Focussing on 12 gm Haemoglobin for Children , Girls & Women in INDIA

1. Is the NEED of TODAY
Dr. Sharda Jain
Focussing on
12 gm Haemoglobin
for
Children , Girls & Women
in INDIA

2. 2021 National Family Health Survey

3. ANAEMIA : its prevalence across age and gender
group has increased.
Aneamia has increased by 2-9% among
children ,
Pregnant women and
men
according to data shared in the National Family
health survey 5 (NFHS-5)
released November 24, 2021

4. In rural area of India ,
68.3% children are
Anaemic , while the
urban load stands at
64.2 % according to
NFHS-5

5. The largest spike is seen in children
between the ages of 6months and 59
months,
Now 67.1 % are Anaemic , as
compared to
58.6% in NFHS – 4 conducted in
2015-2016.
In rural areas
68.3% children are anaemic ,
while the urban load stands at 64.2 %

6. The Second highest increase is
recorded in women between the
ages of 15 and 19th ,
up from 54.1 in 2015 -2016 to
59.1 in 2019-2021.
Here too , more young women
in rural areas (56.5 %) are
Aneamic as compared to urban
areas (60.2%)

7. All women between the ages of 15 and 49 years
reported a four % increase in incidence of Anaemia ,
up from 53.1% in 2015 to 2016
to 57 % in 2019 - 2021

8. PREGNANCY : The % of
pregnant women between
the ages of 15 and 49 years
who are anemic
has increased to 52.2% now
from 50.4%in 2015 -2016

9. MEN , irrespective of age group , have reported the lowest
increase in the incidence anemia at 2.3 % for those between
the ages of 15 and 49 – up to 25% now from
22.7% in 2015 -2016 .
Among them , younger men , between 15 and 19, have
shown a 1.9% increase to 31.1% now from 29.2%

10. WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization;2015.
Anemia affects around 1 billion children and women globally
INDIA USP
:anaemia/Malnutrition
Level of public health
significance:
Severe
Anemia: A Global Burden

11. Work performance
Child development
School PerformanceIQ
Child mortality
Maternal mortality
Perinatal mortality
Other factors
A new conceptual model of IDA and its effects.
Tissue Iron
Deficiency
Moderate&
Severe
Anemia

12. DEFINITION OF ANAEMIA
W.H.O.
Greek word – LACK OF BLOOD
• LEVELS : 12 GM % CHILD OF 2 YEARS ,GIRLS ,WOMEN
• USP : oxygen carrying capacity is by Hb molecule

13. DEFINITION OF ANAEMIA
Greek word – LACK OF BLOOD
• Decrease in no. of RBC’s, or
• Decrease in Hb, or
• Decrease in oxygen carrying capacity of Hb molecule

14. ANAEMIA & PREGNANCY

15. HB –CUT OFFS
• WHO recommendation (2001)
Hb concentration should not fall below 11.0g/dL (Hct < 33%) anytime
during pregnancy
*Mild 9-10.9g/dL * Moderate 7-9g/dL
*Severe <7g/dL * Severe <4g/dL
INDIAN DOCTORSshould aim at 12 gm in pregnancy too,in case to save
Life from PPH

16. Source: India Development and Participation by Jean Dreze and Amartya Sen, OUP 2002
ANAEMIA IN PREGNANCY - 2002

17. National Family Health survey 4 MoHFW 2021
Anemia in Women: Declined in most states from NFHS-3 to
NFHS-4,but still remains high
Anaemia among Children and Adults NFHS 4 (2015-16) NFHS 5(2)
Urban (%) Rural (%) Total (%) Total (%)
Non-pregnant women age 15-49 years
(<12.0 g/dl)
51.0 54.3 53.1 57.2
Pregnant women age 15-49 years
(<11.0 g/dl)
45.7 52.1 50.3 52..2
All women age 15-49 years 50.8 54.2 53.0 55..3
National Family Health Survey - 5 (2021) data

