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8/7/2019 ANAEMIAINPREGNANCYnew

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ANAEMIA IN PREGNANCYANAEMIA IN PREGNANCY

Commonest medical disorder in pregnancyCommonest medical disorder in pregnancy

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

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

Anaemia is responsible for 40Anaemia is responsible for 40--60% of maternal deaths in60% of maternal deaths indeveloping countries. It also increases perinatal mortalitydeveloping countries. It also increases perinatal mortalityand morbidity rates (W.H.O 1997).and morbidity rates (W.H.O 1997).


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DEFINITIONDEFINITION

Anaemia is a condition of low circulating haemoglobin inAnaemia is a condition of low circulating haemoglobin inwhich haemoglobin concentration has fallen below thewhich haemoglobin concentration has fallen below the

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

W.H.O defines anaemia in pregnancy as haemoglobinW.H.O defines anaemia in pregnancy as haemoglobinconcentration of less than 11 g/dl and haematocrit of lessconcentration of less than 11 g/dl and haematocrit of less

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


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ERYTHROPOIESISERYTHROPOIESIS

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

RBCs are formed through stages of proRBCs are formed through stages of pro--normoblastnormoblast

normoblastnormoblast reticulocytesreticulocytes mature nonmature non--nucleatednucleatedarithrocyte.arithrocyte.

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

pigment.pigment.


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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 riboflavinPyridoxine 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.


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ERYTHROPOIETINERYTHROPOIETIN

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

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

Increased secretion occurs during pregnancy due toIncreased secretion occurs during pregnancy due toplacental lactogen and progestrone.placental lactogen and progestrone.

Eryhtropoietin increases red cell volume by stimulatingEryhtropoietin increases red cell volume by stimulatingstem 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 vitaminthere is a growing body of evidence to implicate vitamin

A in nutritional anaemia.A in nutritional anaemia.


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PREVALENCE OF ANAEMIAPREVALENCE OF ANAEMIA

ACCORD

ING TO AGEACCORD

ING TO AGEAGE %

OFWOME

N WITH

ANY

ANEMIA

MILD

AMEMIA

MODRAT

E

ANEMIA

SEVERE

ANEMIA

NO. OF

ANEMIA

15-19 56 36.2 17.9 1.9 7,117

20-24 53.8 34.8 17.6 2.0 14,580

25-29 51.4 34.8 13.7 1.9 15,965

30-34 50.5 34.8 13.7 1.9 13,595

35-49 50.5 35.1 13.6 1.9 28,426


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Anaemia Among Women


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PREVALENCE OF ANAEMIAPREVALENCE OF ANAEMIA

IN PREGNANCYIN PREGNANCYOverall prevalenceOverall prevalence 40% of worlds population40% of worlds population

Prevalence of anaemia is 3Prevalence of anaemia is 3--4 times higher in developing4 times higher in developingcountries. Average prevalence being 56%.countries. Average prevalence being 56%.

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

In India alone the prevalence of anaemia in pregnancy is asIn India alone the prevalence of anaemia in pregnancy is ashigh as 88% (W.H.O GlobalDatabase 1997).high as 88% (W.H.O GlobalDatabase 1997).


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CLASSIFICATION OFCLASSIFICATION OF

ANAEMIA IN PREGNANCYANAEMIA IN PREGNANCYACQUIRED:ACQUIRED:

Iron deficiency anaemiaIron deficiency anaemia

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

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

Megaloblastic anaemia (Vitamin B12 and folic acidMegaloblastic anaemia (Vitamin B12 and folic aciddeficiency)deficiency)

Acquired hemolytic anaemiaAcquired hemolytic anaemia

Aplastic or hypoAplastic or hypo--plastic anaemiaplastic anaemia


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CLASSIFICATION (Contd.)CLASSIFICATION (Contd.)

