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ANEMIA IN PREGNANCY
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Dr Anahita Chauhan
Associate Professor & Unit Head
Seth G S Medical College & KEM Hospita
Honorary Consultant,
Saifee & St. Elizabeth Hospital
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Background
Anaemia is the commonest medical disordepregnancy
Greek meaning without blood
Iron deficiency anaemia is the most commo
of anaemia during pregnancy
NFHS 2003-06: 57.9% of pregnant women
25% direct maternal deaths
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Definitions of Anemia in Pregn
WHO - Hemoglobin concentration
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Classification Based on Sever
ICMR WHO
Mild 10 11 gm/dl 9 11 gm/
Moderate 7 10 7 - 9
Severe 4 7
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Causes of Anemia in Pregnan Physiological anemia
Nutritional anemia IDA, megaloblastic
Anemia of chronic illness
Blood loss
Hemolysis and hemolytic anemias Hemoglobinopathies
Other hereditary anemias
Aplastic anemia
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Increased Iron Demands
1000mg extra elemental iron required in pre
Cannot be met by diet alone
Undernutrition compounds the problem
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Normal Reference Range
Hematological index Reference range
MCV (PCV/ RBC) 75 98 fl
MCH (Hb) 25 31 pg
MCHC 32 36%
TIBC 325 400 / 100ml
Fe/ TIBC ratio 30%
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Morphological Classificatio
By the size of the RBCs
Macrocytic anemia (MCV > 100)
Normocytic anemia (80 < MCV < 100)
Microcytic anemia (MCV < 80)
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Clinical Features - Symptom
Mild anemia is usually asymptomatic
Moderate anemia - weakness, fatigue, exhau
loss of appetite, indigestion, giddiness, breat
Severe anemia - palpitations, tachycardia,breathlessness, increased cardiac output, card
failure, generalised anasarca, pulmonary ede
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Clinical Features - Signs
Pallor
Nail changes
Cheilosis, Glossitis, Stomatitis
Edema
Hyperdynamic circulation (short & soft syst
murmur)
Fine crepitations
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Effects of Anemia on Mothe Antepartum
Preterm labor Pre eclampsia
Sepsis
IUGR
Intrapartum
Uterine inertia
PPH
Cardia failure
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Effects of Anemia on Mothe
Postpartum
Puerperal sepsis
Subinvolution
Pulmonary embolism
Failure of lactation
Delayed wound healing
Cardiac failure
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Fetal Effects
Prematurity and LBW
IUGR
IUFD
Increased perinatal mortality
Iron Deficiency Anemia due to lower iron st
cause poor mental performance or behavior
abnormalities in later life
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Diagnosis Baseline/ Presumpt Haemoglobin Measurement
Peripheral blood smear
Reticulocyte count
Hematocrit
Blood indices
MCV, MCHC, MCHC
Stool Examination
Urine Examination
Proteins, LFT, RFT
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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 3till normal
If no response or incomplete responseadditional tests
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Diagnosis - Additional
Serum Fe
Total iron binding capacity
Serum Ferritin
Saturation
Hb electrophoresis
Bone marrow examination
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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 redu
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Newer investigations Serum transferrin receptors
Transferrin receptor/ ferritin index
Reticulocyte indices
automated counting of reticulocytes, coun
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IDA ACD Thalass-emia S
Severity Variable Mild Mild V
MCV Decreased Normal/decreased
Decreased Nd
S Ferritin Decreased Normal/
increased
Normal I
TIBC Increased Decreased Normal N
S Iron Decreased Decreased Normal I
Marrow iron - + + +
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IDA Beta thal
Population All Greeks, Ita
RDW High Normal
MCV Low Low
Serum iron Decreased Normal
Ferritin Decreased Normal
TIBC Increased Normal
Hb electro-
phoresis
Normal Increased H
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Mentzer Index
Calculation that may (or may not) be useful
differentiating thalassemia minor from IDA
Mentzer Index = MCV/RBC Count
13 Iron Deficiency
Useful in children
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Folic Acid Deficiency Anemi
Deficiency of folate or B12
Anticonvulsants, oral contraceptives, sulfa d
and alcohol can decrease absorption of fola
meals
Folate is essential for normal growth and
development
Coexists with IDA
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Diagnosis
Macrocytes on peripheral smear
Hypersegmentation of neutrophils
Pancytopenia
Low Hb and high MCV Megablastosis on bone marrow
Serum folate
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Prevention
Dietary advice and modification
Iron supplementation of adolescent & non p
women
Treatment of hookworm Infestation
Iron supplementation in pregnant women
