ANEMIA IN PREGNANCY BY DR SHASHWAT JANI

Anemia In PregnancyMother Of Evil

Dr. Shashwat Jani.Dr. Shashwat Jani.M.S. ( Gynec)M.S. ( Gynec)

Diploma In Advance EndoscopyDiploma In Advance Endoscopy..

Consultant Assistant Professor,Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College,Smt. N.H.L. Municipal Medical College,

Sheth V. S. General Hospital, Sheth V. S. General Hospital, AhmedabadAhmedabad..Mobile : +91 99099 44160.

E-mail : [email protected]

Pregnancy -The most dangerous journey of mankind

May 2, 2023May 2, 2023 22Dr Shashwat Jani Dr Shashwat Jani 99099 4416099099 44160

Pregnancy -The most dangerous journey of mankind Anemia is an Ice Berg


Embarrassing ...!!!


INDIAN SCENARIO


Magnitude


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Where do we stand today ?Where do we stand today ?• • Anemia prevalenceAnemia prevalence: : (NFHS 3: 2005-06) (NFHS 3: 2005-06)

20-80% amongst pregnant women 20-80% amongst pregnant women 56% of adolescent girls, 30% boys56% of adolescent girls, 30% boys 79% of children 79% of children (increasing trend compared to NFHS 2; 1998-99) (increasing trend compared to NFHS 2; 1998-99)

• Anemia as a direct cause of maternal deaths: 15-20%

• Indirect cause: ~20%


Hemorrhage30%

Anemia19%

Sepsis16%

Abortion9%

Obst. Lab10%

Toxemia8%

Others8%

CAUSES OF MATERNAL MORTALITY SRS-1998

UNCHANGED FOR 5 DECADESMay 2, 2023May 2, 2023 99Dr Shashwat Jani Dr Shashwat Jani

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Definition “Quantitative or qualitative reduction of Hb or

circulating RBCs or both resulting in decreased O2 carrying capacity”

• • WHO – – Hemoglobin <11gm/dl & hematocrit <33% Hemoglobin <11gm/dl & hematocrit <33% Postpartum Hb < 10 gm/dlPostpartum Hb < 10 gm/dl • • CDC CDC -- -- First and third trimesters : Hb <11gm/dl First and third trimesters : Hb <11gm/dl Second trimester <10.5gm/dl Second trimester <10.5gm/dl

- WHO. (2001) Iron deficiency anaemia: assessment, prevention and control, GenevaWHO. (2001) Iron deficiency anaemia: assessment, prevention and control, Geneva- - Dowdle, W. (1989) Centers for Disease Control: CDC Criteria for anemia in children and childbearing-aged - Dowdle, W. (1989) Centers for Disease Control: CDC Criteria for anemia in children and childbearing-aged

women. Morbidity and Mortality Weekly Report 38, 400–404.women. Morbidity and Mortality Weekly Report 38, 400–404.


Iron deficiencyMegaloblasticHemolyticAplastic

%86064 to 53 to 4

Clinical

MildModerateSevereVery severe

Gm %9 to 117 to 8.94 to 6.9< 4

WHO & ICMR

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Classification• Physiological: - Hemodilution in preg, - Negative iron balance, -Increased Fe binding

capacity & absorbtion. -Normocytic & Normochromic An


• Pathological :• Deficiency An- Fe, Folic acid,Vit B 12,

protein.

• Hemorragic An.- APH, worms, piles.

• Hemolytic An.- Sickle cell Anemia ,chronic malaria, kala-azar, severe infection.

• Bone marrow insufficiency.

• Hemoglobinopathies.


Stages involved in Iron Deficiency Anemia


1. in storage iron in tissue and marrow iron S. ferritin(< 20 mg/dl) S. transferrin

2. in iron for erythropoiesis

MCV & MCH Transferrin saturation Erythrocyte protoporphyrin

3. in peripheral blood Hb Hb & Hematocrit

4. in tissue oxygenation• Clinical manifestation

Earliest Earliest markermarkerof Ironof Iron

deficiencydeficiency

Hb % is a very late indicator

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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 Pregnancy

Why IDA is Common …???Low Dietary Intake Of Iron , Chronic Intestinal Diseases Like Amoebiasis, Sprue,

Diarrhoea, Parasitic Infestation (Hook Worm) Malaria , Schistosomiasis , Phytates In Diet, Chronic Blood Loss ( Menorrhagia , Piles, Fissure In

Ano ---Apathy To Take Treatment) Too many and too frequent pregnancies and plural

pregnancy.


