Rajeev OjhaRajeev Ojha

Anemia in PregnancyAnemia in Pregnancy

Case 1Case 1

Mrs. A. N. is a 28-year-old woman in her Mrs. A. N. is a 28-year-old woman in her second trimester of pregnancy with her first second trimester of pregnancy with her first child, and though her pregnancy had been child, and though her pregnancy had been progressing normally, recently she has progressing normally, recently she has noticed that she tires very easily and is noticed that she tires very easily and is short of breath from even the slightest short of breath from even the slightest exertion. She also has experienced periods exertion. She also has experienced periods of light-headedness, though not to the point of light-headedness, though not to the point of fainting. Other changes she has noticed of fainting. Other changes she has noticed are cramping in her legs, and the fact that are cramping in her legs, and the fact that her tongue is sore. her tongue is sore.

Upon examining, she has tachycardia, pale Upon examining, she has tachycardia, pale gums and nail beds, and her tongue is gums and nail beds, and her tongue is swollen. Given her history and the findings swollen. Given her history and the findings on her physical exam, she is suspected to on her physical exam, she is suspected to be anemic and a sample of her blood is be anemic and a sample of her blood is orderes for examination. orderes for examination.

Table 1. Blood Sample Results

Red Blood Cell Count 3.5 million/mm3

Hemoglobin (Hb) 7 g/dl

Hematocrit (Hct) 30%

Serum Iron low

Mean Corpuscular Volume (MCV) low

Mean Corpuscular Hb Concentration (MCHC)

low

Total Iron Binding Capacity in the Blood (TIBC)

high

A diagnosis of anemia due to iron A diagnosis of anemia due to iron deficiency is made and oral iron deficiency is made and oral iron supplements prescribed. Her supplements prescribed. Her symptoms are eliminated within a symptoms are eliminated within a couple of weeks and the remainder couple of weeks and the remainder of her pregnancy progresses without of her pregnancy progresses without difficulty.difficulty.

Case 2Case 2

A 35 year old woman is seen for easy A 35 year old woman is seen for easy fatigue for many months. She is now 24 fatigue for many months. She is now 24 weeks pregnant with her 3rd child in 3 weeks pregnant with her 3rd child in 3 years. She does not see any obstetrician years. She does not see any obstetrician and does not take any vitamins. Lately, she and does not take any vitamins. Lately, she has developed a taste for eating ice has developed a taste for eating ice (craving to taste ice, soil etc). She has no (craving to taste ice, soil etc). She has no other complaint. Family and past history other complaint. Family and past history are negative. She does not smoke or drink. are negative. She does not smoke or drink. Physical examination is positive for pale Physical examination is positive for pale conjunctiva, mild spooning of nails, and a conjunctiva, mild spooning of nails, and a II/VI systolic murmur at left lower sternal II/VI systolic murmur at left lower sternal border. Stools are negative for occult blood.border. Stools are negative for occult blood.

Labs:Labs:

Complete blood count (CBC)Complete blood count (CBC)- Hb 7.1 gm/dl, Hct 23% - Hb 7.1 gm/dl, Hct 23% - WBC 5,400/mm3 (differential is normal) - WBC 5,400/mm3 (differential is normal)

- Platelets 450,000/mm3- Platelets 450,000/mm3- Mean Corpuscular volume (MCV) is 74 fl - Mean Corpuscular volume (MCV) is 74 fl (normal 85-95 fl) (normal 85-95 fl)- Red cell Distribution Width (RDW) is - Red cell Distribution Width (RDW) is 17.1% (normal 13-15). 17.1% (normal 13-15).

Defination of Anemia during Defination of Anemia during Preg.Preg.

Hemoglobin below 11gm/dl in 1Hemoglobin below 11gm/dl in 1stst and and 33rdrd trimester and below 10.5gm/dl in trimester and below 10.5gm/dl in second trimester.second trimester.

WHOWHO

11gm/dl or less11gm/dl or less

By this standard, 50% of women not By this standard, 50% of women not on hematinics become anemic.on hematinics become anemic.

IncidenceIncidence

Anaemia may affect 10% of pregnancies in developed countries and is considerably commoner in developing countries, where it is a major source of maternal morbidity

and a contributor to mortality. Up to 56% of all women living in

developing countries are anaemic (Hb < 11 g/dl) due to infestations.

