Iron deficiency anemia is most common anemia during pregnancy whic needs careful evaluation and treatment by Dr Susanta Kumar Behera,Department of Obstetrics & Gynecology, MKCG Medical College, Brahmapur,ODISHA,INDIA

1. ANEMIA IN PREGNANY
AND
ROLE OF PARENTERAL IRON THERAPY
Dr SUSANTA KUMAR BEHERA
SENIOR RESIDENT
DEPARTMENT OF O & G
MKCG MEDICAL COLLEGE
BRAHMAPUR, ODISHA; INDIA

2.  Most Common Nutritional Disorder in the World
 Incidence = 40 to 60 % of pregnant women in India
 Commonest Medical(hematological) disorder during
pregnancy
 25% of direct maternal deaths
 Responsible for 40% of maternal deaths in third
world countries.
 India contributes to 80% of maternal deaths due to
anemia in South Asia

3. Pregnancy : Most dangerous
journey of mankind
Anemia begins in
childhood, worsens during
adolescence in girls and gets
aggravated during pregnancy

4.  Quantitative or qualitative reduction of Hb or circulating
RBC’s or both resulting in a reduced oxygen carrying capacity
of blood to organs and tissues
 Woman Hct 33% or Hb 11g/dl – 1st & 3rd trimester and Hct
32% or Hb 10.5 g / dl in 2nd trimester(CDC/WHO)
Gm% ICMR WHO
Mild 10 – 11 10-10.9
Moderate 7 – 10 7-9.9
Severe 4 – 7 <7
Very severe < 4

5. Physiological
Acquired
Nutritional deficiency anaemias
- Iron deficiency (90%)
- Folate deficiency
- Vit. B12 deficiency
Infections : Malaria/Hookworm/UTI
Hemorrhagic –acute/chronic blood loss
Bone marrow- Aplastic anemia
Renal diseases
Genetic/Haemoglobinopathies:
- SCD
- Thalassaemias
COMMON ANEMIAS IN PREGNANCY

6. PHYSIOLOGICAL ANEMIA

7. • Plasma volume 50% (by 34weeks) but RBC mass
only 25%
• Disproportionate increase in plasma vol, RBC vol. and
hemoglobin mass during pregnancy
CRITERIA FOR PHYSIOLOGICAL ANAEMIA
• Hb = 10 gm%
• RBC = 3.2 million/mm3
• PCV = 30%
• Peripheral smear showing normal morphology
of RBC with central pallor

8. IRON REQUIREMENTS DURING PREGNANCY
Maternal req. of total Iron -1000mg
 500 mg  Maternal Hb. Mass expansion
 300 mg  Fetus & Placenta
 200mg  Shed through gut., urine & skin
 2.5mg /day in early pregnancy
 5.5mg /day from 20 -32 weeks Average 4 mg/ day
 6 – 8 mg/ day after 32 weeks
Increases from 1-2mg in 1st trimester to 6-8 mg in 3rd
trimester

9. Absorption of iron depends upon
a) Amount of iron in the diet
b) Bioavailability of iron
c) Physiological requirements
Iron sources are two types
1) Haem iron(5%) : hemoglobin and myoglobin from red
meat, poultry and fish
2) Nonhaem iron(95%): fibers, green vegetables

10. NORMAL IRON CYCLE
Dietary iron
Utilization Utilization
Duodenum
(average, 1 - 2 mg
per day)
Muscle
(myoglobin)
(300 mg)
Liver
(1,000 mg)
Bone
marrow
(300 mg)Circulating
erythrocytes
(hemoglobin)
(1,800 mg)
Reticuloendothelial
macrophages
(600 mg)
Sloughed mucosal cells
Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day)
Storage
iron
Plasma
transferrin
(3 mg)
Iron loss
(Ferritin)
(TIBC)

11. FACTORS THAT MODIFY IRON ABSORPTION
Heme>Fe2+>Fe3+Physical State
Vagotomy, pernicious anemia
H2 receptor blockers, calcium-based antacidsHigh Gastric pH
Crohn’s disease, Celiac diseaseIntestinal Structure
disruption
Phytates, tanninsInhibitors
Cobalt, Lead, StrontiumCompetitors
Ascorbate, Citrate, Amino acids, Iron
deficiency
Facilitators

