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Anemia in pregnancy sunita

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DIAGNOSIS CAUSES AND TREATMENT OF ANEMIA IN PREGNANCY

Publicada em: Saúde e medicina
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Anemia in pregnancy sunita

  1. 1. DR SUNITA YADAV SPECIALIST VMMC
  2. 2. MOST COMMON MEDICAL DISORDER IN PREGNANCY IN DEVELOPING COUNTRIES. 20% OF MATERNAL DEATHS IN DEVELOPING COUNTRIES. PREVALENCE IN INDIA- 69-97%
  3. 3. LOW Hb CONC. RESULTING IN DECREASE IN OXYGEN CARRYING CAPACITY OF BLOOD. WHO- Hb% <11GM%  PCV<33% FOGSI AND ICMR- Hb%<10GM%  PRACTICALLY Hb <11GM% IS TAKEN FOR ANEMIA
  4. 4. MILD- 9-10.9 gm% MODERATE- 7-8.9 gm% SEVERE- <7gm% VERY SEVERE- <4gm%
  5. 5.  A. PHYSIOLOGICAL ANEMIA OF PREGNANCY B. PATHOLOGICAL #DEFICIENCY ANEMIA .IRON DEF. . FOLIC ACID DEF. .B12 DEF. .PROTEIN DEF.
  6. 6.  # HAEMORRHAGIC  #HAEMOLYTIC  -FAMILIAL-  SICKLE CELL,CONGENITAL ACHOLURIC JAUNDICE  -ACQIRED-  MALARIA,SEVERE INFECTION  #BONE MARROW INSUFFICIENCY   #HEMOGLOBINOPATHY
  7. 7.  PLASMA VOLUME INCREASES 40% BUT RBC VOLUME INCREASES 20%- HEMODILUTION.  INCREASE DEMAND ESP. IN SECOND HALF.  TYPE-NORMOCYTIC ,NORMOCHROMIC  CRITERIA-HB-10GM%, PCV-30%  EXPECTED HB AT TERM- HB IN 1st TRIMESTER- 2GM%
  8. 8. BONE MARROW. PRONORMOBLAST  ! NORMOBLAST  ! RETICULOCYTE  !  ERYTHROCYTE
  9. 9.  LIFE SPAN OF RBC-120 DAYS  HAEMOGLOBIN BROKEN INTO- HEMOSIDERIN AND BILE PIGMENT  REQUIRES-  A)IRON AND TRACE ELEMENTS  B)VITAMIN- B-12 ,FOLIC ACID,VITAMIN -C  C)PROTEIN  D)ERYTHROPOIETIN- BY KIDNEY (90%) ,LIVER (10%)
  10. 10.  AVERAGE IRON REQUIREMENT/DAY THROUGHOUT PREGNANCY-  4 MG/DAY .  ABSORPTION OF IRON-10%.  HENCE 40-60 MG OF IRON REQUIRED / DAY TO ACHIEVE 4-6 MG OF ABSORPTION.  AVARAGE INDIAN DIET FAILS TO DELIVER HENCE SUPPLEMENTATION REQUIRED.
  11. 11.  A)FAULTY DIET  -diet rich in phosphates and phytates,tannic acid,calcium  -lack of awareness  -poverty and malnutrition  -food fadism  -faulty cooking  B)FAULTY ABSORPTION  -malabsorption  -diarrhoea  -worm infestation  -hypochlorohydria  C)IRON LOSS  -blood loss –piles,peptic ulcer,hookworm,menorrhagia  -through sweat  -chronic malaria
  12. 12.  A)INCREASED DEMAND  -physiological anemia  -multiple pregnancy  -acute or chronic blood loss  B)DECREASED INTAKE  -nausea and vomitting  -intolerance to iron  C)LOW IRON RESERVE  -multiparity  -teenage pregnancy  D)DECREASED ABSORPTION
  13. 13. MEAT-(LIVER) FISH POULTRY GREEN VEGETABLE-SPINACH, BEANS,MUSTARD,BROCCOLI SPROUTED PULSE JAGGERY DATES FRUITS-APPLE, BANANA
  14. 14.  ASYMTOMATIC IN MILD  TIREDNESS  DIZZINESS  BREATHLESSNESS  LOSS OF APPETITE  INDIGESTION  PALPITATION  SWELLING OF LEGS OR ANASARCA  PICA  O/E-PALLOR  NAIL CHANGES  SSM ON CVS EXAMINATION  BASAL CREPTS IN FAILURE
  15. 15.  INVESTIGATIONS-  HEMOGRAM WITH P/S  PCV  MCV,MCH,MCHC  RETICULOCYTE COUNT  SERUM IRON  TIBC  %SATURATION  S.FERRITIN  URINE R/M  RETICULOCYTE COUNT  STOOL FOR OVA AND CYST  LFT  S.PROTEIN
  16. 16. A) HB%-SAHLI OR CYANOMETHEMOGLOBIN METHOD B) P/S-LEISHMAN STAIN.MICROCYTIC,HYPOCHROMIC,AN ISOCYTOSIS ,POIKILOCYTOSIS,WITH OR WITHOUT TARGET CELLS. C)RETIC. COUNT- >3% D) PCV- 32-36% N  <30% IN IDA
  17. 17. E) BLOOD INDICES-  MCV,MCH,MCHC- ALL REDUCED.  MCHC MOST SENSITIVE INDEX AS NOT BASED ON RBC COUNT. RBC<4 MILLION/MM3 PCV<30% MCV<75 Fl MCH<25PG MCHC<30%
  18. 18.  F)SERUM IRON-  <60 MICROGRAM/dl  (60-120 MICROGRAM/dl N )  G)TIBC(S. TRANSFERRIN)-  >400 MICROGRAM/dl  (300-400 MICROGRAM/dl N)  H) S.FERRITIN-  <15 MICROGRAM/L  (15-300 MICROGRAM/l or ng/ml )  MEASURED BY RIA.GIVES STATUS OF IRON STORES.UNAFFECTED BY RECENT IRON.
  19. 19.  I) % SATURATION OR TRANSFERRIN SATURATION-  <10%  J) FEP –FREE ERYTHROCYTE PROTOPORPHYRIN  >50 MICROGRAM/Dl  (<35 N )  K) RED CELL DISTRIBUTION WIDTH(RDW)-  >15% IN IDA DUE TO HETEROGENOUS POPULATION WITH DIFF. DIAMETERS.
  20. 20. L) S. TRANSFERRIN RECEPTOR-  SENSITIVE AND SPECIFIC MARKER IN IDA IN PREGNANCY.VERY EXPENSIVE.NOT ROUTINELY AVAILABLE. M)BONE MARROW-
  21. 21.  MATERNAL-  preterm labour  PIH  CHF  infections  PPH  H’gic shock  puerperal sepsis  subinvolution  thromboembolism  failure of lactation
  22. 22.  prematurity  growth retardation Poor iron stores Increased perinatal mortality
  23. 23. PREVENT IDA IN ADOLESCENTS- 12 BY 12 INITIATIVE-AIM TO ACHIEVE HB OF 12GM% BY 12 YRS USING PROPHYLACTIC IRON AND FA THERAPY. DEWORMING-  MEBENDAZOLE 100 MG BD X 2 DAYS  ALBENDAZOLE 400 MG.
  24. 24. MIN. OF HEALTH ,GOVT. OF INDIA – 100 MG OF ELEMENTAL IRON WITH 0.5 MG FOLIC ACID IN SECOND HALF FOR 100 DAYS. 1 IRON TAB. OF IRON OF ANY FORM ENOUGH FOR PROPHYLAXIS PROVIDED THERE IS NO PREEXISTING ANEMIA.
  25. 25. ORAL IRON – SEVERAL IRON SALTS. IRON ASCORBATE PREFERRED DUE TO BETTER ABSORPTION. ROUTE OF CHOICE AS RISE IN HB% SAME IN ORAL AND PARENTERAL- 0.8GM% /WEEK. DOSE- 1TDS -2 TDS
  26. 26. SIDE EFFECTS STEP UP DOSE GRADUALLY TO AVOID INTOLERANCE.  CHECK COMPLIANCE RESPONSE OF THERAPY FAILURE OF THERAPY
  27. 27.  INDICATION-  .INTOLERANCE TO ORAL IRON . .NON COMPLIANCE. .ADVANTAGE OF REPLENISHING IRON STORES. AVAILABLE- iron dextran(imferon) iron sorbitol citrate(jectofer) iron sucrose ferric carboxy maltose
  28. 28. DOSE OF IRON(mg) HB%DEFICIT X WT.(KG) X 2.2 + 1000 250MG X HB% DEFICIT
  29. 29.  IRON DEXTRAN-  .100MG/DAY- 1 AMP (2 ML)- AST (1 ML ON DAY 1) THEN 1 AMP ON ALTERNATE DAYS IN UPPER OUTER QUADRANT OF BUTTOCK.   TDI(TOTAL DOSE INFUSION)  SIDE EFFECTS-painful abscess discolouration,rigors,chest pain ,hypotension,fever,myalgia,arthralgia,headache,na usea vomitting,lymphadenopathy,anaphylactic reaction.