ClassificationClassification

PhysiologicPhysiologicPathologic: Pathologic:

a. Deficiency: Iron, Folic A., Vitamin B12a. Deficiency: Iron, Folic A., Vitamin B12b. Hemorrhagic: APH, Hookwormb. Hemorrhagic: APH, Hookwormc. Hereditary: Thalassemia, Sickle, H. Hemolytic c. Hereditary: Thalassemia, Sickle, H. Hemolytic AnemiaAnemiad. Bone Marrow Insufficiency: Aplastic Anemiad. Bone Marrow Insufficiency: Aplastic Anemiae. Infections: Malaria, TBe. Infections: Malaria, TBf. Chronic Renal Diseases or Neoplasm.f. Chronic Renal Diseases or Neoplasm.

Concept of Physiologic Concept of Physiologic AnemiaAnemia

Disproportionate increase in plasma Disproportionate increase in plasma vol, RBC vol. and hemoglobin mass vol, RBC vol. and hemoglobin mass during pregnancyduring pregnancy

Marked demand of extra iron during Marked demand of extra iron during pregnancy especially in second pregnancy especially in second trimestertrimester

Criteria for Physiologic Criteria for Physiologic AnemiaAnemia

Hb: 10gm%Hb: 10gm%RBC: 3.2 million/mm3RBC: 3.2 million/mm3PCV: 30%PCV: 30%Peripheral smear showing normal Peripheral smear showing normal

morphology of RBC with central morphology of RBC with central pallorpallor

Significance of HypervolemiaSignificance of Hypervolemia

1. To meet the demands of the enlarged uterus 1. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system.with its greatly hypertrophied vascular system.

2. To protect the mother, and in turn the fetus, 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired against the deleterious effects of impaired venous return in the supine and erect venous return in the supine and erect positions.positions.

3. To safeguard the mother against the adverse 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.effects of blood loss associated with parturition.

Normal hemoglobin by gestational Normal hemoglobin by gestational age in pregnant women taking iron age in pregnant women taking iron supplementsupplement

12 wks12 wks 12.2 [11.0-13.4]12.2 [11.0-13.4]24wks24wks 11.6 [10.6-12.8]11.6 [10.6-12.8]40 wks40 wks 12.6 [11.2-13.6]12.6 [11.2-13.6]

Most common causes of Most common causes of AnemiaAnemia

Iron loss : sweat, repeated Iron loss : sweat, repeated pregnancy, hookworm infestation pregnancy, hookworm infestation and malariaand malaria

Faulty absorption mechanism : due Faulty absorption mechanism : due to high incidence of intestinal to high incidence of intestinal infestation, there is intestinal hurryinfestation, there is intestinal hurry

Faulty diet habit : rich carbohydrate Faulty diet habit : rich carbohydrate and high phosphate reduce and high phosphate reduce absorption of ironabsorption of iron

Factors lead to develop Factors lead to develop AnemiaAnemia

Increase iron demandIncrease iron demandDiminished intake of ironDiminished intake of ironDisturbed metabolismDisturbed metabolismPre-pregnancy health statusPre-pregnancy health statusExcess demandExcess demand

Iron Deficiency AnaemiaIron Deficiency Anaemia

Symptoms: lassitude, weakness, Symptoms: lassitude, weakness, anorexia, palpitation, dyspneaanorexia, palpitation, dyspnea

Signs: Pallor, glossitis, soft systolic Signs: Pallor, glossitis, soft systolic murmur in mitral area due to murmur in mitral area due to physiologic mitral incompetencephysiologic mitral incompetence

Degree: Mild: 8-10gm%Degree: Mild: 8-10gm% Moderate: 7-8gm% Moderate: 7-8gm%

Severe: <7gm% Severe: <7gm%

pallorpallor

Conjunctival PallorConjunctival Pallor

KoilonychiaKoilonychia

Smooth TongueSmooth Tongue

Interpretation of plasma Iron Interpretation of plasma Iron

IronIron TIBCTIBC FerritinFerritin

Iron deficiency Iron deficiency anemiaanemia

DecreasDecreasee

IncreasIncreasee

DecreasDecreasee

Anemia of Anemia of chronic chronic diseasedisease

DecreasDecreasee

DecreasDecreasee

IncreaseIncrease

PregnancyPregnancy IncreasIncreasee

IncreasIncreasee

NormalNormal

Normal Iron Requirements

Iron requirement for normal pregnancy is 1gm

200 mg is excreted300 mg is transferred to fetus500 mg is need for mother

Total volume of RBC inc is 450 ml1 ml of RBCs contains 1.1 mg of iron450 ml X 1.1 mg/ml = 500 mg

