Dr. Rabi Narayan Satpathy

Asst. professor

Dept. of Obst. & gynaecology

SCB MEDICAL College, Cuttack

Mob-09861281510

MMajor Public Health Problemajor Public Health Problem

MMost Preventable Cause ost Preventable Cause Still the Leading CauseStill the Leading Cause

MAGNITUDE OF THE PROBLEMMAGNITUDE OF THE PROBLEM

WorldWorld

population:population: 5-6 billion5-6 billion

2 billion anemic2 billion anemic

Developing Countries:Developing Countries:

9 out of 11 pt are anemic.9 out of 11 pt are anemic.

Every second preg. WomanEvery second preg. Woman

4 out of 10 pre school4 out of 10 pre school

India:India:

Highest prevalenceHighest prevalence

87% preg women87% preg women

10% severe anemia10% severe anemia

1 in 5 maternal deaths1 in 5 maternal deaths

ANNUAL MATERNAL DEATHS - ANNUAL MATERNAL DEATHS - GLOBALLYGLOBALLY TOTAL 500,000TOTAL 500,000

75%75% : Hemorrhage ; Abortion ; Eclampsia ; : Hemorrhage ; Abortion ; Eclampsia ; Sepsis ; Obs. Labour. Sepsis ; Obs. Labour.

ANAEMIAANAEMIA : Direct cause contributes 20% : Direct cause contributes 20%

Indirect cause further 20%Indirect cause further 20%

Iron Metabolism – Iron Metabolism – The ConceptThe Concept

Iron Metabolism – Iron Metabolism – The ConceptThe Concept

FeFe++++

FeFe++++

FeFe++++

FeFe++++

FeFe++++

FeFe++++

FeFe++++

FeFe++++

Is it Very Confusing !!!Is it Very Confusing !!!Is it Very Confusing !!!Is it Very Confusing !!!

EXTERNAL IRON EXCHANGEEXTERNAL IRON EXCHANGENon-haem IronNon-haem Iron

InorganicInorganic

Haem IronHaem Iron

OrganicOrganic

Fascilitators Fascilitators •AscorbateAscorbate•Gastric pHGastric pH•CitrateCitrate•AAAA

InhibitorsInhibitors•Phytates.Phytates.•Tannin.Tannin.•AntacidAntacid•P-pump inhibitors P-pump inhibitors

CompetitorsCompetitors•Pb.Pb.•Mn. Mn. •Zn.Zn.

Efficient Efficient independent of independent of duodenal pHduodenal pH

Luminal Cell of Duodenum & Luminal Cell of Duodenum & JejunumJejunum

FerritinFerritin

CC

Fe++Fe++

Ferrous Ferrous

More solubleMore soluble

Acidic duodenal pHAcidic duodenal pH

CC

PLASMA TRANSFERINPLASMA TRANSFERIN

Normal men 1 mg/day

Menstruating females 2 mg/day

Pregnant women 4.8 mg/day

Adolescent 1-2 mg/day

INTERNAL IRON EXCHANGEINTERNAL IRON EXCHANGE(IRON CYCLE)(IRON CYCLE)

Transferrin – Transferrin –

Iron ComplexIron Complex

Transferrin – Transferrin –

Iron ComplexIron Complex

Bone marrow erythroid cellsBone marrow erythroid cells

RBCRBC

R-E systemR-E system

Liver Liver

FerritinFerritin

Gut Gut

Recycling

Recycling

release of Iron

release of Iron

120 days120 days

Transferrin Transferrin receptorreceptor

Haemosiderin Haemosiderin (Stable) can’t be (Stable) can’t be

mobilizedmobilized

Iron Iron Absorption Absorption

IncreaseIncrease

Demand by fetusDemand by fetus Net utilisation is 800 mgNet utilisation is 800 mg Twin. Twin.

Bioavailability of iron is Bioavailability of iron is decreased.decreased.

Inadequate calorie Inadequate calorie intake < 2,000 Kcal/day.intake < 2,000 Kcal/day.

Increase in plasma & Increase in plasma & RBC volume.RBC volume.

<<<<

Age group < 20 yrs.Age group < 20 yrs. Low SE status.Low SE status. Literacy.Literacy. Parity > 2.Parity > 2. Sparing Sparing 2 yrs. 2 yrs. Malnutrition.Malnutrition. Vegetarian diet – mostly cereal & pulse.Vegetarian diet – mostly cereal & pulse. Worm infestation.Worm infestation. Unemployment of women, poverty.Unemployment of women, poverty.

NutritionalNutritional

Fe.Fe. Folic.Folic. BB1212..

Combined.Combined.

