Anemia in Pregnancy

Isharyah Sunarno

Introduction

• Anemia: Hb concentration < normal,according to the GA or sex

• Hb < 11 gr% in 1st & 3rd trimester• Hb < 10.5 gr% in 2nd trimester• Hb < 12 gr% in non pregnant ♀• Hb < 7 gr% in severe anemia • Hb < 4 gr% in extreme severe

anemia

Introduction

Anemia:• Iron deficiency anemia• Vit. B12 & folic acid deficiency

anemia• Haemoglobinopathy anemia• Erythropoetin deficiency anemia

Introduction

Iron deficiency anemia• Fe demand is higher than Fe loss

in one day • Unbalanced diet • Permanent iron deficiency

erythropoesis disturbance.

Introduction

Vit. B12 & folic acid deficiency anemia

• Macrositic-hyperkrom• CS: mild jaundice, BW,

neurological deficit, dan glocitis or other epithelial damage.

• Confirmed with Vit. B12 or folic acid in serum and erythrocite.

Introduction

Haemoglobinopathy anemia• Haemoglobinopathy : hemoglobin

protein component synthesis disturbance

• Result: – Alteration in hemoglobin synthesis normal polypeptide chain synthesis

velocity

Introduction

Haemoglobinopathy anemia• Single amino acid chain• Whole amino acid chain• Major cause : erythrocite

destruction, erythrocite life-span, hemolysis

Introduction

Haemoglobinopathy anemia• Accompanied by : abnormal

eryhtrocite morphology, transportation function, deteriorating oxygen transfer, erythropoesis compensatoric with reticulosytosis & bone marrow hyperplasia.

Introduction

Erythropoetin deficiency anemia• Ineffective arythropoesis caused

by : absolute erythropoetin deficiency or inadequate erythropoetin reaction (relative).

• Erythropoetin deficiency major cause of anemia in CRF.

• Normochromic -normocytic.

Introduction

• 3 phases of iron deficiency :• Phase 1 : iron reserve depletion

ferritin level• Phase 2 : erythropoesis

disturbance transferrin saturation because TIBC while iron serum

Introduction

Phase 2 :• Erythrocite protoporphyrin concent.

• Protoporphyrin : heme precursor in

erythrocite if available Fe is not enough for heme synthesis.

• Hb concent. normal or tend to • Serum sTfR .

Introduction

• Phase 3 : – Microcytic-hypochrom– Retyculocite in Hb – Ferritin level

Introduction

• SKRT (2004) in Indonesia: prevalence of anemia in pregnancy: 50,5%

• USA: 6%

Introduction

• WHO according to representative national survey (1993 – 2005) : – 42% pregnant women were

anemia– Non-malaria area : 60% caused by

iron deficiency– Malaria area : 50% caused by iron

deficiency

Introduction

• SKRT (1994) : prevalence of nutritional anemia in pregnancy in South Sulawesi Province : 76,17%.

• Iron deficiency anemia is the most common nutritional problem in the world

Introduction

• World Health Day (April 7th, 2003) → WHO: iron deficiency anemia– 1 out of 10 risk factors of major

health problem– 40% of maternal death in developing

countries ↔ anemia in pregnancy

Patophysiology

• Mature eryhtroid progenitor need Fe for Hb synthesis

Lab

• Parameters to measure Fe status :– Fe plasma or serum– Transferrin & transferrin

saturation– Transferrin receptor – Ferritin

Introduction

• Anemia ~ pregnancy outcome ??– Anemia → ↑ risk of preterm & LBW– Iron reserve ↑ → LBW & oxydative

damage– Diet supply → neonates & placental

size– Micronutrient supply ≠ neonates &

placental size

Patophysiology

• Anemia involved : erythrocite count and / or– Hb concent.

