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    Anemia in Pregnancy - Anahita Chauhan

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    jojolilimomo
    This document discusses anemia in pregnancy, including definitions, classifications, causes, effects, diagnosis, treatment, and management. Some key points: - Anemia is very common in pregnancy, with iron deficiency anemia being the most frequent type. It can have negative effects on both mother and fetus. - Diagnosis involves hemoglobin levels, blood indices like MCV and MCHC, iron studies, and response to iron therapy. Treatment depends on severity and may include oral or parental iron, blood transfusions, or erythropoietin. - Management focuses on prevention through iron supplementation, treatment of underlying causes like parasites, and measures to support the mother during labor and delivery while minimizing blood loss.

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    Anemia in Pregnancy - Anahita Chauhan

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    jojolilimomo
    428 views45 pages
    This document discusses anemia in pregnancy, including definitions, classifications, causes, effects, diagnosis, treatment, and management. Some key points: - Anemia is very common in pregnancy, with iron deficiency anemia being the most frequent type. It can have negative effects on both mother and fetus. - Diagnosis involves hemoglobin levels, blood indices like MCV and MCHC, iron studies, and response to iron therapy. Treatment depends on severity and may include oral or parental iron, blood transfusions, or erythropoietin. - Management focuses on prevention through iron supplementation, treatment of underlying causes like parasites, and measures to support the mother during labor and delivery while minimizing blood loss.

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    This document discusses anemia in pregnancy, including definitions, classifications, causes, effects, diagnosis, treatment, and management. Some key points: - Anemia is very common in pregnancy, with iron deficiency anemia being the most frequent type. It can have negative effects on both mother and fetus. - Diagnosis involves hemoglobin levels, blood indices like MCV and MCHC, iron studies, and response to iron therapy. Treatment depends on severity and may include oral or parental iron, blood transfusions, or erythropoietin. - Management focuses on prevention through iron supplementation, treatment of underlying causes like parasites, and measures to support the mother during labor and delivery while minimizing blood loss.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    428 views45 pages

    Anemia in Pregnancy - Anahita Chauhan

    Uploaded by

    jojolilimomo
    This document discusses anemia in pregnancy, including definitions, classifications, causes, effects, diagnosis, treatment, and management. Some key points: - Anemia is very common in pregnancy, with iron deficiency anemia being the most frequent type. It can have negative effects on both mother and fetus. - Diagnosis involves hemoglobin levels, blood indices like MCV and MCHC, iron studies, and response to iron therapy. Treatment depends on severity and may include oral or parental iron, blood transfusions, or erythropoietin. - Management focuses on prevention through iron supplementation, treatment of underlying causes like parasites, and measures to support the mother during labor and delivery while minimizing blood loss.

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    of 45

    ANEMIA IN PREGNANCY

    Dr Anahita Chauhan
    Associate Professor & Unit Head Seth G S Medical College & KEM Hospital Honorary Consultant, Saifee & St. Elizabeth Hospital

    Background
    Anaemia is the commonest medical disorder during pregnancy Greek meaning without blood Iron deficiency anaemia is the most common type of anaemia during pregnancy NFHS 2003-06: 57.9% of pregnant women 25% direct maternal deaths

    Definitions of Anemia in Pregnancy


    WHO - Hemoglobin concentration <11gm/dl & hematocrit of <33% CDC definition- Hb <11gm/dl during the first and third trimesters and <10.5gm/dl in th second trimester (to allow for the physiological fall due to hemodilution in second trimester) FOGSI - a cut off of 10 gm/dl for India

    Classification Based on Severity


    ICMR Mild Moderate Severe Very severe 10 11 gm/dl 7 10 47 <4 decompensated WHO 9 11 gm/dl 7-9 <7

    Causes of Anemia in Pregnancy


    Physiological anemia Nutritional anemia IDA, megaloblastic Anemia of chronic illness Blood loss Hemolysis and hemolytic anemias Hemoglobinopathies Other hereditary anemias Aplastic anemia