Clinical Features of Anaemia in Pregnancy

Symptoms Signs

Weakness Pallor .

Lassitude , tiredness , exhaustion Glossitis .

Indigestion Stomatitis .

Loss of appetite Oedema

Palpitation Hypoproteinaemia .

Breathlessness Soft systolic murmur in mitral area due to hyperdynamic circulation

Giddiness / dizziness Fine crepitations at lung bases.

Swelling feet eye lids ( peripheral ) Pale nails . Platynaechoea . Koilonaechia

Generalized anasarca. Tenderness in sternum .

Blackouts in front of eyes on sudden standing Hepatic –splenic enlargement .

Symptoms of congestive cardiac failureMay 2, 2023 18Dr Shashwat Jani 99099 44160

Work up of Pregnancy with AnemiaDetailed H/o – age, parity, diet, chronic

bleeding, worm infestation, malaria, race etc Examination

PallorGlossitisSplenomegaly – hemolytic anemiaJaundice – hemolytic anemiaPurpura – bleeding disorderEvidence of chronic disease – Renal , TBAnasarca & signs of cardiac failure in severe cases


Diagnosis of IDACharacteristics Calculation Normal Range IDA

Hb gm % Sahli’s method 11-15 < 11

Mean corpuscular volume(MCV) PCV/RBC 75-96 <75

Mean corpuscular HB Hb /RBC 27-33 <27

Mean corpuscular Hb Conc. (g/dl) HB / PCV 32-35 <32

PBF(peripheral Blood Film ) Normocytic Normochromic

Microcytic Hypochromic

Serum Iron (ug/dl) 60 -120 < 60

Total iron binding capacity (ug/dl ) 300- 400 >350

Transferrin Saturation < 15%

Serum Ferritin (mcg / dl ) 13-27 <12

Free erythrocyte protophyrin (ug/ml) <35 >50

Serum Transferrin Receptors increasedMay 2, 2023 20Dr Shashwat Jani

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Other Investigations are… Zinc protoporphyrin levels- increased Hypochromic Red Cell (HRBC). Peripheral smear - Microcytic,hypochromic RBC, anisocytosis, poikilocytosis, tear cells, target cells. stool ex. For occult blood urine r/m for RBC & CAST X –ray chest. For TB Analysis of gastric juice. S.protien. B.M. study & osmotic fragility.May 2, 2023 21Dr Shashwat Jani

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Effects of Anemia on fetus:Prematurity, PROM, IUGR, IUFD, Fetal programming & Disease of newborn – Behavioral abnormalities, Poor performance on Bayley

Mental development index, decreased cognitive function. Prevention of adult Hypertension by Fe prophylaxis in

ANC• HT associated with low Birth Wt & high ratio of Placenta

to Birth Wt.


Effects of Anemia on pregnancy:

Increased incidence of PIH, APH, PPH, Congestive cardiac failure at 30-32 wks,intra

partum & post-partum, Puerperal sepsis, Subinvolution, Failing lactation, Pulm. Venous thrombosis & Embolism.


MOST CRITICAL PERIOD


MANAGEMENT OPTIONS :

Pre – pregnancy : Treat the cause before conception

Pre-pregnancy balanced diet, education and health support.

Build up iron stores during adolescent phase


Iron rich foodGreen leafy vegetables-chana sag,

sarson ka sag, chauli. Sowa, salgam

Cereals - wheat, ragi, jowar, bajraPulses-sprouted pulsesJaggeryDryfruitsAnimal flesh food - meat, liverVit C - lemon, orange, guava,

amla, green mango etc.


Vegetables / FruitsVegetables / FruitsDaily take 5 different colors in diet!Daily take 5 different colors in diet!

Modalities

Oral Iron Blood transfusionParenteral

Injectable Iron Human RecombinantErythropoietin


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Absorption of Ferrous Salt 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


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


MYTHS OF ORAL IRON THERAPY :

• SR Preparations better tolerated Wrong• Hb Preparation better bio-availability Wrong• Iron preparations should be given with meals Wrong• Iron preparation have significant GI effects Wrong• IPC/Carbonyl Iron are grossly better in efficacy Wrong• Parenteral preparations work faster than OralWrong


Indicators of iron therapy response : Increase in Reticulocyte count (Increases 3-5 days after initiation of therapy )