HERIDITARY:HERIDITARY:

ThalassemiasThalassemias

Sickle cell haemoglobinopathiesSickle cell haemoglobinopathiesOther haemoglobinopathiesOther haemoglobinopathies

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

spherocytosis)spherocytosis)


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HAEMATOLOGICALHAEMATOLOGICALCHANGES IN PREGNANCYCHANGES 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 (g/dl)Serum Iron (g/dl) 6060--175175 6060--7575 DecreasedDecreased

Total Iron Binding Capacity (g/100ml)Total Iron Binding Capacity (g/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


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IRONDEFICIENCYIRONDEFICIENCY

ANAEMIAANAEMIA 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 poolFood iron is made up of two pool

Haem Iron PoolHaem Iron PoolNonNon-- Haem Iron PoolHaem Iron Pool

Haem Iron Pool includes all food containing iron asHaem Iron Pool includes all food containing iron ashaem molecules, such as animal flesh and viscera. Itshaem molecules, such as animal flesh and viscera. Itsabsorption is 15absorption is 15--30%, but it can increase to 50% in30%, but it can increase to 50% iniron deficiency state. Its absorption is usually notiron deficiency state. Its absorption is usually notaffected by inhibitors.affected by inhibitors.


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IRONDEFICIENCYIRONDEFICIENCY

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

and eggs. Its absorption can be increased by enhancersand 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, lowascorbic acid, ferrous iron, gastric acidity, alcohol, lowiron 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.


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CAUSES OF INCREASEDCAUSES OF INCREASED

PREVALENCE OF I.D.APREVALENCE OF I.D.ADietary habits: Consumption of lowDietary habits: Consumption of low--bio availability dietbio availability diet

Food FadismFood Fadism

Defective iron absorption due to intestinal infections,Defective 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, excessivehook worm infestation, chronic malaria, excessivesweating, piles.sweating, piles.

Repeated and closely spaced pregnancies and prolongedRepeated and closely spaced pregnancies and prolongedperiod of lactation.period of lactation.


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CLINICAL FEATURES

SIGNS:

a)PALLOR b)GLOSSITIS c)ULCERATION IN MOUTH

c)SOFT SYSTOLIC MURMUR IN MITRAL AREAd)CREPITATIONS AT BASE OF LUNG

SYMPTOMS:

LASITTUDE,WEAKNESS,EXHAUSTION,ANOREXIA,GIDDINESS,DYSPNOEA


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IRON REQUIREMENT INIRON REQUIREMENT IN

PREGNANCYPREGNANCYTotal iron requirement is 1000 mg.Total iron requirement is 1000 mg.

Fetus and placentaFetus and placenta ---- 300 mg300 mg

in red cell mass in red cell mass 500 mg500 mgBasal lossBasal loss 200 mg200 mg

Average requirement is 4Average requirement is 4--6mg/day.6mg/day. 2.5 mg/day in early pregnancy2.5 mg/day in early pregnancy

5.5 mg/day from 205.5 mg/day from 20--32 weeks32 weeks

66--8 mg/day from 32 weeks onwards8 mg/day from 32 weeks onwards


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SEVERITY OF ANAEMIASEVERITY OF ANAEMIA

ICMR describes four grades of anaemia depending uponICMR describes four grades of anaemia depending uponthe 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


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EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON

PREGNANCYPREGNANCYMaternal effects:Maternal effects:

ANTE NATALANTE NATAL INTRA NATAL INTRA NATAL POST NATAL POST NATAL

Poor weight gainPoor weight gain Dysfunctional labourDysfunctional labour Puerperal SepsisPuerperal Sepsis

Preterm labourPreterm labour Haemorrhage & shock SubHaemorrhage & shock Sub--involutioninvolution

PrePre--eclampsiaeclampsia Cardiac failure Cardiac failure Embolism Embolism

Abruptio placentaeAbruptio placentaeInter current infectionsInter current infections

PROMPROM


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EFFECTS OF ANAEMIA ONEFFECTS OF ANAEMIA ON

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

Risk of preRisk of pre--maturitymaturity

IUGR, LBW, poor apgar scoreIUGR, LBW, poor apgar scoreDepleted iron store in neonates and anaemia inDepleted iron store in neonates and anaemia in

infancy periodinfancy period

High prevalence of failure to thrive and poorHigh prevalence of failure to thrive and poorintellectual development.intellectual development.