12. EFFECTS OF ANAEMA IN PREGNANCY
ANTEPARTUM
a) Pre eclampsia
b) Intercurrent infection
c) Cardiac failure
d) Preterm labour
e) APH
f) PIH
INTRAPARTUM
 PPH
 Cardiac failure
 Shock
POSTPARTUM
a) Puerperal sepsis
b) Subinvolution
c) Failing lactation
d) Puerperal venous
thrombosis
e) Pulmonary embolism

13. Baby
a) IUGR
b) Prematurity
c) Increased risk of IDA early infancy
d) Still births
e) Congenital malformations
f) ↑ in Neonatal deaths/Perinatal mortality
g) Intra uterine deaths(severe maternal anoxemia)
h) Abnormal Social and Emotional behaviour
EFFECT OF PREGNANCY IN ANAEMIA
• Pt. Mildly anemic progresses to marked Anaemia
• Pt. Who is severely anemic becomes symptomatic by the
end of 2nd trimester

14. IDA IN PREGNANCY
a) Grandmulti
b) Hook worm infestation
c) Blood loss : Menorrhagia 20-30%
d) Increase demand for iron particularly in 2nd & 3rd trimester
e) Higher risk with morning sickness
f) Aspirin/NSAIDS
g) Multiple pregnancies
h) Intolerance for red meat
i) Low dietary intake (Vegetarians, Vit. C & Calcium)
j) Malabsorption (Hypo-or achlorohydria)
k) Losses can increase with colorectal cancer, polyps

15. STAGES OF IRON DEFICIENCY
Prelatent(Depletion) :
a) Stores are depleted without a change in hematocrit or
serum iron levels .
b) Reduced stored iron e.g. serum ferritin with normal
hemoglobin
Latent(iron deficient erythropoisis) :
a) Serum iron drops and the TIBC increases without a change
in the hematocrit.
b) Reduced stored and transport iron
c) Increased erythrocyte protoporphyrin concentration
d) Detected by a routine check of the transferrin saturation.

16. Frank IDA :
a) Associated with erythrocyte microcytosis and
hypochromia.
b) Stage of deficiency of stored, transport and
functional iron
c) Reduction of hemoglobin and serum ferritin
d) Low serum transferrin saturation
e) Increased erythrocyte protoporphyrin
concentration
f) Iron deficiency attracts medical attention most
commonly at this stage.

17. SYMPTOMS
 Fatigue
 Weakness
 Headache
 Loss of appetite
 Dysphagia
 Palpitations
 Dyspnea on exertion
 Ankle swelling
 Paresthesia
 Leukoplakia
 Cold intolerance
 irritability
CLINICAL FEATURES
SIGNS
 Glossitis
 Stomatitis
 Heart murmurs
 Increased JVP
 Tachycardia
 Tachypnea
 Postural hypotension
 Pallor
 Dryness or roughness of the skin
 Koilonychia
 Dry & cracked lips & Brittle hair

18. DIAGNOSIS OF IDA
 Low hemoglobin
 Low serum ferritin<15 mcg/dl
 Microcytic & hypochromic in absence of chronic
diseases/hemoglobinopathies
 Low serum iron content(< 30mcg/dL)
 Low PCV, MCV, MCH, MCHC
 High TIBC > 400 mcg/dl

19.  Increased ZPP (>40 mmol/mole heme)
 Low transferrin saturation(<15%)
 Increased serum transferrin(>350mg/dL)
 Increased serum soluble transferrin binding
receptors(> 8 mg/L)
 increased serum neopterin concentration

20. PENCIL CELLS

21. INVESTIGATIONS
• Haematocrit
• RBC Indices:
- Low MCV
- Low MCH
- Low MCHC
- Low PCV
• Peripheral blood
• Urine for haemturia(R&M/C&S)
• Stool examination
• Hb electrophoresis
• X-ray Chest(PA View)