18. ANAEMIA
FREE
INDIA
IDIA
2021  we have come long way
But INCREASE is NOT ACCEPTABLE

19. MAGNITUDE
• 52% of Indian pregnant women suffer from anemia
20 % maternal deaths contributed by anemia
• Iron deficiency anemia (IDA) commonest cause of anemia in pregnancy
Most Common deficiency state in the world
Preventable and correctable cause of anemia.
DR. SHARDA JAIN – AN ACTIVIST OF ANAEMIA FREE INDIA -
90% pregnant women were Anaemic (2000)  55-57% (2021)

20. FEW FACTS

21. Hemorrhage
30%
Anemia
19%
Sepsis
16%
Abortion
9%
Obst. Lab
10%
Toxemia
8%
Others
8%
CAUSES OF MATERNAL MORTALITY
SRS-1998
20% Direct , another 20% Indirect cause of maternal deaths
Nothing is more expensive than a missed opportunity! –TOTREAT
UNCHANGED FOR 5 DECADES

22. Anaemia
Death
Beyond numbers!
For every maternal death, there are 30 more who ‘almost died’.

23. Conditions Associated With Iron Deficiency Anaemia
Physiological
- INFANCY
- ADOLESCENCE IN GIRLS
- PREGNANCY
- Regular blood donation
- Being an elite athlete
Blood Loss
- Digestive tract :Malignancy, IBD, Ulcers
- Gynecological loss
- Surgery
- Hematuria, Epistaxis, Hemoptysis
- Hemodialysis
Malabsorption
- Gastrectomy
- H. Pylori
- Gut resection, atrophic gastritis,
- Bypass gastric surgery
- Proton pump inhibitors,H2 antagonists
-Parasite infestation
IDA associated with chronic diseases
- Chronic heart failure
- Cancer
- Chronic kidney disease
- Rheumatoid arthritis
- Obesity
- Inflammatory bowel diseases
Lancet 2016; 387: 907–16

24. Diagnosis of Iron Deficiency Anemia

25. • SYMPTOMS AND SIGNS
• IMPLICATION ON MOTHER AND FETUS
ARE WELL KNOWN TO OUR OBSTETRICIAN AND GYNAECOLOGIST

26. INVESTIGATIONS
ORDER ONLY THE ONES
YOU CAN INTERPRET
AND
HAVE CLINICAL RELEVANCE

27. Understanding Investigations
• Send immediately for a Complete Blood Count with
Peripheral smear examination.
• Urine and stool routine examination
• Antenatal investigations as per protocol

28. CBC PARAMETERS
PARAMETER UNITS NORMAL RANGE
HEMOGLOBIN gm/dl 11.5 -15.0
TOTAL LEUCOCYTE COUNT cu/mm 4000 -10500
DLC P_L_E_M_B_ %
R.B.C.COUNT million/cum 4.5 – 6.0
PLATELET COUNT lakhs/cum 1.50 -4.00
P.C.V. % 37 – 47
M.C.V. fl 78 – 94
M.C.H. pg 27 – 32
RDW H% 10 – 15
M.C.H.C. g/dl(%) 32 – 38
ESR mm/1st hr 00 – 15
PERIPHERAL SMEAR

29. Information from CBC Parameters
1. HB/PCV : Degree of anaemia. Correlates with patient’s symptoms.
HB : PCV ----- 1 : 3
2. MCV, MCH, Peripheral Smear: allow Morphological Classification of anemia, guide
workup and allow assessment of response to therapy

30. Peripheral smear: Shape, size, degree of pigmentation of cell types,
presence of
abnormal cells and blood parasites aid diagnosis of type of anemia
Reticulocyte count : An appropriate response (after correction) shows
appropriate erythropoietin release, a marrow capable of producing red
cell precursors, and sufficient iron stores.

