01. Anemia in Pregnancy - Anahita Chauhan

7/30/2019 01. Anemia in Pregnancy - Anahita Chauhan

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ANEMIA IN PREGNANCY


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Dr Anahita Chauhan

Associate Professor & Unit Head

Seth G S Medical College & KEM Hospita

Honorary Consultant,

Saifee & St. Elizabeth Hospital


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Background

Anaemia is the commonest medical disordepregnancy

Greek meaning without blood

Iron deficiency anaemia is the most commo

of anaemia during pregnancy

NFHS 2003-06: 57.9% of pregnant women

25% direct maternal deaths


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Definitions of Anemia in Pregn

WHO - Hemoglobin concentration


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Classification Based on Sever

ICMR WHO

Mild 10 11 gm/dl 9 11 gm/

Moderate 7 10 7 - 9

Severe 4 7


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Causes of Anemia in Pregnan Physiological anemia

Nutritional anemia IDA, megaloblastic

Anemia of chronic illness

Blood loss

Hemolysis and hemolytic anemias Hemoglobinopathies

Other hereditary anemias

Aplastic anemia


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Increased Iron Demands

1000mg extra elemental iron required in pre

Cannot be met by diet alone

Undernutrition compounds the problem


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Normal Reference Range

Hematological index Reference range

MCV (PCV/ RBC) 75 98 fl

MCH (Hb) 25 31 pg

MCHC 32 36%

TIBC 325 400 / 100ml

Fe/ TIBC ratio 30%


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Morphological Classificatio

By the size of the RBCs

Macrocytic anemia (MCV > 100)

Normocytic anemia (80 < MCV < 100)

Microcytic anemia (MCV < 80)


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Clinical Features - Symptom

Mild anemia is usually asymptomatic

Moderate anemia - weakness, fatigue, exhau

loss of appetite, indigestion, giddiness, breat

Severe anemia - palpitations, tachycardia,breathlessness, increased cardiac output, card

failure, generalised anasarca, pulmonary ede


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Clinical Features - Signs

Pallor

Nail changes

Cheilosis, Glossitis, Stomatitis

Edema

Hyperdynamic circulation (short & soft syst

murmur)

Fine crepitations


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Effects of Anemia on Mothe Antepartum

Preterm labor Pre eclampsia

Sepsis

IUGR

Intrapartum

Uterine inertia

PPH

Cardia failure


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Effects of Anemia on Mothe

Postpartum

Puerperal sepsis

Subinvolution

Pulmonary embolism

Failure of lactation

Delayed wound healing

Cardiac failure


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Fetal Effects

Prematurity and LBW

IUGR

IUFD

Increased perinatal mortality

Iron Deficiency Anemia due to lower iron st

cause poor mental performance or behavior

abnormalities in later life


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Diagnosis Baseline/ Presumpt Haemoglobin Measurement

Peripheral blood smear

Reticulocyte count

Hematocrit

Blood indices

MCV, MCHC, MCHC

Stool Examination

Urine Examination

Proteins, LFT, RFT


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Therapeutic Trial of Iron

Oral iron therapy

Increase in reticulocytes in 5 7 days

Rise in Hb at a rate of 2-4 gm/dl every 3till normal

If no response or incomplete responseadditional tests


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Diagnosis - Additional

Serum Fe

Total iron binding capacity

Serum Ferritin

Saturation

Hb electrophoresis

Bone marrow examination


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Lab findings in IDA Hb < 11 gm/dl

Peripheral smear - microcytic, hypochromic

MCV and MCHC are low

Serum iron is low - < 50 gm/dl (N 60 -175)

TIBC is increased - > 400 gm/dl Tests of iron stores

Serum ferritin is < 12 gm/dl (N 40-200)

Stainable iron in the bone marrow is redu


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Newer investigations Serum transferrin receptors

Transferrin receptor/ ferritin index

Reticulocyte indices

automated counting of reticulocytes, coun


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IDA ACD Thalass-emia S

Severity Variable Mild Mild V

MCV Decreased Normal/decreased

Decreased Nd

S Ferritin Decreased Normal/

increased

Normal I

TIBC Increased Decreased Normal N

S Iron Decreased Decreased Normal I

Marrow iron - + + +


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IDA Beta thal

Population All Greeks, Ita

RDW High Normal

MCV Low Low

Serum iron Decreased Normal

Ferritin Decreased Normal

TIBC Increased Normal

Hb electro-

phoresis

Normal Increased H


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Mentzer Index

Calculation that may (or may not) be useful

differentiating thalassemia minor from IDA

Mentzer Index = MCV/RBC Count

13 Iron Deficiency

Useful in children


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Folic Acid Deficiency Anemi

Deficiency of folate or B12

Anticonvulsants, oral contraceptives, sulfa d

and alcohol can decrease absorption of fola

meals

Folate is essential for normal growth and

development

Coexists with IDA


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Diagnosis

Macrocytes on peripheral smear

Hypersegmentation of neutrophils

Pancytopenia

Low Hb and high MCV Megablastosis on bone marrow

Serum folate


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Prevention

Dietary advice and modification

Iron supplementation of adolescent & non p

women

Treatment of hookworm Infestation

Iron supplementation in pregnant women

Food fortification

Antenatal care for early recognition


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Management of Anemia

Oral Iron Therapy Prophylactic Iron therapy- 100mg elementa

daily with 500 mcg of folic acid

Deworming of all anemic patients Treatment of Anemia- 200mg of elemental i

folate 5mg/d


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Iron Requirement in Pregnan

2.5mg /day in early pregnancy

5.5mg /day from 20 -32 weeks

6 8 mg/ day after 32 weeks

Average 4 mg/ day


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The tablet can be given with meals