22. • Serum iron < 50 μgm/dl
• TIBC is increased - > 400 μgm/dl
• Serum ferritin is < 12 μgm/dl
• Serum transferrin saturation<20%
• Red cell Zinc Protoporphyrin
• Stainable iron in the bone marrow is reduced-Gold Standard
• Serum transferrin receptor(TfR) : Increased
• Bone marrow examination.
• Reticulocyte hemoglobin conc. : Count of <26pg/ cell
• LFT, RFT
• Trial of iron therapy-diagnostic & therapeutic

23. TREATMENT
 Anaemic gravidas 120 –240mg / per day
 Supplementation with folic acid + Vit C.
 Ferrous sulphate 300mg TID daily after meals X 12
months
 Therapeutic results after 3 weeks – rise in Hb % level of
0.8gm/dl/ week with good compliance
 Rise in Hb at a rate of 2-4 gm/dl every 3 weeks till
normal
 Hb conc. is normal after 6 wks of therapy

24. INDICATORS OF IRON THERAPY
RESPONSE
1. Increase in Reticulocyte count (Increases 3-5 days
after initiation of therapy )
2. Increase in Hb levels. Hb increases 0.3 to 1 g/ week
3. Epithelial changes (esp tongue & nail ) revert to
normal

25. Pregnancy
<30wks
Pregnancy
30-36wks
Pregnancy
>36wks
IDA FA
def.
Oral iron Oral
FA
Intolerance or
Non-compliance
I/M iron I/V
iron
IDA FA def.
Parenteral Oral
FA
I/M iron I/V
iron
Blood
transfusion

26. ORAL IRON THERAPY
WHO : 60 mg elemental iron + 250 ug FA OD/BD.
Govt. of India : 100 mg Fe + 500 ug FA during 2nd
half of pregnancy X 100 days.
Drawbacks:
- Intolerance
- Unpredictable absorption rate.
- Not suitable for patients with GI diseases/ significant
bleeding
- Non Compliant patient.
- Long time for improvement

27. Side effects
a) Nausea & Vomiting
b) Gastric irritation
c) Constipation
d) Abdominal cramp
e) Diarrhoea
Response to therapy:
- Sense of well being/Increased appetite.
- Increase in Hb approximately 2gm% per every 3-4 wk
- Reticulocytosis with in 5-10 days
- hematocrit returning to normal
.

28.  Enteric coated/sustained release preparations
to be avoided as they are carried past duodenum
limiting absorption
 Once hemoglobin is normal therapy is continued
for further 3 months /at least 6 wks postpartum
to replenish stores.

29. IRON SUPPLEMENTS

30. Taking iron tablets
 Absorption helped by vitamin-C(take the tablets
with glass of orange juice)
 Take before or after 1 hr of meal
 Don't take tea/coffee/milk
 Calcium based antacids will reduce the
absorption

31. NEW THERAPEUTIC ALTERNATIVES
• CARBONYL Iron
• Iron ascorbate
ADVANTAGES
a) Outstanding GI Tolerance
b) Very safe with no poisoning even in high doses
c) No interaction with food stuffs
d) Delicious with non-metallic taste and don’t stain the
patients’ teeth
e) Compliance is very high

32. INDICATIONS
a) Failure to oral iron therapy.
b) Non compliance/intolerance to oral iron
c) 1st time seen during last 8-10 wks with severe anemia
d) Malabsorbtion/IBD
e) Small bowel resection
f) When hemorrhage is likely to continue
g) C/I to blood transfusion
h) Combination with recombinant human erythropoietin
i) C/I to oral therapy
PARENTRAL THERAPY

33. Intravenous preparation
a) Iron dextran (Imferon)
b) Iron sucrose
c) Sodium ferric gluconate (ferrlecit)
Intramuscular preparation
a) Iron Sorbitol Citrate in dextrin(Jectofer)
b) Iron Dextran (imferon)
Iron dextran: 50 mg/mL. Iron sucrose: 20 mg/mL. Ferric
gluconate: 12.5 mg/mL

34. Contraindications
a) h/o anaphylaxis to parenteral iron
therapy
b) 1st trimester of pregnancy
c) Active acute/chronic infection
d) Chronic liver diseases
Advantages:
- Certainty of admission.
- Hb rises @1gm/wk.
Disadvantage
a) Nausea and Vomiting
b) Metallic taste on tongue

35. IM ROUTE
Iron Dextran (1ml contains 50mg elemental iron & 1amp=2ml)
Dose : 100 mg IM OD/AD till the total dose over
Drawbacks:
a) Painful injection (less with jactofer).
b) Skin discoloration
c) Local abscess
d) Allergic reaction
e) Fe over load.
f) Category C drug
g) Gluteal sarcoma
h) Test dose needed
Advantage
Can be given in primary care set up
Absolute reticulocyte count increases in 7 days
Hemoglobin increases within 1-2 wks
Whole dose can be given in single setting

36. I/V Route :
a) Repeated Injections
b) Total dose infusion
Side effects:
- Anaphylactic reaction.
- Chest pain, rigors, chills, fall in BP, dyspnoea, hemolysis.
Treatment:
a) Stop infusion.
b) Give antihistaminics, corticosteroids & epinephrine.

37. IRON DEXTRAN
a) Colloidal solution of ferric oxyhydroxide complexed with
polymersised dextran
b) Advantage : patients total iron requirement is given in
one administration
c) Higher rate of adverse effects like delayed
hypotension/ arthralgia/abdominal pain
d) Test dose is necessary
e) Patients should be monitored 1 hr following a test dose
of 25 mg
f) Can given as IV infusion with rate less than 50 mg/min
g) Category B drug

38. TDI – TOTAL DOSE INFUSION
I/V : (IRON DEXTRAN)
TDI=(Normal Hb - Patients Hb) X Blood Volume(65ml/kg)X3.4
100
TDI= (Normal Hb – Pt. Hb) X Wt in Kg X 2.21+1000
TDI=[10 × (target Hb-actual Hb ) × (0.24 × bodyweight )] +0/500
Dose given I/V by slow push 100mg / day or the entire dose
given in 500 ml N/S slow I/V infusion over 1-6 hours

39. FERRIC GLUCONATE COMPLEX IN SUCROSE
1) Given as IV injection/infusion
2) Standard dose of 125 mg may be given IV injection
over 10 min
3) Rate should be < 12.5mg/min
4) Dose can be repeated if ferritin < 100ng/ml or
saturation < 20%
5) Can be safely given to Dextran sensitive patients

40. IRON SUCROSE
• Commonly used in chronic kidney diseases
• MW 34,000-60,000 D
• Iron hydroxide sucrose complex in water
• Given as IV injection/infusion
• Each ml contains 20 mg of Fe
• After IV administration it dissociates into iron &
sucrose
• T 1/2 is 6hrs
• Category B drug

41. • Total iron deficit = Body weight x (Target Hb – Actual Hb) x 2.4 +
Iron stores [mg]
• Administered 100 mg IV over 5 minutes, thrice weekly
until 1000 mg
• 200mg max dose per Sitting
• Rate of administration should not more than 20 mg/min
• Infusion : 50 mg to be injected slowly over 2 minutes,
wait for 2-3 min ,then give another 50 mg over 2 min
• 100mg-200 mg to be diluted with 100ml NS, infuse at
least 15 min
• Marked increase in reticulocyte count expected in 7-14
days

43. Advantages of IRON SUCROSE over others
a) All iron preparations were capable of causing
tissue peroxidation except iron sucrose
b) Less oxidative injury
c) Less risk of tissue parenchymal injury by free iron.
d) Higher availability for erythropoiesis than iron
Dextran
e) IV iron supplementation increases the
erythropoiesis 5 times
f) Safe in dextran sensitive patients
g) Minimal side effects

44.  The Hb rise will be evident in as early as 5 days
 IV iron sucrose is safe & effective
 Iron sucrose is given both bolus push & infusion
Disadvantage
a) Total dose administered in multiple infusions
b) Needs a set up where anaphylactic reaction can
be managed.