31. IDA VERSUS THALASEMIA
MENTZER’S INDEX
MCV/ RBC
< 14 THALASEMMIA
> 14 IDA

32. CBC PARAMETERS IDA THALASSEMIA
RBC count < 5 million/ml >5 million /ml
RDW >14 <14
Mentzer’s Index >14 <14
MCV
MCH
MCHC NORMAL

33. Diagnosing of Iron Deficiency Anemia
Complete Blood Count:
 MCV & RDW :IDA is characterised by Low MCV, Low MCH but up to 40% of pregnant women with true IDA
have normocytic indices
 A combination of low MCV accompanied by elevated RDW can be used as a sufficient evidence to start
iron therapy
 RDW – decreased in Thalassemia
 Serum iron and TIBC : Unreliable markers
 Serum iron shows diurnal variation and is affected by dietary influences
 Pregnancy itself increases total iron binding capacity (TIBC) even in the absence of IDA
RDW –Red cell distribution width, MCV-Mean corpuscular volume, MCH-Mean Corpuscular Hemoglobin, TIBC – Total Iron Binding Capacity
Indian J Hematol Blood Transfus. 2018:1-2.

34. NOT ROUTINELY RECOMMENDED
• SERUM IRON
• TIBC
• % TRANSFERRIN SATURATION
Only when serum Ferritin is normal but clinical and morphological picture
strongly suggestive of Iron Deficiency Anaemia

36. Management Of IDA

37. DIET --- IRON AND PROTEINS

38. SOURCES OF IRON
Green leafy vegetables
Legumes, Nuts
Jaggery , Dried Fruits
Meat , Liver ,
Poultry , Fish
SOURCES OF FOLIC ACID
Green leafy vegetables
Legumes, Nuts
Milk , Fruits
Meat , Liver , Eggs

39. •Anthelminthic medication in pregnant women with
anaemia after 12 weeks of pregnancy
•Drug of choice is single dose Mebendazole 100mg BD
for 3 days
OR Albendazole 400mg
WHO

40. Management Of IDA With Oral Iron Therapy

41. 41
Absorption from Ferrous Ascorbate can be as high
as 67% in Iron deficiency anemia patients
Key:
iron-depleted stores (IDS),
normal Fe status (NIS),
Fe deficiency without anemia (IDWA),
Fe deficiency anemia (IDA)
Biol Trace Elem Res. 2013 Dec;155(3):322-6. doi: 10.1007/s12011-013-9797-2. Epub 2013 Aug 27.

42. 42
Study On Ferrous Ascorbate - PRIDE Study
 Significantly more patients became non-anemic by treatment with ferrous ascorbate (93.33%) than with
carbonyl iron (46.66%).
 Ferrous ascorbate replenished ferritin stores to a greater extent than carbonyl iron.
Hb increase of 5 g/dl vs. 2.8 g/dl in 60 days
IJOG 2005; 8(4):23-30

43. Study On Ferrous Ascorbate - PRIDE Study
43
Rapid rise in Hb % by 5.03 within 60 days
IJOG 2005; 8(4):23-30

44. 44
Study on Ferrous Ascorbate – HERS Trial
N = 1461
The results show that at a dose of 1 tablet daily was effective in treating anemia, with rapid
increase in hemoglobin (mean: 2.37 g/ dl; 95%C.I.: 2.25 - 2.49) within 45 days, and was well
tolerated. The maximum increase of 3.60g/dl (95%C.I.: 3.07-4.13) was observed in those
with baseline hemoglobin less than 6g/dl.
Max 3.6 g/dl rise in 45 days
HERS study Group. IJGO 2005

45. Lets Compare Other Iron Salts With
Ferrous Ascorbate

46. Right Ratio For More Benefits
Right Ratio Of Iron And Ascorbic Acid Is Necessary To Form Stable Ferrous Ascorbate Complex Yielding
High Efficacy And Favourable Tolerability

