fold increase in folate requirement

1000mg extra elemental iron 1000mg extra elemental iron

required in pregnancyrequired in pregnancy

Cannot be met by diet aloneCannot 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

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 WHO - Hemoglobin concentration <11gm/dl & concentration <11gm/dl & hematocrit of <33%hematocrit of <33%

CDC definition- Hb CDC definition- Hb <11gm/dl during the first <11gm/dl during the first and third trimesters and and third trimesters and <10.5gm/dl in th second <10.5gm/dl in th second trimestertrimester

CLASSIFICATION BASED ON SEVERITYCLASSIFICATION BASED ON SEVERITY

ICMR WHO

Mild 10 – 11 gm/dl 9 – 11 gm/dl

Moderate 7 – 10 7 - 9

Severe 4 – 7 <7

Very severe <4 decompensated

CLINICAL FEATURES - CLINICAL FEATURES - SYMPTOMSSYMPTOMS

Mild anemia is usually Mild anemia is usually asymptomaticasymptomatic

Moderate anemia - weakness, Moderate anemia - weakness, fatigue, exhaustion, loss of fatigue, exhaustion, loss of appetite, indigestion, giddiness, appetite, indigestion, giddiness, breathlessnessbreathlessness

Severe anemia - palpitations, Severe anemia - palpitations, tachycardia, breathlessness, tachycardia, breathlessness, increased cardiac output, increased cardiac output, cardiac failure, generalised cardiac failure, generalised anasarca, pulmonary edemaanasarca, pulmonary edema

SignsSigns

PallorPallor

Nail changesNail changes

Cheilosis, Glossitis, Cheilosis, Glossitis, StomatitisStomatitis

EdemaEdema

Hyperdynamic circulation Hyperdynamic circulation (short & soft systolic (short & soft systolic murmur)murmur)

Fine crepitations Fine crepitations

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 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

•Haemoglobin Measurement

•Peripheral blood smear

•Reticulocyte count

•Hematocrit

•Blood indices– MCV, MCHC, MCHC

•Stool Examination

•Urine Examination

•Proteins, LFT, RFT

Diagnosis - Additional Diagnosis - Additional

Serum Fe Serum Fe

Total iron binding capacityTotal iron binding capacity

Serum FerritinSerum Ferritin

Saturation Saturation

Hb electrophoresisHb electrophoresis

Bone marrow examinationBone marrow examination

ANEMIA- MORPHOLOGIC CLASSIFICATION

Microcytic anemia : Microcytic anemia : (MCV < 80)(MCV < 80)

: iron deficiency, lead toxicity and thalasemia

Normocytic anemia :Normocytic anemia :(80 < MCV < 100)(80 < MCV < 100)

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

Macrocytic anemia: Macrocytic anemia: (MCV > 100 (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 Calculation that may (or may not) be useful in differentiating thalassemia minor from IDAdifferentiating thalassemia minor from IDA

Mentzer Index = MCV/RBC CountMentzer Index = MCV/RBC Count

<13 – Thalassemia minor<13 – Thalassemia minor

>13 – Iron Deficiency>13 – Iron Deficiency

Useful in childrenUseful in children

NORMAL REFERENCE RANGESNORMAL REFERENCE RANGES

Hematological index Reference range

MCV (PCV/ RBC) 75 – 98 fl

MCH (Hb) 25 – 31 pg

MCHC 32 – 36%

TIBC 325 – 400 μ/ 100ml

Fe/ TIBC ratio 30%

LAB FINDINGS IN IDALAB FINDINGS IN IDA

Hb < 11 gm/dlHb < 11 gm/dl

Peripheral smear - microcytic, hypochromicPeripheral smear - microcytic, hypochromic

MCV and MCHC are lowMCV and MCHC are low

Serum iron is low - < 50 Serum iron is low - < 50 μμgm/dl (N 60 -175)gm/dl (N 60 -175)

TIBC is increased - > 400 TIBC is increased - > 400 μμgm/dlgm/dl

Tests of iron storesTests of iron stores• Serum ferritin is < 12 Serum ferritin is < 12 μμgm/dl (N 40-200)gm/dl (N 40-200)• Stainable iron in the bone marrow is reducedStainable iron in the bone marrow is reduced