Blood lossBlood loss

Acute.Acute. Abortion.Abortion. Ectopic.Ectopic. Molar.Molar. AbruptioAbruptio Previa.Previa. Coagulopathies.Coagulopathies.

Chronic.Chronic. Hookworm.Hookworm.

Causes Contd…..Causes Contd…..

Hemolytic anemiasHemolytic anemias

Congenital.Congenital. Hemoglobinopathies.Hemoglobinopathies. Thalassemia.Thalassemia. Sickle cell anemia.Sickle cell anemia.

Acquired.Acquired. Malaria.Malaria. Autoimmune disease.Autoimmune disease.

Aplastic Anemias/ Aplastic Anemias/ HypoplasticHypoplastic

Chronic systemic Chronic systemic disease.disease.

Bone marrow depression.Bone marrow depression. Renal disease.Renal disease. Endocrine disorder.Endocrine disorder. Malignancy.Malignancy. Viral infection.Viral infection.

Reliable, Cost effective, Reliable, Cost effective, Easy Indicator of AnemiaEasy Indicator of Anemia

g/dlg/dl g/lg/l PCVPCV

Mild Mild < 11< 11 < 110< 110

Moderate Moderate 6.5-86.5-8 70-10970-109 24-3724-37

Severe Severe < 6.5< 6.5 40-6940-69 13-2313-23

Very severeVery severe < 4< 4 < 40< 40 < 13< 13

WHO standardisation of AnemiaWHO standardisation of Anemia

Decrease Hb Anemia

Story Behind

Negative Iron Balance.Negative Iron Balance.

Iron deficient erythropoiesis.Iron deficient erythropoiesis.

Iron Deficiency Anemia (IDA).Iron Deficiency Anemia (IDA).

BM Iron BM Iron StoresStores

Hb%Hb%

Normal Normal Negative iron Negative iron balancebalance

Iron deficient Iron deficient erythropoiesiserythropoiesis

Iron deficiency Iron deficiency anemiaanemia

S. Ferritin S. Ferritin ((g/l)g/l) 50-20050-200

<15<15

TIBC TIBC ((g/dl)g/dl) 300-360300-360 > 400> 400

S. Iron S. Iron ((g/dl)g/dl) 50-15050-150 N N

Saturation Saturation (%)(%) 30-5030-50 NN

RBC RBC protophyrinprotophyrin N N

RBC RBC morphologymorphology N N N N Microcytic Microcytic

hypochromatichypochromatic

Lack

of

Conce

ntrati

on

Degree of Degree of AnemiaAnemia

SymptomsSymptoms

Weakness

Fatigue

Dizzines

s

Irritability

ModMild

Severe

Vulnerable GroupsVulnerable Groups Problems Problems

Infant (4-24m)Infant (4-24m) Maximum Iron required Maximum Iron required equivalent to adult doseequivalent to adult dose

Growing girl childGrowing girl childWorm infestation, UTI, Worm infestation, UTI, epistaxis, pelvic infection, epistaxis, pelvic infection, chronic malaria, tuberculosischronic malaria, tuberculosis

Adolescent girlAdolescent girl Puberty menorrhagia, Puberty menorrhagia, infection, malnutritioninfection, malnutrition

Diet.

Fortification.

Social factors.

Infection control.

Haem IronHaem Iron

Organ meats.Organ meats.

Poultry.Poultry.

Fish.Fish.

Oysters.Oysters.

Beef.Beef.

Pork.Pork.

Non-haem IronNon-haem Iron

EggEgg

Diary products.Diary products.

Dried beans, peas.Dried beans, peas.

Dark green leafy Dark green leafy vegetables (spinach, vegetables (spinach, mustard greens).mustard greens).

Nuts & sesame seedsNuts & sesame seeds People who are iron deficient absorbs 10 People who are iron deficient absorbs 10 times more than normal subjects.times more than normal subjects.

Vit. C Vit. C → → Citrus fruits, lemon, tomatoes.Citrus fruits, lemon, tomatoes.

Cooking in cast iron pans & utensils. Cooking in cast iron pans & utensils.

Iron fortification of:Iron fortification of:Cereals.Cereals.Bread.Bread.Pasta.Pasta.

Double fortification of salt.Double fortification of salt. Iodine & Iron.Iodine & Iron.

Food vehicles.Food vehicles.

Respect to girl child.Respect to girl child.

Education of girl child.Education of girl child.

Equal rights.Equal rights.

Mid-day meal programmes.Mid-day meal programmes.

Personal hygiene. Personal hygiene.

Marriage after 18.Marriage after 18.

Safe abortion.Safe abortion.

Worm infestation.Worm infestation.

Malaria.Malaria.

