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ANEMIA IN PREGNANCY DR SHABNAM NAZ ASSISTANT PROFESSOR OBGYN CMC,SMBBMU LARKANA
definitionA pathological condition in which the oxygen carrying capacity of red blood cells is insufficient to meet the body ‘s needsWHO recommends the HB% should not fall below 11g/dl at any time during pregnancyCDC refer the value of 10.5 g /dl
PREVALANCE-40% of world ‘s population(35%non-preg 51%pregnant)56% in PakistanMORTALITY40-60% IN Pakistan18% in industerlised countries
PHYSIOLOGICAL CHANGES IN BLOODDURING PREGNANCY Plasma volume increased 50% Red cell mass increased 25% Fall in Hb conc:, haematocrit & red cell count . MCV increased secondary to erythropoiesis MCHC remains stable Sr: iron and ferritin decrease TIBC increased
Severity of anemiaSeverity Percentage hemoglobin valuesMILD 13 10-10.9 mg/dlMODERATE 57 7-10mg/dlSEVERE 12 <7mgldlVERY SEVERE Decompanseted <4mg/dl
CLASSIFICATION of ANEMIA Physiologic Pathologic: a. Deficiency: Iron, Folic A., Vitamin B12 b. Hemorrhagic: APH, Hookworm c. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemia d. Bone Marrow Insufficiency: Aplastic Anemia e. Infections: Malaria, TB f. Chronic Renal Diseases or Neoplasm.
IRON ABSORBTION Dietary iron (heme and non heme)- heme-animal blood flesh viseras-Non heme-cerels, seeds, vegetables, milk eggs. Factors increases iron absorbtion Heme iron Proteins Meat Ascorbic acid Fermentation
Ferrous iron Gastric acidity Alcohol Low iron stores Increase erethropiioetic activity(hight altitue,bleeding) FACTROS DECREASES IRON ABSORBTION Phytates Calcium Tennins, tea, coffee, herbal drinks Fortified iron supplements
IRON LOSSPHYSIOLOGIC FACTORS Desquamation of cells( intestine, skin) Menstruation Delivery LactationPATHOLOGIC FACTORS Hookworms /other helmentis Bleeding from GIT Allergies Occult blood loss, excess menses,APH
Iron requirement in pregnancy Adult woman absorption-2mg/day Total iron requirement during pregnancy-900mgDEMANDS EXPANSION OF RBC-500 -600mg FETUS AND PLACENTA-300mgDAILY IRON REQUIREMENTDURING PREGANCY 4mgEarly pregnancy – 2.5mg20-32wksof pregnancy- 5.5mg>32wks of pregnancy6-8mgIron absorption rate 10%
PREVENTION OF IRON DEFICIENCY1.Iron supplementation during pregnancyAccording to WHO 60 mg elemental iron and 250mg folic acid daily for 6 months and additional 3 months in postpartum period in low prevalence countries2.Treatment of hookworm infestationSingle dose of albendazole 400mg statOr mebendazole 100mg BD for 3 days3.Improvements of dietary habitsIron rich foodCook food in iron utensils
Prevention continue…..4.Social servicesImprovement in sanitationPersonal hygieneBetter education of female regarding dietContraception5.Food fortificationIron fortified salt like iodine salt
Concept of Physiologic Anemia Disproportionate increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy Marked demand of extra iron during pregnancy especially in second trimester
Criteria for Physiologic Anemia Hb: 10gm% RBC: 3.2 million/mm3 PCV: 30% Peripheral smear showing normal morphology of RBC with central pallor
Significance of Hypervolemia . To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.
Normal hemoglobin by gestational age in pregnant women taking iron supplement 12 wks 12.2 [11.0-13.4] 24wks 11.6 [10.6-12.8] 40 wks 12.6 [11.2-13.6]
FACTORS LEAD TO DEVELOP ANEMIA Physiological hamodilution Increase iron demand Diminished intake of iron Disturbed metabolism Pre-pregnancy health status Excess demand
SIGNS AND SYMPTOMS OF ANEMIASymptoms fatigue, Headache Faintness Breathlessness Palpitation Intermittent claudication
SIGNS Palar of skin , conjunctiva, mucous membrane Tachycardia high volume pulse Ankle edema Cardiac failure Systolic flow murmurSpecific signs of iron deficiencykoilonychias, brittle nails atrophy of papilla of tongueAngular stomatisis, brittle hair, palmmer winson syndrome
EFFECTS OF ANEMIA ON PREGNANCYMATERNAL EFFECTS Preterm labour Anasarca CCF Pulmonary edema PPH P-Sepsis Failing lactation Sub involution of uterus thromboembolism
Maternal mortality in 3rd trimester ,during labour ,delivery ,immediately after delivery ,during peurperium due to heart failure and pulmonary embolism .FETAL EFFECTS Pre-term birth SGA Infection Anemia Low iron store High peri-natal mortality
DIAGNOSIS OF IRON DEFICIENCY ANEMIA1.Hb%-practical cheap early performed method2.Blood cell indices-differentiated b/w iron deficiency and thalasemia
Red cell indices in iron deficiency and thalasemiacharacteristics calculation Normal range Iron deficiency ThalasemiaMCV(fl) PCV/RBC 75-96 Reduced Very reducedMCH(pg) Hb/RBC 27-33 Reduced Very reducedMCHC(g/dl) Hb /PCV 32-35 Reduced Normal or slightly reducedHbF(%) hbF/HbA/100 <2% normal RaisedHbA2(%) HbA2/HbA/100 2-3% Normal or Raised raisedFEP(microgram/ ____ <35 >50 NormaldlRed cell width High Normal
3.Serum ferritin –reflect iron storeNormal level 15-300microgram /LLevel <12 microgram/L indicate iron deficiency4.TIBC-serum iron decreased and TIBC increasedTransferin saturation can be estimated from serum iron and TIBCReduce transferin saturation indicate deficient iron supply to tissues.Serum iron 60-120 mcg/dlTIBC-300-350mcg/dl
5.Free erythropoietin receptorsHelp to differentiate b/w iron deficiency and thalasemia6.Serum transfferin receptorsAppear to be specific and sensitive marker of iron deficiency in pregnancy, its level increased in iron deficiency, but not routinely available.7.Bone marrow aspirationWhen no response and for diagnosis of aplastic anemia and kalzar
bone marrow aspiration high cellularity mild to moderate erythroid hyperplasia (25-35%; N 16 – 18%) polychromatic and pyknotic cytoplasm of erythroblasts is vacuolated and irregular in outline (micronormoblastic erythropoiesis)absence of stainable iron8.Stool examination-consequently for 3 days
9.Urine examination- for occult blood shistosomiasis in shistosomiasis prevalent countries.10.Blood film for MP11.Sputum examination /x-ray (TB)12.RFT13.Serum protein(hypo proteienemia)
Iron. Deficiency—DiagnosesMicrophotograph of bonemarrow staining for iron.Iron is stained blue and itis mainly in themacrophages (lower left
Categorizing iron deficiency anemiacategory Serum ferritin Hb% DiagnosisOne >12mcg/dl >11g/dl Normal no iron deficiencyTwo <12mcg/dl >11g/dl Storage iron depletionThree <12mcg/dl <11g/dl Iron deficiencyFour >12mcg/dl <11gdl Other cause of anemia
Treatment of iron deficiency anemia Medical treatment Oral iron Parenteral iron Blood transfusion Recombinant erythropoietin
ORAL IRON PROPHYLAXIS -100mg(elemental iron)+0.5 folic acid /day THERAPUTIC -180mg elemental iron/day Raise of Hb-0.3-0.8g/wkTo improve compliance1. Give drug less frequently then daily2. Change brand3. Give with meal or decrease dose.If no improvementAnother preparation as carbonyl ironBlood transfusion
Oral ironDISAADVANTAGES Intolerance to medication Unpredictable absorption Non complianceSIDE EFFECTS Abdominal cramps Constipation Distaste Nausea vomiting
Oral ironINDICATORS OF RESPONSE TO THERAPY Improvements in symptoms Increase reticulocyte count in 5-10 days Increase in Hb% 0.8g/dl/weekREASONS OF FAILURE Inaccurate diagnosis Non compliance Continues blood loss
PARENTERAL IRON THERAPYAvailable forms Iron dextran (oral and i/v infusion) Iron poly maltose(sucrofer rubiject) Iron sucroseDOSE(Normal Hb-patient’s Hb) x weight(kg)x2.21 +1000=(14-7) x65kg x 2.21+1000=2005mgPrecautions Should be given in hospital setup by doctor Inj :hydrocortisone, epinephrine, and oxygen should be available.
Total dose infusionTotal dose iron replacement in 2nd and 3rd trimester in whichtotal deficit is calculated and given as single infusion which take 3-6 hrs to complete.Various preparations are availableDextran( imferon)withdrawn b/c of high incidence of anaphylaxis
PARENTRAL IRON THERAPY I/M-ROUTE Iron sorbitol citrate (jactosol /jectofer)Advantages low mol:wt: Rapid absorptionDose and technique 50mg test dose then 100mg i/m Z technique
PrecautionsStop oral iron to avoid toxic effectDisadvantages Nausea vomiting Headache Fever Allergic reaction Lymph adenopathy Tattooing of skin Severe anaphylaxis
Parenteral iron therapy continue.. INTRAVENOUS IRONIndication Non compliant GI problems Pregnancy >32-36wksAdvantages Certainty of its administration Raise Hb/wk(rapid raise) Alternate to blood transfusion when oral treatment fails.
ERETHROPOETINRecombinant erythropoietin Anemia of chronic renal failure Autologous production of blood in normal individuals Severe postpartum anemia(life saving) Where blood transfusion avoided as in jehovah witnessesBLOOD TRANSFUSION (pc) preferred Severe anemia Pregnancy beyond 36 wks Blood loss e.g. ; APH,PPH, Pts not responding to oral and parental treatmentEXCHANGE TRANSFUSION Very rare in sever anemia
Obstetrical treatment Frequent A/N visits Caution in use of steroids and beta mimetics in p.t.l Prop up, oxygen Sedation Adequate analgesia Assisted delivery in second stage AMTSL Breast feeding Contraception for 2 years Continue iron for 3 months
Obstetrical treatmentAntenatal care More frequent visit Detect and manage complication as heart failure PTL Fetal monitoring for growth and well being
Obstetrical treatmentManagement in labour Comfortable position (prop up) Sedation Analgesia In pre term beta mimetics and corticosteroids used carefully to avoid risk of pulmonary edema Antibiotic prophylaxis Oxygen in dyspnoic patients Digitalization and cardiac support in cardiac failure.
Obstetrical treatmentSecond stage management Shortened by instrumental deliveryThird stage AMTSL except in severe anemic for fear of cardiac failurePuerperium Adequate rest Iron and folate therapy for 3 months Treatment of any infections Pediatric opinion Effective contraception.(at least 2 years till iron store recover)
Megaloblastic Anemias A form of anemia characterized by the presence of large, immature, abnormal red blood cell progenitors in the bone marrow 95% of cases are attributable to folic acid or vitamin B12 deficiency
Static Test for Folate/B12 StatusFolate Measured in whole blood (plasma and cells) and then in the serum alone Difference is used to calculate the red blood cell folate concentration (may better reflect the whole folate pool) Can also test serum in fasting patientB12 Measured in serum
Functional Tests forMacrocytic Anemias Homocysteine: Folate and B12 are needed to convert homocysteine to methionine; high homocysteine may mean deficiencies of folate, B12 or B6 Methylmalonic acid measurements can be used along with homocysteine to distinguish between B12 and folate deficiencies (↑ in B12 deficiency) Schilling test: radiolabeled cobalamin is used to test for B12 malabsorption
Pernicious AnemiaA macrocytic, megaloblastic anemia caused by a deficiency of vitamin B12. Usually secondary to lack of intrinsic factor (IF) May be caused by strict vegan diet Also can be caused by ↓gastric acid secretion, gastric atrophy, H-pylori, gastrectomy, disorders of the small intestine (celiac disease, regional enteritis, resections), drugs that inhibit B12 absorption including neomycin, alcohol, colchicine, metformin, pancreatic disease
Symptoms ofPernicious Anemia Paresthesia (especially numbness and tingling in hands and feet) Poor muscular coordination Impaired memory and hallucinations Damage can be permanent
Causes of Vitamin B12 Deficiency Inadequate ingestion Inadequate absorption Inadequate utilization Increased requirement Increased excretion Increased destruction by antioxidants
Treatment of B12 Deficiency Before 1926 was incurable; until 1948 was treated with liver extract Now treatment consists of injection of 100 mcg of vitamin B12 once per week until resolved, then as often as necessary Also can use very large oral doses or nasal gel MNT: high protein diet (1.5 g/kg) with meat, liver, eggs, milk, milk products, green leafy vegetables
Folic Acid Deficiency Tropical sprue; pregnancy; infants born to deficient mothers Alcoholics People taking medications chronically that affect folic acid absorption Malabsorption syndromes
Causes of Folate Deficiency Inadequate ingestion Inadequate absorption Inadequate utilization Increased requirement Increased excretion Increased destruction Vitamin B12 deficiency can cause folate deficiency due to the methylfolate trap
Methylfolate TrapIn the absence of B12,folate in the body exists as5-methyltetrahydro-folate(an inactive form)B12 allows the removal ofthe 5-methyl group toform THFA
Diagnosis of Folate Deficiency Folate stores are depleted after 2-4 months on deficient diet Megaloblastic anemia, low leukocytes and platelets To differentiate from B12, measure serum folate, RBC folate (more reflective of body stores) serum B12 High formiminoglutamic acid (FIGLU) in the urine also diagnostic
Other Nutritional Anemias Copper deficiency anemia Anemia of protein-energy malnutrition Sideroblastic (pyridoxine-responsive) anemia Vitamin E–responsive (hemolytic) anemia
Hemolytic Anemia Oxidative damage to cells—lysis occurs Vitamin E is an antioxidant that seems to be protective. This anemia can occur in newborns, especially preemies.
Non nutritional Anemias Sports anemia (hypochromic microcytic transient anemia) Anemia of pregnancy: dilutional Anemia of inflammation, infection, or malignancy (anemia of chronic disease) Sickle cell anemia Thalassemias
SUMMARY Anemia is most common medical disorder of pregnancy with significant maternal ND fetal implications Iron deficiency is major cause of anemia in pregnancy Diagnosis should be establish during nd before pregnancy so to treat timely to prevent complications Screening for iron deficiency in pregnancy is simple