Anemia in Pregnancy


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1 :
2 : Definition Anemia - insufficient Hb to carry out O2 requirement by tissues. WHO definition : Hb conc. ? 11 gm % CDC definition : Hb conc. < 11gm % in 1st and 3rd trimesters and < 10.5 gm% in 2nd trimester For developing countries : cut off level suggested is 10 gm % - WHO technical report Series no. 405, Geneva 1968 Centre for disease control, MMWR 1989;38:400-4
3 : Degree Hb% Haematocrit (%) Moderate 7-10.9 24-37% Severe 4-6.9 13-23% Very Severe <4 <13% WHO Classification of Anaemia
4 : Magnitude of Problem Globally, is about 30 % In developing countries & India, incidence is around 40 – 90%. Responsible for 40% of maternal deaths in third world countries. Important cause of direct and indirect maternal deaths - Vitere FE Adv Exp Med Biol 1994;352:127
5 : Infection Lack of Concentration Weakness Irritability Palpitation Fatigue Dizziness Symptoms
6 : Clinical Features Pallor of skin And m/m Edema Platynychia Koilonychia Glossitis Stomatitis Tachycardia Soft ejection systolic murmur Signs
7 : Physiological Pathological Causes of Anaemia Nutritional Haemorrhagic Haemolytic
8 : Iron Requirement
9 : Early Pregnancy 2.5 mg / day 32 to 40 weeks 6.8 mg / day TOTAL 800 – 1000 mg 20 to 32 weeks 5.5 mg / day RBC =500mg Fetus+Placenta =450mg Third stage blood loss =200mg Total = 1150mg Iron Requirement During Pregnancy
10 : Normal Levels
11 : Laboratory Diagnosis of Anaemia
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13 : Reason For Increased Incidence Of Anemia Poor pre-pregnancy iron balance due to – untreated systemic diseases & menstrual disorders Improper supplementation of iron in pregnancy ( late registration and poor follow up) Repeated childbearing Lack of awareness and illiteracy
14 : Low socioeconomic status and poor hygiene Chronic malnutrition Poor availability of iron due to predominantly veg diet, diet low in calories but rich in phytates. Food and religious taboos GI infections and infestations (e.g. Kala azar, worm infestations) Reason For Increased Incidence Of Anemia
15 : Complications - Pregnancy
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17 : Management Options Pre – pregnancy : Treat the cause before conception Pre-pregnancy balanced diet, education and health support. Build up iron stores during adolescent phase
18 : Modalities of Management
19 : 100 mg elemental Iron ------- ? 0.18 gm % day Iron stores poor Oral Iron
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21 : Oral Iron Therapy Ideal dose – 100mg per day (prophylactic) Ferrous gluconate, ferrous fumarate, ferrous succinate, ferrous sulphate, ferrous ascorbate citrate Rise in Hb – 0.8 gm / dl / week Side effects -G I upset most common Pt. compliance not guaranteed Ineffective in pts with worm infestations Inconclusive evidence on benefit of controlled release Iron preparation
22 : Iron salts are dissociated into bivalent or trivalent iron salts Diffuses as free iron ions through the upper part of the gastrointestinal mucosa Taken up by transferrin and incorporated into ferritin. For binding to ferritin and transferrin ferrous iron has to be converted into ferric iron by oxidation Highly reactive free radicals are produced during this process All ionic iron including carbonyl iron are absorbed similarly Borbolla JR. Cicero RE, Dibilox MM, Sotres RD et al.. Rev Mex Pediatr 2000; 67(2): 63-67 Heubers KA, Brittenham GM, Csiba E, Finch CA. J Lab Clin Med 1986 ; 108 ; 473-8. Absorption of Ferrous Salts Uncontrolled Passive Absorption
23 : Fe+2 Fe+2 Fe+2 Fe+2 Dissociation Passive diffusion Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Gut Lumen Mucosal Cell Blood Ferritin Iron salts Fe+3 Free Radical Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+2 Fe+3 Free Radical Transferrin Incorporation into Hb
24 : Parenteral Therapy : Traditional Indications Intolerance to oral iron Poor compliance to oral iron Gastrointestinal disorders Malabsorption syndromes Rapid blood loss
25 : Inability to maintain iron balance (haemodialysis) Patient donating large amount of blood for auto-transfusion programme ? Pregnant women with severe IDA, presenting late in pregnancy Parenteral Therapy : Traditional Indications
26 : The World Health Organisation states… ‘transfusion should be prescribed ONLY for conditions for which there is NO OTHER TREATMENT’
27 : Diagnosis of Folate Deficiency Anemia (FDA) Special considerations in diagnosis FDA is suspected when the expected response to adequate iron therapy is not achieved Macrocytosis can occur in pregnancy in absence of FDA If FDA + IDA present, it will be masked by IDA Definitive diagnosis – Bone marrow aspirate
28 : Megaloblastic Anemia - Diagnostic Problems HB estimation Peripheral smear MCV estimation Serum folate Red cell folate FIGLU estimations Marrow aspirate
29 : Management of FDA Strong case for routine prophylaxis Prophylaxis with anti convulsants Continue routine oral therapy for hemolytic anaemia Parenteral therapy for severe deficiency
30 : Worm Infestations Common cause of anaemia in developing countries Most common – hookworm infestation, Round worm, whip worm, etc. Oral iron therapy becomes ineffective Treatment by antihelminthics is a must Treatment Mebendazole : 100mg twice daily for three days Pyrantel pamoate : 10mg / kg in single dose. Albendazole : 400mg once a day for three days
31 : Hemoglobinopathies A collective term for the inherited disorders of Hb synthesis Disorders of globin synthesis e.g. Thalassemia Structural Hb variants e.g. Sickle cell anemia, HbC
32 : Thalassemia Genetic disorders; lack or ?sed synthesis of globin chains Two types : ? & ? thalassemia ? chains encoded by 2 pairs of genes on chromosome 16 ? chains encoded by single pair of genes on chromosome 11 ? thalassemia more common and presents as either ?°(major) or ?+ (minor)
33 : Diagnosis of Thalassemia Hb estimations Peripheral smear ?sed MCV ?sed MCH HbA2 (? 2?2)
34 : Diagnostic Strategy for Thalassemias
35 : Sickle Cell Disease Structural Hb variant Exists in homo & heterozygous forms Under hypoxic conditions, HbS polymerizes, gels or crystallizes. ? hemolysis of cells, & thrombosis of vessels in various organs In long standing cases, multiple organ damage.
36 : Take Home Message Anaemia although preventable is a global problem Anaemia still is the commonest cause of maternal mortality and morbidity in spite of easy diagnosis and treatment Anaemia can be due to a number of causes, including certain diseases or a shortage of iron, folic acid or Vitamin B12. The most common cause of anemia in pregnancy is iron deficiency. Iron therapy is best given orally
37 : The youth need to be educated about diet, sanitation and personal hygiene Hookworm infestation should be treated Pregnant women should be given Iron and folate supplements Take Home Message

 

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