45. NEWEST FAST ACTING IV MOLECULES
Iron III Carboxymaltose (FERRINJECT) :
a) Ferric hydroxide carbohydrate complex which
allows for control delivery of iron within cells of
the RES (primarily bone marrow) and subsequently
delivery to the iron binding proteins ferritin and
transferin
b) T1/2 : 16 hr
c) Dose : Single dose of 1000 mg over 15 minutes
(maximum 15mg/kg by injection or 20 mg/kg by
infusion)

46. IRON III ISOMALTOSE(MONOFER)
a) Strongly bound iron in spheroid iron-carbohydrate
particle providing slow release of bioavailale iron
to iron binding proteins
b) Rapidly up taken by RES and little risk of free iron
for tissue damage
c) Dose : 1000 mg in a single infusion
d) Erythropoietic response seen within days
e) Serum ferritin returns to normal by 3 wks

47. FERUMOXYTOL
 USA FDA approved this drug in 2009 for iron
replacement in patients with IDA & CKD
 No test dose required
 Can be given as large dose (510 mg/vial) in <20
Seconds in single settings
 No significant side effects
 Not approved in Europe

48. 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

49. BLOOD TRANSFUSION
Decision based on
• Needs and risk of developing complications of inadequate
oxygenation
• Both clinical and hematological grounds
Indications
a) Severe anemia, especially after 36 weeks
b) Risk of further hemorrhage
c) Associated infections
d) Imminent cardiac compromise

50. Patient factors Type of surgery
Preg Preg Elective Emergency
<36wks > 36wks C/S C/S
-Hb ≤ 5gm% - Hb ≤ 6gm% - with H/o -assess
without CHF without CHF APH,PPH, according
-Hb 5-7gm%,if -Hb 6-8gm%,if previous to situation
CHF, hypoxia, CHF, hypoxia, LSCS
Infection infection
Hb 8 – 10 gm%, confirm BG & cross-matching
Hb <8 gm%, 2 units to be kept ready in OT

51. MANAGEMENT DURING LABOUR
• Consideration for delivery in well equipped hospital.
• Avoid sympathetic stimulation and hyperventilation;
prevent rightward shift of ODC.
• Supplemented with oxygen therapy
• Prophylactic forceps/Vaccum to cut short 2nd stage
• Decreased blood loss by active management of 3rd
stage of labors.
• Avoid maternal stress, patient can go into CHF.
• PPH should be emergently treated(uterotonics)

52. ANAETHETIC CONSIDERATIONS
 Pre oxygenation is mandatory with 100% O2
 Oxygen supplementation should be given in peri and
postoperative periods
 Blood arrangements prior to surgery is must
 Airway maintenance to prevent fall of PO2 due to
airway obstruction
 Hyperventilation to be avoided to minimize respiratory
alkalosis
 General/spinal anaesthesia can be given after platelet
count and excluding h/o spontaneous hemorrhage.

53. MEGALOBLASTIC ANAEMIA
• Incidence – 0.2 – 5 %
• Caused by folic acid deficiency & Vit B12 deficiency
Pathophysiology
 Preg. Causes 20 -30 fold increase in Folate requirement (150-
450 microgram / day ) to meet needs of fetus & placenta.
 Placenta transports folate actively to fetus even if the mother
is deficient.
 Vit.B12 deficiency : Occurs in patients with gastrectomy , ileitis,
ileal resection, pernicious anaemia, intestinal parasites

54. FOLATE DEFICIENCY ANAEMIA
 Folic acid reduced to DHFA then THFA, used in
nucleic acid synthesis, is required for cell growth &
division.
 So more active tissue reproduction & growth more
dependant on supply of folic acid.
 So bone marrow and epithelial lining are therefore at
particular risk.
 Coexists with IDA

55.  Folic acid deficiency more likely if
. Woman taking anticonvulsants.
. Multiple pregnancy.
. Hemolytic anemia, thalassemia & cleft palate
Diagnosis :
-Increased MCV ( > 100 fl)
-Peripheral smear : - Macrocytosis, hypochromia
- Hypersegmented neutrophils(> 5 lobes)
- Neutropenia
- Thrombocytopenia
-Low Serum folate level.(<3ng/ ml)
-Low RBC folate (<20 ng/ml)

56. CLINICAL FEATURES
• Insidious onset, mostly in last trimester
• Anorexia and occasional diarrhea
• Pallor of varying degree
• Ulceration in mouth and tongue
• Glossitis
• Enlarged liver and spleen
• Hemorrhagic patches under the skin and conjunctiva
• Macrocytic Megaloblastic Anemia
• Peripheral neuropathy
• Subacute combined degeneration of the Spinal cord