  30. 30. IRON SUCROSE- SAFE. NO TEST DOSE REQUIRED IV BOLUS OR IV INFUSION-200 MG IV EVERY ALTERNATE DAY INJ.ADRENALINE,ANTIHISTAMINIC, INJ. HYDROCORTISONE .
  31. 31.  INDICATIONS-  SEVERE ANEMIA AFTER 36 WEEKS  ANEMIA DUE TO BLOOD LOSS  ASSOCIATED INFECTION  NOT RESPONDING TO THERAPY  ADV.-RAPID IMROVEMENT IN OXYGEN CARRYING CAPACITY.  RISK-transfusion reaction,overloading heart,preterm labour,infections transmitted.  PACKED CELLS PREFERRED OVER WHOLE BLOOD.
  32. 32. SEVERE ANEMIA IN FAILURE WITHDRAW PT. BLOOD AND CREATE DEFICIT AND SIMULTANEOUSLY TRANSFUSE.
  33. 33. PROPPED UP OR COMFORTABLE POSITION OXYGEN READY IV LINE ARRANGE BLOOD A/B PROPHYLAXIS CUT SHORT SECOND STAGE ACTIVE MX OF THIRD STAGE
  34. 34. VIT B12 AND FOLIC ACID REQIRED FOR DNA REPLICATION.DEFICIENCY- ABNORMAL PRECURSORS CALLED MEGALOBLAST. FOLIC ACID DEFICIENCY MORE COMMON. INCIDENCE-3%
  35. 35.  CAUSE-  .food lacking in green vegetables  prolonged cooking  malabsorption  antiepileptic drugs  increased demand in pregnancy and lactation  hemolytic anemia ,malignancy  inflammatory conditions  h’ge  iron deficiency
  36. 36.  INV.-  MCV>96 FL  MCHC N  P/S-macrocytes.normochromia ,hypersegmented neutrophils,thrombocytopenia ,neutropenia  S.FOLATE-<3NG/ML,RBC FOLATE- <150NG/ML
  37. 37. S. IRON- N RAISED LDH,S.BILIRUBIN MAY BE RAISED INCREASED HOMOCYSTEINE LEVELS BONE MARROW-MEGALOBLASTS  TREATMENT-5MG FOLIC ACID /DAY INJ.-15 MG FA AND 0.5 MG VIT B12 IM FOR 7-10 DAYS
  38. 38. NOT AVAILABLE FROM PLANTS.ONLY ANIMAL SOURCE. CAUSE-VEGETARIANS,PERNICIOUS ANEMIA,MALABSORPTION C/F-ANEMIA ,PURPURA,SORE TONGUE,DIARRHOEA,NEUROLOGICAL MANIFESTATION
  39. 39. B12 LEVEL <90 MICROGRAM/L S.HOMOCYSTEINE RAISED DEOXYURIDINE SUPPRESSION TEST USED TO DIFFERENTIATE BETWEEN FA AND B 12 DEFICIENCY. TREATMENT-B12 INJ IM DAILY OR ALTERNATE FOR 7 – 10 DAYS.
  40. 40. COMMON. DIAGNOSIS-  P/S  HB ELECTROPHORESIS TREATMENT
  41. 41. MORE COMMON IN AFRICA CARRIER STATE-1:100 IN INDIA STRUCTURAL ABNORMALITY IN BETA CHAIN. RBC HAVE HbS .IN DEOXYGENATED STATE AGGREGATES,POLYMERISES AND DISTORTS RBS. HEMOLYSIS,ANEMIA JAUNDICE DX- SICKLING TEST,HIGH S.IRON,ELECTROPHORESIS

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