    Increased Iron Demands


    1000mg extra elemental iron required in pregnancy
    Cannot be met by diet alone

    Undernutrition compounds the problem

    Normal Reference Ranges


    Hematological index MCV (PCV/ RBC) Reference range 75 98 fl

    MCH (Hb)
    MCHC TIBC Fe/ TIBC ratio

    25 31 pg
    32 36% 325 400 / 100ml 30%

    Morphological Classification
    By the size of the RBCs Macrocytic anemia (MCV > 100)

    Normocytic anemia (80 < MCV < 100)


    Microcytic anemia (MCV < 80)

    Clinical Features - Symptoms


    Mild anemia is usually asymptomatic

    Moderate anemia - weakness, fatigue, exhaustion, loss of appetite, indigestion, giddiness, breathlessness Severe anemia - palpitations, tachycardia, breathlessness, increased cardiac output, cardiac failure, generalised anasarca, pulmonary edema

    Clinical Features - Signs


    Pallor Nail changes Cheilosis, Glossitis, Stomatitis Edema Hyperdynamic circulation (short & soft systolic murmur) Fine crepitations

    Effects of Anemia on Mother


    Antepartum Preterm labor Pre eclampsia Sepsis IUGR Intrapartum Uterine inertia PPH Cardia failure

    Effects of Anemia on Mother


    Postpartum
    Puerperal sepsis Subinvolution Pulmonary embolism Failure of lactation Delayed wound healing Cardiac failure

    Fetal Effects
    Prematurity and LBW IUGR IUFD Increased perinatal mortality Iron Deficiency Anemia due to lower iron stores can cause poor mental performance or behavioral abnormalities in later life

    Diagnosis Baseline/ Presumptive


    Haemoglobin Measurement Peripheral blood smear Reticulocyte count Hematocrit Blood indices
    MCV, MCHC, MCHC

    Stool Examination Urine Examination Proteins, LFT, RFT

    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 3 weeks till normal If no response or incomplete response, do additional tests

    Diagnosis - Additional
    Serum Fe Total iron binding capacity Serum Ferritin

    Saturation
    Hb electrophoresis

    Bone marrow examination

    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 reduced

    Newer investigations
    Serum transferrin receptors
    Transferrin receptor/ ferritin index

    Reticulocyte indices
    automated counting of reticulocytes, count of <26pg/ cell is a strong predictor of IDA Reticulocyte production index

    Red cell zinc protoporphyrin level

    IDA
    Severity MCV S Ferritin TIBC S Iron Variable Decreased Decreased Increased Decreased

    ACD
    Mild Normal/ decreased Normal/ increased Decreased Decreased +

    Thalass-emia
    Mild Decreased Normal Normal Normal +

    Sidero-blastic
    Variable Normal/ decreased Increased Normal Increased +

    Marrow iron -

    IDA
    Population
    RDW MCV Serum iron Ferritin TIBC Hb electrophoresis

    Beta thal
    Greeks, Italians
    Normal Low Normal Normal Normal Increased HbA2

    All
    High Low Decreased Decreased Increased Normal

    Mentzer Index
    Calculation that may (or may not) be useful in differentiating thalassemia minor from IDA Mentzer Index = MCV/RBC Count <13 Thalassemia minor >13 Iron Deficiency Useful in children

    Folic Acid Deficiency Anemia


    Deficiency of folate or B12 Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals

    Folate is essential for normal growth and development Coexists with IDA

    Diagnosis
    Macrocytes on peripheral smear Hypersegmentation of neutrophils Pancytopenia

    Low Hb and high MCV


    Megablastosis on bone marrow

    Serum folate <3ng/ ml

    Prevention
    Dietary advice and modification Iron supplementation of adolescent & non pregnant women Treatment of hookworm Infestation Iron supplementation in pregnant women Food fortification Antenatal care for early recognition

    Management of Anemia
    Oral Iron Therapy

    Prophylactic Iron therapy- 100mg elemental iron daily with 500 mcg of folic acid
    Deworming of all anemic patients Treatment of Anemia- 200mg of elemental iron & folate 5mg/d