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

Epithelial changes (esp tongue & nail ) revert to normal

Hb concn. Is normal after 6 wks of therapy


Parenteral Therapy : Parenteral Therapy : Traditional IndicationsTraditional Indications

Intolerance to oral iron

Poor compliance to oral iron

Gastrointestinal disorders

Malabsorption syndromes

Rapid blood loss


Inability to maintain iron balance Inability to maintain iron balance (haemodialysis)(haemodialysis)

Patient donating large amount of blood Patient donating large amount of blood for auto-transfusion programmefor auto-transfusion programme

Pregnant women with severe IDA, Pregnant women with severe IDA, presenting late in pregnancypresenting late in pregnancy


WHO States that…WHO States that…

‘ Transfusion should be prescribed ONLY for conditions for which there is NO OTHER

TREATMENT ’


Parental Iron TherapyPreparations

Iron Dextran (Imferon)- 50mg/ml. I.M.,I.V.

Iron Sorbitol Citrate (Jectofer)- only I.M. use. Better absorption & less toxic reaction.

Low molecular wt Dextran.

Sodium ferric gluconate complex [SFGC].


Iron Sucrose complex – only I.V. use. Dose IV inj. / infusion 100 mg diluted in 100 ml NS over 15 mins, 3 times / wk, max 600 mg per wk.

• Total dose infusion of Fe sucrose is not recommended

• Recombinant human Erythropoietin (rhEPO)- induces proliferation & differentiation of erythriod precursors cells & prevents their apotosis.


IRON SUCROSE

Dose calculated – Wt in Kg x iron deficit x 2.2 + 1000 mg for iron

storesResponse - by increase in Hb level 1g/week Increase in Reticulocyte count with in 5-10

days Clinical symptoms improve


Advantages of Iron sucrose: high safety & stability, (Category B)

low tissue accumulation,

high availability for erythropoiesis

rapid Fe incorporation

No test dose required (No dextran)

Anaphylactic reaction are negligible.


Disadvantage of parental Iron:1. Anaphylatic reaction - flushing of face, giddiness,

headache, drowsiness, fatigue, muscle cramps, abd colic, dyspnea, chest pain, bronchospasm, syncope, tachycardia, anaphylactic shock & death .

Inj. Adrenaline, hydrocortisone, avil, paracetamol should be kept ready.

2. I.M. inj. site – local pain, hematoma , sterile abscess, skin discoloration, fat necrosis, regional lymphadenopathy, athralgia.

3. I.V. inj site - thrombophlebitis, venous spasm, skin staining due to extravasation of drug in tissue.


Remember…!!!Oral iron must not be administered

concomitantly with a course of IV iron.

Allow a period of 5 days after the final dose of IV iron.

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Indications of Blood Transfusion

Severe anemia first seen after 36 weeks of pregnancy

Anemia due to acute blood Loss – APH & PPH

Associated InfectionPatient not responding to oral or

parenteral therapyAnemic & symptomatic pregnant

women (dyspneic, with heart failure etc) irrespective of gestational age


FDA Folic acid is needed in higher doses during

pregnancy because of the increased cell replication , taking place in fetus , uterus and bone marrow.

800 ug is required / day , but pre existing deficiency is common especially in developing countries . It is mainly due to inadequate diet / intestinal malabsorption ( sprue ) syndrome .

Combined iron and folic acid deficiency anemia is common in developing countries.


Maternal complications PIH, Abruptio placenta .

Fetal complications Folate deficiency in mother can cause fetal neural tube defects , abortion , IUGR, premature / small for date fetus and poor folate level in newborn .


Diagnosis of FDACharacteristics Normal range Folic acid deficiency

Hb 11-15gm% <11 gm%

MCV 75-96 > 96

Mean corpuscular HB 27 - 33 33

Mean corpuscular HB Conc.

32-35 Normal

PBF Normocytic Normochromic

Megalobastic , neutropenia , thrombocytopenia, hypersegmentation of neutrophills

Serum Folate >3 <3

Red cell Folate >150 ng / ml < 150

Serum Iron 60-120 ug/dl Normal

Serum lactate dehydogenaseHomoCysteine

Increased

IncreasedMay 2, 2023 46Dr Shashwat Jani 99099 44160

Treatment of FDA WHO recommends 800ug / day in

pregnancy and 600ug / day during lactation period .

Treatment for patient with Folic acid deficiency anaemia should take 5mg folic acid / day for > 4 weeks .

