7a anemia and other common problems 13-sept 2011

1. 1
Anaemia during Pregnancy and
in the Postpartum period
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
BEMoC - Presentation 7 (a)
Session 7a

2. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
2
Session Objectives
 To be able to:
• Diagnose Anaemia & Malaria
• Treat Anaemia & Malaria
• Prevent Anaemia & Malaria
 Refer cases of Severe Anaemia to FRU

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Anaemia

4. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
4
Anaemia in Pregnancy
Definition
 Anaemia is defined as Hb level < 11gm% in
pregnancy or immediate post partum period.
 Anaemia is grouped as (ICMR Classification)
• Mild (10-11gm %)
• Moderate (7-9.9 gm %)
• Severe (4 – 6.9gm %)
• Very severe (<4 gm %)

5. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
5
Diagnosis of anaemia and its severity
Symptoms & signs Probable Diagnosis (ICMR
Classification)
Haemoglobin >11 g/dl
No pallor
No clinical Anaemia
Hemoglobin 10-10.9 g/dl Mild Anaemia
Haemoglobin 7-9.9g/dl
OR
Palmar or conjunctival pallor
Moderate Anaemia
Haemoglobin 4-6.9 g/dl
AND/ OR
Severe palmar and conjunctival pallor or any
pallor with any of the following:
* >30 breaths/minute
* Easy fatiguability
* Breathlessness at rest
Severe Anaemia
Haemoglobin <4 g/dl
AND/ OR as severe anemia
Very Severe Anaemia

6. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
6
Management
 Depends on :
• Severity of anaemia
• Gestational age
 Iron administered either orally or parentally
requires a minimum period of 4 - 6 wks to raise
the Hb to normal levels
 Nutritional counselling for iron rich food(like
jaggery, spinach etc)

7. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
7
Management
 For prophylaxis: 1 IFA tablet (with 100 mg elemental iron and 0.5 mg
folic acid) once daily for 100 days starting after the 1st trimester.
 Mild to Moderate anemia :
• IFA tabs (100 mg elemental iron + 0.5 mg folic acid) twice daily
and to be continued during postpartum period.
• Administer parenteral iron preparation if there is non compliance /
intolerance to oral iron.
 Moderate and Severe anaemia: May receive antihelminthic drugs
(Tab. Mebendazole 100 mg bd for 3 days or Tab. Albendazole 400 mg
single dose) especially in hookworm endemic areas during 2nd/3rd
trimesters of pregnancy.
 Severe anemia :
• Refer to FRU for further investigations & treatment.
• This woman might need a blood transfusion.

8. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
8
Management- Mild & Moderate Anaemia
 Give IFA tablet (with 100 mg elemental iron and 0.5 mg folic
acid) twice daily for 100 days & to be continued in post partum
period for 3 months.
 Counsel the woman on the need for compliance with treatment.
 Nutritional Counselling for Iron Rich Food
• Administer parenteral iron preparation if there is non
compliance / intolerance to oral iron.
 Give LLINs if you are in a malaria-endemic zone.
 Give the woman an antihelminthic for deworming (Tab.
Mebendazole 500 mg stat , or Albendazole 400 mg stat),
especially if you are in a hookworm-endemic area.

9. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
9
Management – Mild & Moderate anaemia
 Reassess after one month.
 If Hb level increases continue treatment
 If no improvement refer to FRU for further management
 If the woman of mild & moderate anemia reports in
labour
• Conduct the delivery with emphasis on AMTSL
• Monitor her for 48 hours
• Check Hb level after 3 days
• Prescribe I tab (100 mg) of IFA twice daily for 6
months post partum
• Reassess her in the next postnatal visit at 6 weeks &
refer to FRU if no improvement

10. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
10
Management – Severe anaemia
 Should ideally be managed in a CEmOC facility where
blood transfusion facility is available
 Refer her to FRU at the earliest
 If she reports in first stage of labor and there is
sufficient time or post partum refer her to FRU
 If she reports in active labor with delivery imminent,
• Conduct the delivery with minimal possible blood
loss (AMTSL)
• Monitor the vital signs intensively during the delivery
• Refer urgently to FRU after stabilizing her condition
 Follow up the woman in two weeks to check the clinical
progress, test results and compliance with treatment of
double dose of iron (1 tablet twice a day) for 6 months
postpartum.

11. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
11

12. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
12

13. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
14
Counselling – Diet & Rest
 Reassure the mother that she can eat normal food ; these will not
harm the breast fed baby
 Diet to be rich in iron & fibre
 Discuss about food taboos especially against food that are
nutritionally healthy
 Talk to family members like mother in law , husband to encourage
them to ensure that the woman easts enough & avoids heavy
physical work
 Take care of the mother so that she can take care of the baby
 Counselling on diet especially for adolescent mother
 IFA Supplementation
 Women with normal Hb are advised to take 1 IFA tablet daily for 3
months
 If Hb below 11 gm%, advise her to take 2 IFA tabs daily and repeat
Hb after 1 month
 Family support specially for girl child
 Rest to the Mother

14. 15
Malaria

15. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
16
Screening and prophylaxis of malaria during
pregnancy
 No prophylaxis is recommended but
insecticide treated bed nets/LLIN be given on
priority basis to the all pregnant women in
vulnerable population
 High malaria endemic areas: Routine testing
& screening for malaria on the 1st ANC & in
each month by RDK tests even if she does not
manifest any malaria symptoms
 Non endemic areas: All clinical suspected
cases (as per NVBDCP guidelines) should
preferably be investigated for malaria by RDK

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Treatment in 1st
Trimester

17. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
18
Treatment: Uncomplicated Malaria
P. vivax
Chloroquine base to be
given as under:
Day 1 4 tabs @10mg/kg
Day 2 4 tabs @10mg/kg
Day 3 2 tabs@5 mg/kg
P. falciparum
Quinine (as tablets) 10
mg. quinine salt/kg. body
weight 3 times daily for 7
days.

18. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
19
Treatment: Severe and complicated malaria
 Parenteral Quinine is the drug of choice in first trimester
 Loading dose :
• 20 mg/kg. body weight on admission (I.V. infusion in 5% Dextrose/
dextrose saline over a period of 4 hours)
• May not be given if the patient has already received quinine or if clinician
feels inappropriate.
 Maintenance dose:
• 10 mg./kg. bw 8 hourly
• infusion rate should not exceed 5 mg salt/kg bw per hour
 NEVER give bolus injection of Quinine
 Parenteral Quinine given for minimum of 48 hours & once the patient
tolerates oral therapy, follow-up treatment is as under:
• Quinine 10 mg./kg. bw three times a day to complete a course of 7 days
PLUS
• Clindamycin 10mg./kg. bw 12 hrly should be given for 7 days
 If Parenteral Quinine to be given after 48 hours, reduce dose to 7 mg/kg
body weight 8 hourly.
 Parenteral Treatment should be given for a minimum of 24 hours once
started
 If Quinine unavailable, artemisin derivatives may be used

19. 20
Treatment of Malaria in
2nd
& 3rd
Trimesters

20. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
21
TREATMENT:
P. vivax
Chloroquine base to be
given as under:
Day 1 4 tabs @10mg/kg
Day 2 4 tabs @10mg/kg
Day 3 2 tabs@5 mg/kg
P. falciparum
ACT to be given as
under:
1st
day
2nd
day
3rd
day
AS 4 tabs 4 tabs 4 tabs
SP 3 tabs Nil Nil
AS- artesunate 50 mg
SP-Sulfadoxine 500 mg +
Pyrimethamine 25 mg

21. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
22
Treatment: Severe and complicated malaria
 Parenteral artemisin derivatives preferred in 2nd
& 3rd
trimesters.
 To be given as under:
• Artesunate
 2.4 mg/kg bw iv or im given on admission then at 12
hours & 24 hours, then once a day
 Care should be taken to dilute artesunate powder in 5%
Sodium bicarbonate provided in the pack
• Artemether
 3.2 mg/kg body weight im given on admission then 1.6
mg/kg bw per day
• Α-βArteether
 150 mg daily im for 3 days

22. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
23
Side effects of Quinine
 Metallic taste
 Nausea
 Tinnitus
 Hypoglycaemia
Note:
 Pregnant women should not take quinine on an
empty stomach and should eat regularly, while on
quinine treatment
 No special diet is needed
 Primaquine is contraindicated during pregnancy.

23. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
24
Key Messages
 Prophylaxis of anaemia
 Management of Anaemia
 Management of Complicated and
Uncomplicated Anaemia in First, Second &
Third Trimesters
 Referral of Severe Anaemia Cases

24. ANAEMIA DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
25
Case Studies
 Case Study Number 23 on page number 88 &
89 of Trainees Hands Book

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Thank you