NEWER INVESTIGATIONSNEWER INVESTIGATIONSSerum transferrin receptorsSerum transferrin receptors

Transferrin receptor/ ferritin indexTransferrin receptor/ ferritin index

Reticulocyte indices Reticulocyte indices • automated counting of reticulocytes, count of <26pg/ cell is a automated counting of reticulocytes, count of <26pg/ cell is a

strong predictor of IDAstrong predictor of IDA

• Reticulocyte production indexReticulocyte production index

Red cell zinc protoporphyrin levelRed cell zinc protoporphyrin level

MANAGEMENTObjectives: 1- To achieve a normal Hb by end of pregnancy 2- To replenish iron storesTwo 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 <32WRecommended 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

THERAPEUTIC TRIAL OF IRONTHERAPEUTIC TRIAL OF IRON

The tablet can be given with meals or The tablet can be given with meals or

different brand may be trieddifferent brand may be tried

SIDE EFFECTS OF ORAL SIDE EFFECTS OF ORAL IRONIRON

NauseaNausea

VomitingVomiting

ConstipationConstipation

Abdominal crampingAbdominal cramping

DiarrhoeaDiarrhoea

FACTROS DECREASES IRON ABSORBTION

Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements

NEW THERAPEUTIC NEW THERAPEUTIC ALTERNATIVESALTERNATIVESThe side effects NauseaThe side effects Nausea

VomitingVomiting

ConstipationConstipation

Abdominal crampingAbdominal cramping

DiarrhoeaDiarrhoea

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

be triedbe tried

Newer preparations Newer preparations are better tolerated, are better tolerated, have less side have less side effects with better effects with better compliancecompliance

Carbonyl IronCarbonyl Iron

Iron ascorbateIron ascorbate

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 &

DOSAGEIron Dextran IM and IV – high molecular wt stable Iron Dextran IM and IV – high molecular wt stable complexes release iron slowly, can cause complexes release iron slowly, can cause anaphylaxisanaphylaxis

Iron citrate sorbitol Iron citrate sorbitol IM – less stable, rapid release of IM – less stable, rapid release of ironiron

Iron sucrose IV Iron sucrose IV – intermediate stability, rapid – intermediate stability, rapid metabolism hence readily available iron. Since they metabolism hence readily available iron. Since they do not form biological polymers, there are no do not form biological polymers, there are no reactionsreactions

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

DISADVANTAGESDISADVANTAGESPain

Nausea, vomiting, headache

Skin discolouration

Abscess formation

Fever

Lymphadenopathy

Allergic reaction

Anaphylaxis

REASONS FOR FAILURE TO REASONS FOR FAILURE TO RESPONDRESPOND

Non complianceNon compliance

Concomitant folate deficiencyConcomitant folate deficiency

Continuous loss of blood through hookworm Continuous loss of blood through hookworm infestation or bleeding haemorrhoidsinfestation or bleeding haemorrhoids

Co-existing infectionCo-existing infection

Faulty iron absorptionFaulty iron absorption

Inaccurate diagnosisInaccurate diagnosis

Non iron deficiency microcytic anaemiaNon iron deficiency microcytic anaemia

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 rarePacked cells preferred ,Exchange transfusion rare

,

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 ANAEMIAFolic 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 SYMPTOMSInsidious 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 VALUESHb<10gm%

Hypersegmentation of neutrophils

Megaloblast

MCV>100micrometer3

Serum Fe is Normal or high TIBC is low

Folic acid<3ng/ml

B12<80pg/ml

TREATMENTProphylactic- 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 LABORMANAGEMENT IN LABOR

Make patient comfortable, oxygenMake patient comfortable, oxygen

Sedation and analgesiaSedation and analgesia

Prevent cardiac failurePrevent cardiac failure

Aim to deliver vaginallyAim to deliver vaginally

AntibioticsAntibiotics

Cut short second stageCut short second stage

Active management of third stageActive management of third stage

SICKLE CELL DISEASEPre pregnancyCounseling 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 TourniquetsPrenatal fetal surveillanceScreen for- UTI- pre-eclampsia-liver and renal function.IUGR -Hemolytic disease of new born (Ab)

Labor/delivery (-Post partum)Ensure adequate hydrationAvoid hypoxia-Sepsis- acidosis-prolonged labor.Continuous MonitoringContraception counseling → IUD

: