DIAGNOSIS CAUSES AND TREATMENT OF ANEMIA IN PREGNANCY

1. DR SUNITA YADAV
SPECIALIST VMMC

2. MOST COMMON MEDICAL DISORDER
IN PREGNANCY IN DEVELOPING
COUNTRIES.
20% OF MATERNAL DEATHS IN
DEVELOPING COUNTRIES.
PREVALENCE IN INDIA- 69-97%

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. MILD- 9-10.9 gm%
MODERATE- 7-8.9 gm%
SEVERE- <7gm%
VERY SEVERE- <4gm%

5.  A. PHYSIOLOGICAL ANEMIA OF
PREGNANCY
B. PATHOLOGICAL
#DEFICIENCY ANEMIA
.IRON DEF.
. FOLIC ACID DEF.
.B12 DEF.
.PROTEIN DEF.

6.  # HAEMORRHAGIC
 #HAEMOLYTIC
 -FAMILIAL-
 SICKLE CELL,CONGENITAL ACHOLURIC
JAUNDICE
 -ACQIRED-
 MALARIA,SEVERE INFECTION
 #BONE MARROW
INSUFFICIENCY

 #HEMOGLOBINOPATHY

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. BONE MARROW.
PRONORMOBLAST
 !
NORMOBLAST
 !
RETICULOCYTE
 !
 ERYTHROCYTE

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.  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.  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.  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. MEAT-(LIVER)
FISH
POULTRY
GREEN VEGETABLE-SPINACH,
BEANS,MUSTARD,BROCCOLI
SPROUTED PULSE
JAGGERY
DATES
FRUITS-APPLE, BANANA

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.  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. 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. 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.  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.  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. L) S. TRANSFERRIN RECEPTOR-
 SENSITIVE AND SPECIFIC MARKER
IN IDA IN PREGNANCY.VERY
EXPENSIVE.NOT ROUTINELY
AVAILABLE.
M)BONE MARROW-

21.  MATERNAL-
 preterm labour
 PIH
 CHF
 infections
 PPH
 H’gic shock
 puerperal sepsis
 subinvolution
 thromboembolism
 failure of lactation

22.  prematurity
 growth retardation
Poor iron stores
Increased perinatal mortality

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. 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. 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. SIDE EFFECTS
STEP UP DOSE GRADUALLY TO AVOID
INTOLERANCE.

CHECK COMPLIANCE
RESPONSE OF THERAPY
FAILURE OF THERAPY

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. DOSE OF IRON(mg)
HB%DEFICIT X WT.(KG) X 2.2 + 1000
250MG X HB% DEFICIT

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. IRON SUCROSE-
SAFE.
NO TEST DOSE REQUIRED
IV BOLUS OR IV INFUSION-200 MG IV
EVERY ALTERNATE DAY
INJ.ADRENALINE,ANTIHISTAMINIC,
INJ. HYDROCORTISONE .

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. SEVERE ANEMIA IN FAILURE
WITHDRAW PT. BLOOD AND CREATE
DEFICIT AND SIMULTANEOUSLY
TRANSFUSE.

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. VIT B12 AND FOLIC ACID REQIRED FOR
DNA REPLICATION.DEFICIENCY-
ABNORMAL PRECURSORS CALLED
MEGALOBLAST.
FOLIC ACID DEFICIENCY MORE
COMMON.
INCIDENCE-3%

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.  INV.-
 MCV>96 FL
 MCHC N
 P/S-macrocytes.normochromia
,hypersegmented
neutrophils,thrombocytopenia ,neutropenia
 S.FOLATE-<3NG/ML,RBC FOLATE-
<150NG/ML

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. NOT AVAILABLE FROM PLANTS.ONLY
ANIMAL SOURCE.
CAUSE-VEGETARIANS,PERNICIOUS
ANEMIA,MALABSORPTION
C/F-ANEMIA ,PURPURA,SORE
TONGUE,DIARRHOEA,NEUROLOGICAL
MANIFESTATION

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. COMMON.
DIAGNOSIS-
 P/S
 HB ELECTROPHORESIS
TREATMENT

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