National Nutritional Anemia Prophylaxis Programme (NNAPP)

Universal Oral Iron Supplementation of All Pregnant Women

60 mg/ 100 mg/ 120 mg

100 mg of Iron x 100 days

Aims at

As Recommended by WHO & implemented by GOI

1st trimester 2nd trimester 3rd trimester

< 11 g/dl

200 mg Elemental Iron

Reassessment on 2nd & 3rd

9 – 11 g/dl

200 mg Elemental Iron

MonitoringMaintenance

Therapy

< 9 g/dl

Lab. Test: CBC (PS), Iron Studies, BM studies, Lab. Test: CBC (PS), Iron Studies, BM studies, Opinion of HematologistOpinion of Hematologist

IDAIDA:: 200 mg Elemental Iron200 mg Elemental Iron

MonitoringMonitoring

IUGR

IUD IUH

CCF

INFECTION

PRETERM LABOUR

PIH

Medical Disorde

r

Supplement FormsSupplement FormsSupplement FormsSupplement Forms

Elemental IronElemental Iron

Ferrous saltsFerrous salts 60 mg 60 mg(Sulphate, Ascorbate, Citrate,(Sulphate, Ascorbate, Citrate,Lactate, Carbonate)Lactate, Carbonate) Ferrous fumarateFerrous fumarate 65 mg65 mg Ferrous gluconateFerrous gluconate 36 mg36 mg Sustained releaseSustained release 105 mg105 mg

Polysaccharide iron complexPolysaccharide iron complex Carbonyl ironCarbonyl iron

Iron & Ascorbic Acid.Iron & Ascorbic Acid.

Vit. C enhances the absorption of iron.Vit. C enhances the absorption of iron.

Fewer side effects.Fewer side effects.

Better tolerated.Better tolerated.

Good bioavailability.Good bioavailability.

Ferric hydroxide Ferric hydroxide polymaltose complex.polymaltose complex.

Expensive.Expensive.

Bioavailability Bioavailability controversial.controversial.

Small Iron Particles - 5Small Iron Particles - 5mm

Slow absorption.Slow absorption.

Good bioavailability Good bioavailability

Least GI side effect Least GI side effect

Environment stability.Environment stability.

Seems to be promising in Seems to be promising in rise of Hb status.rise of Hb status.

Constipation

Diarrhea

Gastric irritation

PROBLEMS WITH ORAL IRON

Free Radical Generation

If a child consumes 3 adult iron tablets, If a child consumes 3 adult iron tablets, acute fatal iron poisoningacute fatal iron poisoning can occur. can occur.

Highly controversial.Highly controversial.High side effects & adverse reaction.High side effects & adverse reaction.Should have hematology consultation.Should have hematology consultation.

I.V. (TDI)I.V. (TDI) // I.M.I.M.

Iron Dextran (Imferon)Iron Dextran (Imferon) Recent:Recent:

IV Sodium ferric gluconate.IV Sodium ferric gluconate. Iron sucrose.Iron sucrose. Used with recombinant erythropoietin therapy.Used with recombinant erythropoietin therapy.

Acute blood loss.Acute blood loss.

Preparation of cesarean.Preparation of cesarean.

Obstetric complications.Obstetric complications.

??? to raise Hb in last trimester??? to raise Hb in last trimester

Requirement: 400 Requirement: 400 g/dayg/day Megaloblastic anemia.Megaloblastic anemia.

S. folate.S. folate. RBC folateRBC folate Macrocytosis.Macrocytosis.

Rich in:Rich in: Bananas, fruits, green leafy Bananas, fruits, green leafy

vegetable, yeast.vegetable, yeast. Periconception, pregnancy, Periconception, pregnancy,

lactation.lactation.

Rich source:Rich source: Diary products.Diary products. Animal products.Animal products. Egg.Egg. Fish oil.Fish oil.

RDA – 2.4 RDA – 2.4 g/day.g/day.

It is paradoxical but It is paradoxical but true, that anaemia is true, that anaemia is preventable condition, preventable condition, however due to its however due to its multifactoral origin we multifactoral origin we could not conquer it could not conquer it and even today it and even today it remains one of the remains one of the major cause of major cause of maternal mortality.maternal mortality.

DREAMING DREAMING PREGNANT WOMANPREGNANT WOMAN

FREE OF FREE OF NUTRITIONAL NUTRITIONAL

ANEMIAANEMIAKeep the lamp of knowledge burning to achieve Keep the lamp of knowledge burning to achieve the vision. Only the vision will ignite the billion the vision. Only the vision will ignite the billion souls. Ignited soul is the most powerful resource souls. Ignited soul is the most powerful resource making dream to reality.making dream to reality.

A. P. J. Abdul KalamA. P. J. Abdul Kalam