Food fortification
Antenatal care for early recognition
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Management of Anemia
Oral Iron Therapy Prophylactic Iron therapy- 100mg elementa
daily with 500 mcg of folic acid
Deworming of all anemic patients Treatment of Anemia- 200mg of elemental i
folate 5mg/d
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Iron Requirement in Pregnan
2.5mg /day in early pregnancy
5.5mg /day from 20 -32 weeks
6 8 mg/ day after 32 weeks
Average 4 mg/ day
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The tablet can be given with meals
different brand may be tried
Side effects of Oral iron
Nausea
Vomiting
Constipation
Abdominal cramping
Diarrhoea
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Reasons for Failure to Respo 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
N Th i Al i
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New Therapeutic Alternative
The side effects of older Iron preparations &
poor compliance even on providing free tabthe most important reasons of failure of ana
control programmes
Newer preparations are better tolerated, ha
side effects with better compliance
Carbonyl Iron
Iron ascorbate
Merits of New Preparation
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Merits of New Preparation
Outstanding GI Tolerance in contrast to 20%
side effects with conventional therapy Very safe with no poisoning even in high do
No interaction with food stuffs
The newer preparations are delicious with nmetallic taste and dont stain the patients t
Hence the compliance is very high
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Parenteral Iron therapy
Indicated when the pregnant woman is unatake iron due to side effects or is non compl
Its main advantage is certainty of administra
Rise in hemoglobin is similar to oral iron (upper wk)
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Preparation & dosage
Iron Dextran IM and IV high molecular wt st
complexes release iron slowly, can cause anap
Iron citrate sorbitol IM less stable, rapid rele
iron
Iron sucrose IV intermediate stability, rapid
metabolism hence readily available iron. Sinc
not form biological polymers, there are no re
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Precaution
Oral Iron to be suspended 48 hours beforeparenteral therapy
Emergency measures like inj hydrocortisone
adrenaline, oxygen cylinder to be kept ready Look for reaction while giving infusion
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Dose calculation
Older preparations: each 1ml = 50mg eleme
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
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Disadvantages Pain
Nausea, vomiting, headache Skin discolouration
Abscess formation
Fever Lymphadenopathy
Allergic reaction
Anaphylaxis
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Blood Transfusion
Severe anemia, especially after 36 we
Hemorrhage
Associated infections
Packed cells preferred
Exchange transfusion rare
f h i
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Use of Erythropoetin
Used in severe anemia & renal failure for sigincrease in Hb and to avoid blood transfusio
Gynaecological surgeries - preop use of
erythropoietin and Iron Dextran has been savoid the need for blood tranfusion later
h
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Dosage Regimen Erythropoe
Inj erythropoetin can be given subcut or iv 10
On day 1, 3 & 5 along with parenteral iron or
5 6000units s/c erythropoetin and iron dextra
deep im daily for 5 day
First dose given after subcut sensitivity test
Adrenaline, hydrocortisone, oxygen to be kep
Produces 3gm% rise in Hb over a 2wk period
M i L b
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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
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Clinical Case Scenarios A primigravida presents at 28 wks of gestatio
pallor, hemoglobin 7.8g%, no other medical
comorbidity, good functional status. Mostpragmatic first line therapy in cases with ass
compliance would be
a. blood transfusion b. parenteral iron
c. oral iron
d. oral plus parenteral iron An
Clinical Case Scenarios
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Clinical Case Scenarios
Foodstuff with highest available iron is
a. Red meat
b. Figs
c. Groundnut
d. Soyabean
A
Cli i l C S i
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Clinical Case Scenarios
A lady at 32 weeks gestation with hemoglob
red cell width is increased, taking iron suppLeast likely situation is
a. non compliance
b. intestinal parasites
c. thalassemia trait
d. anti epileptic medication
A
Cli i l C S i
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Clinical Case Scenarios
Single most important set of investigations i
recently diagnosed case of anaemia in pregn
a. Red cell indices
b. Retic count and peripheral smear
c. Iron studies
d. Hemoglobin electrophoresis
An
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Clinical Case Scenarios
G5P2L0A2 at 35 weeks gestation in early pre
labor. Hb is 8.8g%. All can be part of manageexcept
a. Steroids
b. Frusemide
c. Blood transfusion
d. Intra partum antibiotics
A