Loss of blood oxygen transfer

capacity

Management

Iron Deficiency anemia

pallorpallor

Conjunctival Conjunctival PallorPallor

KoilonychiKoilonychiaa

Smooth TongueSmooth Tongue

Normal Iron Requirements

• Iron requirement for normal pregnancy is 1gm

200 mg is excreted300 mg is transferred to fetus500 mg is need for mother

• Total volume of RBC inc is 450 ml1 ml of RBCs contains 1.1 mg of iron450 ml X 1.1 mg/ml = 500 mg

• Daily average is 6-7 mg/day

TreatmentTreatment• Prophylactic: Supplement Fe – 60 : Supplement Fe – 60

mgmgelemental Fe with Folic Acidelemental Fe with Folic Acid

• Curative: 200mg FeSo4 3 times Curative: 200mg FeSo4 3 times daily till Hb level becomes normal, daily till Hb level becomes normal, then maintenance dose of 1 tab for then maintenance dose of 1 tab for 100 100 ddaysays

Megaloblastic AnemiaMegaloblastic Anemia

Angular CheilosisAngular Cheilosis

TreatmentTreatment

• ProphylacticProphylactic- all woman of reproductive - all woman of reproductive age should be given 400mcg age should be given 400mcg of folic acid dailyof folic acid daily

• CurativeCurative-daily administration of Folic -daily administration of Folic acid 4mg orally for at least 4 acid 4mg orally for at least 4 wks following deliverywks following delivery

Hemoglobinopathy

Sickle cell Sickle cell HemoglobinopathyHemoglobinopathy

• Hbs comprises 30-40% total HbHbs comprises 30-40% total Hb• There is substitution of Lysine for glutamic There is substitution of Lysine for glutamic

acid at the sixth position of B chain of Hbacid at the sixth position of B chain of Hb• Red cells in oxygenated state behave Red cells in oxygenated state behave

normally, but in deoxygenated state it normally, but in deoxygenated state it aggregates, polymerises and distort red aggregates, polymerises and distort red cells to sickle. cells to sickle.

• These cells are more fragile and increased These cells are more fragile and increased destruction leads to hemolysis, anemia destruction leads to hemolysis, anemia and jaundice.and jaundice.

ManagementManagement

• Careful antinatal supervisionCareful antinatal supervision• Air travelling in unpressurised Air travelling in unpressurised

aircraft to be avoided.aircraft to be avoided.• Prophylatically Folic A. 1gm Prophylatically Folic A. 1gm

daily.daily.• Regular blood transfusion at Regular blood transfusion at

approx. in 6 weeks intervalapprox. in 6 weeks interval

Management

• History and physical examination is sufficient to exclude serious disease (e.g pregnant or lactating women, adolescents)

- CURE ANEMIA• History and/or physical examination is

insufficient (e.g old men, postmenopausal women)

- FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL TREATMENT)

• Benzidine test • Gastroscopy• Colonoscopy• Gynaecological examination

ORAL IRON ABSORPTION TEST

1. baseline serum iron level2. 200 - 400 mg of elemental iron

orally3. serum iron level 2-4 hours after

ingestion

SIDEROBLASTIC ANEMIAS

• HEREDITARY DISORDERS (rare)• SYNONIM FOR MDS (RA,RAES)• DISTURBANCES IN INTRACELLULAR

IRON METABOLISM• HIGHER SIDEROBLASTS NUMBER IN

BONE MARROW• CORRECT OR HIGHER IRON

CONCENTRATION

Anaemia prophylaxis/control programme for pregnant women

Programmes for prevention and management of anaemia in

pregnancy

• In India : an attempt was made to identify all pregnant women and give them 100 tablets containing 60mg of iron & 500μg of folic acid

• In hospital settings, screening for anaemia and iron-folate therapy in appropriate doses and route of administration for the prevention and management of anaemia have been incorporated as an essential component of antenatal care

Management of anaemia in pregnancy

• Hb < 5 g/dL– Constitute 5- 10 % of anaemic women– Admission and intensive care preferably

in secondary or tertiary care institutions to ensure maternal and fetal salvage

• Hb 5 to 7.9g/dL– Constitute 10 to 20% anaemic women– Screen for systemic/obstetric problems

and infections– If she has no other systemic or obstetric

problems give her IM iron therapy

Effect of IM iron dextran on Hb & birth weight

Group No. No.

Hb < 8g/dl untreated 443 2530 + 651

IM iron from 20 weeks 76 2890 + 428

IM iron from 28 weeks 105 2734 + 416

Following initial successful trials by Dr Menon, Dr Bhatt and others, IM iron dextran injections were widely used in medical college hospital settings on out patient basis ; between 10-30 % report side effects fever, arthralgia or myalgia .

