ANEMIA IN PREGNANCY BY DR SHASHWAT JANI

1. Anemia In Pregnancy
Mother 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 : drshashwatjani@gmail.com

2. Pregnancy -The most dangerous
journey of mankind
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3. Pregnancy -The most dangerous
journey of mankindAnemia is an Ice
Berg
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4. Embarrassing ...!!!
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5. INDIAN SCENARIO
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6. Magnitude
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8. 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 women20-80% amongst pregnant women
56% of adolescent girls, 30% boys56% of adolescent girls, 30% boys
79% of children79% 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%
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9. Hemorrhage
30%
Anemia
19%
Sepsis
16%
Abortion
9%
Obst. Lab
10%
Toxemia
8%
Others
8%
CAUSES OF MATERNAL MORTALITY
SRS-1998
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10. 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
•• CDCCDC ---- First and third trimesters : Hb <11gm/dlFirst and third trimesters : Hb <11gm/dl
Second trimester <10.5gm/dlSecond 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-- 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.aged women. Morbidity and Mortality Weekly Report 38, 400–404.
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11. Iron deficiency
Megaloblastic
Hemolytic
Aplastic
%
86
06
4 to 5
3 to 4
Clinical
Mild
Moderate
Severe
Very severe
Gm %
9 to 11
7 to 8.9
4 to 6.9
< 4
WHO & ICMR
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12. Classification
• Physiological: - Hemodilution in preg,
- Negative iron balance,
-Increased Fe binding
capacity & absorbtion.
-Normocytic & Normochromic An
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13. • 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.
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14. Stages involved in Iron Deficiency Anemia
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15. 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
EarliestEarliest
markermarker
of Ironof Iron
deficiencydeficiency
↓Hb % is a
very late
indicatorJune 8, 2016 15

16. Early
Pregnancy
2.5 mg / day
32 to 40
weeks
6.8 mg / day
TOTAL
800 – 1000 mg
20 to 32
weeks
5.5 mg / day
RBC =500mg
Fetus+Placenta
=450mg
Third stage blood loss =200mg
Total = 1150mg
Iron Requirement During Pregnancy

17. 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.
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18. 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 failureJune 8, 2016 18
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19. Work up of Pregnancy with Anemia
Detailed H/o – age, parity, diet, chronic
bleeding, worm infestation, malaria, race etc
Examination
Pallor
Glossitis
Splenomegaly – hemolytic anemia
Jaundice – hemolytic anemia
Purpura – bleeding disorder
Evidence of chronic disease – Renal , TB
Anasarca & signs of cardiac failure in severe cases
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20. Diagnosis of IDA
Characteristics 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 increased
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21. 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.
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22. 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.
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23. 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.
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24. MOST CRITICAL PERIOD
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25. MANAGEMENT OPTIONS :
Pre – pregnancy :
 Treat the cause before conception
 Pre-pregnancy balanced diet, education and
health support.
 Build up iron stores during adolescent
phase
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26. Iron rich food
Green leafy vegetables-chana sag,
sarson ka sag, chauli. Sowa,
salgam
Cereals - wheat, ragi, jowar, bajra
Pulses-sprouted pulses
Jaggery
Dryfruits
Animal flesh food - meat, liver
Vit C - lemon, orange, guava,
amla, green mango etc.
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27. Vegetables / FruitsVegetables / Fruits
Daily take 5 different colors in diet!Daily take 5 different colors in diet!

28. Modalities
Oral Iron
Blood
transfusionParenteral
Injectable IronInjectable Iron
Human Recombinant
Erythropoietin
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29. June 8, 2016 29

30. 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
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31. 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
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32. 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 Oral Wrong
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33. 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
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34. Parenteral Therapy :Parenteral Therapy :
Traditional IndicationsTraditional Indications
♦ Intolerance to oral iron
♦ Poor compliance to oral iron
♦ Gastrointestinal disorders
♦ Malabsorption syndromes
♦ Rapid blood loss
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35. ♦ Inability to maintain iron balanceInability to maintain iron balance
(haemodialysis)(haemodialysis)
♦ Patient donating large amount of bloodPatient 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
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36. WHO States that…WHO States that…
‘ Transfusion should be
prescribed ONLY for conditions
for which there is NO OTHER
TREATMENT ’
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37. Parental Iron Therapy
Preparations
 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].
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38.  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.
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39. IRON SUCROSE
 Dose calculated –
Wt in Kg x iron deficit x 2.2 + 1000 mg for iron
stores
Response - by increase in Hb level 1g/week
 Increase in Reticulocyte count with in 5-10
days
 Clinical symptoms improve
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40. 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.
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41. 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.
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42. 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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43. Indications of
Blood Transfusion
Severe anemia first seen after 36
weeks of pregnancy
Anemia due to acute blood Loss –
APH & PPH
Associated Infection
Patient not responding to oral or
parenteral therapy
Anemic & symptomatic pregnant
women (dyspneic, with heart failure
etc) irrespective of gestational age
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44. 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.
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45. 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 .
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46. Diagnosis of FDA
Characteristics 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
dehydogenase
HomoCysteine
Increased
IncreasedJune 8, 2016 46
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47. 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.
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48. 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.
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49. 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 .
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50. 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 Raised
HbA2 2-3%
Normal Raised
Red cell width high Normal
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51. 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.
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52. 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 .
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53. 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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55. Labor should be supervised
Proper counseling & consent to be taken
Blood (whole & packed) kept cross matched
Women nursed in propped up position
Intermittent O2 to be given
Precaution to prevent infection & blood loss
Strict aseptic precautions & minimal P/V exams
Prophylactic antibiotic can be given
Patent iv line but fluids are avoided
In decompensated patient diuretic given
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56. 2nd
& 3rd
Stage of labour
Second stage cut short by forceps or ventouse
Active management of 3rd
stage of labour to be done
Oxytocics, P/R misoprostol can be given after
delivery of fetus
Injection methergin iv contraindicated
Even normal blood loss may be tolerated poorly in
anemic patient
IV Frusemide given after delivery to decrease
cardiac load
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57. Post natal Care & Contraception
Early ambulation is encouraged
Hematinics are continued for 3-6 months
Watch for subinvolution , puerperal
sepsis, CHF, thrombo-embolism &
lactation failure
Avoid pregnancy at least for 2 years
LAM, barrier contraception, POP after 3
weeks, IUCD or permanent sterilization
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58. ANEMIC MYTHS…
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59. 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
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60. • Social services
• Improvement in sanitation
• Personal hygiene
• Better education of female regarding diet
• Contraception
• Food fortification Iron fortified salt like iodine
salt
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61. Thank youThank you