Daily average is 6-7 mg/day

TreatmentTreatment

Prophylactic: Supplement Fe – 60 mg: Supplement Fe – 60 mg elemental Fe with Folic Acidelemental Fe with Folic Acid

Curative: 200mg FeSo4 3 times daily Curative: 200mg FeSo4 3 times daily till till Hb level becomes normal, Hb level becomes normal, then then maintenance dose of 1 tab for maintenance dose of 1 tab for

100 days 100 days

Megaloblastic AnemiaMegaloblastic Anemia

Due to impaired DNA synthesis, Due to impaired DNA synthesis, derangement in Red Cell maturationderangement in Red Cell maturation

It may be due to Def. of VitB12 or Folic It may be due to Def. of VitB12 or Folic Acid or both.Acid or both.

Megaloblastic anemia in pregnancy is Megaloblastic anemia in pregnancy is almost always due to Folic Acid def.almost always due to Folic Acid def.

Vit B12 def is rare in Pregnancy becoz its Vit B12 def is rare in Pregnancy becoz its need is less in amount and amount is met need is less in amount and amount is met with any diet that contains animal with any diet that contains animal products. products.

Sign and symptomsSign and symptoms

Insidious onset, mostly in last Insidious onset, mostly in last trimestertrimester

Anorexia and occasional diarrhoeaAnorexia and occasional diarrhoeaPallor of varying degreePallor of varying degreeUlceration in mouth and tongueUlceration in mouth and tongueHemorrhagic patches under the skin Hemorrhagic patches under the skin

and conjunctivaand conjunctivaEnlarged liver and spleenEnlarged liver and spleen

Angular CheilosisAngular Cheilosis

Blood valuesBlood values

Hb<10gm%Hb<10gm%Hypersegmentation of neutrophilsHypersegmentation of neutrophilsMegaloblastMegaloblastMCV>100micrometer3MCV>100micrometer3MCH>33pg, but MCHC is NormalMCH>33pg, but MCHC is NormalSerum Fe is Normal or high TIBC is Serum Fe is Normal or high TIBC is

lowlow

TreatmentTreatment

ProphylacticProphylactic- all woman of reproductive age - all woman of reproductive age should be given 400mcg of folic acid should be given 400mcg of folic acid dailydaily

CurativeCurative-daily administration of Folic acid -daily administration of Folic acid 4mg orally for at least 4 wks 4mg orally for at least 4 wks following deliveryfollowing delivery

Sickle cell HemoglobinopathySickle cell Hemoglobinopathy

Hbs comprises 30-40% total HbHbs comprises 30-40% total Hb There is substitution of Lysine for glutamic There is substitution of Lysine for glutamic

acid at the sixth position of B chain of Hbacid at the sixth position of B chain of Hb Red cells in oxygenated state behave Red cells in oxygenated state behave

normally, but in deoxygenated state it normally, but in deoxygenated state it aggregates, polymerises and distort red aggregates, polymerises and distort red cells to sickle. cells to sickle.

These cells are more fragile and increased These cells are more fragile and increased destruction leads to hemolysis, anemia destruction leads to hemolysis, anemia and jaundice.and jaundice.

Effects on pregnancyEffects on pregnancy

Increase incidence of abortion, Increase incidence of abortion, prematurity, IUGR and Fetal loss.prematurity, IUGR and Fetal loss.

Perinatal mortality is high.Perinatal mortality is high. Incidence of pre-eclampsia, Incidence of pre-eclampsia,

postpartum hemorrhage and postpartum hemorrhage and infection is increased.infection is increased.

ManagementManagement

Careful antinatal supervisionCareful antinatal supervisionAir travelling in unpressurised Air travelling in unpressurised

aircraft to be avoided.aircraft to be avoided.Prophylatically Folic A. 1gm daily.Prophylatically Folic A. 1gm daily.Regular blood transfusion at approx. Regular blood transfusion at approx.

in 6 weeks intervalin 6 weeks interval

My ReferencesMy References

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