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


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PREVENTION OF IRONPREVENTION OF IROND

EFICIENCYD

EFICIENCY Prophylaxis of nonProphylaxis of non--pregnant womenpregnant women 60 mg of elemental60 mg of elemental

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

Iron supplementation during pregnancy.Iron supplementation during pregnancy.

Routine iron supplementation is debatable in westernRoutine iron supplementation is debatable in westerncountriescountries

It has to be given in nonIt has to be given in non--industrialized countriesindustrialized countries

W.H.O RECOMMENDATION:W.H.O RECOMMENDATION: Universal oral ironUniversal oral ironsupplementation for pregnant women (60 mg ofsupplementation for pregnant women (60 mg ofelemental iron and 250 g of folic acid) for 6 monthselemental iron and 250 g of folic acid) for 6 monthsin pregnancy and additional of 3 months postin pregnancy and additional of 3 months post--partumpartum

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


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EFICIENCY (Contd.)D

EFICIENCY (Contd.) MINISTRY OF HEALTH, GOVT. OF INDIAMINISTRY OF HEALTH, GOVT. OF INDIA

RECOMMENDATION:RECOMMENDATION: 100 mg of elemental iron with100 mg of elemental iron with500 g of folic acid in second half of pregnancy for atleast500 g of folic acid in second half of pregnancy for atleast

100 days. 2 injections of iron dextran (250 mg each) given100 days. 2 injections of iron dextran (250 mg each) givenIMI at 4 weeks interval with TT injection.IMI at 4 weeks interval with TT injection.

Treatment of hook worm infestationTreatment of hook worm infestation

Single albendazole (400 mg) or mebendazole (100 mg x BD

xSingle albendazole (400 mg) or mebendazole (100 mg x BD

x3 days)3 days)

Change in defecation habits and avoidance of walking bareChange in defecation habits and avoidance of walking barefooted.footed.


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EFICIENCY (Contd.)D

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

availability of food ironavailability of food iron

Iron fortification of food.Iron fortification of food.


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INVESTIGATIONSINVESTIGATIONS

Haemoglobin estimationHaemoglobin estimation

Peripheral blood smearPeripheral blood smear microcytosis, hypochromiamicrocytosis, hypochromia

anisocytosis, poykilocytosis and target cellsanisocytosis, poykilocytosis and target cellsRBC indicesRBC indices MCV, MCH, MCHC, MCV is theMCV, MCH, MCHC, MCV is the

most sensitive indicatormost sensitive indicator

Serum ferritin Serum ferritin first abnormal laboratory testfirst abnormal laboratory test

Transferrin saturation Transferrin saturation second to be affectedsecond to be affected

FEP FEP third test to become abnormalthird test to become abnormal

Serum transferrin receptor Serum transferrin receptor best indicatorbest indicator


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INVESTIGATIONS (Contd.)INVESTIGATIONS (Contd.)

Bone marrow examinationBone marrow examination no response to treatment afterno response to treatment after4 weeks of therapy4 weeks of therapy

Aplastic anaemiaAplastic anaemiaDiagnosis of kalaDiagnosis of kala--azarazar

Urine examinationUrine examination

Stool examinationStool examination for three consecutive daysfor three consecutive days

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

For responseFor response haemoglobin and PBS, reticulocytehaemoglobin and PBS, reticulocyte

countcount


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MANAGEMENT OF IRONMANAGEMENT OF IROND

EFICIENCY ANAEMIAD

EFICIENCY ANAEMIAAIMAIM

To correct iron deficiencyTo correct iron deficiency

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

CHOICE OF THERAPYCHOICE OF THERAPY

Depends on severity of anaemiaDepends on severity of anaemia

Duration of pregnancyDuration of pregnancy

Associated complicating factorAssociated complicating factor


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MANAGEMENT (Contd.)MANAGEMENT (Contd.)