57. a) Hb < 10gm%
b) Hypersegmentation of neutrophils
c) Megaloblast, Howell-Jolly bodies
d) MCV > 100 fl
e) MCH > 33pg, but MCHC is Normal
f) Serum Fe is Normal or high, TIBC is low
g) Serum Vit B12 levels < 100 pg /ml
h) Radio active Vit B12 absorption test (Schilling Test)
DIAGNOSIS

58. MEGALOBLASTIC ANEMIA(PS)
MEGALOBLASTIC ANEMIA(BM)

59. TREATMENT
• Replace iron and treat underlying disease.
• Oral route is preferred for replacement.
• Response can be followed by retic. increase in 1-2
weeks (5-7 days)
• Hb response to treatment
– half normal by a month
– returns to normal by 2-4 months

60. • Replacement therapy is prolonged by 6-12 months to
replenish stores of iron.
• 1000 microgram Parenteral Cyanocobalamin every
wk X 6 weeks
• Prophylactic : All woman of reproductive age should
be given 400mcg of folic acid daily
• Curative : Daily administration of Folic acid 4mg
orally up to at least 4 wks following delivery

61. HAEMOGLOBINPATHIES
Sickle cell disease
a) Sickle cell anaemia (most common & severe)
b) Sickle cell beta thalassemia,
c) Haemoglobin SC disease
Thalassemia
- Alpha thalassaemia.
- Beta thalassaemia:
. Major
. Minor

62. SICKLE CELL ANAEMIA
• Valine substituted for glutamic acid at 6th position on β chain of
Hb molecule
• Common variants - SS ( sickle cell anemia)
- SA ( sickle cell trait)
Hb SS Hb SA
Cell trait Homozygous Heterozygous
HbS 70 – 90%, rest HbF 10 – 40%, 40-60% HbA
Hb (g/dl) 6 - 9 13 -15
Life expectancy 30 yrs normal
Propensity for
sickling
++++ + (O2 falls < 40%)

63. SIGNS & SYMTOMS
Vaso-occlusive complications
a)Painful episodes-most common(50%)
b) Acute chest syndrome(20%)
c) Strokes
d) Renal insufficiency
e) Splenic sequestration
f) Proliferative retinopathy
g) Priapism
h) Spontaneous abortion
i) Bone pains, leg ulcers, Osteonecrosis

64. Complications related to hemolysis
a) Anemia (Hct 15 – 30%)
b) Cholelithiasis
c) Acute aplastic episodes
Infectious complications
a) Streptococcus pneumonia sepsis
b) E.coli sepsis
c) Osteomyelitis
DIAGNOSIS
• Hb solubility test-specific, cheap, rapid and simple.
• Sickling test
• Hb electrophoresis,

65. MANAGEMENT
 Multidisciplinary approch
 Routine BP measurement and urinalysis to detect
hypertension and proteinuria
 Retinal screening/fundoscopy for prliferative
retinopathy
 Screening for iron overload(serum ferritin)
 Screening for PAH by echocardiography
 Antibiotic prophylaxis-penicillin/eruthromycin
 Termination planned for homozygous state

66.  Folic acid-5 mg should be given OD
preconceptually and throughout the pregnancy
 Hydroxurea if taking should be stopped 3 months
prior conception
 ACE inhibitors & angiotensin receptor blockers
stopped before conception
 Early detection and treatment of malaria and
infections
 Low dose Aspirin from 12 wks of gestation

67.  Thromboprophylaxis with LMWH
 NSAIDS between 12 to 28 weeks
 Fluid and oxygen therapy(oxygen saturation > 95%) in
painful crisis
 BT indicated only during complications like acute
anemia/ACS/twin pregnancies, preeclampsia,
septicemia, renal failure
 Goals : Hb > 8gm/dl & HbA > 40% of total Hb
 Iron therapy to be given if there is evidence of iron
deficieny