47. Reported % Absorption Elemental Iron
Iron % absorption reference
Ferrous ascorbate 30.6- 67% British J Haemat, 1972, 22, 81, 281-286;
European Journal of Clinical Nutrition (2004) 58,
555–558; Archives Latinoamericanos de
Nutricion, 2001, 51,217-224; Arzneim-
Forsch/Drug Res, 1987, 37 (1a), 121-129
Biol Trace Elem Res. 2013 Dec;155(3):322-6. doi:
10.1007/s12011-013-9797-2. Epub 2013 Aug 27.
Ferrous sulphate 7.7 – 10.9% Nutrition Research. 1999, 19, No. 2, pp. 179-90
Iron polymaltose 8.8% Arzneim-Forsch/Drug Res, 1987, 37 (1a), 121-
129
Ferric ammonium citrate 2.4% Archives Latinoamericanos de Nutricion, 2001,
51,217-224
Ferric hydroxide 2.4% Sacnd J Haematology, 1982, 29, 1, 18-24
Ferric orthophosphate 8.3% British J Haemat, 1972, 22, 81, 281-286
Sodium iron
pyrophosphate
6.3% British J Haemat, 1972, 22, 81, 281-286
Ferric pyrophosphate 0% British J Haemat, 1972, 22, 81, 281-286
Ferrous fumarate 3 - 6.3% British Journal of Nutrition (2003), 90, 1081–
1085
Ferrous bisglycinate 6 – 9.1 % Am J Clin Nutr 2000;71:1563–9.
Ferrous gluconate Less than or equal
to ferrous sulphate
Nutritional Anemia, ISBN 3-906412-33-4
Carbonyl iron 70% of ferrous
sulphate
Eur J Haematol. 1991 May;46(5):272-8.

48. Non-Nutritional Causes Of Anemia
 Accelerated increase in requirement for iron during growth spurts
and pregnancy.
 Loss of blood in case of heavy menstrual bleeding.
 Loss of Blood during Post partum Period.
 Infections such as Malaria, Hookworm infestation etc.
 Teenage marriage and early pregnancy

49. Incidence and Prevalence of Menstrual Disorders

50. Impact of Heavy Menstrual Bleeding
In India, the reported
prevalence of AUB is
≈ 20%.
Nearly 28- 40 % of the
female population
consider their
menstruation as excessive
and plan their social
activities according to their
menstrual cycles.
10 -15 % of the employed
women take time off work
because of excessive
menstrual loss thus leading
to loss of productivity.
AUB accounts for
approximately 50% of
the visits of adolescent
girls /40 % adult
women to gynecologist.
1. https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/abnormal-uterine-bleeding
2. International Journal of Interdisciplinary and Multidisciplinary Studies (IJIMS), 2016, Vol 3, No.2,41-46.
3. Gaur SS et al., IOSR Journal of Dental and Medical Sciences 2020, 19(7).

51. Post Partum Haemorrhage
Postpartum
hemorrhage (PPH)
is a major cause of
maternal mortality,
accounting for 25%
of all maternal
deaths worldwide.
Postpartum
bleeding is the
quickest of
maternal killers;
can kill even a
healthy woman
within two hours, if
not treated.
Incidence of PPH is
reported as 2% - 4%
after vaginal
delivery and 6%
after cesarean
section.
WANT TO
DECREASE
MMR
CONTROL
PPH.
Ref: https://www.nhp.gov.in/disease/gynaecology-and obstetrics/postpartum-haemorrhage accessed on 01st Oct 2020

52. Focus on Tranexamic Acid

53. Focus On Tranexamic Acid (TXA)
PowerPoint templates and Guidelines 53
Anti-Fibrinolytic Drug
Indication: Prevention and treatment of haemorrhage due to general or
local fibrinolysis.
Dosage: 500-1000 mg 2-3 times daily.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/212895s000lbl.pdf

54. Mechanism Of Action
• TXA is a competitive inhibitor of plasminogen, and at high concentrations, is a noncompetitive
inhibitor of plasmin.
• Inhibition of both plasminogen activation and plasmin leads to stabilization of a preexisting
clot by impairing the process of fibrinolysis.
Stable Clot