    Iron Requirement in Pregnancy


    2.5mg /day in early pregnancy

    5.5mg /day from 20 -32 weeks


    6 8 mg/ day after 32 weeks Average 4 mg/ day

    Side effects of Oral iron


    Nausea Vomiting Constipation Abdominal cramping Diarrhoea The tablet can be given with meals or different brand may be tried

    Reasons for Failure to Respond


    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

    New Therapeutic Alternatives


    The side effects of older Iron preparations & their poor compliance even on providing free tablets are the most important reasons of failure of anaemia control programmes
    Newer preparations are better tolerated, have less side effects with better compliance Carbonyl Iron Iron ascorbate

    Merits of New Preparations


    Outstanding GI Tolerance in contrast to 20% severe side effects with conventional therapy Very safe with no poisoning even in high doses
    No interaction with food stuffs

    The newer preparations are delicious with nonmetallic taste and dont stain the patients teeth Hence the compliance is very high

    Parenteral Iron therapy


    Indicated when the pregnant woman is unable to take iron due to side effects or is non compliant Its main advantage is certainty of administration

    Rise in hemoglobin is similar to oral iron (upto 1gm per wk)

    Preparation & dosage


    Iron Dextran IM and IV high molecular wt stable complexes release iron slowly, can cause anaphylaxis Iron citrate sorbitol IM less stable, rapid release of iron

    Iron sucrose IV intermediate stability, rapid metabolism hence readily available iron. Since they do not form biological polymers, there are no reactions

    Precaution
    Oral Iron to be suspended 48 hours before parenteral therapy Emergency measures like inj hydrocortisone adrenaline, oxygen cylinder to be kept ready Look for reaction while giving infusion

    Dose calculation
    Older preparations: each 1ml = 50mg elemental iron

    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

    Disadvantages
    Pain Nausea, vomiting, headache Skin discolouration Abscess formation Fever Lymphadenopathy Allergic reaction Anaphylaxis

    Blood Transfusion
    Severe anemia, especially after 36 weeks

    Hemorrhage
    Associated infections Packed cells preferred

    Exchange transfusion rare

    Use of Erythropoetin
    Used in severe anemia & renal failure for significant increase in Hb and to avoid blood transfusion Gynaecological surgeries - preop use of erythropoietin and Iron Dextran has been shown to avoid the need for blood tranfusion later

    Dosage Regimen Erythropoetin


    Inj erythropoetin can be given subcut or iv 100-15 iu/kg On day 1, 3 & 5 along with parenteral iron or day 1, 3 & 5 6000units s/c erythropoetin and iron dextran 100mg deep im daily for 5 day

    First dose given after subcut sensitivity test


    Adrenaline, hydrocortisone, oxygen to be kept ready Produces 3gm% rise in Hb over a 2wk period

    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


    A primigravida presents at 28 wks of gestation with pallor, hemoglobin 7.8g%, no other medical comorbidity, good functional status. Most pragmatic first line therapy in cases with assured compliance would be a. blood transfusion b. parenteral iron c. oral iron d. oral plus parenteral iron Answer: c

    Clinical Case Scenarios


    Foodstuff with highest available iron is a. Red meat b. Figs c. Groundnut d. Soyabean

    Answer b

    Clinical Case Scenarios


    A lady at 32 weeks gestation with hemoglobin 8.9, red cell width is increased, taking iron supplements. Least likely situation is a. non compliance b. intestinal parasites c. thalassemia trait d. anti epileptic medication Answer: c

    Clinical Case Scenarios


    Single most important set of investigations in a recently diagnosed case of anaemia in pregnancy is a. Red cell indices b. Retic count and peripheral smear c. Iron studies d. Hemoglobin electrophoresis Answer: b

    Clinical Case Scenarios


    G5P2L0A2 at 35 weeks gestation in early preterm labor. Hb is 8.8g%. All can be part of management except a. Steroids b. Frusemide c. Blood transfusion d. Intra partum antibiotics Answer: c

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