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 June 8, 2016June 8, 2016 22Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

3. Pregnancy -The most dangerous journey of mankindAnemia is an Ice Berg June 8, 2016June 8, 2016 33Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

4. Embarrassing ...!!! June 8, 2016June 8, 2016 44Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

5. INDIAN SCENARIO June 8, 2016June 8, 2016 55Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

6. Magnitude June 8, 2016June 8, 2016 66Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

7. June 8, 2016June 8, 2016 Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160 77

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% June 8, 2016June 8, 2016 88Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

9. Hemorrhage 30% Anemia 19% Sepsis 16% Abortion 9% Obst. Lab 10% Toxemia 8% Others 8% CAUSES OF MATERNAL MORTALITY SRS-1998 UNCHANGED FOR 5 DECADESJune 8, 2016June 8, 2016 99Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

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. June 8, 2016June 8, 2016 1010Dr Shashwat JaniDr Shashwat Jani 99099 4416099099 44160

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 June 8, 2016 11Dr Shashwat Jani 99099 44160

12. Classification • Physiological: - Hemodilution in preg, - Negative iron balance, -Increased Fe binding capacity & absorbtion. -Normocytic & Normochromic An June 8, 2016 12 Dr Shashwat Jani 99099 44160

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. June 8, 2016 13 Dr Shashwat Jani 99099 44160

14. Stages involved in Iron Deficiency Anemia June 8, 2016 14 Dr Shashwat Jani 99099 44160

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. June 8, 2016 17 Dr Shashwat Jani 99099 44160

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 Dr Shashwat Jani 99099 44160

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 June 8, 2016 19 Dr Shashwat Jani 99099 44160

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 June 8, 2016 20 Dr Shashwat Jani 99099 44160

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. June 8, 2016 21 Dr Shashwat Jani 99099 44160

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. June 8, 2016 22 Dr Shashwat Jani 99099 44160

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. June 8, 2016 23 Dr Shashwat Jani 99099 44160

24. MOST CRITICAL PERIOD June 8, 2016 24 Dr Shashwat Jani 99099 44160

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 June 8, 2016 25 Dr Shashwat Jani 99099 44160

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. June 8, 2016 26 Dr Shashwat Jani 99099 44160

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 June 8, 2016 28 Dr Shashwat Jani 99099 44160

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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 June 8, 2016 30 Dr Shashwat Jani 99099 44160

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 June 8, 2016 31 Dr Shashwat Jani 99099 44160

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 June 8, 2016 32 Dr Shashwat Jani 99099 44160

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 June 8, 2016 33 Dr Shashwat Jani 99099 44160

34. Parenteral Therapy :Parenteral Therapy : Traditional IndicationsTraditional Indications ♦ Intolerance to oral iron ♦ Poor compliance to oral iron ♦ Gastrointestinal disorders ♦ Malabsorption syndromes ♦ Rapid blood loss June 8, 2016 34 Dr Shashwat Jani 99099 44160

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 June 8, 2016 35 Dr Shashwat Jani 99099 44160

36. WHO States that…WHO States that… ‘ Transfusion should be prescribed ONLY for conditions for which there is NO OTHER TREATMENT ’ June 8, 2016 36 Dr Shashwat Jani 99099 44160

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]. June 8, 2016 37 Dr Shashwat Jani 99099 44160

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. June 8, 2016 38 Dr Shashwat Jani 99099 44160

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 June 8, 2016 39 Dr Shashwat Jani 99099 44160

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. June 8, 2016 40 Dr Shashwat Jani 99099 44160

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. June 8, 2016 41 Dr Shashwat Jani 99099 44160

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. June 8, 2016 Dr Shashwat Jani 99099 44160 42

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 June 8, 2016 43 Dr Shashwat Jani 99099 44160

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. June 8, 2016 44 Dr Shashwat Jani 99099 44160

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 . June 8, 2016 45 Dr Shashwat Jani 99099 44160

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 Dr Shashwat Jani 99099 44160

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. June 8, 2016 47 Dr Shashwat Jani 99099 44160

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. June 8, 2016 48 Dr Shashwat Jani 99099 44160

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 . June 8, 2016 49 Dr Shashwat Jani 99099 44160

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 June 8, 2016 50 Dr Shashwat Jani 99099 44160

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. June 8, 2016 51 Dr Shashwat Jani 99099 44160

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 . June 8, 2016 52 Dr Shashwat Jani 99099 44160

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

54. June 8, 2016 Dr Shashwat Jani 99099 44160 54

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 June 8, 2016 55 Dr Shashwat Jani 99099 44160

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 June 8, 2016 56 Dr Shashwat Jani 99099 44160

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 June 8, 2016 57 Dr Shashwat Jani 99099 44160

58. ANEMIC MYTHS… June 8, 2016 58 Dr Shashwat Jani 99099 44160

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 June 8, 2016 59 Dr Shashwat Jani 99099 44160

60. • Social services • Improvement in sanitation • Personal hygiene • Better education of female regarding diet • Contraception • Food fortification Iron fortified salt like iodine salt June 8, 2016 60 Dr Shashwat Jani 99099 44160

61. Thank youThank you

ANEMIA IN PREGNANCY BY DR SHASHWAT JANI

ANEMIA IN PREGNANCY BY DR SHASHWAT JANI

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