However IM iron dextran injections never reached primary health care settings

IM IRON SORBITOL COMPLEX

Initial trials by Dr Menon showed promising results but it was not widely used because

1/3rd of the drug gets excreted in urine and higher dose of is required

It was more expensive

Advantages

Side effects are mild: nausea, metallic taste in the tongue and giddiness; all these respond readily to symptomatic treatment

Impact of IM iron sorbital on Maternal Hb & birth-weight(NFI)

Maternal Hb (g/dl) N Birth weight(g)

I - < 8.0 97 2577+378.3

II - 8.0 – 11.0 645 2796+394.7

III - > 11.0 103 2921+418.1

Total 845 2786+4055

All women who had IM iron therapy

340 2805+379.3

NFI study showed that IM iron sorbital therapy is feasible in primary care institutions. Mean Hb rose and there was significant improvement in birth weight. BUT majority of women who received 900 mg of iron sorbital had Hb levels around 10 g/dl and birth weight was lower than the birth weight in non-anaemic women.

It would appear that 1500mg of iron sorbital citric acid complex would be required for optimal results .

Side effects of IM iron sorbitol citric acid complex

Metallic taste in the mouth 32.4%

Nausea/vomiting 15.3%

None had muscle or joint pain which is commonly seen with iron dextran injections

Nausea and vomiting was treated with anti-emetics.

It maybe worth while to initiate its use in medical colleges and later at smaller hospitals

IM iron therapy

IM iron therapy mainly iron dextan was used mainly in some medical colleges and rarely at district hospitals. It never reached primary health care level

There were problems in ensuring continuous supply of drugs even at medical colleges

Some women found it difficult to come to OPD daily for ten days for IM injections

With iron dextran women who developed trouble some side effects like arthralgia wanted to discontinue;

Iron sorbital citric acid complex was associated with fewer and milder side effects but this drug has not been widely used

Strategy for prevention of anaemia in pregnancy

health and nutrition education to improve over all dietary intakes and promote consumption of iron and folate-rich foodstuffs- possible through NRHM’s health and nutrition days dietary diversification inclusion of iron folate rich foods as well as food items that promote iron absorption- possible with proper linkages with National Horticultural Mission introduction of iron and iodine-fortified salt universally to improve iron intake- possible with NIN technologyOpportunity: Affordable & sustainable interventions to improve iron and folate intake of the entire family and prevent anaemia are readily available .

Strategy for prevention of anaemia in pregnancy focus on Hb estimation for detection and treatment of anemia in adolescent school girls as a part of school health check – possible through school health system

focus on Hb estimation in girls / women who are married, for detection and treatment of anemia prior to pregnancy- can be attempted through coordination with AWW

screening all pregnant women for anemia-Possible using filter paper technique

providing one tablet of IFA to prevent any fall in Hb levels in non anaemic pregnant women- possible through NRHM

Opportunity:All these interventions are feasible& affordable for the individual and health system. With universal coverage and monitored supplementation it is possible to ensure that non anaemic women do not become anaemic

Strategy for management of anaemia in pregnancy

iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with Hb between 8 –10.9g/dL – possible through convergence between AWW and ANM

IM iron therapy for women with Hb between 5 and 7.9 g/dL if they do not have any obstetric or systemic complication- possible with urban & rural PHCs taking the major responsibility

hospital admission and intensive personalised care for women with haemoglobin less than 5 g/dl- possible with referral to tertiary care centres using of emergency transport funds and ASHA

screening and effective management of obstetric and systemic problems in anaemic pregnant women possible in hospitals

improvement in health education to the community to promote utilisation of available care possible through AWW, ASHA, ANM and PRI

Opportunity:All these interventions are feasible& affordable for the individual and health system.

Opportunities for prevention, detection and management of anemia in pregnant women

India currently has the necessary infrastructure , manpower, technology for this task

Indians are rational and responsive; people’s institutions are in place for providing the necessary community support

Prevention, detection and appropriate management of anemia in pregnant women and preventing the adverse consequences of anaemia on the mother child dyad is feasible under NRHM and its urban counterpart

The country should take this opportunity to show case how it can cope with a major challenge to maternal and child health effectively within a short time