different brand may be tried

Side effects of Oral iron

Nausea

Vomiting

Constipation

Abdominal cramping

Diarrhoea


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Reasons for Failure to Respo Non compliance

Concomitant folate deficiency Continuous loss of blood through hookworm

infestation or bleeding haemorrhoids

Co-existing infection Faulty iron absorption

Inaccurate diagnosis

Non iron deficiency microcytic anaemia

N Th i Al i


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New Therapeutic Alternative

The side effects of older Iron preparations &

poor compliance even on providing free tabthe most important reasons of failure of ana

control programmes

Newer preparations are better tolerated, ha

side effects with better compliance

Carbonyl Iron

Iron ascorbate

Merits of New Preparation


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Merits of New Preparation

Outstanding GI Tolerance in contrast to 20%

side effects with conventional therapy Very safe with no poisoning even in high do

No interaction with food stuffs

The newer preparations are delicious with nmetallic taste and dont stain the patients t

Hence the compliance is very high


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Parenteral Iron therapy

Indicated when the pregnant woman is unatake iron due to side effects or is non compl

Its main advantage is certainty of administra

Rise in hemoglobin is similar to oral iron (upper wk)


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Preparation & dosage

Iron Dextran IM and IV high molecular wt st

complexes release iron slowly, can cause anap

Iron citrate sorbitol IM less stable, rapid rele

iron

Iron sucrose IV intermediate stability, rapid

metabolism hence readily available iron. Sinc

not form biological polymers, there are no re


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Precaution

Oral Iron to be suspended 48 hours beforeparenteral therapy

Emergency measures like inj hydrocortisone

adrenaline, oxygen cylinder to be kept ready Look for reaction while giving infusion


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Dose calculation

Older preparations: each 1ml = 50mg eleme

0.3 x Wt in lb x (100 Hb%) + 500

Iron sucrose: each ml = 20mg elemental iron

Dose: 200mg slow IV alternate day

0.24 x wt in kg x (target Hbpt Hb) + 500


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Disadvantages Pain

Nausea, vomiting, headache Skin discolouration

Abscess formation

Fever Lymphadenopathy

Allergic reaction

Anaphylaxis


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Blood Transfusion

Severe anemia, especially after 36 we

Hemorrhage

Associated infections

Packed cells preferred

Exchange transfusion rare

f h i


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Use of Erythropoetin

Used in severe anemia & renal failure for sigincrease in Hb and to avoid blood transfusio

Gynaecological surgeries - preop use of

erythropoietin and Iron Dextran has been savoid the need for blood tranfusion later

h


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Dosage Regimen Erythropoe

Inj erythropoetin can be given subcut or iv 10

On day 1, 3 & 5 along with parenteral iron or

5 6000units s/c erythropoetin and iron dextra

deep im daily for 5 day

First dose given after subcut sensitivity test

Adrenaline, hydrocortisone, oxygen to be kep

Produces 3gm% rise in Hb over a 2wk period

M i L b


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Management in Labor

Make patient comfortable, oxygen

Sedation and analgesia

Prevent cardiac failure

Aim to deliver vaginally

Antibiotics

Cut short second stage

Active management of third stage Clinical Case Scenarios


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Clinical Case Scenarios A primigravida presents at 28 wks of gestatio

pallor, hemoglobin 7.8g%, no other medical

comorbidity, good functional status. Mostpragmatic first line therapy in cases with ass

compliance would be

a. blood transfusion b. parenteral iron

c. oral iron

d. oral plus parenteral iron An

Clinical Case Scenarios


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Foodstuff with highest available iron is

a. Red meat

b. Figs

c. Groundnut

d. Soyabean

A

Cli i l C S i


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A lady at 32 weeks gestation with hemoglob

red cell width is increased, taking iron suppLeast likely situation is

a. non compliance

b. intestinal parasites

c. thalassemia trait

d. anti epileptic medication

A

Cli i l C S i


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Single most important set of investigations i

recently diagnosed case of anaemia in pregn

a. Red cell indices

b. Retic count and peripheral smear

c. Iron studies

d. Hemoglobin electrophoresis

An


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G5P2L0A2 at 35 weeks gestation in early pre

labor. Hb is 8.8g%. All can be part of manageexcept

a. Steroids

b. Frusemide

c. Blood transfusion

d. Intra partum antibiotics

A

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01. Anemia in Pregnancy - Anahita Chauhan

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