GENERAL TREATMENTGENERAL TREATMENT

Dietary adviceDietary advice

Treatment of associated complicating factorTreatment of associated complicating factorIRON THERAPYIRON THERAPY

OralOral

ParenteralParenteral


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ORAL IRON THERAPYORAL IRON THERAPY

For women presents in mid trimester or early thirdFor women presents in mid trimester or early thirdtrimestertrimester

For treatment more than 180 mg of elemental iron/day isFor treatment more than 180 mg of elemental iron/day isrequiredrequired

To minimize side effects, start with low doseTo minimize side effects, start with low dose

Treatment is continued till blood picture becomes normal,Treatment is continued till blood picture becomes normal,thereafter maintenance of one tablet daily for 3 months tothereafter maintenance of one tablet daily for 3 months toreplenish iron storesreplenish iron stores


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INDICATIONS OF RESPONSEINDICATIONS OF RESPONSE

TO THERAPYTO THERAPY Sense of well beingSense of well being

Improved outlook of patientImproved outlook of patient

Increased appetiteIncreased appetite

haemoglobin, haematocrit, reticulocytosis within 5 haemoglobin, haematocrit, reticulocytosis within 5--1010daysdays

If no significant clinical or haematological improvementIf no significant clinical or haematological improvementwithin 3 weeks, diagnostic rewithin 3 weeks, diagnostic re--evaluation is needed.evaluation is needed.


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INDICATIONS OF RESPONSEINDICATIONS OF RESPONSE

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

After a lapse of few days haemoglobin concentration isAfter a lapse of few days haemoglobin concentration isexpected 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 THERAPYCAUSES OF FAILURE OF ORAL THERAPY

Incorrect diagnosisIncorrect diagnosis

Malabsorption syndromeMalabsorption syndrome

Presence of chronic infectionPresence of chronic infection

Continuous loss of ironContinuous loss of iron

Poor patient compliancePoor patient compliance

Concomitant folate deficiency.Concomitant folate deficiency.


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PARENTRAL IRON THERAPYPARENTRAL IRON THERAPY

INDICATIONS:INDICATIONS:

In tolerance to oral ironIn tolerance to oral iron

Poor patient compliancePoor patient complianceUnpredictable absorptionUnpredictable absorption

Patient near termPatient near term

ADVANTAGEADVANTAGE

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


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PARENTERAL IRON THERAPYPARENTERAL IRON THERAPY

Intra muscularIntra muscular

Intra venousIntra venousTwo preparationsTwo preparations Iron dextranIron dextran IM/IVIM/IV

Iron sorbitol citrateIron sorbitol citrate IMIM

IRONDEFICITIRONDEFICIT

Elemental iron needed (mg) = (Normal HbElemental iron needed (mg) = (Normal Hb Patients Hb) xPatients Hb) xWeight (kg) x 2.21 + 1000Weight (kg) x 2.21 + 1000


(Contd.)(Contd.)


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

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

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

IMI using Z technique.IMI using Z technique.I.V. ROUTEI.V. ROUTE

Total dose in fusion (TDI)Total dose in fusion (TDI) Dose calculated by sameDose calculated by same

formulaformula


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INDICATION OF BLOODINDICATION OF BLOOD

TRANSFUSIONTRANSFUSION Severe anaemia beyond 36 weeksSevere anaemia beyond 36 weeks

Refractory anaemiaRefractory anaemia

To correct anaemia due to blood lossTo correct anaemia due to blood lossAssociated infectionAssociated infection


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MEGALOBLASTIC ANAEMIA

DEARRANGEMENT IN RED CELL MATURATION

IMPAIRED DNA SYNTHESIS

EITHER VIT B 12 OR FOLIC ACID DEFICIENY ADDISONIAN PERNICIOUS ANAEMIA DUE TO

DEFFECTIVE B 12 ABSORPTION


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FOLIC ACIDDEFICIENY

CAUSES:-

INADEQUATE INTAKE

INCREASED DEMAND DUE TO:a)d maternal tissueb)product of conception

DIMINISHED ABSORPTION

ABNORMAL DEMAND:a)twins b)infection

c)haemorrhagic states

FAILURE OF UTILISATION

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