Response is observed by fall in LDH level in 3-4 days and increase in reticulocyte count in 5-8

days.


B12 Deficiency A rare cause of anaemia in pregnancy . ,

as daily requirement of 3ug is easily met with a normal diet .

Pernicious anaemia due to absence of intrinsic factor , resulting in decrease absorption of Vit B12 is rare in pregnancy ., as it usually causes infertility.

Parenteral Vit B12 ( cynocobalamin ) 250ug / month is the treatment.


THALASSEMIA Characterized by impaired of one or more of globin chains . ALPHA Thalassaemia when alpha chains are impaired . If only

one alpha chain is impaired the it is called Alpha Thalassaemia Trait.

BETA thalassaemia When both Beta chains are impaired. Beta Thalassaemia Trait if only one Beta chain is impaired.

Children With Beta Talassaemia usually die before reaching reproductive age .

Repeated blood transfusion and Iron chelating therapy some women remain alive , get married and become pregnant.

Need to be differentiated from IDA., by Blood indices and Hb F and HbA 2 Levels .


D/D Of IDA & Thalassaemia Characteristics Normal Range IDA Thalassaemia

MCV 75-96 Reduced Very Reduced

Mean Corpuscular Hb 27-23 Reduced Very Reduced

Mean Corpuscular Hb Conc.

32 -35 Reduced Normal

Fetal HB (HbF) <2% Normal RaisedHbA2 2-3% Normal Raised

Red cell width high Normal


THALASSEMIA If mother has Thalassaemia Trait , husband

should be investigated for Trait .If both partners are positive for trait , prenatal diagnosis for foetal is indicated .

There is 1: 4 chances of fetus being Thalassaemia major .

Therapeutic termination of pregnancy is indicted in such situation .

If foetus has normal Hb Or Trait only, Pregnancy can be continued and manage the anaemia by blood transfusion as per need.


Sickle cell Hbpathy

O.1- 1.0 % in west African and American blacks .

RBC have abnormal HB called HbS, having faulty Beta chains in Hb, results from a single Beta chain substitution of glutamic acid by Valine at colon 6 of Beta globin chain .

When HbS is exposed to low O2 tension , Hb precipitates in long crystals , cell become elongated and sickle shape .

Red cell membrane changes make these abnormal shaped cells more fragile –life spine reduces resulting in anaemia .


Sickle cell anemia It may have serious implications in pregnancy and

women may develop Sickle cell crisis. Patient frequently experience vicious circulation

events as progressive low O2 tension develops. Sickle cell crisis is an emergency with infarction in

various organs due to sequestration of sickle cells , causing severe pain more so in long bones.

It can happen any time in pregnancy , labour and puerperium

Low Po2 in general anaesthesia can worsen the crisis Treatment is by Iv hydration , O2 administration and

PCV transfusion. Prenatal diagnosis is indicate in sickle cell Trait women

with sickle cell trait husband , with advice of MTP of an affected pregnancy 53

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Labor should be supervisedProper counseling & consent to be takenBlood (whole & packed) kept cross matchedWomen nursed in propped up positionIntermittent O2 to be givenPrecaution to prevent infection & blood lossStrict aseptic precautions & minimal P/V examsProphylactic antibiotic can be givenPatent iv line but fluids are avoidedIn decompensated patient diuretic given


2nd & 3rd Stage of labourSecond stage cut short by forceps or ventouseActive management of 3rd stage of labour to be doneOxytocics, P/R misoprostol can be given after

delivery of fetusInjection methergin iv contraindicatedEven normal blood loss may be tolerated poorly in

anemic patientIV Frusemide given after delivery to decrease

cardiac load


Post natal Care & Contraception

Early ambulation is encouragedHematinics are continued for 3-6 monthsWatch for subinvolution , puerperal sepsis,

CHF, thrombo-embolism & lactation failureAvoid pregnancy at least for 2 yearsLAM, barrier contraception, POP after 3

weeks, IUCD or permanent sterilization


ANEMIC MYTHS…


PREVENTION• 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

• Treatment of hookworm infestation : Single dose of Albendazole 400mg stat Or

Mebendazole 100mg BD for 3 days• Improvements of dietary habits : Iron rich food

Cook food in iron utensils


• Social services• Improvement in sanitation• Personal hygiene• Better education of female regarding diet• Contraception• Food fortification Iron fortified salt like iodine

salt


Thank youThank you

Health & Medicine

ANEMIA IN PREGNANCY BY DR SHASHWAT JANI