55. Clinical Evidences With Tranexamic Acid

56. Use In Heavy Menstrual Bleeding
TXA has been studied for the treatment of Heavy Menstrual Bleeding since the 1960s.
Callender et al. evaluated the efficacy of TXA in women with HMB in a Clinical study.
• Women received either 500 mg of TXA four times daily for the first 4 days of their menstrual cycle,
or placebo, for three menstrual cycles.
• TXA use resulted in a significant reduction in pad count
Lukes et al. randomized women with HMB to either TXA 1.3 g three times daily for 5 days during
menstruation or matching placebo.
• TXA use had a 40% reduction in menstrual blood loss compared with an 8% reduction with
placebo (P ≤ 0.01).
“When compared with oral progestin therapy, TXA was found to be more effective in reducing menstrual
blood loss.”
1. Callender ST et al. Br Med J. 1970;4(5729):214–216.
2. Lukes AS et al. Obstet Gynecol. 2010;116(4):865–875

57. 57
Acta Obstet Gynecol Scand 2016; 95:28–37.
Meta-analysis of 9 RCTs; 2365 women
Prophylactic Tranexamic acid administration:
1. Is associated with a significant decrease in postpartum blood loss (mean difference –160.27 mL, 95% CI
224.63 to 95.92)
2. A significantly lower incidence of PPH and severe PPH
3. A significantly lower hemoglobin drop
4. Significantly less need for additional uterotonic agents
 We suggest consideration for adding tranexamic acid, 1 g (or 10 mg/kg) i.v. 10–20 min before skin incision
or spinal anesthesia.

58. 58
Study Population – 20,060 women
aged 16 years and older with a
clinical diagnosis of post-partum
haemorrhage after a vaginal birth
or caesarean section from 193
hospitals in 21 countries.
Objective – To evaluate effects of
early administration of Tranexamic
acid on death, hysterectomy, and
other relevant outcomes in women
with post-partum haemorrhage.
Intervention - 1g IV Tranexamic
acid or matching placebo in
addition to usual care. If bleeding
continued after 30 min, or
stopped and restarted within 24 h
of the first dose, a second dose of
1 g of Tranexamic acid or placebo
could be given.
2017 The WOMAN trial, The Lancet

59. WOMAN Trial - 2017
Results:
Death due to bleeding was significantly reduced in women given tranexamic acid [RR] 0·81
(Overall), 95% CI 0·65–1·00; p=0·045).
Women given treatment within 3 h of giving birth death due to bleeding decreased by 31 % (RR
0·69) in the tranexamic acid group.
59
Interpretation:
The administration of Tranexamic acid to women with post-partum haemorrhage reduces
deaths due to bleeding with no evidence of any adverse effects or complications.
2017 The WOMAN trial, The Lancet

60. Recommendations For Tranexamic Acid
World Health Organization :
• TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital
tract trauma or other causes after 3 hours of delivery.
• TXA should be part of the standard comprehensive PPH treatment package.
American College of Obstetricians and Gynaecologists:
“TXA should be considered in the setting of PPH when initial medical therapy fails”
60

61. New Ways Of Managing Anemia
Management With Ferrous Ascorbate:
 Superior Absorption, 4 times higher than most other
irons.
 Proven safety and efficacy. Achieves rapid Hb rise
 No interaction with food…can be given any time
 Ascorbic acid - Intrinsic free radical scavenging
property
 Better tolerated than other Iron preparations and
better compliance
Management With Tranexamic Acid:
 Safe and highly effective treatment for excessive
bleeding in Menstruation
 Offers a first-line, non-hormonal, nonsurgical
treatment option for women with cyclic heavy
menstrual bleeding.
 Tranexamic acid is safe in reducing the risk of death
in postpartum hemorrhage.
 Also useful in, post-operative hemorrhage,
dysfunctional uterine bleeding and trauma.

62. Focussed Discussion On Management of IDA
• As you know, Ferrous Ascorbate is considered as the reference iron molecule; In your
clinical practice, what average increase in Hb is noted with Ferrous Ascorbate?
• We have discussed about the landmark clinical studies and right ratio of Iron and
Ascorbate; In your opinion how relevant is this in Clinical Practice?
Q.

63. • What are your real life experiences about the tolerability of Ferrous
Ascorbate?
• In which type of patient profile do you consider Tranexamic acid
alone or with MF?
• Do you think here is a role of TXA in prevention of Anemia?
Focussed Discussion On Management of IDA
Q.