68. • Vaccine : H influenza type b, conjugated
menigococcal C vaccine, peneumococcal vaccine &
Hepatitis-B vaccine
• Timing of deliver : 38 -40 wks of gestation either
by induction of labour/elective CS
• Factors to be avoided favouring sickling
- Dehydration
- Hypotension
- Hypothermia
- Acidosis
- High conc. of HbS

69.  CS is preferred over vaginal delivery when labour is
not progressing well.
 Continuous FHR monitoring due to increases rate of
still births/abruption/compromosed placental reserve
 Counseling the parents regarding partner screening
for carrier detection.
 Contraceptives
a) Porgesterone only pill
b) Injectable contraceptives
c) LNG-IUS
d) Barrier methods
e) Sterilization

70. THALASSAEMIAS
• The synthesis of globin chain is partially or completely
suppressed resulting in reduced Hb. content in red
cells,which then have shortened life span.
• TYPES:
- Alpha thalassaemia.
- Beta thalassaemia: Major & Minor
• Microcytic haemolytic anaemias
• Reduced synthesis of one or more of polypeptide globin
chains.
• Higher transfusion requirements in pregnancy worsen
haemosiderosis & cardiac failure.

71. CLINICAL FEATURES
• Usually asymptomatic
• Weakness, fatigue, exhaustion, loss of appetite, indigestion,
giddiness, breathlessness
• Palpitations, tachycardia, breathlessness, increased cardiac
output, cardiac failure, generalised anasarca, pulmonary edema
a) Pallor
b) Nail changes
c) Cheilosis, Glossitis, Stomatitis
d) Edema
e) Hyperdynamic circulation (short & soft systolic murmur)
f) Fine crepitations

72.  Women with hemoglobinopathy should be offered oral
iron therapy if serum ferritin<30 mcg/L
 Referral to secondary/tertiary care to be done if
a) Severe anemia
b) Significant symptoms
c) Late gestation(34 wks)
d) Failure to respond to oral iron
TREATMENT

73.  WHO - 60 mg Elemental iron + 400 micro gram
Folic acid / day up to 3 months postpartum
 GOI - 60 mg elemental Iron + 500 mcg Folic acid
as Prophylactic supplementation x 100 days in 2nd
trimester up to 3 months postpartum

74. ANAEMIA ASSOC. WITH CHRONIC
INFECTIONS / DISEASE
• Common in developing countries
• Poor response to Haematinics unless primary cause is
treated
• Worm infestations is common ( Diagnosed by stool
examination )
• Urinary tract inf, & asymptomatic bacteriuria in preg.
is assoc. with refractory anaemia
• Chronic renal disorders = due to erythropoietin def.

75. • Identifying the etiology and treat accordingly
• Deworming with mebendazole/albendazole/levamisole
• Treated with recombinant Erythropoietin for renal
disease.
• ATT to a patients with tuberculosis
• Antibiotics to treat UTI according to sensitivity
TREATMENT

76. PREVENTION
• Dietary advice and modification(red meat/ poultry/fish)
• Germination and fermentation of cereals and legumes
improve the bioavailability of iron in food
• Green peas/Whole wheat/Green vegetables/Jaggery
• Iron supplementation of adolescent girls & non pregnant
women
• A nutritious diet in a pregnant woman should be
providing about 40 mg elemental iron daily.

77. • Food fortification
a) Fortification of staple food like wheat flour which is
technically simple(USA)
b) Fortification of curry powder, salt and sugar, dried
and liquid milk(SA)
c) Fortification of infant foods (INDIA)
d) Fortification of complimentary foods (USA)

78.  Treatment of hookworm Infestation, malaria,TB
 Avoidance of Hypoxia, Acidosis, Infection, Dehydration
Stress , Exercise, Extreme, Temperature
 Avoidance of frequent child birth.
 Supplemented Viamin-C (250-500mg/day) with iron
 Adequate treatment for any infection like UTI

79.  Early detection of falling Hb level, levels should be
estimated at 1st A/N visit, 30th & finally 36th week
 Mandatory monthly screening for anemia should be
done in all antenatal clinics(especially at booking and at
28 wks with FBC)
 Screening and effective management of obstetric and
systemic problems in all pregnant women

80. THANK Q